;:--m;
t#*.,
fWi^s
'■%'■>  •
i*.
*•*«
ft
#*> 'X

*ft
¥•
$%
\&
Wi
w
*fc*V *kc
■fe
:t,A*
•f^a-:
 
JJ
0
C rlfo " f^Jc< v
   J
 
-^^^o 
 
A0                :,>.
 
 
ON THE
THEORY  AND  PRACTICE
on
MIDWIFERY.
                   BY
  FLEETWOOD CHURCHILL, M.D., M.R.I.A.,
HON. FELLOW OF THE COLLEGE OF PHYSICIANS IN IRELAND; CORRESPONDING MEMBER OF THE AMEAKUM
              NATIONAL INSTITUTE, ETC. ETC.
WITH NOTES AND ADDITIONS,
               BY D. FRANCIS CONDIE, M.D.,
»          SECRETARY OF THE COLLEGE OF PHYSICIANS; MEMBER OF THE AMERICAN MEDICAL ASSOCIATION; MEMBER
\                   OF THE AMERICAN PHILOSOPHICAL SOCIETY, ETC. ETC.
WITH ONE HUNDRED AND THIRTY-NINE ILLUSTRATIONS.

             A NEW AMERICAN,
      JROM THE LAST IMPROVED DUBLIN EDITION.
      PHILADELPHIA:
BLANCHARD AND LEA.
            1857. 
          Entered, according  to the  Act of Congress, in the year 1851, by

                          BLANCHARD  AND  LEA,

In the Clerk's Office of the District Court of the United States, in and for „he Eastern
                             District of Pennsylvania.
       Philadelphia:
Printed by T K. & P. G. Collin. 
                       TO


    CHARLES JOHNSON,  ESQ., M.D.

                       AND

       ROBERT COLLINS, ESQ.,  M.D.


            £!jt5 $nltinu is fhuiraku",

                     WITH THE

GREATEST RESPECT FOR THEIR PROFESSIONAL ATTAINMENTS
         AND GRATITUDE FOR THEIR KINDNESS.
(iii) 
 
        PREFACE

BY  THE AMERICAN EDITOR.
  The preparation for  the  press of Dr. Churchill's Treatise
on the Theory and  Practice of Midwifery has been under-
taken by the present editor, at the request of the American
publishers;  Dr. R. M. Huston having been prevented by his
numerous other engagements from # performing in regard to
this edition  the same editorial office he has so ably executed
in reference to those which have preceded it.
  The present is reprinted from a very late Dublin* edition,
which had been revised and brought up by the author to the
present time, and which confessedly presents a most faithful
and able exposition of every important particular embraced
in the department of  Midwifery.
  The editor of the present edition may, perhaps, be accused
of temerity  in presuming to add anything to a work affording
so full and accurate a view of the subjects of which it treats;
he nevertheless believes that the notes and additions he has
made, which include most of those by the editor of the pre-
ceding editions, will be found not altogether valueless.
                                                D. F. C.
  Philadelphia, March, 1851.

        * See the Author's  Preface to the Second Dublin Edition.
A 2                      00 
 
AUTHOR'S  PREFACE
TO  THE FIRST  EDITION.
  The object of the publishers of this volume  is to offer to
the student in Midwifery a work, embracing the modern dis-
coveries in the physiology of the uterine system, with all the
recent improvements in practice, in a condensed form, amply
illustrated, at a moderate price.
  At their request I have  undertaken the literary depart-
ment, and I must confess, with diffidence, after  the excellent
treatises  of Drs. F. Ramsbotham  and Rigby.  I have, how-
ever, entered more fully into the physiology of the system
than they have thought necessary:  nor have I hesitated to
avail myself of their  labours,  and those of  other distin-
guished authors, so as to render  the theory and practice as
complete as possible.
  I regret very much that it was incompatible  with the size
of the volume to  admit ample  references;  however, after
the avowal I have just made, it will be understood  that their
omission has resulted neither from a wish to claim the merit
of originality, nor  from a desire  to save myself trouble.   I
can truly say that I have examined every  author of emi- 
viii
PREFACE.
nence within my reach, in the course of composition of the
work, and have done my utmost to lay before the  student a
condensed and  yet extensive statement of the present  state
of the science.
  Perhaps I ought to  say a word as  to the statistics I  have
given.   I would not overrate their importance; at  the ut-
most they only afford an approximate estimate, owing to the
drawbacks upon their exactness, and  could not alone  furnish
us with accurate conclusions; nevertheless, I think that  their
value is considerable, as showing the frequency and relative
mortality of the deviations from natural labour,  and  of the
different operations.   Whatever value they may possess it is
evident will be in proportion to their extent  and accuracy;
and to  secure both these points, I have examined  the various
reports myself, and obtained access to many but little  known
in this  country. 
AUTHOR'S  PREFACE
TO THE SECOND DUBLIN EDITION.
  I have carefully revised the new edition of this work,
thankfully availing myself of the suggestions of all parties
so far as I believed them to be right;  and although I cannot
hope that it is  yet free from errors, I am certain their num-
ber is considerably diminished.

  I have made no change in the principles inculcated in the
first edition, because, after a searching investigation and some
experience, none has  appeared to me to be required; nor in
the practice, except  to add  any recent information which I
have obtained.

  On one point it will be convenient for me to make a few
remarks here rather than in the body of the work.   I allude
to the statistics.  I believe I was  one  of the first in these
countries  to endeavour to collect a large body of statistics
from  all  available sources,  and to draw certain deductions
from them, which I published first in the " Dublin Journal,"
with a distinct expression of my conviction that the conclu-
sions ought not to be  rigorously drawn,  but that considerable
allowance should be made for disturbing causes. 
X             PREFACE TO THE SECOND EDITION.
  No one can be more alive than I am  to  the difficulty of
attaining  accuracy in the collection of a large  number of
cases.   They are scattered through many volumes, recorded
in many forms, requiring arrangement, tabulation, &c.;  and
even if this be done carefully and correctly, there is still a pro-
bability of error in the printing.  These considerations should
be always borne in mind in estimating statistical tables, and
with those who  have had much experience, will be a suffi-
cient apology for a certain amount of inaccuracy.   I trust it
will be  found that my former errors  have been corrected in
this edition.

  In a letter to one of the  periodicals some years  ago, Dr.
Francis Ramsbotham objected  to the use  I  made of his
father's  cases, on the ground that they were selected ones,
and that conclusions drawn from them must be inaccurate as
regarded the entire of his father's practice, and give a higher
rate of mortality than was really the case.   I frankly admit
the truth of this  observation as regards Dr. Ramsbotham,
senior, but utterly deprecate any thought or wish of depre-
ciating either his skill or success.  I do not see how this can
be avoided, unless the whole of his cases  were published, or
I left them out altogether, which  I think would  be a great
loss.  I have only done with his cases what all  writers (in-
cluding Dr.  Ramsbotham, jun.)  have done with  Smellie,
Portal, Giffard, and Perfect's cases; and in giving them also,
it should always be remembered, that there may  be an error
of excess or the reverse.

  I have already alluded to the errors to which every one is
exposed who attempts to collect statistics; let me now men-
tion other causes  which, to a certain extent, weaken the
conclusions at which we may arrive. 
PREFACE TO THE SECOND  EDITION.
xi
   In grouping together a number of cases to ascertain their
positive or relative frequency, their causes, the ratio of mor-
tality positive and comparative, &c, it is next to impossible
to obtain exactly similar cases, or patients  under exactly
similar circumstances;  for this we  have to make allowance,
and also for differences in habits of life, constitution, or at-
mospheric influences,  modes  of  previous treatment, &c,  so
that we  shall find abundant reason to use our statistical de-
ductions with caution and allowance;  in fact,  we cannot
possibly  ascertain the exact truth,  but only a more or less
close approximation to it.  But even thus far these calcula-
tions are of great value, for,

   1. They lead to a habit of definite thought and statement;
so that instead of general terms, we use numbers or propor-
tions, and in  so far as  accuracy is  attained, we  give a fixed
and scientific character to our observations.

   2. As  Dr. Simpson, in his excellent essay on the value and
necessity of statistics in operative  surgery, has remarked,
" Statistics  offer a test  by which  the impressions of our re-
corded  and limited experience  are corrected; and they
furnish a mode of investigation capable of resolving many
existing practical problems in surgery."

   3. They afford  us in  general  the only true and  ultimate
" measure of value" of any proposed alternative operation, or
of any new practice in surgery or midwifery.

   For these and other reasons I still hold the opinion that
numerical calculations, applied  to  midwifery, are of  great
value,  notwithstanding the numerous chances of error, and
the  impossibility  of drawing  conclusions from  them with
absolute accuracy. 
Xii            PREFACE TO  THE SECOND EDITION.
  I cannot conclude  without expressing my deep sense of
obligation to  the profession for  their kind  reception of this
work.  Feeling the responsibility incurred by even the hum-
blest of those who attempt to teach others, I  have shrunk
from no amount of labour, and no cost has been spared which
could render  this volume clear, practical, and useful.
  137, Stephen's Green, Dublin.
EXTRACT FROM THE AUTHOR'S PREFACE TO A FORMER AMERICAN
                         EDITION.
  " I owe a  large debt of gratitude  to my kind  American
friends, which I gladly take this opportunity of acknowledg-
ing, and also  to the profession in America for the flattering
reception they have given to my volumes.  No reward could
be more highly valued by me, nor could anything make me
more anxious, by labour  and study,  to make my works as
perfect as possible, than the knowledge that their usefulness
may extend to another hemisphere."
  Dublin. November. 1847. 
CONTENTS.
                             W\AA/yVWWVW\


                                                                   PAGE.
Preliminary Observations.................................   33


                              PART I.

         THE ANATOMY OF THE PELVIS AND OF  THE ORGANS  OF
                              GENERATION.
CHAP.
 1. Of the bones of the pelvis..................................   35
 2. Of the joints of the pelvis..................................   39
 3. Of the pelvis collectively...................................   41
 4. Abnormal deviations in the pelvis — Deformities.................   49
 5. Of the external organs of generation..........................   58
 6. Of the internal organs of generation..........................   63


                             PART II.

             PHYSIOLOGY OF THE ORGANS OF  GENERATION.

 1. Physiology of the uterus and ovaries — Menstruation.............   75
 2. Disorders of menstruation..................................   86
 3. Generation — Conception...................................   98
 4. Utero-gestation...........................................  105
 5. Signs of pregnancy........................................  14o
 6. Duration of pregnancy.....................................  158
 7. Sterility................................................  16'2
 8. Superfoetation............................................  166
 9. Extra-uterine pregnancy....................................  169
10. Pathology of the foetus — Signs of its death....................  176
11. Abortion — Premature labour...............................  179 
 XlV                           CONTENTS.


                              PART  III.

              PHYSIOLOGY  OF THE UTERUS. — PARTURITION.
 CHAP.                                                               PAGE.
  1.  Classification — Definitions..................................  188
  2.  Mechanism of parturition..................................  192
  3.  Natural labour...........................................  210
  4.  Convalescence after parturition..............................226
  5.  Tedious labour...........................................  236
  6.  Powerless labour..........................................  250
  7.  Obstructed labour.........................................  255
  8.  Deformed pelvis..........................................  268
  9.  Obstetric operations — Induction of premature labour.............272
 10.  Version or turning........................................  290
 11.  The vectis or lever........................................  303
 12.  The forceps..............................................  312
 13.  Craniotomy..............................................  341
 14.  The Csesarean section......................................  358
 15.  Symphyseotomy..........................................  370
 16.  Mal-positions and mal-presentations...........................  377
 17.  Plural births — Monsters...................................  400
 18.  Prolapse of the funis umbilicalis.............................  409
 19.  Retention of the placenta  ..................................414
 20.  Flooding...............................................420
 21.  Convulsions............................................. 435
 22.  Lacerations.............................................. 447
 23.  Inversion of the uterus....................................469
 24.  Puerperal  fever .......................................... 477
25.  Phlegmasia dolens........................................498
26.  Puerperal mania......................................... 503
27. Ephemeral fever or weed................................... 506 
LIST OF WOOD  ENGRAVINGS.
no.                                                               PA^E.
  1. Os Innominatum........................................   35
  2.       Ditto      ........................................   37
  3. Os Sacrum.............................................   38
  4. Skeleton of trunk.........................................   41
  5. Pelvis—front view.......................................   42
  6.    "    brim...........................................   43
  7.    "    cavity..........................................   44
  8.    "    lower outlet.....................................   45
  9.    "    canal of.......................................    46
 10.    "    equable excess of.................................   49
 11.    "        "   diminution of.............................   50
 12.    "    distortion of brim................................   50
 13.    " t      "         "  ................................   51
 14.    "        "        "  ................................   51
 15.    "        «        «  ................................   51
 16.    "        "      cavity................................   52
 17.    "        "        "  exostosis.........................   52
 18.    »        "        "................................   53
 19     u        U        «  ................................   53
 20.   lt        "      lower outlet............................   54
 21.   «        "        «  ................................   54
 22.   "    oblique distortion.................................   55
 23. Calliper for measuring pelvis (Baudelocque's)..................   57
 24. Measurement of pelvis by the fingers.........................   58
 25.      "          "          "    .........................   58
 26.  External organs of generation..............................   59
 27.  Section of pelvis (Huston)................................   64
 28.  Uterus, tubes and ovaries..................................   65
 29.    "   cavity of.........................................   66
 30.    "   double..........................................   69
 31.    «     "   ..........................................   70
 32.    "      "   ..........................................   Y0
 33     a      <c    .........................................   70
 34. Section of ovary, Graafian vesicles...........................   72 
xvi
LIST OF WOOD  ENGRAVINGS.
fig.                                                               FAGE-
35. Ovum of rabbit.........................................   TS
36.   "   of man.......................................••••   74
37. Ovary at menstrual period.................................   80
38.    «         "      "   ..................................   83
39. Graafian vesicle after impregnation...........................  101
40. Ovary after escape of ovum................................  103
41. Corpus luteum.........................................  103
42. Vessels of gravid uterus...................................  105
43. Nerves  of gravid uterus...................................  106
44. Cervix uteri at 3d month of gestation........................  107
45.       "     at 6th month.................................  107
46.       "      at 8th month.................................  108
47.       "      at 9th month.................................  108
48. Decidua vera............................................  109
49. Decidual cotyledons......................................  110
50. Human ovum of  two weeks................................  112
51.        "            "      laid open........................  112
52. Placenta and cord........................................  115
53. Human ovum about 3 weeks...............................  125
54.        "           "       ...............................  125
55.        "           2 months..............................  126
56.        "             "      ..............................126
57.        "           3 months..............................  126
58. Section of a hen's egg....................................  128
59. Vitelline membrane, Blastoderma — T. "W. Jones...............  128
60. Changes in the hen's egg during incubation...................  130
61.     "             "      "       "      ...................  130
62.     "             "      "       "      ...................  131
63. Vesicula umbilicalis, from Baer.............................  132
64.     "       "            "    ..................,.........  134
65. Diagram of foetus and membranes about the 4th week, from Carus..  135
66.     "        "         "        "       6th week...........  135
67. Position of foetus  in utero.................................  138
68. Foetal head diameters ....................................  139
69. Nipple and areola during pregnancy..........................  148
70. Mode of examination by ballottement.........................  152
71. Extra-uterine gestation.........................,..........  171
72. Dewees' wire crotchet.....................................  185
73. Bond's placental forceps...................................  185
74. Planes of the pelvis......................................  195
75.   "           "......................................  196
76.   "           «   ....................'.................  190
77    "           "   ....................'..................  197
78    "           "......................................198 
                     LIST  OF WOOD  ENGRAVINGS.                 Xvii

 FIQ.                                                              PAGE.
 79. Planes of the pelvis...................................... 198
 80. Foetal head, diameters....................................200
 81. Mechanism of parturition — 1st position...................... 204
 82.      "           "        2d position....................... 204
 83.      "           "        3d position.......................205
 84.      "           "        4th position...................... 206
 85. Head at the lower outlet................................... 207
 86.    "            "      ...................................217
 87. Internal examination..................................... 219
 88. Obstructed labour — polypus uteri........................... 259
 89.      "       "     ovarian tumour......................... 262
 90.      "       "     vaginal cystocele........................ 264
 91. Version or turning....................................... 299
 92.     "        "    .......................................300
 93. Koonhuysen's veotis...................................... 304
 94. Modern vectis........................................... 304
 95. Application of vectis..................................... 310
 96. Chamberlen's forceps..................................... 314
 97. Short forceps............................................ 315
 98. Long forceps........................................... 316
 99. Dr. Kadford's forceps..................................... 317
100. Operation with long forceps................................ 327
101.       "      short forceps................................ 329
102. Axes of pelvis.......................................... 334
103. Dr. Huston's forceps...................................... 335
104. Dr. Hodge's forceps...................................... 336
105. Dr. Bond's forceps....................................... 338
106.      «       «....................................... 338
107.      "       "   ....................................... 338
108. Smellie's perforator...................................... 343
109. Crotchet............................................... 343
110. Mr. Holmes' perforator.................................... 344
111. Knife for amputating limbs...............................344
112. Blunt hook............................................ 345
113. Dr. Davis' bone forceps................................... 345
114. Craniotomy forceps...................................... 345
115. The cephalotribe........................................ 346
116. Dr. Meigs' Embryulcia instruments.......................... 347
117.       "         "         "     .......................... 347
118. Use of the perforator..................................... 353
119.      "        "     ..................................... 354
120. Application of the Crotchet................................ 355
121.      "             "     ................................ 356
122. Face presentation — 1st position............................ 377
          3                         b2 
xviii
LIST  OF WOOD ENGRAVINGS.
 FIG.                               X                                 *AGE
123. Face presentation — 1st position.............................  378
124.           "        2d position.............................379
125. Forehead under the arch of the pelvis........................  382
126. Breech presentation — 1st position..........................  384
127.    "        "            "      ...........................  385
128.    "        "         2d position...........................  386
129. Breech presentation — extraction of head.....................389
130. Presentation of inferior extremities..........................  391
131.      "            "        "     ____......................  391
132. Arm presentation — 1st position............................394
133.          "         2d position............................395
134. Compound presentation — hand, foot, and funis................399
135. Hydrocephalus..........................................407
136. Prolapse of the funis.....................................409
137. Placenta praevia.........................................426
138. Laceration of perineum, Dr. Horner's operation................467
139.      "          "            «        «    .......            46" 
                           ON

THE   THEORY  AND  PRACTICE

                           OP

             MIDWIFERY.
             PRELIMINARY  OBSERVATIONS.

   1.  The theory and practice of Midwifery includes the  anatomy and
physiology of  the  organs  of generation, and  also the anatomy of the
region in which they are contained.   A correct knowledge of the struc-
ture,  magnitude, and other peculiarities of the pelvic cavity is indispen-
sable to a due appreciation of the mechanism of parturition: the anatomy
of the organs of generation must of  course be preliminary to an investi-
gation into their functions, and  it  is only  by  a careful observation  of
these functions that we  are able to  detect and understand the deviations
from  their normal course;  in other words, their pathology.

   The  three  great functions  of the uterine system  are  menstruation,
conception, and parturition, which are so intimately connected, that each
is dependent on the other,  and for the development of either, a co-opera-
tion of organs is necessary.  A breach  of this union, or the  absence of
this co-operation, will give rise to  functional  irregularity; and together
with the individual deviations, and those arising from organic deficiencies,
will constitute the pathology of the  sexual system.

   2.  We have  thus, in a  few words, a natural arrangement  of  subjects
laid down, which we shall  follow in the subsequent parts of this volume.
Part I.  will include the  normal and abnormal  anatomy of the pelvis,
of the external, and of  the internal organs of generation.  Part II. the
function of menstruation, with  its abnormal conditions;  and  of  concep-
tion,  utero-gestation, ovology, &c. with  their abnormal deviations, as
                                                          (33) 
34
PRELIMINARY  OBSERVATIONS.
 sterility, superfcetation, extra-uterine gestation, fcetal pathology, abortion
 &c.  Part III. Midwifery properly so called,—that is, parturition, with
 its abnormal varieties.

   This arrangement will bring under our  notice  all that relates to the
 theory and practice of midwifery.

   In addition to the description of the different functions  noticed  above
there  will be appended full  details for  their management, and for the
treatment of their deviations; all which I have  endeavoured to  give as
clearly yet as concisely as possible. 
PART  I.
THE ANATOMY OF THE PELVIS AND OF THE ORGANS OF
                      GENERATION.
                           CHAPTER I.

                  OF THE BONES OF THE PELVIS.

  1. The Pelvis is an irregular bony cavity, situated at the base of the
spinal column and above the inferior extremities, with which it is  con-
nected by muscles and  articulations, and for which, as well  as for the
muscles of the trunk, it constitutes a '■'■point d'appui."

                                Fig. 1.
As it forms  one of the two  mechanical  elements  of parturition, it is. of
great importance rightly to  understand  its component parts, their con-
nexions, relations, coverings,  and abnormal varieties.   These we shall
now proceed to investigate.
   2. In  the adult, the  pelvis may be divided into four parts or bones.
viz.  two ossa innominata, the os sacrum, and the  os  coccygis; but in
early life they are more minutely divisible.
   3. Each  Os Innominatum at an  early period of intra-uterine  life,
consists of cartilage only, in which subsequently numerous spiculae of
ossification are seen, and which at birth have coalesced «o as to form
three bones, separated by cartilage. 
36
BONES OF  THE  PELVIS.
  After birth, the process of ossification continues until  these separate
bones meet in the  acetabulum, where they are identified with each other,
and at the symphysis pubis, where the opposite ossa pubis are united by
cartilage and ligaments.
  4. The breadth of each os innominatum, from the anterior superior to
the posterior  superior spinous process, is six inches, and the height, from
the tuber ischii to the crest of the ilium, is seven inches.
  The  three bones  into which each  is divided  at birth  have received
different names, and require  distinct notice.
  5. The Os Ilium, hip  or haunch-bone  (fig.  1), is the larger of the
three,  of a triangular  shape,  situated  superiorly, and with  its fellow
forming what is called the false pelvis.
  Its external surface ('), or dorsum., is convex, irregular, with elevations
and depressions, which serve for  the  attachment of the glutsei muscles.
Its  internal surface, or venter (10), is  concave  and* smooth, affording  a
bed for the iliacus internus muscle.  The lower portion, body or base (5),
is the  thickest part  of the bone,  and forms more than one third of the
acetabulum.   Above the body, the bone spreads out into its dla or wing,
which  rises obliquely forwards, upwards, outwards, and then backwards,
terminating in the crest, or crista ilii, a semicircular ridge  of some thick-
ness, which  at its posterior  part  curves downwards  and  inwards.  Its
borders serve for the  attachment of the abdominal muscles and certain
ligaments to be hereafter described;  and it terminates anteriorly, in the
anterior superior and inferior  spinous processes (4,6), and posteriorly in
the posterior  superior and inferior spinous processes  (6,7).  The former
afford   attachment to Poupart's and  Gimbernat's ligaments,  the tensor
vaginae femoris, the sartorius, and a portion of the rectus femoris muscles.
Between the posterior spinous processes is  a deep arch, the sciatic notch,
which is divided by ligaments into the two  sciatic foramina: through the
upper  of these, which  is the larger, pass the  gluteal, sciatic  and pudic
arteries, the  sciatic and pudic nerves, and  the pyriform muscle; whilst,
through the  inferior opening, the  pudic arteries  and  nerve re-enter the
pelvis, and the obturator internus muscle passes out.   The posterior part
of  the crest of the ilium expands  and  exhibits  an irregularly oval rough
surface with  numerous prominences, which  occupy corresponding depres-
sions in the sacrum, and  constitute (with  a thin layer of  cartilage inter-
posed) the sacro-iliac synchondrosis of each side.  The body of the bone
is divided from the  ala internally by a well-marked  ridge (12), running
from the junction of the ilium with the sacrum, forward; this is part of
the linea ilio-pectinea, and defines the boundary of the true pelvis.
   Thus we find that the ilium is connected posteriorly with the sacrum,
and identified anteriorly with the ischium and pubis in the acetabulum.
   6.  The Os  Ischium, os  sedentarium, &c. is  the  lower of the  three
bones  composing the os innominatum, and the next in size to the os ilium.
Its base or body (2), which forms  the inferior portion  of the acetabulum,
is the thickest part;  below this we find a narrower portion, from which a
spinous process juts out backwards and inwards, and  affords insertion  to
part of the  sacro-sciatic  ligament.   This  process varies in length and
direction, and is  occasionally of  some importance obstetrically.  From
the neck, the bone  descends downwards and forwards, until, enlarging
at  its  lower portion, it forms the tuber ischii (I4), the  bony seat, a rough 
BONES OF THE PELVIS.                     37
thick protuberance; and, turning upwards  at an  obtuse  angle, becomes
the ascending ramus (13) of the ischium.  Its internal surface is smooth
and even, and forms one of the inclined planes of the pelvic cavity.  Its
                                Fig. 2.
external surface is rough, and  gives attachment to the sacro-sciatic liga-
ment, to the semi-membranosus, semi-tendinosus, the long head of the
biceps flexor cruris, and the quadratus femoris muscles.
   Thus the ischium is identified with the ilium and pubis in the acetabu-
lum, with the descending  ramus of the os pubis,  and connected by liga-
ment with the sacrum.
   7. The Os Pubis, pecten or share-bone, is the smaller and most anterior
of the  three bones.   Its base is the thickest part, and forms the anterior
and  smaller third of  the  acetabulum, beyond which the bone narrows ;
and, proceeding  forwards, constitutes  the horizontal ramus  (I6) of  the
pubis ; somewhat triangular in shape, and about half an inch in breadth.
It meets its opposite at the symphysis pubis {"), and completes the anterior
wall of the pelvis.  From the  inferior part of the symphysis, and at an
acute angle with the horizontal ramus, a thin plate  of bone, the descending
ramus  (18), proceeds  downwards to meet the ascending ramus of  the
ischium, and with it to form one  side of the arch of the pubis.   Upon
the angle formed by these  bones and their  opposites will depend  the
dimensions of the arch, and the facility or difficulty of the transit of the
child through the lower outlet.
   The inner and  superior  edge of the horizontal ramus  is a continuation
of the linea ilio-pectinea, which it completes;  and near  its pubic termina
tion  is a small spinous process, to which is  attached the inner end of
Poupart's ligament, and near it  the pectineus muscle, whilst the inner and
outer edges of this portion of the bone,  afford insertions to the abdominal
muscles.  Although  I have said that the anterior part of the  pelvis is
completed by the ossa pubis and ischium, yet in  the centre of each side
a considerable  space  is left, called the obturator foramen (20),  which is
nearly  closed by the obturator ligament.  The  object  attained by this
arrangement is, lightness of  structure where strength is not needed.
                                 D 
38
BONES OF THE  PELVIS.
   The os pubis is identified with the ilium and ischium in the acetabulum,
with the ascending  ramus of the ischium ;  and  connected with its fellow
opposite by cartilage at the  symphysis pubis.
   Of the three  bones, the  ilium forms a part of the brim of the pelvis,
but none of the  outlet;  the  ischium, part of the outlet, but none of the
brim ; whilst the pubis enters into the formation of both brim and outlet.
   8.  The Os Sacrum, os basilare, &c, terminates the vertebral column,
and maybe said to consist of several vertebrae anchylosed.   Its formation
commences by about thirty-five points of ossification ; these shortly coa-
lesce  into fifteen ; at birth the number is reduced to five (the number of
vertebrae of which the bone  consists), and subsequently they form but one
bone.   In the adult, it is of a triangular shape, the base of the triangle
being above,  and  inclining forwards; the  apex  below, and somewhat
backwards.  Its length is from four to four and a half inches, its breadth
four inches, and its greatest thickness two and a half inches.  M. Baude-
locque found  that the thickness of this bone  scarcely varies a line,  even
in deformed pelves.  Its specific gravity is small, owing to its spongy
texture; so that, for its  size, it is probably the lightest bone in the body.
Its external surface is rough and convex, exhibiting four or five spinous
processes like those of the vertebrae,  but smaller, and diminishing in size
as they descend.  Anterior to these  we find a continuation of the spinal
canal, containing the cauda  equina, with four holes on each side commu-
nicating with it,  for the transmission  of nerves.  Its internal surface (2) is
smooth, and concave to the  amount of half an inch, crossed by four trans-
verse  lines, marking the former division of its bones by cartilage:  here
are also four pairs of holes sloping outwards, through which pass nervous
filaments, which afterwards  form part of. the great sciatic nerve.   The
upper edge of this bone completes the brim of the pelvis;  the oval shape

                                Fig. 3.
of which, however, is broken by the projection of the  central portion,—
the  promontory of the sacrum (x).   The lateral  surfaces (3)  are rough,
uneven, and covered with a thin layer of cartilage; the irregularities cor-
respond to  similar ones in the ilium, and with them  form the sacro-iliac 
OF THE JOINTS OF THE PELVIS.
39
synchondroses.   This is probably the most important bone in the pelvis,
obstetrically considered, inasmuch as it forms a great portion of the brim
and cavity, and enters largely into the various deformities of the pelvis.
  It is connected  superiorly with the last lumbar vertebra, laterally with
the ossa  ilia, inferiorly with the os coccygis, and by ligaments with  the
ossa ischia.
  9.  The Os Coccygis, or huckle-bone (4), is the continuation and ter-
mination of the os sacrum and vertebral column.   It is formed by four or
five points of ossification in the foetus, which do not  afterwards unite,  but
are tipped with cartilage,  and moveable by a  ginglymoid joint.   The
entire bones form a pyramid, the apex of which  is below.   The external
surface is irregular, and the internal smooth, terminating the plane of the
sacrum,  and extending it anteriorly.  The small sciatic ligament and the
ischio-coccygeal muscle are inserted into  it.
   To the accoucheur, this apparently insignificant  bone, or bones, is of
importance,  as any deviation from its  normal direction or usual mobility
may influence the progress of parturition.
                           CHAPTER  II.

                  OF THE JOINTS OF THE PELVIS.

   10.  Before proceeding to the consideration of the pelvis collectively,
let us  briefly examine  the joints by which the separate bones are con-
nected, and especially as deficient information  on this subject formerly led
to erroneous practical conclusions.   We shall notice, 1, the sacro-iliac
synchondroses; 2, the symphysis pubis; and, 3, the sacro-coccygeal joint.
   11.  The  Sacro-iliac  Synchondrosis, of  either  side, consists of a
rough irregular surface on the posterior part of the  ilium and  the side of
the sacrum, each of  which is covered by a layer of cartilage from one-
sixth to one-eighth of an inch  in thickness;  the  sacral layer being  the
thicker, and the entire, when the bones  are forcibly separated, adhering
to the  sacrum.  At the point of junction of these  two layers, their sub-
stance  is somewhat softer, which has led to the erroneous supposition that
it is a joint, properly so called.   This union of the bones is strengthened
by strong ligamentous bands, which by some writers are described as the
superior,  inferior, anterior, and posterior sacro-iliac ligaments.   They
stretch across from one  bone to the other, in front and behind; rendering
the joint perfectly immoveable, unless force be used.  Additional firmness
also is  obtained by the sacro-sciatic ligaments connecting the lower part
of the  sacrum with the  ilium.
   12.  The mode in which the sacrum is inserted between the ossa ilia is
worthy  of notice; it  resembles  the  position of the keystone  of an arch
inverted: i.e., its transverse diameter is greater inside than outside, because
the pressure to which it is exposed is from within.  The interposition of
cartilage is probably for the purpose of diminishing the effect of shocks
and  so preserving the integrity of the joint. 
40                OF  THE JOINTS OF THE PELVIS.
  13. The Symphysis Pubis is situated anteriorly, and formed by the junc-
tion of the two ossa pubis, whose extremities are covered by cartilage, or
fibro-cartilage.   It was formerly supposed that the junction was effected
by the interposition of a single  mass of cartilage;  but the researches of
Dr. W.  Hunter led him to the conclusion that the end of each bone is
covered with cartilage^ and between them, so covered, is a matter resem-
bling intervertebral substance.  With this view Baudelocque and Burns
agree; but M. Tenon thinks  that sometimes the one and  sometimes the
other mode obtains.   Occupying two-thirds  of the length, and the poste-
rior third  of the centre of this junction, we find a true arthrodial articula-
tion, six lines in length  and two in breadth, in shape  like an  almond,
lined by synovial membrane, and containing a small quantity of synovia.
M.  Gardien defines this joint as " an  arthrodial articulation in part, and
the remainder a true synevrotic synchondrosis."
  14. Though the joint be weak in itself, it is strongly fortified by liga-
ments.  The capsule is  strong, and is connected with, or partly formed
by, the  anterior and posterior pubic and sub-pubic  ligaments, which con-
sist of interlacing fibres stretched across the  joint on all sides, and firmly
attached to each os pubis.
  15. Ambrose Pare, Severin  Pineau, and other ancient writers, with
Sigault, Chaussier, Gardien, &c, among the moderns, judging  from its
occurrence in certain animals,  have concluded  that the ossa pubis are
separated  to a certain extent during labour, and that this joint is a special
provision  for increasing  the antero-posterior diameter of the  brim of the
pelvis ;  and certain post-mortem examinations, especially of females who
died near the full term of utero-gestation, have -been adduced as proving
the fact.  On the other hand, this separation is denied by Denman,  Bau-
delocque, Boyer,  Burns,  Dewees,  &c.  Baudelocque  and others  have
sought in  vain for it in cases where no violence has  been used; and, from
a fair estimate of the experience on  record, we may conclude that it does
not take  place as a natural process, but that it occurs occasionally as an
accident.   The  arguments of Dewees are,  in my mind, conclusive:—
1. It is not  stated to  be more frequent in distorted than  in well-formed
pelves,  which ought to be the case  on account of the greater pressure.
2. When it does occur, it is  attended with severe inconveniences, which
are not  observed after ordinary labour.   3. That such a separation as has
been imagined, would not materially increase the antero-posterior diameter
of the brim, as " it would require the ossa pubis to be separated one inch
from each other, to gain two  lines," and such a separation would rupture
the pubic ligaments  and the sacro-iliac synchondroses, in many cases,
beyond recovery.
   16. The  Sacro-coccygeal  joint is of the kind called ginglymoid,
admitting of extensive motion, especially backwards, so as to permit the
enlargement of the lower outlet at least one  inch.  The articulating sur-
faces are  covered with cartilage, and between them is a synovial capsule;
whilst on the  outside,  and  entirely embracing the joint,  is  a fibrous
capsular ligament. 
CHAPTER III.
                  OF THE PELVIS COLLECTIVELY.

  17. Having thus examined each bone of the pelvis separately, and the
joints by which they are united, our next object is the consideration of
the pelvis as a whole, its  relation to the rest of the  body, its magnitude,
axes, &c.
  It is connected with  the  trunk by the articulation of the sacrum with
the last lumbar vertebra, effected in the same manner as the junction of
the vertebrae with each  other; with  the lower extremities it is connected
by means of the hip-joints.

                               Fig. 4.
   18.  But the position of the pelvis in situ is very different from what we
might suppose, from examining it separately.  The brim of the pelvis is
neither horizontal nor perpendicular, but oblique.   When the  body is
erect, the upper part of the  sacrum and  the  acetabula are  nearly in the
same descending  line.   The obliquity has been variously estimated; that
of the brim from 35° to 60°,  and that of the outlet from 5.1° to 18°.  Nae-
d2
m 
42
OF THE PELVIS.
ge\e states the obliquity of the brim to be from 50° to 60°, and that of the
outlet from 10° to 11° ; the point of the coccyx being seven or eight lines
above the summit of the arch of the pubis, and the  sacro-vertebral angle
three inches nine lines higher than the pubis.
  19. The advantages of  this obliquity  are obvious; as Dr. F. Ramsbo-
tham  has truly  observed: "Were  the axes  of the trunk and pelvic
entrance in the  same line, owing to the upright position of the  human
female, the womb, towards  the close of gestation, would  gravitate  low
into the pelvis, and  produce most injurious  pressure on the contained
viscera; while, in the early months, not only would the same distressful
inconvenience be occasioned, but there would be great danger of its pro-
truding externally, and appearing as a tumour between the thighs, covered
by  the inverted vagina."   We may add, that, when not pregnant, the
patient would be obnoxious to prolapse of the uterus and the other pelvic
viscera, upon making very slight expulsive efforts.
  20. Now let us examine the Pelvis  itself.   It is divided by the linea
iho-pectinea  into the false and true, or upper and lower pelvis.  The
Upper or False Pelvis is formed by the lateral  divergence of the alae of

                                Fig. 5.
the ossa innominata.  It is not of much importance obstetrically, except
for the general relation which  its  normal size bears  to  that of the true
pelvis, and the inference to be drawn therefrom as to the normal or ab-
normal condition of the latter.  Dr. Burns  gives the following measure-
ments, which I believe are correct:—" From the symphysis pubis to the
commencement of the iliac wing at the inferior spinous process, is nearly
four inches.  From the inferior spinous process to the posterior ridge of
the ilium, a line subtending the hollow of the costa, measures five inches.
The distance from the superior spine is the  same.  From the  top of the
crest of the ilium to the brim of the  pelvis, a direct line measures three
inches and a half.  The distance between the two superior anterior spinous
processes of the ilium is fully ten  inches.  A line drawn from  the top of
the crest of the ilium to the opposite side measures rather more than eleven
inches, and touches, in its course, the intervertebral  substance  between
the fourth  and fifth lumbar vertebrae.  A line drawn from the centre of
the third lumbar vertebra, counting from the sacrum to the upper spine of 
OF THE PELVIS.                        43
the ilium, measures six inches and three quarters.   A line drawn from
the same vertebra to the top of the symphysis, measures seven inches and
three  quarters; and, when the subject is erect, this line is exactly per-
pendicular."
   21.  The Lower or True Pelvis is the part involved in parturition, and
which it is therefore essential to know with minute accuracy.   For the
purpose of description, it is divided into the brim, cavity, and outlet.
   22.  The  Brim of the Pelvis is defined by the linea ilio-pectinea; it
is of an oval form, except posteriorly, where it is broken by the promon-
tory of the  sacrum.  Its influence upon labour will be understood, when
we recollect that it is the first solid resistance the head of the foetus meets;
that any diminution in its size is more hazardous and less remediable than
in  any other portion of the  passages; and, lastly, that deviations from
the normal proportions of the brim, most frequently entail similar ones in
the cavity.
   The three  principal diameters  are the  antero-posterior ('), from  the
prominence of the sacrum to the inner and upper edge of the symphysis
pubis; the  transverse (2), across the widest  part of  the  brim,  at right

                                Fig. 6.
angles to the antero-posterior;  and the oblique diameter (3), from the sacro-
iliac synchondrosis of one side, to the opposite side of the brim,, just above
the acetabulum.
  23. The measurements of their diameters are not exactly the same \n
different women, though the variation is but slight.   I  shall place the
measurements given by some of the chief authorities before- the reader.
Antero-pos-terior diam'r. Transverse Oblique	Denman.	Bums.	Ramsbo-tham.	Rigby.	Baude-locque.	Velpeau.	Moreau.
	4 in. & a fraction. 5	4 in. 5*	4 in. 5	43 in. 5-4 4-8	4 in. 5 41-	4 in. 41	4 in. 5 42
If we  take  the  smallest of these estimates, there will still be space 
44
OF THE PELVIS.
enough to admit the head of the child;  and if we allow half an inch for
variations, this will give us a pretty correct idea of the  diameters of the
brim.  The circumference varies from  thirteen  to  fourteen and a half
inches,                                         ic-n     ^
  Dr. Burns  has added  other  measurements: —" *rom the  sacro-iliac
symphysis to the crest of the pubis on the same side is four inches  and a
half; from the top of the sacrum to that part of the brim which is directly
above  the  foramen thyroideum, is  three inches and a half;  the line, if
drawn to the acetabulum in place of the foramen, is a quarter of an inch
shorter;  a line  drawn  across the fore  part of the brim, from one aceta-
bulum to the other, is nearly four inches and a quarter."
  24.  The  Cavity  of the Pelvis, whose  fixed  boundaries  are the
sacrum, the ischium, and the pubis, is of unequal  depth.  Posteriorly it
measures five inches, or six if the coccyx be extended ; from the brim to
the tuber ischii, three inches  and three quarters;  and the depth of the
symphysis pubis is from two to  two and a half inches.
  25. The antero-posterior diameter, from the  hollow of the sacrum to
the symphysis pubis, is about four inches  and a half; the transverse, at
right angles with the former, is about four inches and three quarters; and
the oblique about five inches: a variation of a quarter of an inch  either
way being allowed.
  There are other measurements of considerable importance, inasmuch as
the child's head passes obliquely through the cavity of the pelvis.   Thus,
from the  sacro-iliac synchondrosis of one  side to the  tuber ischii  of the
other, is six inches ; and to the ramus of the ischium, five  inches : from
the anterior margin of the sacro-sciatic notch, to the opposite side, is six
inches,  or six and a quarter; from the anterior margin of the descending
ramus of the ischium, to the opposite side, at the same level, is four inches
and three quarters.
   26.  The bones which constitute  the pelvic cavity are  smooth on their
inner surface, and present a series of inclined planes, calculated to influ-
ence the direction of the fcetal  head in its  descent.  They tend at first
downwards and slightly backwards, then downwards and forwards.
   27.  The Outlet of the Pelvis is of an oval shape, but irregular.  Its
lateral boundaries are immoveable;  but its antero-posterior diameter may 
OF THE PELVIS.
4o
be extended, owing to the mobility of the coccyx.  The arch of the pubis,
according to Osiander, forms an angle varying between 90° and 100°, and
will permit the passage of a circular body whose diameter is an inch and
a quarter.
  28. The antero-posterior diameter of the outlet, from the arch of the
pubis to the point of the coccyx, is  from four to five inches; the trans-

                                Fig. 8.
 verse, from one  tuber ischii to the other, is  about  four inches; and  the
 oblique, four inches and three quarters, allowing for a variation of half
 an inch.
   29.  Now, if wre compare the  diameters of the brim with those of  ?ne
 outlet, we find that the  proportions are completely changed;  that which
 was  the  shortest at the  brim, being the longest at  the outlet, and  the
 longest diameter of  the brim, being the shortest at the  outlet.  This
 remarkable change is, however,  effected gradually; for in the  cavity we
 observe merely an approximation in the diameters.  The effect of these
 changes upon  the mechanism of parturition are very important, as  we
 shall  see by and by.
   30. The axes  of the  upper and lower outlet of  the pelvis form an
 obtuse angle with each other; the former being  described  by a line run-
 ning  from the  coccyx upward to  a little above the  umbilicus, and  the
 latter by a line drawn from the second  bone of the sacrum through  the
 centre of the pubic arch.
   If  we combine these  together with  the inclination of the  pelvis,  we
 shall  obtain a tolerably accurate  notion of the direction  of the canal of
 the pelvis.   This is  marked out by the central line  in  the  following
 figure, which I have copied from one given by M. Danyau in his transla-
 tion of Naegele's work on Oblique  Distortion.
   31.  There is a considerable difference  between  the male and female
 pelvis,  both in  shape and size.  In the former, the brim is  more circular,
 and the cavity deeper.   In the male, the  depth of the symphysis pubis
 is  nearly double that of the female: the sacrum is  more perpendicular;
the sacro-sciatic notches and  foramina smaller;  the arch of the pubis is
narrower, its angle being about 70° or 80°;  the  tubera ischii are nearer
to  each other, and the coccyx less moveable.
   From the greater width of the female pelvis,  the acetabula are furtner 
46
OF THE PELVIS.
Fig. 9.
apart than in the male, although the thigh-bones approach each  other in
their descent, and the knees (in the erect position) are nearly in contact,
giving a peculiarity to the movements of the  female, not observable in
the other sex.
   32.  Hitherto we have  considered the skeleton pelvis only;  but the
subject would be incomplete without a brief  description of the soft parts,
lining  the pelvis,  and  covering it externally.  The former  modify the
diameters of the pelvis, and the  latter  must  be  taken into  account in
forming a diagnosis in the living subject.
   The iliac  fossae are each occupied by the iliacus internus muscle, inter-
nal to which, and slightly overlapping  the edge of the brim, is the psoas
muscle ;  these pass over the  anterior part of the brim to their insertions.
Near the inner margin of  the  psoas muscle we find the iliac artery and
vein, with the crural nerves  and lymphatics,   In the cavity we  find the
obturator internus and  the pyramidalis  muscles, with  the hemorrhoidal
and sacral  vessels, and the  sacral nerves.   The  rectum passes  down
nearly in the centre of the sacrum, and the bladder lies behind and above
the symphysis pubis: these parts  are held in situ by cellular  membrane,
superficial and deep fascia, &c.
   The lower outlet is nearly closed by soft parts, which are  capable of
great distension.   On either side of the  sacrum and coccyx are  situated
the sacro-sciatic ligament, the coccygeus muscle, and layers of fascia and
cellular substance;  whilst the termination of the rectum, and the perineum
consisting of transverse muscular fibres, fascia and  cellular tissue, close
the outlet posterior  to the  orifice of the vagina.
   33. The effect of these additions in  diminishing the  internal measure-
ments  of the pelvis is  not very great, except  at the lower outlet.  The
transverse diameter of  the  brim is diminished about  half an  inch, or
rather  more  when  the  psoae  muscles  are  in action, and  the conjugate
diameter about a quarter  of  an inch.   The  diameters  of the cavity are 
OF THE PELVIS.
47
not lessened  more than  a quarter of an  inch.   The lower outlet may be
said to be almost closed  in the absence of any distending force, the orifice
of the vagina being the only vacancy ;  but the elasticity of the perineum,
&c. occasions the soft parts to be little  or no diminution  of  the antero-
posterior diameter.
   34.  To the crest of the ilium the abdominal muscles are attached;  and
on the outer  surface of the ossa innominata, there is a large mass of mus-
cles,— the  glutaei,  pyriformis,  gemellus superior,  obturator internus,
gemellus inferior, obturator externus, and quadratus femoris;  these mus-
cles are separated by fascia, and  are covered by a thick layer of adipose
tissue and the skin.   The  anterior wrall of the pelvis gives  origin  to  a
great number of muscles, most of which have been already enumerated.
   35. The external measurements of the pelvis are of considerable import-
ance  in the diagnosis of deformity, as deviations externally appreciable,
will in most cases (though not  in  all) be found to accompany internal
ones.   Unfortunately, the  data we possess  are  but  few; however, the
following, I believe, are  correct.

   The  external  antero-posterior  diameter of the pelvis, is from 7  to  8  *
     inches.
   The  external transverse, between the  crista ilii of each side, 13 to 16
     inches.
   From the anterior superior spine of  one side to  the  other, 10 to 12
     inches.
   From the  great trochanter of one side to the sacro-iliac symphysis of
     the other, 9 inches.
   The  depth of the pelvis, from the  top of the sacrum  to the coccyx,
     from 4 to 5 inches.

   In order, from these measurements, to form a sufficiently correct esti-
mate of the  internal diameters of the  pelvis, we must deduct from them
the thickness of  the parietes; i.  e. about three inches antero-posteriorly,
and four inches laterally, according to  Baudelocque, Navas, and Velpeau.
The  depth is  easily ascertained externally; posteriorly, by  taking the
the length of  the sacrum; laterally, by measuring  from  the  anterior
superior spine of the ilium,  and  dividing by  two; and anteriorly, by
taking the depth of the symphysis pubis.
   It  is but fair  to  add, that  doubts have been expressed of the utility
and accuracy of these measurements, by Mesdames Boivin and Lachap-
pelle, on account of the varying  thickness  of the parietes of the pelvis:
but, even allowing for this, they  appear to me of value as an approxima-
tive estimate.
   36. In this opinion I am supported by M. Naegele, who, in his recent
work on  Oblique Distortion, has pointed out certain external measure-
ments as a means of diagnosis, and has  given a careful estimate  of forty-
two cases.  His French  translator, M. Danyau, has  added to these,
eighty cases  measured by himself, and the average result is as follows:

   1.  From the tuber ischii of one side  to the posterior superior spinous
     process  of the opposite side, 6 inches 6 lines.
   2.  From the anterior superior spine of the ilium of one  side to th«»
     posterior superior spine of the other side, 7 inches 10 lines.
       4 
48
OF THE PELVIS.
  3. From the spinous process of the last lumbar vertebra to the anterioi
    superior spine of the ilium of either side, 6 inches 7 or 8 lines.
  4. From the great trochanter of one side to the posterior superior spine
    of the ilium of the opposite side, 8 inches 2 lines.
  5. From the centre of the inferior edge of the  symphysis pubis to the
    posterior superior spine of the  ilium  of either side, 6 inches 3 or 4
    lines.
  These measurements are those of ordinary-sized  pelves;  they will  of
course vary if the pelvis  be unusually large  or small:  but the  utmost
variation  of No. 1 was 6 lines, of  No. 2 was 11 lines, of No. 3 was 7
lines,  of No. 4  was 9 lines, and of No. 5 was 9 lines;  and  these were
almost all single exceptions.
  37. The next point relates to the practical application of these facts,
or, in other words, to the best  mode of ascertaining the size  of the pelvis
in the living subject.  A certain amount of information may be obtained
from the general and equable form of the pelvis, the breadth of the hips
as compared with  the shoulders, the degree  of obliquity of  the pelvis,
the  curve of the sacrum, &c.; and in many cases we may pronounce,
from a cursory glance, that the patient is well made.   Should  this not be
so apparent, we must have recourse to external  measurement, which is
easily effected by means of a pair of curved calipers and a foot measure.
Care must be taken in placing the  points of the instrument, as a slight
deviation may produce different and incorrect results.  The measurements
thus obtained  we  can reduce  to the internal diameters of  the pelvis by
making the deductions already specified.
  38. There is  greater difficulty in ascertaining the magnitude of  the
pelvis internally.   In  Great Britain we are almost limited to  the informa-
tion afforded by the "toucher;" and undoubtedly, by tins  means alone,
a well-educated finger  may obtain  a sufficiently accurate  estimate  for
practical purposes.   When making  an examination  for this  purpose,  the
finger should be passed to the  promontory of the sacrum, and thence
carried forward  slowly  to  the symphysis pubis: we may  then  pass it
across the pelvis, in the direction of the transverse and oblique diameters,
and finally follow the course of the brim, taking note of any deviation
from the  usual form, or of any obstacle.   The state of the sacrum and
cavity generally, and the  mobility  of the coccyx, can readily be  ascer-
tained by the finger, as  well as  the dimensions  of the  lower outlet.
Although deficient in precision, the  information thus obtained may satisfy
us of the possibility of the passage of the  child; and of course, if  the
patient be pregnant or in labour, there will be more certainty, as we shall
then have the child's head as a standard of comparison.
  39. But,  in order  to arrive at  greater accuracy, certain instruments
have  been invented, chiefly by  continental  obstetricians, for measuring
the  internal as well  as  the  external diameters of the pelvis.  Thus we
have  the "compass d'epaisseur" of  Baudelocque, the  "cephanometre" of
Stein, the "mecometre" of Chaussier, the "pelvimeters" of  De Creve,
Aitken, Coutouly, Bang, Traisnel,  &c,  with various modifications of
modern invention.   I do not deem it necessary to describe  these instru-
ments, as they are  seldom, if ever,  used in these countries.   The natural
delicacy of the sex precludes their employment in the cases in  which they
would be of the greatest value;  I mean,  before  marriage, or conception. 
CHAPTER TV.
     ABNORMAL DEVIATIONS IN THE PELVIS. —DEFORMITIES.

  40. Under this title I shall include  not  merely  distortions of the  pel-
vis, but also certain equable deviations  from its normal dimensions, which
are of importance.   The abnormal deviations of the pelvis may be either
general or special.  The general or equable deformity of the pelvis involves
the whole of the  cavity equally, and may consist either  in  an excess or
diminution of its usual dimensions.
   41.  The former of these (the pelvis cequabiliter justo major of conti-
nental writers) is not very unusual, nor is it advantageous in parturition,

                                Fig. 10.
except perhaps in face presentations, and it may be attended with incon-
venience.   Giles de  la  Tourette  has recorded one where  the  antero-
posterior diameter wTas five inches and a half, the transverse six and a
half, both diameters of the lower outlet five and a half, and the distance
between the crests of  the ilia twelve and a half inches.  Dr. Burns  men-
tions his having  a very large one, but not quite equal  to the one just  men-
tioned.   My friend Dr. Murphy possesses  one of about  the  same  size.
The relative proportion  of the  diameters sometimes varies, so  that the
brim  may assume an  oval shape antero-posteriorly, or a heart  shape, and
still all the diameters  be excessive.
  42. It is evident that a pelvis preternaturally large may be a disadvan-
tage to a female who  is  not  pregnant, as it will  favour prolapse of the
pelvic viscera; and also to one who is pregnant, by more readily permit-
ting descents, displacements, &c.   Its inconvenience  during parturition
consists in the want of that degree of contact with the head of the child,
necessary to impress  upon  it the usual partial rotations and changes of
direction; and the facility with which it would admit of  prolapse of the
womb afterwards.
                                  E                        (49) 
50
DEFORMITIES.
  43. It is  more rare to find a pelvis whose size is equably diminished
(the pelvis aquabiliter justo minor), without  much relative disproportion
between its diameters, although Naegele and Velpeau think it more com-

                                Fig. u.
mon than writers  in  general  have supposed; and,  in  support of this
opinion, it may be  added, that  modern investigations have discovered that
in many, if  not most cases of rickets, even where there is no apparent
distortion of the pelvis, there is a certain diminution (one-fourth, I believe)
in the aggregate diameters.  The obstruction which this  deformity offers
to delivery is sufficiently obvious.
   44. The special  distortions of the pelvis are much more frequent. They
occur at the brim, in the  cavity, or at the lower outlet, but are rarely
limited to one of these situations.   The distortion may also occur in any
of the diameters, though the antero-posterior  diameter of the brim, and
the transverse of the lower outlet, present them most frequently.

                                Fig. 12.
  45. At the brim we find distortions more common in the antero-poste
rior diameter, as I have said ; next in the oblique, and lastly in the trans-
verse diameter
  The sacrum  may be pushed forward toward the  symphysis, or the
symphysis toward the sacrum. 
DEFORMITIES.

    Fig. 13.
51
  If the sacrum be more slightly pressed forward, it will make the open-
ing a heart shape, and may change the length of the oblique  as well as
the antero-posterior diameters.
Fig. 14.
  In some cases the acetabula are pushed inwards, as well as the sacrum
forwards, diminishing the oblique and antero-posterior  diameters, and
Fig. 15.
 
52
DEFORMITIES.
completely distorting the brim.   This was the case with Isabel Redman,
operated upon by Dr. Hull;  and similar examples are recorded by Weid-
mann, Aitken, Mad. Boivin, &c.
  In  other cases, the oval of the brim is  transposed, the  long diameter
being  antero-posterior  instead  of transverse; as  in the  accompanying
drawing, (fig. 15.)
  46.  In the cavity, distortions  are in most cases consequent upon those
of the brim or outlet; though we occasionally meet with instances where
the sacrum is too much or too little curved, when the other parts of the

                                Fig. 16.
pelvis are of normal  form.   In some very rare cases, the cavity contracts
gradually from the brim to  the outlet, forming what has  been called  a
" funnel-shaped pelvis."

                               Fig. 17.
  The capacity of the cavity may also be diminished by a fibrous or bony
growth from the sacrum, as in the annexed  figures.  The first (fig. 17) is
comparatively small, though sufficient to interfere seriously with labour;
but the second  (fig. 18) would preclude the possibility of delivery "per 
DEFORMITIES.
53
Fig. 18.
vias naturales."   These morbid growths from the periosteum, or bone,
involve  the  same difficulty as  distortions, inasmuch as they are  incom-
pressible and immoveable.

                               Fig. 19.
  47.  The lower outlet is comparatively independent  of the brim  and
cavity.   It is by no means uncommon to experience delay, arising from
a narrowing of the brim, with a rapid passage of the head through the
outlet; but, of course, in  extreme cases  of distortion the outlet  partici-
pates, as is shown in the figures annexed; fig. 20 being the lower outlet
of fig. 14, and fig. 21 of fig. 16.   On the other hand, distortions of the
lower outlet may occur with a normal shape and size of the brim.  They
                                e2 
54
DEFORMITIES.
Fig. 20.
are most frequent in the transverse diameter, owing to the approximation
of the tubera ischii, which at the same time will diminish the span of the
arch of the pubis, and so effectually, though not  apparently, shorten the

                                Fig. 21.
antero-posterior diameter.   The other way in which the latter diameter is
lessened, is by too great a curve forward of the lower part of the sacrum
and coccyx, and by the anchylosis of the coccygeal joint.  The spinous
process of the  ischium may offer some obstruction, if  it be unusually
long, and curved inwards.
  48.  The amount of these distortions varies as much as possible: it
may be so slight as merely to retard delivery;  or it may be so great as
to preclude it altogether, as in Mr. Bell's case, where the antero-posterior
diameter was about half an inch, or in  that  recorded by M. Naegele, in
which it was even less.
  49   In  most cases of pelvic deformity,  the distortion is  somewhat
unequal, one side suffering more than the other; but there is a  class of
cases in which this distortion is almost entirely confined to one side.  An
allusion to such will be found in several authors; but it remained for M.
Naegele to add to his high reputation by a careful and accurate descrip- 
DEFORMITIES.
Fig. 22.
tion  of this oblique distortion (" die schrdg verengte becken,"  or  "pelvis
oblique ovata").   In these cases (fig. 22), the  affected  side is flattened,
and the sacro-iliac synchondrosis anchylosed.  Half the sacrum is imper-
fectly developed; and the other,  though at first sight it appears  well-
formed, is found to be awry: the promontory of the sacrum and  the
symphysis pubis are not (as they ought to be) opposite to  each other,  but
the former leans to the affected side, and the latter is pushed  over  (as it
were) to the sounder side, so as to make the form of the pelvis oblique.
   50.  As we should expect, the planes and axes are altered more or less
in all  well-marked  cases of distortion.  When  the promontory of  the
sacrum projects, the axis  of  the upper outlet is more horizontal; but, if
the acetabula  are pressed inwards, it  may become more perpendicular.
The  axis  of the  lower outlet  may be changed in the opposite, but more
frequently in the  same direction, the two becoming almost parallel: nay,
there is a  case quoted  by Velpeau in which they were  reversed; that of
the lower outlet  looking forward, whilst that of the brim was directed
backward.  In the  majority of cases,  I believe we may say, that  the
planes and axes of both outlets approximate to the plane  of the horizon.
   51.  The principal causes of distortion are,  1, rickets  in infancy and
childhood;  and, 2, malacosteon,  or  mollities ossium, in adults.   The
effect of both diseases is to deprive the bony structure of the earthy matter
which gives it firmness; in the absence of which, the bones become flex-
ible, and are influenced by muscular motion, or long-continued pressure.
Thus,  if in such  circumstances  the patient maintain the sitting posture
long, the promontory of the sacrum may be pushed forwards,  or the sym-
physis upwards;  the lower part of the sacrum  may be too much curved,
and the os coccygis rendered horizontal.  If the upright position be con-
tinued long, the  acetabula may be pressed inwards, and  the  promontory
of the sacrum forwards.  If the patient lie much on her back, the sacrum
may be flattened; or if on one side, it may be  rendered unequal.
   Besides these special deformities, it has already been mentioned, that,
in patients affected  with rickets, the aggregate of the diameters of the
pelvis  is lessened one-fourth, even when the pelvis is apparently unaf-
fected. 
56
DEFORMITIES.
  52. Any of these special distortions may occur in the same way  in
adults affected with malacosteon, and at any period of their life; so that
it has happened that a female, who had borne children naturally, has at a
subsequent labour exhibited such an extent of pelvic distortion as required
the use of instruments, or the  Caesarean operation.
  Both diseases appear to be more frequent in manufacturing towns than
in country districts.
  53. It is extremely difficult to assign the cause of oblique distortion.
Naegele states that he could detect no traces of rickets or mollities ossium
in any of his cases, nor  had  any suffered from external violence.  The
bones presented the same appearance as those of healthy young females.
Dr. Rigby, however, thinks that  ulcerative  absorption must have existed
at the sacro-iliac junction, probably in  early life.
   54. I have  already mentioned as a cause  of deformity, 3, exostosis;
and may further add, 4,  fractures of the pelvis, and, 5, inflammation of
the sacro-coccygeal joint, terminating  in anchylosis, upon which it  is
unnecessary that I should dwell.
   55. The diagnosis of distortion is  easy in  proportion to its amount.   If
the pelvis be much  deformed,  it may be detected by an external or inter-
nal examination, and estimated with  sufficient accuracy for practical pur-
poses.   But if it be only  slightly affected,  it will not be so easy to decide
upon the possibility of the passage of the  child, unless we  have the head
of the  child, to compare with the pelvis.  Without this, we must chiefly
depend upon a comparison of the external measurements with those of a
well-formed pelvis,  and upon the information afforded by a careful  inter-
nal examination.   From  these sources, an  experienced practitioner will
probably obtain data for a satisfactory though cautious diagnosis.   But if
we are not consulted until the patient be in labour, our task will be com-
paratively easy, because the head will be in apposition with the part (brim,
cavity, or outlet) where we suspect the narrowing.
  56. Oblique  distortion  may be detected in two ways, according to M.
Naegele:  1, by dropping a line perpendicularly from the spinous process
of the last lumbar vertebra, and another from the symphysis pubis;—when
the pelvis is well formed, these two lines are exactly one behind the other;
but when it  is obliquely distorted, they are parallel, with a considerable
interval:  2dly, by measuring the pelvis externally, in the way described
in § 36, we  find that there is always  a  difference between the two  sides
of the pelvis, varying from one to two inches.  To give an example in a
pelvis affected with oblique distortion of the left side, the measurement
No. 1 (see § 36) was
           6 in. 11 lines on the left side, and 5 in. 8 lines  on  the right.
   No. 2,   7 "   9   "    "    "         6 " 10   "    "    "
   No. 3,   6 "   6   "    "    "          5 "  3   "    "    «
   No. 4,   9 "•   0   "    "    "         8 "  0   "    "    "
   No. 5,   6 "  11   "    «    "         6 "  1   "    "    "

   Let the reader compare these with the measurements of a well-formed
pelvis, as  already given,  and he will be convinced that either method,  or
the two combined, will afford  fair grounds for a diagnosis.
   Anchylosis of the sacro-coccygeal joint will be discovered by its immo-
bility when pressed by the finger during the internal examination. 
DEFORMITIES.
57
   The effect of the different kinds and  degrees of deformity.upon  the
mechanism of  parturition, and  the practical considerations  upon which
the management of such cases must be founded, will be  discussed in the
Third Part of this work.*
  * In a great majority of the cases of reduced or distorted pelves, the degree of devia-
tion from  the natural standard, although perhaps sufficient to cause great difficulty in
delivery, is nevertheless too small to be readily detected by the external measurements
pointed out by the author.  The calliper, or " Le compas d'6paisseur de Baudelocque,"
(fig. 23,) so much relied on by some, is only calculated for measuring the antero-poste-
                                     Fig. 23.

tb
 rior diameter, and its indications are not always to  be depended  on here.  In  expe-
 rienced hands, it will afford important but not conclusive testimony as to the probable
 distance between the promontory of the sacrum and the symphysis  pubis.  The manner
 of accomplishing this is to place the patient on her side on the bed, and then, separat-
 ing the thighs, the extremity of one branch  of the instrument is  applied to the first
 Bpinous  process of the sacrum behind, and the opposite extremity upon the middle of
 the symphysis in front: the intervening space is shown by the scale (d), and ought to
 be full seven inches.   By deducting half an inch for the thickness of the pubis, and
 two and a half inches for the sacrum, four inches remains as  the probable antero-poste-
 rior diameter of the upper strait, or brim.  The oblique  diameters are  also measured
 by the same instrument. Placing one of its ends upon the external surface of the great
 trochanter,  and the other on the projecting portion of the opposite sacro-iliac junction,
 in a well-formed pelvis, we should have about nine inches of separation.  Allowing two
 and three quarter inches for the trochanter, neck of the femur, and  acetabulum, and
 one inch and three quarters for the  posterior symphysis, leaves four inches  and  three
 quarters as  the oblique diameter.  But  this measurement, for obvious reasons, is less
 to be relied on than the first; in fact, two occasions of error exist, more or less, in both;
 viz., 1, In fixing the extremities  of the instrument exactly on the right points;  and, 2,
 the variations that occur in different individuals, in the thickness of the  bony walls of
 the pelvis, and especially of the soft parts covering them. In ordinary or well-formed
 pelves these difficulties are not great, it is true; but when much malformation exists,
 they are sufficient to destroy all confidence in  the accuracy of the results.  In figure
 21, page 54, for instance, the instrument, properly adjusted,  would indicate a full-sized
 antero-posterior diameter, although in reality the space which is available for the pass-
 age of the child is extremely small.
   A careful examination with the hand, applied along the lumbar column, the sacrum,
 and coccyx, and over the arch of the pubis, observing the angle formed by these parts,
 one with another, and, in short, their general form and proportions, will convey to one
 well acquainted with their normal state a more- satisfactory opinion than any instrument
 that has yet been invented.
   But there may be exostoses or other tumours within the pelvis, very seriously affect-
 ing the space, and totally undiscoverable by external examination, so that, for all cer-
 tainty, internal investigation alone can assure us of the true condition of  the parts.
 The pelvimeters of Coutouly, Mad.  Boivin, and others,  for internal  admeasurement,
 have been found painful, inconvenient, and  uncertain, and  are now, at least in this
 country,  entirely discarded; the only instrument here  employed for such explorations
is the finger; — as justly observed by a late continental writer, "It is the best and
 surest of all pelvimeters."
   The manner of making this examination is thus described by Chailly: " To appreciate
the extent of the antero-posterior diameter of the superior strait, the index finger should
be passed in the vagina in the axis of the inferior strait, towards  the sacro-vertebraj
angle, the radial side of the finger being applied immediately under the pubis.  If the 
CHAPTER V.
            OF THE EXTERNAL  ORGANS OF GENERATION.

   57. We  may now proceed  to describe  the generative organs in the
female.   These  are ordinarily divided into the external and internal, or,
with  regard to their  functions, into the copulative and formative.    The
external, or copulative, consist of the mons veneris, the labia majora and
minora, the clitoris, the hymen, and the vagina.   The internal, or forma-
tive,  consist of the ovaries, the Fallopian tubes, and uterus.   Most Eng-
lish writers place the vagina among the internal organs; but, as it belongs
to  the  copulative, I  have  classed  it with them:  the  point  is  of little
importance.   There is a striking  analogy between the male  and female
organs, except as to situation;, and, at an  early period of fcetal  life, the

end of the finger does not touch the sacro-vertebral angle, it is because the diameter is
of normal dimensions; or, if it is contracted, that the degree of contraction is so small
that parturition will not be materially affected by it.  But, if the finger readily touches
the sacro-vertebral angle, there is reason to  apprehend  more  or less difficulty.  To
measure, in this case, the extent of the sacro-pubic diameter, it is necessary to mark,
with the nail of the index finger of the other hand, the finger introduced, directly below
the pubis,  the labiae and nymphae being carefully separated for the purpose; on with-
drawing the finger,  the length of the part  introduced  may be readily measured with a
graduated scale.
Fig. 24.                                 Fig. 25.
  11 Some little allowance is to be made for the length of the oblique line represented
by the finger, which,  instead of passing directly to the centre  of  the pubis, falls
under it.
  " With the finger we can easily discover whether the concavity of the sacrum is aug-
mented or diminished, which will enable us to determine whether the antero-posterior
diameter of the excavation is deranged.
  " The antero-posterior diameter of the inferior strait may be ascertained in the same
manner  as the corresponding diameter of the upper strait: the  end of the forefinger
being placed on the extremity of the coccyx, the hand must be raised  until  the  radial
edge of the finger  touches beneath the pubis;  being marked at this point, it can be
measured as before described.
  " The finger thus introduced enables us at the same time to judge of the flexibility
or otherwise of the sacro-coccygeal joint."*  There is  indeed very little difficulty in
ascertaining accurately the diameters of the inferior strait with the fingers  externally
applied.
  During labour, the internal examination of the pelvis is greatly facilitated by the
relaxed condition of the internal parts; and, if necessary, the hand may be introduced
for the purpose. — Editor.
* L'Art des Accouchemens, par Chailly, 175—189.
                                                 (58) 
                 EXTERNAL ORGANS OF  GENERATION.              59

sex cannot he distinguished.  In the present chapter we shall notice the
external organs.
Fig. 26.
  58.  The Mons Veneris is the triangular cushion-like prominence  at
the lower part of the abdomen and upper part of the symphysis pubis.
It consists of a thick layer of adipose tissue underneath the  skin, upon
which  at puberty a quantity of hair makes its appearance.  In the cellular
tissue is lost the round ligament, and there is sometimes a small pouch
of peritoneum.  The skin is plentifully supplied with sebaceous glands.
  The use of this cushion is not very evident.
  59. Abnormal deviations.—Occasionally the growth of hair is excessive
In one case Dr. Davis found it necessary to destroy it on account of the
itching it caused.
  This part is also the seat of cutaneous eruptions and abscess.*
  60.  The Labia Majora vel Externa are two folds of skin externally,
and mucous membrane internally, continued downwards from the sides
of the  mons veneris  to the fourchette.   Their junction superiorly consti-
tutes the anterior commissure of the vulva, and they enclose the external
organs of generation.   Their breadth and thickness  are greatest  supe-
riorly,  gradually decreasing until  they disappear near  the  fourchette.
Superiorly-they are in contact, but they are separated posteriorly.   The
external labia contain (between the skin  and mucous membrane) subcu-
taneous fascia,  adipose  and cellular  tissue,  nerves,  and  bloodvessels.
Externally they are thinly  covered with hair, and thickly  studded with
sebaceous follicles.
  Their use is to protect the sensitive organs  contained between  them,
and at the time of labour to facilitate the distension of the external orifice.
  61.  Abnormal deviations. — These  are chiefly, 1,  excessive  growth,
attended with  mechanical  inconveniences; 2, inflammation  and abscess;
3, cutaneous eruptions and pruritus; 4, encysted tumours, hernia, &c.
  62.  The  Labia Minora or  Nymphs are two lateral folds  of mucous
membrane, internal to the labia  majora, with which  they are in contact
externally, and by which they are covered, in the adult.   They extend
  * It would be inconsistent with the object of a work  like the present, to enter into
details upon the various diseases to which the parts are  subject; I must therefore con-
tent myself with enumerating them, and refer my reader to my work  on Diseases of
Females. 
60
EXTERNAL ORGANS OF GENERATION.
from the anterior  commissure  of the vulva, to about  the  middle of the
orifice of the vagina, and contain between their mucous coats a spongy
vascular tissue and nerves.   They enfold the clitoris,  the  meatus urina-
rius, and part of the vaginal orifice.   In young persons they are firm and
elastic, but in old age they become flabby and loose.
   They doubtless contribute,  with  the labia  majora, to maintain  the
integrity and sensibility of the parts they cover.
   63. Abnormal  deviations.—The nymphae  are obnoxious to inflamma-
tion, follicular ulceration, and hypertrophy, either congenital or the result
of disease.
   64.  The Clitoris is the analogue of the penis in the male; it consists
of two corpora cavernosa,  which arise  from the rami of the  ischia and
pubis,  and  unite  on the symphysis pubis.   It  possesses two muscles
analogous to the erectores penis, and terminates in a gland covered  by a
prepuce, but which is imperforate.   The clitoris projects about the eighth
of an inch,  and is situated  just below the point of junction of the nym-
phae.   It is extremely sensitive, capable of  erection, like  the penis, and
is said  to be the seat of sexual pleasure.   In the foetus it is dispropor-
tionately large, but it does  not  increase afterwards in  proportion  to the
surrounding parts.
   65. Abnormal deviations.—The  clitoris may. vary in size from  conge-
nital malformation or disease ; but the researches of M. Parent Duchatelet
have disproved the opinion that it enlarges from frequent sexual indulg-
ence ; nor, according to the same  authority, does its excessive develop-
ment entail  extreme sexual desire.
   The organ may be  attacked by inflammation, or by malignant disease.
Bartholin  relates  the  case of a courtesan whose  clitoris was the seat of
calcareous deposition.
   66.  Below the clitoris there is a smooth triangular space, the Vestibu-
lum ; at the lower part of which we find  the Orifice  of the Urethra,
or Meatus Urinarius, just at the upper edge of the orifice of the vagina.
The exact situation of this opening is important, because we are frequently
called upon to introduce the catheter, and, in ordinary  cases, it should be
done without exposure.   The operation is not difficult; the patient being
placed on her back, and the labia being separated, the point of the fore-
finger of the left  hand  should  be placed just within  the  orifice  of the
vagina, so as to press slightly its upper edge ; the catheter should then be
passed along the inner surface of the finger, until it reaches the vestibulum
near the edge of the vaginal opening; when there, a very slight  move-
ment will cause it to enter the meatus urinarius.   Or, the patient may be
placed on her left side,  in the ordinary position for labour,  and the finger
carried  from behind forward  to the vestibulum ; the catheter should  then
be passed along the finger  in the direction of the axis  of the outlet,  and,
on reaching the vestibulum, a slight movement will  detect the orifice.
The operation is more difficult  when the parts are swollen or distorted, as
happens occasionally from disease, during pregnancy or labour, and  after
delivery; and if we cannot detect the orifice by the touch, we  must of
course use  a light;  and then, for obvious reasons, it is  better that the
patient should be placed on her side.
   The orifice is round, though its  sides  are usually in contact, and its
edges are somewhat thickened. 
EXTERNAL ORGANS OF  GENERATION.              61
   67. The Urethra is a  membranous canal about an inch or an inch
 and a half in length, dilatable, and directed obliquely from before, back-
 wards ; and from below, upwards;  running under and behind the sym-
 physis pubis, from which it is separated by loose cellular tissue.  Inter-
 nally it opens into  the bladder.   Its direction is subject  to variation;
 during pregnancy, the bladder being carried upwards with the uterus, the
 urethra curves under the pubic arch, and then ascends perpendicularly.
 The  same change occurs when the uterus is enlarged from other causes.
 In prolapse  of the pelvic viscera its course is reversed.  These changes
 should be borne in mind when catheterism is required.
   68. Immediately below  the orifice of the urethra, we find a much
 larger opening, of about an  inch in diameter, the Orifice of the Vagina.
 Its sides are in contact ordinarily, but it is capable  of enormous disten-
 sion, and  of again  returning to its  natural  size.   The opening is closed
 inferiorly in  infants, by a fold of mucous membrane of a crescentic shape,
 the concavity looking upwards, and which  is called the Hymen.  This
 membrane is easily destroyed, or it may become so relaxed as scarcely to
 be perceptible, which will  account for its  rarity in  adults.  It was for-
 merly held to be peculiar  to the  human female; but the  researches of
 MM. Duvernoy, Cuvier, and Steller have proved its existence  in many
 animals.   From very early  times it has been made  the test  of virginity,
 its absence being considered conclusive proof of sexual intercourse hav-
 ing taken place ; and the fate of the wives of Henry VIII.  is an extreme
 instance of the injustice to which this opinion led.   Modern investigations
 have proved, not only that  it may be destroyed by  many causes uncon-
 nected with  sexual  indulgence,  but  that  intercourse  may take place,
 followed  by pregnancy, without  its destruction.   It is, therefore, of no
 value as a test.
   69. Abnormal deviations.—The principal ones  are the following: 1, It
 may be unusually thick and strong, so as to preclude intromission; 2, in-
 stead  of the  single  opening superiorly,  it  may be pierced with several
 small  holes;  3, instead of the usual form,  the hymen may consist of a
 single or double  bridle stretching across the  orifice of the vagina; 4, it
 may be imperforate, and close the vagina completely.  Examples of each
 kind  may be found in works on midwifery.   These  abnormal deviations
 are of importance only as they may prevent  sexual connexion, or impede
 the natural discharges or delivery; and, once discovered, they are easily
 remedied.
   70. The Caruncul^: myrtiformes are  four or five small tubercles,
 which in most females occupy the situation  of the hymen, of which they
 are considered the " debris," by most anatomists; others, however, sup-
 pose them to be small duplicatures of the mucous membrane of the vagina.
 They may possibly facilitate the distension of the orifice of the vagina by
 unfolding.
   Abnormal deviations.—Occasionally they  are greatly hypertrophied.
   71.  The parts contained within  the vulva  are abundantly  supplied with
 nerves, owing to which, and to the extreme delicacy of their texture, they
 possess great sensibility.  This explains  the severe pain which accompa-
 nies even trifling diseases of these parts; and it is merely a repetition of
 the fact observed in other mucous membranes, viz., that they acquire theii
highest point of sensibility near their junction with the skin.
                                  F 
62               EXTERNAL  ORGANS OF  GENERATION.
   72.  The  Fourchette is the posterior commissure of the vulva, and
the anterior border of the perineum; it is formed by the union, poste-
riorly, of the labia.   It consists of a fold of mucous membrane, meeting
externally the skin of the perineum, and is frequently torn in first labours.
   73.  The  Perineum is the name given to the space between  the four-
chette and  the  anus.  It is  of a somewhat triangular shape, and its
medium breadth, in women who have not borne children, is from an inch
to an inch and a half.  It is narrower, of course, in those who have had
children.  In the  centre, a prominent  line  may be  observed, running
antero-posteriorly, called the  " raphe."   The perineum is composed of
various tissues: externally there is the  skin,  then  adipose and cellular
tissue, fascia, a portion  of the  constrictor vaginae, levator  ani, transverse
and sphincter muscles;  besides which, it contains the superficial and
transverse arteries,  veins, nerves, and lymphatics.   Very few hairs grow
on this part.
   The use of the perineum is obvious:  it closes  the lower outlet poste-
riorly, so as to prevent the displacement of the pelvic viscera;  whilst it
admits  of distension when  necessary,  and,   by  its elasticity,  speedily
resumes its former condition.
   74.  Abnormal deviations. — The  perineum is sometimes unusually
broad, increasing the risk of its laceration during labour; or it may be
very narrow, and  so afford inadequate  support to the  super-imposed
viscera.   It may be torn in various ways  during labour, as we  shall see
hereafter, and either not unite, or present the cicatrices of former lacera
tions.   It is sometimes  the seat of hernia, according to Smellie, Mery
and Curade.
   75.  The Vagina is a musculo-membranous canal, extending from iti
orifice in the vulva (§ 68) obliquely through  the  cavity of the  pelvis to
the uterus.   It passes upwards from the vulva  behind  and below the
urethra and  bladder, between the ureters, and anterior to the rectum, de-
scribing nearly the line  of the canal of the pelvis  (§ 30).  Its form  is
cylindrical,  somewhat flattened superiorly;  but, when  quiescent,  its
parietes are  in contact.   Its dimensions vary according to age, and  other
circumstances; for  instance, it is proportionately longer in  the foetus than
in the child.  In  some  individuals it is very long, in others very short.
Dr. Dewees  mentions a case where it was only an inch and a half long,
and I have met with others nearly as short.  It is also longer and  narrower
in virgins, than in those who have borne children.   Ordinarily, it is about
six inches in length, by one in width.
   The proper tissue of the vagina is  dense, and of a grey pearly colour,
resembling in some degree fibrous tissue, and about a line and  a half in
thickness anteriorly, though less near the  womb.   It.is well supplied with
vessels, which are multiplied and interlaced so much towards its anterior
extremity as to constitute a kind of erectile tissue, which has received the
name of plexus  retiformis.   Internally,  the vagina is lined by mucous
membrane of a pink  colour, continued from  the  vulva, and which near
the orifice, and  there only, possesses great sensibility, except when it is
the seat of inflammation, and  then  the whole  canal is very tender.  The
mucous  coat is  disposed in  the form of transverse rugae, anteriorly anc
posteriorly, which, by unfolding, permit the distension of the vagina.
   From the  " cul de sac," at the inner extremity of the vagina, the mucous 
INTERNAL  ORGANS OF GENERATION.
63
membrane  is reflected down upon the projecting cervix uteri, and in this
situation is thickly studded with small glandular follicles.   In addition to
its proper tissue  and mucous coat, the vagina has  some muscular fibres
surrounding its orifice, which have received the name of constrictor vaginae,
and which  serve to  contract the orifice, and to draw  down the clitoris.
The vagina, in common with the vulva, is abundantly supplied with blood-
vessels from the internal iliac arteries, and with nervous  filaments from the
pudic nerves.   The lymphatics, which  are very numerous, are derived
from the hypogastric plexus.   The  use  of the vagina  is two-fold; first,
for copulation, and, secondly, for the transmission of the foetus ; and, to
facilitate the latter process, the inner membrane, which in its ordinary
state secretes just enough mucous to  lubricate its surface ; during labour,
secretes it most  profusely.
   76.  Abnormal  deviations.—The  vagina varies  much  in length, as
already stated ;  its width  differs equally in different subjects; it may be
so narrow as to render intercourse difficult and painful; its exit may be
closed  by  the hymen, or by a membrane higher up; its  sides may be
adherent, or the seat of cicatrices and callosities ; or it may be altogether
wanting.   Of course,  occlusion or absence of the  canal will prevent the
escape  of  the  menses,  and render copulation  impossible,  constituting
one cause  of sterility; but, though  a partial closure may  impede intro-
mission, it does  not  render  impregnation impossible.    I may  add,
that the narrowness or width of the  canal is no proof of virginity, or the
contrary.   M.  Parent Duchatelet states,  that in many of the  youngest
prostitutes  of Paris it was wide and dilated; whilst in others, who had
followed their degrading  " metier" for twenty years, it might have been
mistaken for the vagina  of virgins.   Dr. Montgomery mentions, what
most practitioners must have observed, how very quickly,  after delivery,
the vagina recovers its usual size and tone.
   The vagina is also obnoxious to attacks of inflammation,  and its conse-
quences ; to lesions of nutrition and malignant diseases.
                           CHAPTER VI.

           OF THE INTERNAL ORGANS OF GENERATION.

   77.  According to the arrangement  proposed, our next subject is the
formative or internal organs of generation; but, before we proceed to
take them in detail, it will not be unprofitable, to direct the attention of
the student to the relative situation of the pelvic viscera, as  shown in the
accompanying engraving.
   Proceeding from before, backwards;  we find the urethra passing in an
oblique direction antero-posteriorly, and from below', upwards, under the
arch of the pubis, and then merging in the bladder, which, when distended,
rises about half its height above the symphysis pubis.  Below the urethra,
but with  an  interval  between them,  is the vagina, running its oblique
course to the os uteri, which is a little above the level of the pubes.  The
position of the uterus is not vertical, but inclining a little forward, with
its fundus  above the  level of the bladder.   The peritoneum is reflected
      5 
64              INTERNAL ORGANS  OF GENERATION.
from the abdominal parietes, on the fundus and  posterior  wall  of the
bladder down to the level of the cervix uteri; from whence it passes over
the anterior surface, fundus, and posterior surface of the uterus, down to
about an inch below the level of the os uteri; and from thence it is re-
flected upon the rectum.   The latter organ lies between the uterus and
the sacrum, and a little to the left side of the  uterus.  I do not, of course,

                               Fig. 27.
mean that this exact position of the part never varies, but  the  sketch I
have given is sufficiently accurate for practical purposes; and it is very
important for the practitioner to be acquainted with the position and ele-
vation of the pelvic viscera.
  We may now pass  on to the description of the uterus, fallopian tubes,
and ovaries.
  78. The Uterus is the  receptacle provided for the nutrition, matura-
tion, and, ultimately,  for the expulsion of the foetus.   It is the largest of
the generative organs, and is peculiar to the human female,  though there
is an approach to  such an organ in the mammalia.  It is a hollow sym-
metrical viscus, in shape somewhat triangular or pyramidal, resembling a
flattened pear, but rounder posteriorly than anteriorly;  situated,  as we
have just seen, in the centre of the pelvis, behind the bladder, above the
vagina, below the  small intestines; and in front of the  rectum.  For the
convenience of description, anatomists ordinarily divide it into the fundus,
or that part above  a line drawn from  the  orifice of one fallopian tube to
the other, the cervix,  or the narrow and inferior part; and the body,  or
that part between  the fundus and cervix.   Dewees maintains that the
cervix differs essentially, in  structure and function, from the  rest  of the
uterus;  and  it is  certain that its  structure  is more dense,  less vascular,
and that the menses are not excreted by this part.  In  the unimpregnated
state it projects into the vagina  about half or three quarters of  an inch,
the anterior lip being  the lower.
  79. The uterus  gradually assumes its normal form during fcetal and in-
fantile life.  Dr. Rigby remarks, " It is at first divided into two cornua. 
INTERNAL  ORGANS OF GENERATION.
65
and usually continues so to the end of the third month, or even later; the
younger the embryo, the longer are the cornua, and the more acute the
angle which they form; but  even after this  angle  has disappeared, the
cornua continue for some time longer.   The  uterus is at first of an equal
width throughout; it is perfectly smooth, and not distinguished from the
                               Fig. 2a
vagina either internally or externally by any prominence whatever.   This
change  is first observed when  the cornua disappear and leave the uterus
with a  simple  cavity.   The upper portion is proportionably smaller, the
younger the  embryo is.  The  body  of  the uterus  gradually increases,
until at  the  period of puberty  it is no longer cylindrical, but pyriform;
even in the  full-grown foetus the length of the body is not more than a
fourth part of the whole  uterus, from  the seventh to the thirteenth year it
is only a third, nor does it reach half until puberty has been fully attained
The os tincae, or os uteri externum, first appears as a scarcely perceptible
prominence, projecting into the  vagina."  "The parietes of the uterus are
thin in proportion to the age of the embryo.   They are of equal thickness
throughout, at first;  at the fifth month, the cervix  becomes thicker than
the upper parts; between five  and six years of age, the uterine parietes
are nearly of  an equal thickness, and remain so until the period of puberty,
when the body becomes somewhat thicker than the cervix."
  80. The adult healthy uterus may vary a little in size, but the following
measurements, given by  Dr. Burns,  are sufficiently accurate:—"The
length  of the uterus, from the  margin of the'  lip to the fundus, is two
inches and three quarters; breadth  between the insertion of the fallopian
tubes, from two inches and three-eighths  to  two and five-eighths; the
middle  of the fundus rises a quarter of an inch above a line drawn from
the insertion  of one tube to that of the other ; the commencement of the
body is an inch and  a quarter broad, its  thickness is an inch; the whole
of the wall is half an inch, but at  the fundus it is  seven-eighths, or one
eighth  of an inch less.  The thickness  of that part of the cervix which
projects into  the vagina, including the coat of that canal which is reflected
over it,  is an  inch and one eighth; its breadth an inch and a quarter.
The breadth of the  termination or lips of  the  os uteri, an inch and one
eighth; thickness, including both lips, three quarters  of an inch.   The
length  of the transverse chink, or os uteri, from three eighths to half an
inch; each lip is  three-eighths of an inch thick, though the posterior is
said to  be thinnest."   " From the margin of the lip to the top of the
                                  f2 
66
INTERNAL  ORGANS  OF GENERATION.
cervix is an inch, but sometimes only three quarters, or even less.   From
the top of the triangular cavity of the  fundus to the end of the narrow
cylindrical  cavity of the body is  an inch and one-eighth;  the  extreme
breadth of  the top of the cavity stretching from the entrance of one tube
to that of the other is nearly an inch and a half."
   According to the calculations of Levret, its superfices may he reckoned
at sixteen inches, and its cavity at eleven twelfths, or about three quarters
of a cubic  inch.
   The weight of a virgin uterus,  according  to Meckel, is from seven to
eight drachms;  but  after child-bearing, it amounts to an ounce and a
half.
                                Fig. 29.
  81. The Os Uteri or Os Tinea,  is situated  at the lower  part of the
cervix, varying in form in different individuals; in many it is a transverse
chink or slit, in others a circular opening, and in some triangular, resem-
bling a leech-bite, especially in those who have borne  many children.
It is generally about the size of a goose-quill, or rather smaller.
  The Canal of the Cervix is from  half to three quarters  of an inch long,
leading from the os uteri; it first widens, and then contracts again where
it enters the cavity of the uterus, marking the os uteri internum, as it has
been called.   Between the os uteri externum and internum the mucous
membrane is curiously disposed in rugae,  branching out from a central
line; this has been called the  arbor vita.   The  internal surface of this
canal is thickly studded with mucous follicles, called glandulce JVabothi,
and which, after impregnation, secrete a thick mucus which blocks up the
canal.
  The  cavity of thfc uterus is of a triangular  shape,  the  base being
upwards ; its dimensions have already been given.
  82. Much difference of  opinion has existed, and many discussions
bave taken place, as to the structures which compose the uterus; though 
INTERNAL  ORGANS OF GENERATION.
67
of late years the opinions of authors are more  harmonious.  It possesses
three distinct tunics:  I. We have  already seen (§ 77) that it is  covered
anteriorly and posteriorly by peritoneum, which is  reflected  laterally to
the sides of the pelvis, near the sacro-iliac synchondrosis, forming the
broad ligaments of the uterus or the alee vesperidioms, on each side, con-
taining the fallopian  tubes, ovaries, and  round ligaments.   From their
attachment to the pelvis they may perhaps  serve as supports to the uterus,
at least  before conception.   This serous  covering  is identical with the
lining  of the abdomen.
   83.  II. The Middle Coat of the Uterus is by some asserted, and by
others denied, to be muscular; but this really appears to me little  more
than a dispute about the name, for those who deny its muscularity, admit
that it performs the functions of a muscle.  It differs in colour from ordi-
nary muscle, being yellowish,  with a faint tinge of red, like  the  middle
coat of arteries, and it is much more dense than muscular tissue.  It
consists of fibrous structure, though it is not easy to trace the course of
me fibres in the  unimpregnated womb;  however, when the uterus is
enlarged from impregnation or other causes, it can readily be done, and
they may be divided into  several sets.   The superficial set are very irre-
gular, interlacing with each other in every direction,  though with a general
tendency from the fundus  towards the  cervix; but some regularity is
observable in the deeper sets; for instance, there  is a circular arrange-
ment  around  the  orifice of each fallopian tube, and at the  os  uteri; a
layer diverging from  the middle line anteriorly and posteriorly, and per-
pendicular bands descending to the os uteri.   Among these more regular
layers there are irregular fibres interspersed.
   From the middle  coat, fibres are sent off to the fallopian tubes and
round ligaments.  The reader will do well to consult Meckel's Anatomy
on this subject, and Sir C. Bell's  valuable paper in the fourth volume of
Med.  Chir.  Transactions.
   84. III. The Mucous Coat.—A considerable number of distinguished
foreign writers, among whom  we find Morgagni,  Assoguidi, Chaussier,
and Moreau, have denied the existence of any lining membrane in the
uterus, from the difficulty of separating and demonstrating it.   I cannot
understand this ; for  it has always appeared to me  very evident, even in
a state of health and quiescence, but  still more when the  seat of disease
or pregnancy.
  ■ Others, as Dewees, Boivin, and Duges, &c. do not question the presence
of a lining membrane, but contend that it is not mucous,  and apparently
for the sole reason that one of its functions (menstruation) is not a function
of mucous membranes.   This  objection, however,  is refuted by the fact,
that other mucous membranes  do  occasionally secrete  a fluid apparently
identical with the menses (vicarious menstruation); and we may add,
that the uterine membrane presents  the anatomical characteristics of
mucous membrane; that it secretes mucus, undistinguishable from that
of the vagin" ;  and  lymph (decidua), analogous  to that thrown off by
mucous membranes  in certain diseases (croup).   Its pathology also is
that of mucous membrane.
   For these reasons I have no doubt that the uterus is lined by mucous
membrane,  continued from the mucous  membrane of the vagina after it
covers the  cervix uteri.  In the canal of the cervix, as we have seen, 
68
INTERNAL  ORGANS OF GENERATION.
it is thrown into numerous folds ; but in the cavity it is smooth, sending
off a process into each fallopian tube.  Its  colour is a pale pink, except
during menstruation, when it becomes of a deep red, in which, however,
the cervix  does  not  participate.  Under  ordinary circumstances,  but
little mucus is  secreted; but it becomes morbidly profuse occasionally,
and after conception, the cervix is closed by mucus of a thicker consist-
ence.
   85. The Arteries of the uterus are four in number, furnished by the
aorta, the hypogastric, and emulgent arteries.   The two superior — the
spermatic — arise from the aorta or emulgent arteries, and descend along
the sides of the womb in a serpentine course; they are distributed to the
upper part of the uterus, to the fallopian  tubes and ovaries.   The  two
inferior—the uterine arteries — given off by the hypogastric arteries, run
along the sides of the uterus, to within a short distance of the lips, then
divide, and supply the cervix and upper part of the vagina.  The sperm-
atic and uterine arteries anastomose freely with each other.
   86. The Veins are more numerous than the arteries, are capable of
greater distension, and lie superior to their corresponding arterial branches.
They possess no valves, and, like the arteries, are  of small size so  long
as the genital system is quiescent, but increase very greatly during preg-
nancy, when they form what have been called  the uterine sinuses.
   87. Some uncertainty has  existed as to the JYerves of the uterus;  but
the researches of Dr. R. Lee, added  to those of his  predecessors, have
rendered  our information more complete.   They arise  from  the aortic
plexus, and from the hypogastric nerves and plexus, being a mixture of
spinal and sympathetic nerves.   I shall take the liberty of quoting  Dr.
Lee's account of a dissection of these nerves in the unimpregnated uterus:
"The aortic plexus, the hypogastric nerves and plexuses, were all much
smaller than in any of the gravid uteri I had previously seen.   From the
fore  and middle part of the left hypogastric plexus, a small branch passed
down on the inside of the ureter, to  the trunk of the uterine  artery  and
veins, which was surrounded with  a plexus of nerves, as in the gravid
uteri  before  examined.  From this, branches passed upwards  to  the
fundus uteri, and  a  communication  between these and the  spermatic
nerves was quite evident.   From the left hypogastric plexus numerous
branches passed also directly into the uterus, without entering the  ganglia
at the cervix, which ramified on the peritoneum behind, and on the mus-
cular coat.  Branches from the posterior part of the hypogastric  plexus,
communicated with some branches of the sacral nerves behind the ganglion.
The trunk of the  left hypogastric nerve was easily traced through the
plexus to the upper  part of the ganglion, which  was remarkably large
and  distinct, and consisted of white and grey matter.   Into the posterior
part of the ganglion the third sacral nerve sent  numerous branches. From
the anterior margin of the  ganglion, a broad band  of  white and  grey
nerves passed  round the outer surface of the ureter, and, after  uniting
with a similar band on the inside, sent branches to the plexus surrounding
the uterine artery and vein, and also  branches to the anterior surface of
the uterus.   Large flat nerves were  seen  passing  off from the anterior
border of the ganglion, to the  bladder and vagina, and from its  inferior
and  posterior borders to  the vagina  and  rectum.  A great number of
nerves likewise passed off from the  inner surface  of the ganglion, into 
INTERNAL ORGANS  OF GENERATION.
69
the cervix uteri.   The nerves sent off from the ganglion were both larger
and more numerous than those which entered it.  A great web of nerves
was seen under the peritoneum, both on the anterior and posterior surface
of the uterus, intimately connected with the nerves sent off by the gan-
glion  and the hypogastric plexus."*
   88. The Lymphatics are very numerous, though very small, in  the
unimpregnated uterus.   The most numerous  set of these vessels, runs
from the upper part of the  body and cervix of the womb along with the
spermatic vessels, and  with those from  the ovary, in  front of the  psoae
muscles, and terminates  in the glands, in  front of the aorta, vena cava
and lumbar vertebrae.  Another set accompanies the uterine artery, and
issues with the round ligament through the inguinal  ring.   A third  set
joins  the lymphatics of the vagina, and enters the hypogastric plexus.
   89. The lower portion  of the body of the uterus  is within the reach
of a vaginal examination, so that we can  estimate its size, temperature,
integrity, mobility, sensibility, &c.; and by the use of the speculum we
are able to ascertain its colour, the state of  its  surface, and, if necessary,
to apply local remedies.  Further information as to  its condition may be
obtained in many cases by abdominal manipulation; and, in the case of
enlargements,  by the application of the stethoscope.  An  examination
"per  rectum" is of  value in certain diseases of the uterus, and  especially
of the ovaries.
   90. Abnormal deviations.—1. The uterus may be altogether  wanting;
several  such cases are on record.  2. The  canal of the  cervix may be
extremely narrow throughout, or it may be  the' seat of stricture.   3. It
may be  closed, either by the union of its sides, or by the  mucous mem-
brane being continued  over the os  uteri.   4. The uterus may be mal-
formed ; and it is remarkable that these  malformations, which are owing
to an  arrest of development, appear to  reproduce the analogous organs

                               Fig. 30.
of lower classes  of animals; for instance, the double uterus  (fig. 30)
resembles in some degree the tubular oviduct of birds;  it opens by two
ora uteri into the  vagina.
  The uterus bicollis (fig. 31) exhibits two bodies with but one  os  uteri,
and resembles the organ of some rodentia and carnivora.
  Again, the junction of the cornua may take place higher up, constitut-
ing the uterus bicorporeus; here the lowest part of the body of the uterus
is single, and the upper double.
    * The Anatomy of the Nerves of the Uterus, by Robert Lee, M. D. &c. p. 7. 
70              INTERNAL ORGANS OF  GENERATION.
Fig. 31.
  In the uterus biangularis the body of the womb is tolerably well formed,
and terminating in cornua, as in the monkey tribes.  Several intermediate
stages of this progress, from  the lowest to the highest form of a single
                               Fig. 32.
uterus, have been  noticed; but I shall only add two more  illustrations ;
one when the uterus is double, opening by two orifices into two separate
vaginae (fig. 32), and  another when the uterus was separated into  two
cavities by a septum, but having only a common opening inferiorly (fig. 33).
                               Fig. 33.
  These congenital malformations are by no means very rare; Dr. Cassan
collected forty-one examples, and many others have since been recorded
  The effect of the first three abnormal deviations will be either the ab-
sence of menstruation, and  consequent sterility, or inefficient or painful
menstruation.  The deviations from arrest of development may exert no 
INTERNAL  ORGANS OF GENERATION.
71
injurious influence upon menstruation or conception, but they have been
adduced to explain the phenomenon of superfcetation, as it is pretty cer-
tain that a double conception may take place;  and when it is single, the
vacant cavity is lined by decidua.   In addition, the uterus is the seat of
many forms of disease.*
   91. The Fallopian Tubes are two cylindrical canals, about four inches
long, proceeding from the upper angles of the uterus.  They are contained
in the superior and lateral folds of the broad ligaments.  Internally, they
open obliquely into  the  uterus, at which point the canal  is narrow;  it
afterwards expands,  and then again contracts towards its external termi-
nation,  where it is open to  the abdomen.   Externally, the tubes are  of
equal thickness for about three inches and a half, when  they expand and
terminate in a fringed process, called the fimbria, or morsus diaboli, which
is applied to the  ovary after impregnation.   The tubes are  covered exter-
nally by peritoneum, beneath  which  is their proper  tissue, of a spongy
erectile nature, with  some  circular and longitudinal  fibres, derived from
the  middle coat  of  the  uterus.  Internally, they are lined by mucous
membrane, disposed  in longitudinal  folds, the villi of which are highly
developed after impregnation.  The tubes share in the vessels and nerves
by which the  ovaries  are supplied.
   Their function is the transmission of spermatozoa to the ovary in the
first instance, and afterwards of the impregnated ovum to  the uterus; in
fact, they are the excretory ducts of  the ovary.
   92. Abnormal  deviations. — The  tubes, one or  both, may be imper-
vious, from disease,  or  as  a congenital malformation.  The closure  of
both of course entails sterility.   They are  also subject to inflammation
and its  consequences, and to malignant diseases.
   93. The Ovaries  are the essential organs of generation  in the female;
they are the " analogues " of the testes in the  male,  and,  up to the time
of Steno, were called "testes mulieris."  They are situated on each side
of the  uterus, to which they are attached by the posterior  duplicature of
the broad ligaments,  hence  called the ligamentum ovarii.
   They are small, oval, flattened bodies, broader at the end distant from
the womb ;  about an inch and a quarter or an inch and a half long, from
half to five-eighths of an inch at their greatest breadth, and a quarter of
an inch thick.  They hang  loosely in the  pelvis, beneath  and somewhat
behind the fimbriated extremity of the fallopian tubes.   Smooth externally
in virgins, they become wrinkled in old age.
   Their external covering is the serous membrane, constituting the broad
ligament, in which they are completely enveloped,  except at the part
where the vessels enter.
   Underneath the peritoneum they possess a proper fibrous coat of dense
structure, called the  Tunica Albuginea.
  * A singular instance of malformation of the uterus is recorded by M. Lecluyse.  The
Bubject of it " was a smaU female, who had previously been twice confined with an arm
presentation.   The occurrence of the same accident for the third time caused the ac-
coucheur to make a minute examination, in order, if possible, to find an explanation of
so unusual a circumstance.  The result of the investigation was, the womb, instead of
being of the natural pyriform shape, had its greatest diameter in a transverse direction;
so that the long axis of the elliptic form which the foetus occupies in utero was hori-
zontal.  This anomaly was thought by M. Lecluyse to account for the three consecutive
arm presentations." — Ranking''s Abstract, p. 240, American edition, from Journal <k
Chirurgie, Mars, 1845.—Editor. 
72              INTERNAL  ORGANS OF GENERATION.
  94. When laid open, we find their internal structure to consist of cel-
lular tissue, permeated by numerous blood-vessels derived from the  sper-
                              Fig. 34.
matic arteries,  running tortuously across the  ovaries in nearly parallel
lines, and by nerves.  Embedded in the cellular parenchyma of the organ,
in the adult, a number (from 10 to 20) of small vesicles may be observed,
which, though noted by Fallopius and Vesalius, were more particularly
described by De Graaf,  and called, after him, Graafian Vesicles.
   They vary somewhat in number;  and in size, from that of the head of
a small pin to that of a small pea.
   95. There is some difference of opinion as to the age at which these
vesicles are developed; some say, about the period of puberty; others,
among whom is Dr. Rigby, state that they make their appearance about
the seventh year; but, according to M. Negrier, in his "Recherches sur
les Ovaires," lately published, they are to be found much  earlier.  He
states that at birth the texture of the ovarian parenchyma is homogeneous,
but that,  in the course of a year, an uncertain number of miliary granula-
lations  may be  observed; after a short time, these  granulations  are  sur-
rounded by an opaque zone, and a  small vesicular globule, whose walls
are formed by this zone, is annexed  to the granule.  This globule con-
tains a vesicle (the Graafian) formed  by two  membranes, concentric and
in contact.  At the age of ten or twelve, certain of the vesicles increase
in size, and cease to be transparent, because  of the interposition between
the two membranes of a grey pulpy matter.  At the same time, the vesi-
cles go on increasing more rapidly than the cavity in the ovarian tissue in
which they are lodged, which gives  to  them a compressed and  slightly
corrugated  appearance.  The grey pulp of the vesicle is gradually changed
to a yellow colour, marking the epoch of puberty.  The vesicles are con-
nected to the part in which they are imbedded by cellular filaments, which
become weaker in proportion to the  age  of the child.   During early life
the vesicles occupy the deeper parts of the ovary, but gradually approach
towards the circumference ; and, at the time  when the pulp becomes yel-
low, some of them are in contact with the envelope of the ovary.  I have
condensed this account from M. Negrier, but am not able to decide upon
its correctness.
   96. So much for the development of the Graafian vesicles: upon their
intimate  structure, very great light has been thrown of late years by the
labours of Baer, Rathke, Purkinje, Valentin, Wagner, &c, in Germany,
of Prevost,  Dumas,  Coste,  &c,  in  France;  and of  Allan Thompson,
Wharton Jones, and Martin Barry, &c, in England.  From their writings
the following description has been gathered, which I believe to be correct,
with the exception of a few minor points not yet settled.
   The Graafian vesicle consists of an  external and an internal membrane:
the former (tunic of the ovisac, Barry) is extremely vascular;  the latter 
INTERNAL  ORGANS OF GENERATION.
73
Fig. 35.
Ovum of Rabbit.
                          aa. Discus proligerus.
                          66. Pale oil globules.
                           c. Zona pelTucida.
                           d. Vitelline membrane.
                           e. Vitellus.
                           /. Germinal vesicle.
                           g. Germinal spot.

(ovisac, Barry) is smooth and velvety, deriving its vessels from the former.
The cavity enclosed by these membranes is far from being filled by the
ovum ; it contains, besides, a whitish or yellowish albuminous mass, which
consists chiefly of granules, from the ¥fo to the 3^ part of a line in dia-
meter, connected  together by a tenacious fluid, and  forming the tunica
granulosa of Bischoff, Wagner,  and Barry.  Its density is  unequal;
towards some part of the periphery of the vesicle these granules are accu-
mulated in  a disk-like form, making a slight  prominence, in which is a
depression.
  The disk  and prominence are termed by Baer the discus proligerus and
cumulus.  Dr. Barry has also observed certain granular cords, resembling
the chalazse  in  the  egg in appearance and function, and which he has
called  the retinacula.   In the depression in the  cumulus is lodged the
ovum (ovulum, Baer), the discovery of which by Professor v. Baer ex-
plained satisfactorily the small size  of the ova observed in the fallopian
tube by De Graaf, Cruiksbank, and Haighton, compared with the Graafian
vesicle  in the  ovary.   The  ovum is  surrounded  by a thick white ring,
which  has been  called zona pellucida, but which  Valentin  and Wagner
conceive to  be a  membrane ; internal to which we find a granular layer,
the vitellus, the larger granules of which are superficial and  compact,
whilst internally it is a clear albuminous fluid, almost  devoid of granules.
  Embedded in this vitellus, but nearer to its circumference than centre,
is the germinal vesicle  or vesicle of Purkinje,  a very important part of the
ovum.   It was first discovered in eggs by Purkinje, but in  mammalia by
Wharton Jones, Coste, Valentin, and Bernhardt.   It appears like a clear
ring of very small size, measuring in man and mammalia at most ^ part
of a line in diameter.   Upon the  surface  of  the germinal vesicle a dark
spot was discovered by Wagner, and called by him macula germinativa.
" It is almost always seen as a  simple rounded body, from  ^hn to sou
part  of a line  in diameter;  it is very rarely observed double, or as  an
                                 6 
74
INTERNAL  ORGANS OF  GENERATION.
Fig. 36.
                      Ovum of Man, from Bernhardt.
                        1. Germinal vesicle.
                        2. Vitellus.
                        3. Chorion..  (Zona pellucida ?)
                        4. Tunica granulosa.

aggregate of granules, which, however, is sometimes the  case  in imma-
ture ova."
  It may serve  to  render this minute description more intelligible to the
student, if I give the summary of Valentin and Barry of the contents of a
Graafian vesicle:
	Valentin.		Barry.
1.	An external membrane (yolk-	1.	Tunic of the ovisac.
	bag).	2.	Ovisac.
2.	Fluid contents (yolk).	3.	Membrana granulosa, in which
3.	Layer of granules which form		are found—
	the disk (blastoderma).	4.	Tunica granulosa and retina-
4.	Ovum or ovulum, in which is		cula (disk and cumulus of
	to be distinguished—		Baer).
5.	An outer membrane.	5.	Zona pellucida.
6.	A granular layer, internal to it.	6.	Membrana vitelli.
7.	A transparent half-fluid con-	7.	The yolk.
	tent.	8.	Germ vesicle, with Wagner's
8.	The germinal vesicle.		germinal spot.
  Dr. Barry states that the tunic of the ovisac is not always present; but
that, when it is, it is furnished by the ovary.   The order of time in which
the parts are formed is thus given by him: — 1, the  germinal vesicle with
its  contents; 2, an envelope  consisting of peculiar granules  and oil-like
globules; 3, the ovisac; 4, the yolk; 5, the membrana  vitelli;  6, the
zona pellucida;  and,  7, the tunic of the  ovisac, tunica granulosa, retina-
cula, and membrana granulosa.
  97. Abnormal deviations. — One or both ovaries may be absent,  or
atrophied.   There may be few or  no  Graafian  vesicles, or they may be
morbidly changed.  The ovaries may also be the  seat of inflammation,
dropsy, malignant  diseases, &c.
  The absence or  disorganization  of both ovaries,  or of all the Graafian
vesicles, entails  sterility; but  conception is not impossible, so long as a
portion remains healthy.
  Having thus minutely investigated the anatomy of the sexual system in
the female, we may now proceed to consider its  functions. 
                  PART  II.

PHYSIOLOGY OP THE ORGANS OF GENERATION.
                            CHAPTER I.

 PHYSIOLOGY OF THE UTERUS AND OVARIES. —1. MENSTRUATION.

   98.  The generative organs of the female are in a state of activity only
during the  prime of life, embracing a period of about  thirty years; and
during this  time, the  most remarkable characteristic of their functions is
their periodicity.
   It is impossible to separate the functions of the uterus  from those of
the ovary, because in each  we may  discern their  combined  influence.
Those offices which are peculiarly uterine, may thus be enumerated:—
1, the  secretion of mucus; 2, secretion of the menses; 3, secretion of
decidua;  4, reception and nutrition of the foetus; and, 5, the expulsion
of the foetus.  From  the  ovary, on  the other hand, is derived, 1,  the
effective stimulus to menstruation, and, 2, the fecundated  germ; so that
we see that the effective co-operation  of both the organs is necessary for
the fulfilment of either of the three great functions of the uterine system,
viz., Menstruation, Conception, and Parturition.  We shall consider these
functions in order.
   99.  Menstruation.—In healthy women,  at the period of puberty,  a
certain amount of sanguineous fluid  is  eliminated by the uterus, and
escapes from the vagina, every month;  this is termed  the catamenia, or
menses, and the function itself, menstruation.
   That it is excreted  by the uterus  has been ascertained in cases of pro-
lapse and inversion of the organ ;  and that it is really  a secretion  by its
lining  membrane, and not blood mechanically filtered through it, is,  I
believe, now generally admitted.*
   A female  in whom this discharge recurs at the usual periods, in the usual
quantity, and of the usual quality, is  said  to be "regular;"  and various
conventional phrases  are  in  use to  avoid a more direct reference, as
" being regular,"  " unwell," &c.
   100. The occurrence of menstruation defines the period of puberty, at
which  the girl becomes a woman and capable of conception; as its cessa-
tion terminates the prolific period of  female  life.  In Great Britain this

  * It has been shown by the researches of  modern physiologists, that the catamenial
fluid is ordinary blood mixed with the mucus of the vagina  and epithelial cells.  Men-
struation is, therefore, a periodical hemorrhage from the uterus.  The doctrine of the
secretion of the menses is altogether untenable.—Editor. 
76
MENSTRUATION.
generally happens  between the ages of thirteen and sixteen, although we
meet with cases of earlier and later puberty, dependent, probably, upon
peculiarity of constitution, habits of life, pursuits, &c.   A case is recorded
by Dr. Wall, in the second volume of the Med. Chir. Trans., of a child
who menstruated at nine months  old, and continued to do so regularly
afterwards.   There is  another instance in the American Journ.  of Med.
Science, for Nov. 1832, by Dr. Le Beau of New Orleans, of a child born
with the marks of puberty, in whom the catamenia  appeared  at three
years of age, and recurred regularly.   Additional examples may be found
in the  writings of Lobstein, Meyer, Ploucquet, &e.  &e.  Mr. Roberton,
of Manchester, in a valuable paper " On the Natural  History of Menstru-
ation," in the  thirty-eighth volume of the Edinburgh Med.  and  Surg.
Journal, has stated the age at  which it commenced in 450 cases.

          10 menstruated for  the first time at 11 years of  age.
19	a	a	12
53	«	it	13
85	a	it	14
97	«	u	15
76	a	a	16
57	((	a	17
26	it	it	18
23	((	u	19
4	it	a	20
  Mr. Whitehead, in his work  on abortion, gives the following table,
showing the age at which puberty was established in 4000 individuals in
Manchester:—

             At the age of 10 years
                   «      11   «
                   "      12   "
                   "      13   "
                   "      14   "
                   a      15   u
                   u      16   a
                   "      17   "
                   "      18   "
                   u      19   u
                   «      20   "
                   "      21   "
                   "      22   "
                   "      23   "
                   "      24   "
                   «      25   "
                   "      26   "

  101.  In these countries the discharge continues until the age of forty-

  • M. Brierre de Boismont, in his work, "De la Menstruation considerie dans ses Rap-
ports Physiologiques et Pathologiques," among a mass of interesting facts, gives  the
9 first menstruated.
26	u
136	a
332	it
638	tt
761	a
967	a
499 '	a
393	a
148	a
71	a
9	«
6	a
2	u
1	a
1	a
1	u *
 
MENSTRUATION.
77
five or fifty; in some cases it ceases earlier, in others it continues longer;
generally according to  the  age  at  which  it  commenced.   From Mr.
Roberton's essay I extract the periods at which it ceased in 77 individuals:
following curious table  of  ages  at which  menstruation commences.   It is the most
extensive table yet published, and includes  the results of 2352 cases.
-------	Paris,	Paris, 85	Lyons,	Marseilles, 68	Manchester,	Gottfngen,
Age.	1200 cases by	cases by Marc	■ 432 cases by	cases by Marc	450 cases by	137 cases by
	Meniers.	D'Espine.	Petrequin.	O'Espine.	Roberton.	Osiander.
5	1	0	0		0	0
7	1	0	0	0	0	0
8	2	0	0	0	0	0
9	10	1	0	0	0	0
10	29	0	5	0	0	0
11	93	3	14	6	10	3
12	105	14	26	10	19	1
13	132	6	47	13	53	0
14	194	18	50	9	85	20
15	190	14	70	16	97	32
16	141	7	79	8	76	24
17	127	6	58	4	57	11
18	90	5	38	2	26	18
19	35	8	21	0	23	10
20	30	3	9	0	4	8
21	8	0	5	0	0	1
22	8	0	1	0	0	0
23	4	0	0	0	0	1
24	0	0	3	0	0	0
   This table demonstrates that by far the greater number of women begin to menstruate
during their 14th or 15th year, and  that the proportion  diminishes both above and
under that age.*
   "It is  a common opinion, generally admitted  all over Europe, that puberty occurs
earlier in hot climates than in those lying within the temperate zone.  Muller says that
it is stated that, in the hot  regions of Africa, the changes of  puberty take place in the
female sex as early as the eighth year, and during the ninth year in Persia.   Yoong
Jewesses are also said to  menstruate earlier than other females in our own country.
This opinion Mr. Roberton, of Manchester, has essayed to  controvert, in the belief that
it was no other than a vulgar error.   To enable  him to obtain the necessary informa-
tion with respect to the negress, Mr. Roberton applied to  the superintendents of the
Moravian Missions in Antigua and Jamaica, by whom registers of births had been kept,
the registry being important in fixing the date of the first appearance of the catamenia.
From these gentlemen he received the information he desired, and which confirmed him
in the belief that  menstruation does  not commence earlier in the negress  than in the
white.  Out of 21 cases, menstruation appeared in one aged 16, in three at 15,  in three
at 14, in three at 13, and in two at 12 ;  while  it had not appeared  in one aged 14,  in
two aged 13, in one aged 12, in one aged llj one aged 10, one aged 9, and two aged 8.
It is further added,  that many cases of negresses, from 8 to 11 years of age, who have
not yet had any menstrual secretion, might be added. "■}•
   A very interesting case by Dr. Carus, of Dresden, is mentioned in the recent medical
journals, of a child born in the mountains of Saxony, in whom menstruation began at
two years of age.
   " She was scarcely a year old, when she began to grow rapidly.  At the end of her
second twelvemonth, the catamenia appeared, and have continued ever  since to flow
regularly once a month.   The Academy of Medicine of Dresden sent for both  her and
her mother, and, in order to examine more particularly into the case, kept them under
their observation during  several weeks.  The infant was 37 inches 3 lines long.   The
  * Edinb. Med. and Surg. Journ., Jan. 1843.
  f Braithwaite's Retrospect of Med. and Surgery, vol. vi., page 251—from Provincial
Med. and Surg. Journal, Aug 1812.
                                     g2 
78
MENSTRUATION.
In 1 at the age of 35          In 26 at the age of 50
4	a	40
1	a	42
1	it	43
3	a	44
4	it	45
3	it	47
10	a	48
7	a	49
2	a	51
7	it	52
2	it	53
2	a	54
1	it	57
2	tt	60
1	u	70
   The period of its cessation is called by women the "time, or turn of
life," and is preceded by irregularity and  occasional interruption.  It is
looked upon as a critical  period, from  the  supposed liability to serious
attacks, and the greater mortality;  but the researches  of MM. Benoiston
de Chateauneuf, Bellefroid, &c, have shown that  the mortality at this
period of female life is not greater  than amongst males at the same age.
   102.  By most writers on the subject, we  find it stated that menstruation
commences and terminates much earlier than the period I have named in
hot climates, and much later in cold ones.   Women are stated to be
mothers at ten or twelve years old in the East, and to cease bearing at
twenty-five  or thirty; and that in Lapland, and other northern climes,
they do not begin to menstruate until about twenty or twenty-four, and
continue until sixty years of age.   That such cases  do  occur there seems
no reason to doubt; but it appears extremely probable, that such is not
the ordinary course.  Mr. Roberton has collected a great mass of evidence
to prove that these instances are exceptions; and taking into account the
limited  opportunities for observation of travellers, upon whose statements
the former opinion is founded, and other causes of error, I am inclined to
agree with him, that there is probably no such great difference in the age
of uterine activity in different countries, as has been stated.
   103.  As  the name (menses, catamenia) implies,  the  discharge recurs
every month; that is, deducting four or six  days for the time of  its flow,
every twenty-seven or twenty-eight days.  Mr. Roberton found that, out
of 100  women, 61 menstruated  every month, 28 every three  weeks, 10
at uncertain intervals,  and one, a healthy woman  aet. twenty-three, every
fortnight.    The shortening of the interval of twenty-six or twenty-eight
days is  a deviation from functional integrity, owing,  most likely, to habits
of life, impaired constitution,  &c.  Dr. Gall made some very curious
observations, from a journal which he kept of the periods of menstruation
in different  women: "It resulted" (I quote  from Elliotson's Physiology,
not having the original at hand) " that women are divided into two great
classes, each having a different period.  The women of the same class all
menstruate within eight days ; after this time an interval of ten or twelve
days follows, during which very few women  menstruate.  At the end of

mammas were firm, like those of a strong girl of 16.  Her body was stoutly made, and
the genital organs were covered with dark brown hair.  Her physiognomy and tone of
voice were childish, which contrasted  singularly with the strength of her body.  Her
intellectual functions were equal to those of a child three years old, and her head was
covered with beautiful dark brown hair."*—Editor.

  ♦American  Journal of  the Medical Sciences, April, 1843, page 436—from Allge-
meine Zeit. fur Chirurgie. 
MENSTRUATION.
79
the ten or twelve days, begins the period  of the second great class, all
the individuals of which also menstruate within eight days."  Admitting
exceptions to the rule, Dr. Gall  says that it applies generally to all parts
of Europe.
   104.  The duration of each menstrual period varies from three to six
days, or even longer.  The quantity which escapes each time is from four
to eight ounces, varying according to the temperament or constitution of
the individual.   It  is not discharged at once, but slowly and gradually.
As to the character of the secretion, it greatly resembles venous blood,
being of a dark red colour, thin, and either without odour, or with a very
faint one.  It differs from blood in containing no fibrine; it is not eoagu-
lable, nor easily decomposed.  It is found to redden litmus  paper, and
to contain free phosphoric and lactic acids, with some phosphate of lime.
   105. The symptoms which precede and accompany the first menstrua-
tion  are very slight in some cases, well marked in others.  There  is gene-
rally  a  degree of languor and lassitude, fatigue after exertion, inequality
of spirits, dark  shade under the eyes, headach, sometimes pain in the
thyroid gland, pain in the back, weight and aching in the pelvis and down
the thighs, &c.: occasionally there is a smart attack of fever.
   If the discharge take place, most of these symptoms disappear, and the
female merely complains of weakness, and exhibits pallor of countenance.
   But the symptoms may pass off once or twice without the appearance
of the  menses, or with a  white  discharge only.  This may generally be
remedied by an improvement in diet, or tonics at the approach of the
next menstrual period.
   Sometimes the colour of the discharge is  light at first, growing deeper
each  period.  During  its flow, the skin  exhales  a peculiar odour, the
appetite is diminished, ancV often capricious,  and occasionally sympathetic
pains are  felt in  the breasts.   There  is a case, related in the British and
Foreign Med. Review for October,  1840, of a woman whose breasts se-
creted milk after each menstrual period.  I have  lately had one  under
my care.
   The  amount  of suffering differs, as  I  have said, in different women;
and I may add,  that the first menstruation is not necessarily a type of the
subsequent periods.   The more perfectly the function is performed, the
less is the distress.
   106. The  effects  of the  development of this function upon the body
and  mind of a young girl, are very striking.   The figure enlarges, becomes
rounder and more fully formed, the pelvis expands, the mammae  enlarge,
and  the general bearing becomes graceful  and  dignified.   The mental
change is as remarkable: the pursuits of girlhood are exchanged for more
womanly interests; and a more exquisite perception of her position and
relations, results in  higher enjoyment, veiled by a more delicate modesty.
These changes are rapid, and, occurring at this peculiar period, doubtless
fit the individual for the more perfect fulfilment of the  duties  about to
devolve upon her.
   107. The  causes  of menstruation have been divided into the efficient
and final: as to the first of these, — the efficient cause, — much time has
been wasted in speculations, which, after all, are  nothing but guesses:
thus, it has been attributed to general and local plethora, to lunar influence,
&c.   We do not know why the catamenia  occur at monthly periods ;  il
        6 
80
MENSTRUATION.
is one instance of the periodicity which characterises the functions of the
female sexual system, and which we shall observe again and again.
  108.  A much more important question is the nature and extent of the
influence exerted by the ovaries upon menstruation.  By most writers the
uterus is regarded as the sole organ involved; but from time to time ova-
rian influence has been  admitted.  A reference of this kind is made  by
Dr. Friend,  in  his  " Emmenologia;" and Dr. Power goes further, and
attributes menstruation  entirely to the action of the ovaries; Dr. Vaughan
also regarded the menses as  a secretion dependent upon the ovaries;  and
other authorities might be adduced.  Indeed, there are certain facts which
cannot but lead to an admission of a certain influence exerted over men-
struation by  these organs: for instance, it is well  known that they partici-
pate in the congestion which is observed  in  the  uterus at the monthly
periods; again, when the ovaries have both been atrophied or diseased,
as noticed by Morgagni and  Frank;  or when one was congenitally absent
and the other disorganised, as in a case  related to me by my friend Dr.
Montgomery; the secretion of the menses has been prevented altogether,
or it has ceased prematurely. Moreover, when the uterus  is absent, but
the  ovaries present,  the menstrual molimen  and other sexual peculiarities
are  observed.  Lastly,  when the ovaries have been removed, as  in the
case mentioned by Mr.  Pott,  menstruation ceased entirely.
  From these considerations we may conclude, that although the  uterus
be the seat, and its lining membrane the agent in  the process, yet that the
ovaries furnish the impulse or stimulus upon which the function depends.
  109.  An inquiry  into the  changes which take place in the  organs dur-
ing menstruation, will confirm the conclusions at  which we have arrived,
and throw some light upon the nature of the stimulus.  For almost all the
accurate information we possess, we  are indebted to the recent researches
of Drs. Girdwood,  Lee, Ritchie, in  this country, and Pouchet, Negrier,
Gendrin, Bischoff, Raciborski, Chereau, &c,  on the continent; although
the  main fact established by their labours was cursorily noticed  by Mr.
Cruikshank so long  ago as 1797: " I have also," he says, " in my pos-
                               Fig. 37.
session the uterus and ovaria of a young woman, who died with the men-
ses upon her.  The external membranes of the  ovary were burst at  one
place, from whence I suspect an ovum  escaped, descended through the
tube to the uterus, and was washed off by the menstrual blood."  Several 
MENSTRUATION.
81
similar observations have been published by Dr. Lee in  the Cyclop,  of
Pract. Medicine, and since in the Med. Chir. Transactions; Mr. Girdwood
and M. Gendrin  have each added five cases, and M. Negrier five more,
of the same kind.   All the observations agree, that, in females dying dur-
ing or soon after menstruation, a  small irregular  rupture  or  cicatrix was
found in the  coats of the ovarium (fig. 37), and that this communicated
with the  remains of  one  of the Graafian vesicles;  from  which Dr. Lee
concludes that it is "  extremely probable that all the phenomena of men-
struation  depend  upon,  or are connected with, some peculiar changes in
the Graafian vesicles, in consequence of which, an  opening  is formed in
the peritoneal and proper coats.  Whether  an entire vesicle, or only the
fluid it contains, escapes through this opening at the period of menstrua-
tion, further observations may hereafter determine."*

  * The "efficient" cause of  menstruation has long been a subject of speculation with
physiologists.  The changes that are now ascertained to take place in the ovaries, which
render it probable that one or more Graafian vesicles are ruptured at each menstrual
period,  shed new light upon the subject, and may lead to clearer views in relation to it.
The following facts are derived from Lecture IV., by Dr. Robert Lee, On the Physiology
of the Unimpregnated Uterus and its Appendages, contained  in the London Medical
Gazette of November 5th, 1842: —
  " On the  11th of March, 1831, I  examined the body of a  young woman who died,
during menstruation, from inflammation of the median basilic vein.  The left ovarium
was larger than the right, and at one point a small  circular opening, with a thin irre-
gular edge, was observed  in the peritoneal coat, which led to a cavity of  no great depth
in the ovarium.  Around the opening, to an extent of three or four lines, the surface
of the ovarium was of a bright red colour, and considerably elevated above the sur-
rounding part of the peritoneal coat.  On cutting into  the  ovarium,  its substance
around  the opening and depression was vascular, and several  Graafian vesicles,  of dif-
ferent sizes,  were observed.   The right ovarium was in the ordinary state.  Both fallo-
pian tubes were intensely red and swollen, and their cavities were filled with what
appeared to  be menstrual fluid.  The lining membrane of the uterus was coated with
the same fluid, and the parietes were soft and vascular.   The size of the uterus was
not increased.  I pointed out this  opening in the  peritoneum of the ovary, which I
accidentally  observed, to  Dr. Girdwood  and Dr. Prout, and suspected that there was
some relation between this and the state of the uterus.  At this time I had not seen the
human ovum in the Graafian vesicle before impregnation, and was not then aware that
cicatrices are never present on the surface of the ovaria before menstruation has com-
menced.
  " In the autumn of 1831, Dr. John Prout saw a woman, under 20 years of age, who
died suddenly from acute inflammation of the lungs while menstruating.   He examined
the body, and brought the uterine  organs  to me, having taken the greatest care that
they should not suffer from any force during their removal from the pelvis. A red, soft,
elevated portion of  the right  ovarium was also here  observed, and at one part the peri-
toneal coat, to a  small extent, had been removed.   The edge  of the opening was ex-
tremely thin and irregular;  and in  the substance of the ovarium, under the opening,
was an enlarged Graafian vesicle, filled with transparent fluid.   Numerous small blood-
vessels were  seen running along the  peritoneal coat of the ovary to the opening.  "When
the substance of the ovarium was laid open, several vesicles,  of various sizes, and at
different depths,  were found embedded  in it.  The  left ovarium presented  a natural
appearance.  The free extremities of the fallopian tubes were gorged with blood.  Their
cavities were filled with a red-coloured fluid.  The uterus was not  enlarged, but the
parietes were unusually full of blood, and the lining membrane of flie fundus was coated
with menstrual fluid.   A small  coagulum of blood likewise adhered to the upper part
of the uterus.   I now felt convinced that there must be some  connexion between this
state of the ovaria and menstruation, and mentioned the facts  to Sir Astley Cooper.
  " On the 2d of July, 1832, Sir Astley sent me the ovarium of a woman who died from
cholera while menstruating.  The ovarium was much larger than natural, and at one
point there was  a small irregular aperture in its peritoneal coat, through which  a por-
tion of a slender coagulum of blood was suspended.   On cutting into the substance  cf
the  ovarium, it was  found to be occupied with three small cysts or cavities, one  of
which was filled with  a clear ropy fluid, another with semi-fluid blood, and the  third, 
82
MENSTRUATION.
   The changes which take place in the vesicle  are thus  summed  up by
M. Negrier:  an afflux of transparent fluid occurs in the vesicle,  distend-
ing and ultimately causing its  rupture at  the least resisting part, which
corresponds to the surface  of the ovary.   This opening is cicatrised, at
least  externally, in about eight or ten days, so as to  prevent  the escape
of the blood which proceeds from the  lacerated vessels of the vesicle, and,
in consequence, a clot is frequently formed in the  capsule  of the vesicle
(fig. 38).  Sometimes it  contains a serous fluid, colourless, or tinged with
blood.
   A careful examination of the facts connected with menstruation, appears
to me to justify the following conclusions: —
   1.  That ovarian influence  is  necessary to  menstruation:  a.  because
when  the ovaries  are congenitally absent,  or have been removed, or have
become disorganized, menstruation   is  absent  or  ceases,  b. Because,
when  the uterus is absent or has been removed, the ovaries being present,

which communicated with the opening in the peritoneal coat of the ovum, with a firm
coagulum.
  " On the 18th of November, 1832, Dr. Girdwood and Mr. Webster removed the ute-
rine organs from the body of a young woman who had died suddenly the preceding day,
when the catamenia  were flowing.  Both ovaria were remarkably large; and both fal-
lopian  tubes  were red and turgid.  The peritoneal coat of the  left ovarium was perfo-
rated, at that extremity which was nearest to the uterus, by a circular opening, around
which aperture, for several lines, the surface of the ovarium was slightly elevated,  and
of a bright scarlet colour.  The margin of this opening was thin and smooth, and did
not appear to have been  produced  by any external force.  Its centre was slightly de-
pressed below the level of the edges, but there was scarcely the appearance of a cavity
beneath. The right ovarium was much larger than the left; and when cut into, a cyst
or cavity was seen, filled with half coagulated blood.  The peritoneal coat of the ova-
rium was entire.  The uterus was  large, and, when cut into, appeared to contain an
unusual quantity of blood. The inner membrane was of a bright red colour, and coated
with a thin layer of  catamenial fluid.  Both fallopian  tubes were red and turgid, and
the interior of the left was filled with menstrual fluid.
   " On the 14th of January, 1837, a woman, thirty-seven years of age, who had long
suffered from hysteria, died suddenly in St. George's Hospital during menstruation.
No morbid appearance was found to account for her death.  A small circular aperture
was observed in the  peritoneum of the left ovarium.   This opening communicated with
a cavity in the substance of the ovarium, which was surrounded with a soft yellow sub-
stance, of an oval shape.
   " On the 31st of May,  1841, Mr. A. Shaw was present at the inspection of the body
of a woman who died during  menstruation  in the Middlesex Hospital.  In the right
ovarium, he  says, the appearance was presented of one of the Graafian vesicles having
been recently ruptured.  A part of the surface, of the size of a four-penny piece, was
distinguished by a dark stain upon it; and  here  the  peritoneal coat was slightly ele-
vated,  and the ragged edges  towards the centre  of the stained spot were of  a particu-
larly black colour."
  In Gendrin's Traite" Philosophique de Me"decine Pratique (1839), there is a description
of the  same state of the ovaria in five women who died during menstruation.  In the
first, the left ovarium was vascular, and in the middle was an aperture about a  line in
diameter, with an irregular margin.  Its cavity would have contained a hemp-seed, its
walls were red,  and  it was obviously a ruptured Graafian vesicle.   In the second case,
a small circular ragged opening led to a cavity two lines in diameter, the walls of which
were of a bright red colour.   In the fourth,  the right  ovary had an aperture  a line and
a half in diameter,  leading  to a small  cavity, with vascular  walls.   M. Negrier has
given  an account of similar appearances in the  ovaria during menstruation.   On the
other hand, the  recent observations of Dr. Ritchie on this subject seem to have led him
to different conclusions—"that although such a discharge from the ovisacs takes place
most frequently at the menstrual period, yet that the two occurrences are not necessarily
co-existent, for menstruation may take place without any such rupture; whilst, on the
other hand, the  maturation and discharge of mature ova may occur in the intervals of
menstruation, and even at periods of life when that  function is not taking place."—
(Carpenter's Human Physiology.) — Editor. 
MENSTRUATION.                        88
Fig. 38.
the menstrual molimen still recurs periodically,  c.  Because, coincident
with the commencement and cessation of menstruation, we find correspond-
ing organic changes in the ovaries.
   2.  We find that the ovaries do not contain a definite and limited num-
ber of  Graafian vesicles, as Haller and others have thought, but  a  vast
assemblage,  according to  the  researches of Dr. Martin Barry, and  the
number of which vesicles may  be  increased, according to Dr. Ritchie.
   3.  In the ovaries of women who  menstruate  regularly, there  may be
observed a number of the Graafian vesicles, in different degrees of deve-
lopment, from the size of a millet seed to that of a cherry stone.
   4.  There are cases on record of women who died just before menstru-
ating, in one of whose ovaries a vesicle was observed in a state of great
maturity, enlarged and prominent, with its outer coverings much thinned,
semitransparent, and in one point  apparently about to burst.
   5.  In a considerable number of cases of death during menstruation, one
ovary presented a cavity recently emptied,  or partially filled by  a clot,
from  which  a duct-like canal passed through the coats of the ovary.  That
this cavity contained a Graafian vesicle cannot reasonably be  doubted.
   6.  On examining the ovaries, a number of cicatrices may be observed,
some more, some less recent; and in  several cases these have been ascer-
tained to correspond exactly with the number of the menstrual periods.
According to Mr.  Girdwood's researches, this is always the case.
   7.  These  cicatrices,  when cut  open,  exhibit the yellow spots which
have  been so often alluded to in all the controversies about corpora lutea.
   8.  Cases are on record  in which (according to Dr. Ritchie) menstrua-
tion has taken place without the escape of a vesicle, and others,  also, in
which there was evidence of the escape of a vesicle previous to menstrua-
tion.  This  latter case has occurred more  frequently than  the former, (and
answers to  those  cases  in which  conception has preceded menstruation,
or occurred during lactation,) but  both are so  rare as scarcely, if at  all,
to affect the  question.
   9.  From all this evidence we are obliged to conclude that there  is a
periodical evolution of Graafian vesicles, and that this occurs at a men-
strual period.
   110.  The uterus is congested during menstruation; its vessels are  dis-
tended  with blood, its substance more flaccid than usual, of  a more  de-
cided pink colour, and its lining membrane  of a deep red, studded with
bloody  points, and covered with menstrual fluid.   The  cervix, however,
^participates but slightly in the increased vascularity, and  its lining mem- 
84
MENSTRUATION.
brane is scarcely'altered in colour, so that the os uteri internum is marked
by the abrupt termination of the dark colour of the lining membrane of
the body.  On making a vaginal examination, we find the cervix  softer,
more puffy, and  slightly swollen, and the os uteri more  open, than at
other times.  The Fallopian tubes are also somewhat more vascular than
usual.
  These changes rapidly subside when the function ceases, and the parts
return to their ordinary state.
   111.  The final cause of menstruation is said to be, 1, to get rid of the
surplus  blood employed during gestation in the nutrition of the foetus, but
which in the  unimpregnated state might be injurious;  and, 2, to prepare
the uterus for impregnation and conception.  The first is a mere hypothe-
sis, grounded on  an assumption, for it is not proved that there is any sur-
plus  blood when the female is  not  pregnant; I need, therefore,  say no
more about it.
   As to the second theory, it is based upon the observation, that concep-
tion seldom or never takes place  before the period of the  first menstrua-
tion, or puberty;  that it does not occur in those who do not  menstruate,
or after the cessation of menstruation; and that calculations  show that it
takes place more readily soon  after  a menstrual period.  This has been
the received  opinion for some time, and may be the true one; but I  should
be to blame if I did not point out some considerations which, if confirmed
by more extended investigation, may lead to another view of the matter;
viz., that menstruation is for the relief of a certain condition of the  organs
which occurs periodically, and which condition  is  a preparation,  not for
menstruation, but for conception.
   For instance,  1, we find congestion  of the uterus and ovaries, with
certain  changes in the Graafian vesicles, occurring at menstrual periods,
analogous, to a certain  extent,  with those which take  place at and  imme-
diately  after  conception; the difference being, that,  if no  fecundating
stimulus be applied, the vesicle bursts and its contents are lost.
   2. By various  writers, Reaumur, Cruikshank, Blundell, Laycock, &c,
menstruation is regarded as  analogous to the "heat" of animals, and the
similar condition of the organs seems to confirm this view; but conception
in animals takes place during, and not after, the " heat."
   3. I am not sure of the correctness of the calculations which place con-
ception immediately  after menstruation.  In reckoning for the time of
delivery, women  calculate from the mid-period between the last menstrua-
tion  and  the first omission, or, in other words, from  a fortnight after the
last menstruation.  Now it follows, that, so far as the regularity of gesta-
tion can be depended upon, if  conception take place more readily imme-
diately  after  menstruation, they ought actually to anticipate the calculated
period  of delivery just so  much; or, on the  other hand, to  exceed the
period fixed  upon, if conception take place just before a menstrual  period.
This brings the question within the reach of experience, and I cannot but
think that more  women overrun their calculations than anticipate them ;
and, if so, the evidence is in favour of the changes at a menstrual period
being preparatory to conception.
   4. It does not appear that the  discharge of the  catamenia is absolutely
necessary to  impregnation ;  for cases not unfrequently occur in which im-
pregnation takes place without previous menstruation; such a one has 
MENSTRUATION.
85
recently come under my care.   Other cases are recorded by Perfect, Reid,
Velpeau, &c. in wrhich the menses appeared for the first time during gesta-
tion ;  and some  by Deventer, Baudelocque, and Dewees, who only men-
struated  during  pregnancy.   Lastly, it  is  not uncommon for women  to
conceive  during lactation,  or immediately on weaning, before the cata-
menia appear.
   Now, from these cases  alone, it is evident that  it cannot be  assumed
that menstruation is an essential preparation for conception;  and it may
be more  correct to consider it as the ordinary termination of a series of
changes which had another object, and would have  terminated  differently,
had not the proper stimulus  been wanting.*

   * On this point we have conflicting testimony.  The  late Dr.  Dewees, whose expe-
rience  was very extensive, wrote as follows: " The final cause of the menses  is perhaps
enveloped in some obscurity; but of this we know at least one  incontrovertible  fact,
namely, that the healthy performance of this function is in some way or other connected
with the capacity for impregnation;  as no well-attested instance is upon record, where this
has taken place in a female who never had had this discharge, or even when it was not of a
healthy character,  and with a greater or less degree of regularity."  In these remarks
we must understand Dr. Dewees as merely asserting his own experience, for the expe-
rience  of numerous equally competent observers is in direct opposition.   The regular
and healthy performance of the menstrual function is certainly indicative of a natural
condition of the female genital organs, and of the consequent aptitude of the individual
for impregnation;  yet it is not always so; every healthy menstruating  female is not
fruitful; and I have known many instances  where women bore children  regularly,
although the menstrual  office was neither regularly nor healthfully performed.  Pro-
fessor  Dunglison well observes:  "As a  general rule, the appearance of the  menses
denotes the capability of being impregnated, and their cessation the loss of such capa-
bility.   Yet, females have  become mothers without ever having menstruated.   Fodere"
attended a woman  who had menstruated  but once—in her seventeenth year, although
thirty-five years of age, healthy,  and the  mother of five children.  Morgagni instances
a mother and daughter, both of whom were mothers before  they menstruated.  Sir E.
Home mentions the case  of a young woman, who was married before she was  seventeen,
and having never menstruated, became pregnant; four months after her delivery, she
became pregnant  again; and  four months after the second delivery, she was a third
time pregnant, but miscarried.  After this she menstruated  for the first time, and con-
tinued  to do so for several periods, when she again became pregnant;  and  Mr. Harrison,
at a meeting of the Westminster  Medical Society, remarked, that he knew an instance
in which the mother of a large family had never menstruated.*   Such instances prove
that ova are  maturated  without  the ordinary recurrence of a sanguineous  exhalation
from the lining membrane of the  womb."
   The  modern ovular doctrine of menstruation  is unquestionably encompassed  with
some difficulties: these have caused it by a few to be considered rather as " a plausible
and ingenious hypothesis, than as a well-established theory."   Mr. Kester, in the London
Medical Gazette, (Nov. 1849,) thinks  that " the actual state of our knowledge of the
nature of menstruation may be expressed in the following propositions:—
   " 1.  Menstruation is a, periodical function of  the uterus.
   " 2.  Ovulation is the constant function of the ovaries.
   " 3.  Ova are matured in the ovaries at all ages, but more rapidly during menstrual
life.
   " 4.  Ova are discharged  at all periods of female life, in the intervals of, as well as at
the time of, menstruation.
   " 5.  Ovulation and menstruation being often concurrent, indicate that they are both
the result  of the  attainment of a certain point in  the development of the female
economy.
   " 6.  The law of  periodicity in the one not obtaining in the other, leaves still wanting
the inseparable link in the chain  of causation whereby menstruation can  be  shown to
be tho  effect of ovulation.
   " 7.  At the menstrual period, the ovaries experience an extension of the uterine
* Human Physiology, 4th edition, vol. ii., p. 357.

                       H 
86                   DISORDERS  OF MENSTRUATION.
  Abnormal  deviations.—These are of sufficient importance to  demand
a separate  chapter;  we shall therefore next consider the  disorders  of
menstruation.
                              CHAPTER II.

                    DISORDERS OF MENSTRUATION.

   112. These functional  derangements are  divided  into  three classes:
1, Amenorrhoea; 2, Dysmenorrhcea, or difficult menstruation; and 3, Me-
norrhagia, or excessive menstruation.   Each will require a separate though
brief notice.
   113. 1. Amenorrhea may be divided into two classes:  emansio men-
sium, when the menses have never appeared; and suppressio mensium,
when, having been regular, they are obstructed.   In considering absent
menstruation as a disease,  the reader will  bear in mind  the difference of
age  at which  the  catamenia appear, as  it is not intended to include late
menstruation, as such, in the present class.
   114. Emansio Mensium.—Menstruation may be absent from congenital
malformation.   The ovaries may be wanting, or,  if present, they may be

congestion,  and become, equally with the  uterus, the seat of increased functional
activity.
  " 8. The menstrual flow is a true haemorrhage, as shown by chemical analysis, and
by the phenomena of disease."
  In connection with this subject, the following case, recorded by Dr. Janzer, in the
Medicinische Annalen, vol. xiii.,  p. 4, is in the highest degree interesting.   It illustrates
the changes which the mucous membrane of the uterus undergoes during the menstrual
period.
  The young girl who was the  subject of the observation had menstruated four days
before being murdered.  She had never been pregnant.  Her body was examined six-
teen  hours  after death.   The  surface of the  left ovary presented a deep  red spot,
surrounded by finely injected vessels.  The spot was  formed by a small globular mass,
imbedded in the ovary, and of  an intense red  throughout its whole thickness.   This
mass was separated  from the  tissue of the ovary by a  thin yellow envelope, and was
composed of fibres like those of areolar tissue,  arranged in superimposed layers.  The
yellow envelope was formed by  the same kind of fibres, among which was a pretty con-
siderable quantity of fat, not contained in  cells.  Near this body there was seen a
small, yellow, spherical, modulated mass, composed of areolar tissue and  fat.  The
right ovary contained two yellow bodies.  The  Fallopian tubes, which  did not embrace
the ovaries, were tumefied in the upper two thirds.   On slight pressure, a white matter
issued from them, resembling pus, and entirely  composed of round epithelial cells, some
of which were furnished with vibratile cilia.   No ovule, nor any traces of spermatozoa,
were found.
  The uterine mucous membrane, between the body and the neck, was much swollen.
In the uterus itself, it formed a velvety membrane, glossy and brilliant, easily detached
with the handle of the scalpel,  and presenting a fine network of vessels.   This mucous
membrane was  evidently thickened; it was composed of the uterine glands, ranged
perpendicularly alongside each  other, and fitted with cylindric epithelium/not ciliated.
The structure between the uterine glands was composed of a network of delicate fibres,
of some nucleated cellular fibres, and of amorphous tissue.   The surface of the uterus
was covered with a thin layer of mucus, and lined with cylindrical epithelium, without
cilia.  The orifices of the Fallopian tubes were  open.  The vaginal  mucous membrane
was pale, but was only covered with a thin layer of mucus, containing epithelial cells.
  It results from this observation, that the mucous membrane of the uterus presents,
during menstruation, characters analogous to those which exist during gestation; such
as the hypertrophy of the uterine follicles, and the disappearance of vibratile cilia.—
Land. Journ. of Med., from Gaz. Med. de Paris, March, 1850.—Editor. 
DISORDERS OF  MENSTRUATION.
87
atrophied or diseased; the vesicles  may  be diseased or absent.   But,
although the ovaries be well developed, other organic irregularities may
prohibit the periodic evacuation:  for example, the uterus may be absent,
or incompletely developed ; the canal of the cervix may be closed, the os
uteri impervious, the vagina absent; its sides adherent or its orifice  closed
by adhesion, false membrane, or an imperforate hymen.
  When the defect is ovarian, we find no effort at menstruation  at all;
the body is generally pretty well developed, and its functions (except the
one) tolerably correct; but the sexual characteristics are wanting.  When
the uterus is absent or defective, on the contrary, these sexual peculiarities
are observed, and there is an effort at menstruation  every month,  but of
course no discharge.   There is a considerable difference, however, when
the passage merely is obstructed;  then the menses may be secreted, and
retained  in the cavity of the uterus or vagina, until  from over-distension
the parietes give way.
   115. The diagnosis will  depend upon these peculiarities, and the treat-
ment must be adapted accordingly.  Nothing effectual can be done if the
uterus or ovaries be absent; but, in occlusion of the os uteri or vagina,
an effort must be made to remove the obstacle.   The os uteri, or canal of
the cervix, may  be pierced by a pointed probe, a trocar, or an  instrument
like that used by Mr. Stafford for strictures of the urethra.  An artificial
vaginal canal may be formed by the knife, or by forcibly separating the
parietes.   Occlusion of the vaginal orifice may be remedied by the knife
or trocar.   Great care will be required  after any of these  operations;
leeches, cold lotions, fomentations, or poultices  may be necessary.  A
piece of lint, spread with simple cerate,  should  be  introduced into the
opening  to prevent the formation  of new adhesions.
   116. Simple Amenorrhoea is the name  given to those cases where the
sexual system is  developed, the  signs of puberty present, but where no
discharge at all escapes from the vagina.   The subjects of this disease
may be  of robust habit of body, or weak, pale, and delicate.   In the
former, the constitutional suffering is more  severe, with some febrile action,
flushed face, headach, full pulse, &c.   In the latter, the sympathies of
distant organs are manifested more slowly,  and there is little, if any, febrile
action.   They appear, in fact, something like the acute and chronic stages
of other  diseases.   In either, an attempt at menstruation may be made
every month, accompanied by rigors, pain in the  back and loins, weight
at the lower part of the abdomen, aching  along the  thighs, general lassi-
tude and uneasiness, &c. &c, without any discharge.  But, though these
symptoms pass away, another series  arise: the patient complains  of fre-
quent headach, sometimes with intolerance of light and  sound, throbbing
and a sense of fulness in the head, pain in the side or back; the stomach
and bowels become  irregular, the countenance pale, and  the strength
reduced.   Paroxysms of dyspnoea and  hysteria  may also occur, and-the
patient acquires  the appearance of confirmed ill-health.   Of course, these
symptoms will differ in different constitutions; and cases occur occasion-
ally,  in  which  a  long  continuance of  amenorrhoea  has  but slightly
disturbed the general health.
  A vaginal examination with the finger or bougie affords no information
in these cases.
   The causes of this variety, says Dr. Locock, " are  generally to be found 
88
DISORDERS OF MENSTRUATION.
in the previous habits of the patient; for it is most frequently met with in
those who have  led sedentary and indolent lives, who have  indulged in
luxurious  and gross  diet, and been accustomed to hot rooms, soft beds,
and too much sleep."
   The proximate cause is probably some peculiar condition of the ovary
in the majority of cases.
   The diagnosis must  be formed  upon the  fact of there being a men-
strual effort or not; and, if there be, upon the existence or non-existence
of obstructions.   If the menstrual molimen  occur, and  there be neither
obstruction nor discharge, we may conclude  the case to be one of simple
amenorrhoea.
   117. The treatment must depend upon the constitution of the patient,
and will vary as it is administered  during an interval, or at a menstrual
period.   In patients of  a  full habit, venaesection will often  afford relief.
This  must be followed during an interval by  a diminution in the  quantity
of the food, absence of stimulants,  exercise,  and occasional  purgatives.
When the patient is of a weak,  nervous, or leucophlegmatic constitution,
the system should be strengthened by generous diet and the moderate use
of wine, with  gentle  exercise.   Preparations  of iron will be  found very
useful.   By the older writers a long list of emmenagogues is  given ;  but
modern experience has  reduced the number.  Iodine, strychnine, elec-
tricity, and iron, certainly seem to have a direct power on  the uterus,  and
may be given advantageously.   Stimulating injections into the vagina or
uterus have been recommended, but they are very questionable.   M. Car-
ron du Villard has  succeeded with the cyanuret of gold, Dr. Loudon by
leeches to the breasts, Sir J. Murray by cupping-glasses to these organs,
Rostan by leeches  to the os  tineas, Soult with aconite, Hannay with  the
ammoniated tincture of guaiacum, and Schonlein by enemata of aloes.
Stimulating the  neighbouring organs (the rectum and bladder)  is often
beneficial.*

  * The author has shown less than  his wonted clearness on  this subject; indeed, he
appears to have fallen into the common error of regarding amenorrhoea  as a disease;
whereas it is only an occasional symptom—merely the non-performance of a function
not always necessary for the health of the individual, even during the period of female
life when it usually occurs.   It has been shown (page 85) that women  may likewise
bear children without menstruating.   I know a maiden lady, now nearly fifty years old,
who has generally enjoyed very good health, although  she never menstruated more than
twice  a year, and  sometimes only once in twelve or fifteen months.   Amenorrhoea,
therefore, is not properly a disease, but a consequence of either individual  organiza-
tion, disorder of the uterus or ovaries, or of some other organ or  organs sufficiently
important to affect materially the patient's constitution. When it is the consequence
of peculiar organization, of course all attempts to excite or produce the discharge will
be vain, and most likely pernicious; where it depends upon disorder of any one or more
organs, it is obvious that the pathological condition must be sought out  and removed
before we can hope that the  menstrual or any other of the deranged functions can be
restored.   Viewed in this light, all the means  that restore the system to health, medi-
cinal or hygienic, may be regarded as emmenagogue; but that we possess any article
having the direct power of causing or restoring the secretion, apart  from its property
of overcoming some morbid condition  of the uterus or ovaries, or other organ affecting
the general health of the individual,  has not  yet been proved, nor is it probable  that
any such exists.   Nothing can be more opposite and  heterogeneous than the  articles
commonly prescribed as emmenagogues; and it is therefore with justice  that they are
classel by Dr. Ferguson as "nostrums."  The little confidence reposed in such agents
has induced some  practitioners to attempt the restoration or establishment of the dis-
charge by the means referred to above of a more direct nature.   In some instances of
mere torpor, electricity has been useful in exciting the capillaries to greater activity by 
DISORDERS OF  MENSTRUATION.                  89
   118. Amenorrhoea, with vicarious Uterine Leucorrhcea, differs essentially
from the preceding varieties, inasmuch as uterine secretion exists, whereas
in them the uterus was quiescent.   The product is a white or colourless
fluid, and, so  far, not the  menses;  but the symptoms of menstruation
occur, and  the patient does not  require  medicine  acting  directly upon
the uterus.  I  have  already  alluded (§ 105)  to  the leucorrhcea, which
occurs at  the  commencement of menstruation, and which is generally
superseded by the menses after one or two periods.   It is only when this
change does not take place  that we need interfere.   The white discharge
may continue  periodically to usurp the place of the catamenia; but, in
addition, it often continues  during the interval.
   119. Treatment.—When  the white discharge is persistent, the case is
one of uterine  leucorrhcea,  and requires the appropriate treatment; but
when  it occurs only at  intervals, as vicarious  of the menses, our object
should be to strengthen the  constitution by generous diet, exercise, bath-
ing, &c, and tonic medicines.  I have found  great benefit in such cases
from the carbonate of iron.
   120. Suppressio Mensium.—A  suppression of the menstrual discharge
may occur suddenly, or  more gradually; in other words, it may be acute
or chronic.
   121. Among the  causes  of Acute Suppression of the Menses may be
mentioned cold caught during their flow, by wet feet, &c.; sudden mental
emotion, or a bodily shock, fear, disease, &c.
   The amount of disturbance consequent upon the sudden arrest, varies
a good deal.   Most frequently a degree of fever results, with headach,
hot skin, thirst, quick pulse, &c.;  or  the patient may be attacked by local
inflammation of the  brain, lungs,  intestinal canal, or of the uterus  itself.
Sometimes, instead of inflammation, we see attacks of hysteria simulating
inflammation, or of neuralgia of different  parts.   Occasionally derange-
ments  of  the  senses, aphonia, imperfect  vision,  &c, or  paralysis and
apoplexy follow.
   The sudden suppression, from  a  definite cause, will distinguish this
form of amenorrhoea from all others.
   122.  Treatment.—The first object is to recall the discharge, if possible.
For this  purpose  the  patient should take a hip-bath or pediluvium, and
swallow some  warm drinks.   Mild   diaphoretics  and  gentle purgatives
will also be useful.   Should all our attempts  fail, we  may content our-
selves with mitigating the  severer symptoms,  until the approach of the
next  menstrual period, when the  diligent use of the ordinary remedies

its direct impression on the  nerves of the uterus; but  it is a means which is adapted
to a very limited class of cases.  "Stimulating injections into the vagina and uterus,"
are indeed questionable — into the  latter organ, imminently dangerous.  This is the
expression of Bretonneau, Ricord, and several other respectable authorities. " M. Hour-
mann  relates a case where violent abdominal pain, followed  by metro-peritonitis, was
caused  by the injection of a decoction of walnut leaves  into the uterus, for the cure of
an obstinate leucorrhoeal discharge, which had been traced to come from the cavity of
that organ.  Wishing to ascertain whether  these dangerous symptoms could  be pro-
duced from a portion of the  fluid having passed through the Fallopian tubes into the
cavity of the abdomen,  he found, on injecting fluid into the uterus after death, that
such was actually the case."   If the opinion  now prevalent with physiologists shall be*
established, that menstruation is intimately connected with, or dependent on, the matu-
ration and shedding of Graafian  vesicles, it  is manifest that little good can be expected
from articles that are not calculated to impress favourably the ovaries. —Editor.
                                  h2 
90                 DISORDERS  OF MENSTRUATION.
(hip-bath, purgatives) will probably be followed by the proper secretion,
or by a colourless  discharge.  If neither take place, then we must have
recourse to some of those remedies, already mentioned, wThich act directly
upon the uterus.
   123. Chronic Suppression of the Menses may be the issue of  an acute
attack, or it may arise from  the  gradual supervention of delicate health,
or from disease of the ovaries, uterus, &c, or it may occur as the  termi-
nation of menstruation.   The quantity of the  discharge  may diminish,
and  the  periods become irregular, until  at  length the function ceases.
But very often the menses are  superseded  by  leucorrhcea, at first periodic,
but ultimately persistent.
   The symptoms which develope themselves are headach, loss of appetite,
pain in the side and back, debility, and general deterioration of health.
   The most important point  for diagnosis is to distinguish this form of
suppression from pregnancy, and which mainly rests upon the absence of
the usual signs of pregnancy.
   124. Treatment. — When  the suppression has been the result of dis-
ease, upon its removal  the catamenia will  return; and if it has been
caused by leucorrhcea, the proper treatment of that disease will generally
end in the restoration of the menstrual discharge.   When the suppression
is uncomplicated, the remedies for simple  amenorrhoea may be tried ; but
caution will be necessary, and a careful estimate of the general condition
of the patient, together with a  vaginal examination, in order to make sure
that there  is neither organic disease, nor obstruction of the womb, and
that the case be  not one of premature but normal cessation of the menses.
   125. Vicarious Menstruation. — This is a  very curious  deviation from
normal menstruation, and seems a provision for, in some degree, mitigat-
ing  the constitutional effects  of suppressed menstruation, by substituting
a similar discharge from some other part.  It  is recorded to have taken
place  from the  nostrils, eyes, ears, gums, lungs, stomach, anus, bladder,
nipples, the  ends of the fingers and  toes, from different joints,  from the
axilla, from  the stump of an amputated limb,  from ulcers, from varicose
tumours, and from the surface of the skin generally.  The more extensive
mucous  membranes  are,  however, most  frequently the seat  of the dis-
charge.   It appears to be sometimes blood; in others, it has the characters
of catamenial fluid, being dark-coloured, thin,  and not coagulable.   The
repetition  of this discharge may occur at the  regular  period, or it  may
intermit; and it does not  appear  that any  serious result follows, even
when delicate organs are the seat of  it.  Sooner or later the uterus re-
sumes its functions, and the attack ceases.
   126.  Treatment. — After this discharge has once  occurred, it will  be
proper to take measures to  relieve the system in a less questionable man-
ner, by venaesection, cupping, or leeches, and a  careful  watch will  be
necessary.  If the evacuation  take place from the lungs or stomach, opium
combined with  lead or bismuth, and  the mineral acids, will  be found
 beneficial.   During an interval, the  patient may be treated much in the
same way as for amenorrhoea, and occasionally we may try some of the
 direct remedies.
   127. 2.  Dysmenorrhea,  difficult or painful menstruation.—This form
 of abnormal menstruation, consists  of severe pain  in the  secretion or
 emission of the discharge, which may be scanty, profuse, or about the 
DISORDERS OF  MENSTRUATION.
91
usual amount.  The attack is occasionally confined to one or two periods,
but more frequently lasts for a longer time, and sometimes for many years.
From the  different character  of the pain and  constitutional symptoms, I
have divided the disorder into three  species, — neuralgic, inflammatory,
and mechanical dysmenorrhcea.
   128.  JYeuralgic Dysmenorrhcea. — This variety may occur at any age,
but is more frequent after the thirtieth year than before; in unmarried than
in married women, and, if married, in  those  who have  not borne  chil-
dren.   It is almost confined to those of a nervous temperament, and of a
thin delicate  habit.   The monthly paroxysms present all the characteristics
of neuralgia; and I am very much inclined to agree with Dr. Tyler Smith
that the chief  seat is  in  the ovaries.  For a short time previously, there
is a sense of general uneasiness, a deep-seated feeling of cold, and head-
ache, sometimes alternating with pain in the back.   The latter commences
in the region of the sacrum, and extends round to the lower part of the
abdomen,  and  down the thighs.   The amount of suffering varies; but it
is sometimes very great.  After a longer or shorter period, the catamenia
appear, sometimes  slowly and scantily, in others, in slight gushes.  The
quantity differs in different persons, and in the same person at different
times.   The quality of the  discharge may be unchanged, but  we  fre-
quently find it  paler, and occasionally mixed with small clots.
   In some cases, there is a  membrane,  composed of plastic lymph,  dis-
charged either  in shreds, or in the form of the uterine cavity which it has
lined.  It  seldom occurs regularly, contrary to the opinion of Dr. Den-
man.   It  was first, I  believe,  described by Morgagni;  and since  by
Denman, Burns, and other obstetric writers.  Dr. Simpson has recently
expressed  an opinion  that these productions  " are  not  the results, as is
generally supposed, of fibrinous or plastic exudations  upon the free surface
of the  uterus, but  that they consist of exfoliations of that membrane
itself."   At  present I  confess I am not prepared to agree with the able
and learned  Professor.  Denman states that he never  knew  a  woman
conceive by whom  this membrane was secreted; but this conclusion ap-
pears to be too general.   Conception is rare  under  such circumstances;
but it has occasionally taken place.
   The symptoms enumerated are not always mitigated on the appearance
of the menses ; the pulse  is scarcely quickened, nor is there any feverish-
ness.   The duration of a period is variable.   In some cases there  is com
paratively little constitutional injury sustained, but in others the patient's
health is much deteriorated.
   The  cervix  uteri undergoes the change usually observed during men-
struation, but nothing else is detected by an internal  examination.
   From an  attentive examination of these cases, I  have been led to the
conclusion that the disease  is generally of a simple neuralgic character.
Probably in those cases where the membrane is discharged there may be,
as Dr. Locock  thinks, a degree of inflammation of the mucous membrane,
of a peculiar kind.
   The causes are cold, sudden shocks, mental emotions, &c. acting upon
an irritable condition of the womb.
   129.  Treatment.—The indications are two-fold: first, to reduce  the
pain during  an attack; and, secondly, to prevent its return, by appro-
priate remedies during an interval.  The first indication is best answered 
92
DISORDERS  OF MENSTRUATION.
by sedatives, opium or some of its  preparations, hyoscyamus, conium,
&c. which may be given alone or in combination with camphor.  Should
the stomach be  irritable, they may be  exhibited  in an enema.   I have
remarked that  the  discharge increases when the pain is relieved.   Other
remedies  have been  tried with success; as, the acetate  of ammonia by
Massuyer, Cloquet, and  Patin; ergot  of rye, by Dewees and Gooch,
&c. &c.
  During the  intervals, every effort should be made to strengthen the
patient, and  to diminish  general and local  irritability.   The  diet should
be nourishing,  and  plenty of exercise in the open air should be taken by
the patient.  Chalybeate waters or some preparation of iron may be given.
Dr. LoCock speaks highly of a mixture  of equal parts of vinumferri and
the spirit, other, sulph. co.,  of which from  half a drachm to a drachm
may be taken two or three times a day.  Dr. Dewees has tried the tinct.
cantharid., and Dr. Chapman the senega root, with success.    A blister to
the sacrum, or a caustic issue,  is  often of great use;  and I have seen
much benefit derived from the daily use of vaginal injections  of tepid or
cold water, during the interval.   On the approach of the  next period,
warm water should be  substituted, and the  patient should use a hip-bath
or pediluvium  for two  or  three nights  in succession,  antecedent to the
eruption of the menses.   Since  the first edition of this work I have suc-
ceeded in curing a case  of this kind, in which the false membrane in
shreds was discharged  every month, by repeated applications of the
caustic  tincture of iodine to the cervix uteri.   This  is  by far the most
obstinate variety of the disorder.*
  130.  Inflammatory Dysmenorrhcea. — The subjects of  this  form differ
as widely from those of the former as its symptoms.  It occurs in females
of a full habit  and  of a sanguine temperament, in the married as well as
in the unmarried, and in those who have borne children.   Few precursory
symptoms announce the attack; a degree of  restlessness and feverishness,
rigors, flushing, and headach,  generally precede the severer  symptoms.
For some time before and  after the  catamenia appear, the suffering is very
great; the patient complains of pain across the back, aching of the limbs,
weariness, and intolerance of light and sound; the face is  flushed, the
skin hot, and the pulse full, quick, and bounding.  Delirium occasionally
supervenes.  Most frequently the symptoms are mitigated when menstrua-
tion takes place, and by degrees  subside.  The  discharge is generally
sufficient, and in some cases  is accompanied  by the secretion of the plastic
membrane spoken of above.
  During the intervals, the health of the patient is little affected; she' may
be subject to headachs  and pain in the side, but these are generally tran-
sient, and do not interrupt the functions of the different organs.   Uterine

  * In a few instances, I have derived advantage from the administration of ten grains
of ergot, morning, noon, and night, commencing three or four days before the expected
attack, and continuing it daily until the period arrived.  As soon as the attack com-
mences, I have always found it advisable to moderate its violence by sending the patient
to bed, applying warmth to the feet and to the vulva, and administering some of the
preparations of opium.  Three grains of opium as  a suppository, or  sixty drops of
laudanum, suspended in a tablespoonful of mucilage, as an enema, has always afforded
great relief at the time, and, apparently, lessened the disposition to a return at the next
period.  In severe cases, it may be proper to repeat the anodyne every  day until tho
pain ceases. — Editor. 
DISORDERS  OF MENSTRUATION.                 93
leucorrhcea is not unfrequently present during the interval.  An internal
examination during the attack affords evidence of some congestion of the
uterus; the cervix is swollen, and the heat of the parts increased.  Dr.
Dewees has noticed pain and swelling of the breasts as an occasional ac-
companiment of this form of dysmenorrhcea.
   A severe attack of either variety has the effect of precluding conception;
but I have repeatedly known conception  to take place in spite of and with
benefit to slighter cases.*
   131. Treatment. — The  success of remedies in this variety of dysme-
norrhcea affords  a  confirmation of its character.  Vensesection, cupping
the  loins, leeches, or scarifications to the cervix uteri, afford the quickest
relief.  They should be followed by saline  purgatives,  with  febrifuge
medicines, and cooling drinks.  When  by these means the inflammatory
symptoms are subdued, a dose of calomel  and opium at bed-time is often
very useful.
   During the interval great benefit may be derived from judicious man-
agement.  The patient  should take  active  exercise, and  be as much as
possible (if the weather be fine) in the open air.   Walking is preferable
to riding or driving.  Brisk purgatives, and the aloetic are the best, should
be regularly  administered; and on  the approach of the next monthly
period, if much  excitement arise,  it may be  well to abstract blood  by
cupping before the regular  attack comes on.
   132. Mechanical Dysmenorrhea. — I have  applied this title to a diffi-
culty in the  emission  of the menses,  caused by a narrowing or stricture,
in some part of the canal of the cervix.   What may be the cause of this
diminution of calibre, whether it be congenital or the result of inflamma-
tion, is not easy to  determine ; but there can be no doubt of its existence.
Capuron enumerates it among the causes of dysmenorrhcea; and the late
Dr.  Macintosh, of  Edinburgh, states  that  he  repeatedly  detected it.   I
found it remarkably evident in  a case I attended with Dr. Charles O'Reilly
of this  city.   It may occur at  any part of the canal, and  the degree  of
obstruction may vary  up to complete closure.  I  apprehend  that there
can  be little doubt, that dysmenorrhcea may result from this cause, though
I am far from thinking it so common, as  was supposed by Dr. Macintosh;
neither do I  believe that, even where  it  exists, it is always the  cause  of
the  difficulty and pain.  In the case I saw, although we cured the stric-
ture, the  dysmenorrhcea continues  to  this day.  Nor,  even in Dr. Mac-
intosh's cases, is  there sufficient evidence  to prove his point, for he does
not show  that there was  any retention  of the menses, but  merely, that at
subsequent periods menstruation  was easier and more abundant: this
might have arisen from the direct stimulus to the uterus afforded by the
introduction  of bougies.
   133.  Treatment. — The  fact that such a stricture  of the canal of the
cervix has been observed,  should lead us to make an examination with a
small-sized bougie, in all cases of very obstinate  dysmenorrhcea.  Such
an examination is neither difficult, painful,  nor injurious, if proper caution
be observed.   Should stricture be detected, the remedy is the repeated
introduction  of bougies  about every second or third  day,  and increasing

  * According to Dr. Ashwell, when pregnancy occurs  during the continuance of the
disease, " the patient is exposed to the risk of abortion."—(Diseases of Females, Philada,
Ed. p. 80.)—Editor. 
94
DISORDERS OF  MENSTRUATION.
m size, until the obstacle be overcome.   No force must be used; and, if
any irritation manifest itself, it must  be allowed to subside before the
operation be repeated.
  Dr. Simpson has invented an instrument for the division of the cervix
in these cases; but I rather think the  object can be more safely attained
by dilatation, and quite as satisfactorily.
  134.  3. Menorrhagia. — I shall follow Dr. Locock's example,  and
apply this term to an increase in  the monthly evacuations, whether accom-
panied by blood or not.  Excessive  menstruation  may occur in various
ways: the menses may return  too  frequently,  or  too copiously, or at
unusual intervals,  as  during gestation and  suckling.   Some allowance,
also, must be made for differences of constitution, and perhaps of climate.
  I  have observed three distinct forms of the disease.  In the first, the
discharge is of the natural quality, but the quantity or frequency of recur-
rence is  greatly increased.   In  the second, the discharge is large, and
occasionally mixed with  blood;  but no change  in  the  condition of the
body or neck of the womb  can  be  detected by an internal examination.
In the third, there is a considerable  loss of blood, with a marked change
in the size  and position of the  uterus.   Let us examine each of these
varieties in detail.
  135.  The first variety of  Menorrhagia occasionally commences with a
sudden and violent gush from the vagina, after which it stops for some
hours, and then recurs; and this alternation may  continue  during the
usual period of menstruation.   Sometimes, on the  other  hand, the  dis-
charge goes on regularly, but lasts for ten days or a fortnight, or  even
three weeks; or, the quantity each time not being excessive, it may return
every two or three weeks; and, although this latter case is most frequently
met  with in women who have borne many children, I have seen it occa-
sionally in unmarried females.  It is, also, more than the  others,  con-
nected with that state of  the lining membrane which gives rise to uterine
leucorrhcea.
  The symptoms  are exactly those we might anticipate from  the  long
continuance of a  debilitating discharge.  Exhaustion, languor, indispo-
sition to exertion, weakness across  the  loins and hips, pallor of counte-
nance, headach, throbbing of the temples, tinnitus aurium and giddiness,
occur more or less  in these  cases.   If relief be  not obtained, and espe-
cially if uterine leucorrhcea be present, all these symptoms will be aggra-
vated.  The exhaustion and languor  increase, the face  becomes sallow,
an aching pain is felt across the loins and round the  lower part of the
abdomen, pain in the left side, repeated and severe headachs, derange-
ments of the stomach and bowels follow, and, in short,  all the secondary
symptoms and disturbance of the general health which result from amenia,
no  matter how produced.   In  some  extreme, but rare cases, we  have
diarrhoea and  anasarca, with nervous symptoms, melancholy, and  even
epilepsy, resulting from the  disease.   Nothing is discovered by  a vaginal
examination;  there is neither swelling  nor increase of heat about the
uterus;  the os uteri is slightly open,  as usual  during menstruation, but
there is no tenderness.
  Among  the causes we may  enumerate  repeated child-bearing, over-
■mckling, excessive coition,  cold, mental emotion, &c.
   136.  Treatment.—The first indication is to  remove the cause;  if it 
DISORDERS OF MENSTRUATION.
95
proceed from over-suckling, the child should be weaned, and the patient
should live " absque marito."
   In persons of a full habit of body, when the attack is recent, it may be
necessary to take blood from the arm, cup the loins, or apply leeches to
the anus.  The  discharge may be moderated by a  combination of the
acetate of lead with opium.  When this has failed, I have generally suc-
ceeded with  ergot  of rye, in five-grain  doses, three times a day.   Dr.
Locock recommends cold to the vulva, hips, and abdomen, with vaginal
injections of cold water;  and Dr. Dewees has used a vaginal injection of
sugar of lead and  laudanum, wTith rest  on a hard bed, twenty drops, of
elixir of vitriol, and gentle purgatives, wTith success.  I should altogether
deprecate injections into the womb, recently advised by French writers,
as a very hazardous practice, and which even their own experience does
not justify.   A far safer, and, as I have found it, a very effectual practice,
is to employ enemata of cold water.  Plugging the vagina has also been
recommended, and asa" dernier resort" may be tried, though it is not a
very scientific remedy.   Dr. Macintosh speaks highly of an enemata con-
taining a scruple of the  acetate of lead.  The tincture of Indian hemp
has a powerful effect upon this form of the disease.   It was first tried by
my friend, Dr. Maguire  of Chapelizod,  and on his  recommendation by
Dr. Hunt and  myself, with  extraordinary success, both  in  the  number
relieved and the rapidity  of cure.   From  five to ten drops, three times a
day, in some suitable menstruum, will be found sufficient.
   During the intervals, a blister may be  applied to the sacrum, and either
kept open or repeated.   Vaginal injections, at first of tepid and afterwards
of cold water, daily, will be  found very useful.   Benefit will  also be
derived from sponging the loins and lower part of the abdomen with cold
salt-water.  Tonics may be given, comfortable warmth preserved, and a
generous, but not too stimulating, diet allowed.
   137. The second variety of Menorrhagia differs from  the first, in the
discharge of blood which accompanies the secretion.   It  seldom occurs
in unmarried or young females, and generally in those of a leuco-phlegm-
atic constitution, who have been debilitated by disease  or frequent  child-
bearing.   The progress of the disorder is gradual; one  or two small clots
appearing at first, then an intermission,  and a more  copious  recurrence.
After some time, the  discharge of blood  may be considerable, so as in
some cases to produce fainting.   It is of course  impossible to ascertain
whether the catamenia themselves  are altered in quantity or quality.  A
vaginal examination throws no light  upon the nature of the disease, the
uterus being in  its usual state during menstruation.  The constitutional
effects are similar to those noticed under the  first form (§ 135), hut more
severe, and produced more rapidly.
   138.  Treatment.—The remedies recommended for the former variety
are equally available here.   Opium, alone or in combination with lead,
and ergot, or Indian hemp, during the attack; with  counter-irritation to
the sacrum, the douche to  the loins or cold  sponging, vaginal injections or
enemata, during the interval, are our chief resources.*
  * The juice of the common lesser nettle ( Urtica urens) is strongly recommended by
M. Ginestet, in doses of 15 to 30 drachms.  In  preparing the juice, a quantity of the
green herb is bruised, with  the addition of a little water, and the fl'aid portion then
Btrained off by pressing the mass  in a linen bag.  One  dose is  said to bo  generally
        7 
96
DISORDERS  OF MENSTRUATION.
  139.  The third variety of Menorrhagia  differs considerably from the
other two ; the discharge is more profuse, and its effects  more severe ;  it
is accompanied by marked alterations in the condition and relations of the
uterus, occurs at a later period of life, and  is more difficult to cure.  The
attack is not confined to any one kind of constitution or temperament •  it
occurs in the plethoric  and in the debilitated, in the melancholic as well
as in the sanguine.  I have never seen it in a patient under forty years of
age, nor after the cessation of the catamenia.
  The attack  is  preceded  for some time  by irregularity of the menses
both as  to time, quantity, and the duration of each period, with occa-
sional uterine leucorrhcea during the intervals.  It is not  until the menses
have flowed  naturally for about twenty-four hours,  that the sanguineous
discharge appears.  Large  clots are then expelled,  in addition to a oreat
increase in the fluid discharge.  At first,  the attack lasts seven or ten
days only; but in cases of longer standing I have occasionally known  it
to continue throughout the interval, and terminate after the next period
either  gradually or suddenly.   The quantity lost varies,  of course; it  is
sometimes very large;  it was sufficient  in  one case to excite fears of a
fatal result.
  The  recumbent posture  appears to have no effect upon the discharge,
there being as  much observed during the night as the day.  Any exertion
or long standing never fails to increase the  amount.
  During the  attack, the patient complains of excessive exhaustion, of a
sense of weight in  the pelvis, of a dull  pain there occasionally, and  of
weakness of  the loins.   In all the cases I have seen there was considera-
ble dysuria, especially after long standing:  several,  indeed, were obliged
to lie down, before they were able to evacuate the contents of the bladder
completely.
  The general health, of course, suffers considerably; the appetite dimi-
nishes, the tongue is clean,  though pale, the bowels become constipated,
the surface blanched, and the strength much reduced.
  The  pulse is occasionally quickened, but more  generally quiet, and
enfeebled in proportion to the loss of blood.
  An internal  examination will detect the os uteri somewhat lower in the
pelvis  and directed more  towards  the sacrum than usual.  It is rather
more patulous than ordinary, and  the cervix  is more or less swollen,
especially anteriorly, where it expands  into the body.  It appears to be
tilted forward by its increased weight, so as to press upon the bladder,
thus affording  a satisfactory  explanation of the dysuria which  I have
noticed in every well-marked  case.  No increase of heat is observed in
the  vaginal canal, or about the cervix.   The cervix  and lower part of the
body of the uterus are generally, but  not always,  slightly tender on
pressure.  Of course the amount of these alterations will  vary in different
cases.
  The disease  must  be regarded as congestion of the uterus occurring at
the  menstrual period, and  giving rise by its excess to a rupture of some
small vessels.   Whether it has  anything to say to the  production of the
organic diseases of the time of  life at which it occurs, may not be easy to
decide :  I think it not improbable.
sufficient to check the discharge. Ranking's Half- Yearly AbsUfrom Encyclop. Med. d*
M Lartigue, Oct. 1844.—Editor 
DISORDERS OF MENSTRUATION.
97
   The diagnosis will  not  be difficult if we bear in mind the mode of
 invasion, the character of the discharge, the local characteristics, and the
 subsidence of the attack.
   140. Treatment.—Although the complaint appear simple, it is neither
 easy nor possible in all cases to restrain the hemorrhage by means applied
 during the attack.  I have found opium alone, and in combination with
 large  doses of  the  acetate of lead, ineffectual.  Cold  to the  vulva and
 enemata  of cold water were equally powerless.  Plugging the vagina
 arrested the discharge for a time, but the irritation it excited  seemed to
 aggravate the other symptoms.   Leeches to  the vulva had no effect upon
 it, and the preparations of iron did little or no good.  The only remedy,
 in short, which  seems to have  the  power of controlling the discharge
 during the menstrual period, is the ergot of rye.   It may be given in
 doses of five or ten grains twice or thrice a day.   I have never  seen  it
 produce any ill effects in this disease, although I have certainly known it
 fail altogether.
   During an attack, the patient should be kept in a state of perfect rest:
 she should lie on a hard mattress, covered rather lightly with bed-clothes,
 but with warmth applied to the feet.   All her drinks should be cool and
 devoid of stimulants, unless she become faint, and then a little wine may
 be allowed.
   At this period, ergot of rye, or any astringent medicine, may be given.
 If the discharge  be not arrested, and  show a disposition to continue
 throughout the interval, it  may perhaps be justifiable to inject  the vagina
 with cold water or an  astringent lotion.  I have never tried this, but have
 found enemata of cold water answer the purpose very well.
   So  long as  the discharge continues, the  employment  of the remedies
 for the cure of  the  disease must be  suspended;  but, when once  it  has
 entirely ceased, not a moment should be lost.  A blister should be applied
 to the sacrum,  and either kept  open or repeated;  I have always  found
 good result from this;  the pain in the back generally becoming less
 severe, and the whites diminishing in quantity.  But by far the  most pow-
 erful means we  possess, are vaginal injections of cold water, of a solution
 of acetate of lead, or  other astringents, two  or three times a day.  The
 patient should lie on her back in  bed, and the fluid  should be  thrown up
 gradually.  An almost immediate improvement is the result, followed by
 the subsidence of all the prominent symptoms, even in those cases which
 relapse subsequently.   The swelling of the uterus  will  be  found upon
 examination to have disappeared  ; there is probably scarcely any whites,
 no pain  in the  back or weight in the pelvis, and the patient  is able to
 walk about without inconvenience.
   When  the improvement is so  marked as this, there is but little fear
 (with due caution) that the patient will relapse at the next monthly period ;
 but where  the relief, though decided, is not complete—where the disease
 still lingers, then  in all probability the next menstruation will  be accom-
panied with the old symptoms, to be met again and perhaps more suc-
cessfully by the  same remedies.*
  * In a recent very interesting treatise on the Diseases of Menstruation, &c, Dr. E.
J. Tilt has endeavoured to show: —
  1st. That dysmenorrhcea is often the result of subacute ovaritis; sometimes the result
of the uterine engorgement which it determines.
  2d. That dysmenorrhcea is often  the result of morbid ovulation, and often a symptom 
CHAPTER III.
                   GENERATION. — CONCEPTION.

   141. Immediately after the effective  intercourse of the male with the
female, a series  of changes commences,  which ultimately  issue in the
formation of a new being, possessed of individual or independent  life.
The first step in this process is called Generation, Fecundation, Concep-
tion, &c.   The period of fecundity in the human female lasts about thirty
years, i. e. from the fifteenth to the forty-fifth year, or thereabouts; in other
words, it is contemporaneous with menstruation.
   142. From the hidden nature of the process and the stupendous results,
the subject has always possessed the deepest interest for physiologists, and
at the  same  time given rise to a multitude of theories, most of them, to
say the least, mere hypotheses.  Dr. Allen  Thompson, in  his  valuable
paper on Generation, in  the Cyclopedia of Anatomy, &c. thus classifies
them:  " The greater number of the older theories  of generation may be
brought under one or other  of these divisions; viz. the theory of the
ovists,  of the spermatists,  or of that of combination, evolution, or  epi-
genesis.  According to the first-mentioned of these hypotheses, or  that
of the ovists, the female parent is held to afford all the materials necessary
for the formation of the offspring, the male doing no more than awakening
the formative powers, possessed by and lying dormant in the female pro-
duct.  This was  the theory of Pythagoras, adopted in a modified form by
Aristotle : and we shall afterwards see  that it resembles most closely the
prevailing opinion of more  modern times.  The terms, however, in which
some of the  older authors  expressed this  theory are very vague; as, for
example, in the notion that the embryo or new product is formed from the
menstrual blood  of the female, assisted by a sort of moisture descending
from the brain, during sexual  union.
   "According to the  second theory, or that  of the spermatists, among
the earlier supporters of which, Galen may be reckoned, it was supposed
that the male semen alone furnished all the vital parts of the  new animal,
the female organs merely  affording the  offspring a fit place  and suitable
materials  for its  nourishment.  Immediately upon the  discovery of the
seminal animalcules,  these minute  moving  particles  were  regarded by
some as the rudiments of the  new animal.  They were said  to be minia-
ture representations of men, and were styled homunculi ;  one  author going
so far as to delineate in the seminal animalcule, the body, limbs, features,
and all the parts of the grown human body. The microscopic animalcules
were held by others to be of different sexes, to copulate, and thus to en-
gender male and female offspring; and the celebrated Lieuwenhoek, who
of ovarian peritonitis.  That, frequently, subacute ovaritis, by determining the inflam-
matory swelling of the neck of the womb, is a mediate cause of dysmenorrhcea; the
painful symptoms being, in many instances, produced by the partial closure of the neck
of the womb, and the consequent effusion of menstrual secretion into the peritoneum.
  3d. That, in many cases of menorrhagia, it is subacute ovaritis, which, by some un-
explained process, disposes the engorged uterus to let the vital fluid run in waste.
  4th. That subacute ovaritis, by inducing cerebro-spinal reflex action, in certain pre-
disposed subjects, is the most probable cause of hysteria. — Editor.
                                                          (98) 
GENERATION. — CONCEPTION.
99
was among the first to observe these animalcules, described minutely the
manner in which they gained the interior of the egg, and held that after
their entrance they were retained by a vulvular apparatus.
   " The theory of syngenesis or combination seems to have been applied
principally to the explanation of the reproduction of quadrupeds and man,
the  existence and  nature of the ova of which, were involved in doubt.
This hypothesis consists in the supposition, that male and female parents
both furnish simultaneously some semen or product; that these products,
after sexual union, combine with one another in the uterus, and thus give
rise to the egg or structure from which the foetus is formed.  In connexion
with this  theory, we may also mention  that of metamorphosis, according
to which, a formative  substance is held to exist, but is allowed to change
its form in order to be converted into the new being; as also the notion
of Buffon, that organic molecules universally pervade  plants and  animals,
that these are all endowed with productive powers, that a certain number
are employed in the construction of the texture of organised  bodies, and
that in the process of generation, the superabundant quantity  of them
proceeds  to the sexual organs,  and there constitutes the rudiments of  the
offspring."
   It would be mere waste of time to enumerate the modifications of these
theories, which  have been promulgated in profusion from time  to time;
of which "groundless hypotheses" Drelincourt  reckoned two  hundred
and sixty-two, and in addition to which, as Blumenbach remarks, "  no-
thing  is more certain, than that Drelincourt's own theory formed the two
hundred and sixty-third."
   143. The best plan will be to state briefly such facts as we  possess,
which bear upon the conditions of generation and the changes produced
by it.   We have already ascertained that  the  ovaries contain certain
vesicles, and we have reason  to believe that these undergo certain changes
before and after a successful coitus, and that their contents, or that of one,
constitutes the contribution of the female towards the production of a new
being.  Again, we know that the testes of the male secretes a peculiar
fluid called semen, which in the act of intercourse is projected into  the
vagina and uterus of the female, and is supposed to exert a peculiar influ-
ence upon the Graafian vesicles; but  the difficulty has been to explain
how that  influence is communicated or  carried to the ovary.   Various
theories have been propounded (that of an aura seminalis, for example),
but  none  were consistent with  the  observations made upon other orders
of animals; from which it appeared that contact of  the semen  with  the
ova was necessary.   However, this  obstacle has been  removed by  the
recent observations of Dr. Bischoff of Heidelberg,  Dr. M.  Barry, and
Professor  Wagner  of Berlin, who  have detected spermatozoa (seminal
animalcules) in the fallopian  tubes, especially at their ovarian extremity.
This fact  confirms  the conclusion drawn from comparative anatomy, that
contact is essential  to  generation, and  is further strengthened by the ex-
periments of Cruikshank, Haighton, and Blundell, who found that if  the
fallopian tubes were rendered impermeable, impregnation was prevented :
although it  does not  prove that  impregnation may not take place in the
uterus  in some cases.*
  * The question as to how the sperm arrives at the ovarium, has not yet been settled.
" Professor Wagner, who is high authority, considers that the sperm reaches the ovary 
100
GENERATION. — CONCEPTION.
  The  experiments  of Spallanzani and others have proved that a very
small quantity of  semen is sufficient for fecundation.
  144.  Thus, then, we may enumerate as the conditions of generation,
the actual contact of  the  male semen or its  spermatozoa with a healthy
Graafian vesicle or an ovule.   The immediate effect of this  contact or of
successful intercourse,  is the production of great excitement and vascular
turgescence  of the uterus, ovaries,  and fallopian tubes,  which lasts  for
some time, and during which  an alteration  takes place in  the relations of
the different  parts.  The fimbriated extremity  of one of the fallopian tubes
is turned towards the ovary of that side, and embraces it closely, over the
vesicle  which has been impregnated.   This  delicate operation has been
attributed partly  to  the vascular turgescence, and partly,  as in  certain
animals, to muscular action.  How soon it takes place after  impregnation
is not yet determined ;  it may perhaps occur at each menstrual period as
Dr. Tyler Smith supposes.
   145.  With regard to the ovum itself, the  microscopical researches of
Von Baer and Barry have proved that its impregnation takes place in the
ovarium.  After a successful coitus, one or more of the vesicles enlarges
and becomes vascular, the vessels converging  towards the  point, at which
the rupture of its  coats is to occur.  " The fluid," says Dr. Allen Thomp-
son, in  the  essay already quoted, " contained in the vesicles which are
about to burst, previously transparent and nearly colourless, now becomes
more viscid  and  tenacious, somewhat turbid, and of a reddish colour;
and in some animals, it is possible in such ripe vesicles, to perceive with
the unassisted eye, in  a favourable  light, a whitish  opaque  spot  on the
most  prominent part, indicating the layer of granules, or proligerous disc,
in the centre of which the ovum is situated.    After a certain time a small
opening is  formed at  the most prominent  part of the coverings of the
vesicle ; the  vesicle bursts, and its contents escape through  the opening;
they  are  received into the infundibulum, which is  now applied firmly
against  the   ovary ; and the ovum entering the fallopian tube is conveyed
along it, probably by its slow and gradual  vermicular contractions, until
it at  last arrives  at  the uterus."   Recent observations would lead us to
partly by the ciliary motions, which begin in the cervix uteri, partly by the contractions
of the tubes, and partly by the motility of the spermatozoa."*  Dr. Carpenter, however,
seems to think the  latter is the sole means!   " That the spermatozoa make their way
towards the ovarium, and fecundate the ovum either before it entirely quits the ovisac,
or very shortly afterwards,  appears to be the general rule in regard to mammalia ; and
the question naturally arises,—by what means do they arrive there ?  It has been sup-
posed that the action of the cilia, which line the fallopian tubes, might account for
their transit; but the direction of this is from the ovaria towards the uterus, and would
therefore be opposed to it.   A peristaltic action of the fallopian tubes  themselves may
generally be noticed in animals killed soon after  sexual intercourse;  and in those
which have a  two-horned membranous uterus, such as is evidently but a dilatation of
the  fallopian tube, this  partakes of the same movement, as may be well seen in the
rabbit; in animals, however, which have a single uterus with  thicker walls (as in the
human female), it must  evidently be unavailable.  Among the tribes whose ova are
fertilized out  of the body, the power of movement  inherent in the  spermatozoa is
obviously the means  by which they are brought into contact with the ova;  and it does
now seem unreasonable to  suppose  that the  same is  the case in regard to the higher
classes ;  and that the transit of these curious particles from the vagina to the ovaries,
is effected by  the  same  kind of action as that which  causes them to traverse the field
of the microscope."  Human Physiol, p. 595. — Editor.
* Dunglison's Human Physiology, vol. ii. p. 372. 
GENERATION. — CONCEPTION.
101
attribute some influence in this transmission, to the ciliary motions of the
villi of the mucous membrane lining the tube.
  146. It is scarcely possible to obtain an opportunity of examining the
minute changes which take  place in the Graafian vesicle  in the human
female; we must therefore avail ourselves of the information afforded by
comparative physiology, and the more readily, as the process does not
differ essentially.   The following description is extracted from Dr. M.
Barry's beautiful  paper in the Phil.  Trans.  1839, part ii. p.  350: —
"Among the changes occurring in the  ovum (of the rabbit) before it
leaves the ovary, are the following: viz. the germinal spot, previously at
the inner surface, passes  to  the centre of the germinal vesicle ; the ger-
minal vesicle, previously at the surface, passes to the centre of the yelk;


                                Fig. 39.


    1. Tunica granulosa.
    2. Chorion.
    3. Zona pellucida.
    4. Thick transparent
       membrane.
    5. Yelk ball.
    6. Germinal vesicle.
    7. Germinal spot.
and the membrane investing the yelk, previously extremely thin, suddenly
thickens."  The tunica granulosa and retinacula are discharged with the
ovum.
   " Among the changes usually taking place in the  ovum during its pas-
sage through the fallopian tube are the following: viz.  1. An outer mem-
brane, the chorion, becomes visible ; 2. The membrane originally investing
the yelk, which had  suddenly thickened, disappears by liquefaction;  so
that the yelk is  now immediately surrounded by  the  thick transparent
membrane (zona pellucida) of the ovarian ovum; 3. In the  centre of the
yelk there arise  several very large and exceedingly transparent vesicles.
These disappear, and are succeeded by a smaller and more numerous set.
Several sets  thus successively come into view, the vesicles of each suc-
ceeding set being more numerous and smaller than the last, until a mul-
berry-like structure  has been produced, which occupies the centre ot the
ovum.  Each of these vesicles contains a colourless  and pellucid nucleus,
and each nucleus presents a nucleolus."
   " In the uterus, a layer of  vesicles, of the same kind as those of ihe
last and smallest here mentioned, makes its appearance on  the whole  of
the inner  surface of the membrane wrhich  now  invests the yelk.   The
mulberry-like structure then passes from the centre of  the yelk to a cer-
tain part of that layer, (the vesicles of the latter coalescing with those  of
the former, where the two sets  are in contact, to form a membrane, the
future amnion,) and the interior of the mulberry-like structure is now seen
to be occupied  by a large vesicle, containing  a fluid and dark granules.
In the centre  of the fluid of this vesicle is  a  spherical body,  composed
of a substance having a finely granulous appearance,  and containing a
                                 i2
 
102                  GENERATION. — CONCEPTION.
cavity  filled  with a colourless  and pellucid  fluid.   This hollow  and
spherical body seems to be the true germ.  The vesicle containing it dis-
appears, and in its place is  seen  an elliptical depression, filled with a
pellucid fluid.  In the centre of this depression is the germ, still presenting
the appearance of a hollow sphere."
   It is unnecessary to apologise for this minute account of the  changes in
the vesicle; the interest of the question,  and the light thrown  upon it by
the able and careful researches of the  distinguished physiologist from
whom I have quoted, are more than sufficient reason for laying the results
before my readers.
   147. Let  us  now retrace our steps a little:  during the increase of the
vesicle in the ovary, " the inner coat becomes intensely vascular, and on
its external surface, a soft gelatinous substance of a yellowish red colour,
consisting apparently in part of blood and in  part of lymph, is poured
out  between the two coats of the vesicle, in  considerable  quantity all
around, except at the point where it is pressed toward  the external surface
of the ovary."  Such  is Dr. Montgomery's description of the formation
of the corpus luteum, which he conceives aids  in  the expulsion  of the
ovum, after having served " as a  sort of little temporary uterus"  to  the
contained germ, "lined with a serous membrane, covered externally by
another, and having interposed  between  them  the  fleshy or glandular
structure of the corpus luteum, through  which blood-vessels ramify, and
exhale through the  lining membrane a serous fluid for the support of the
early ovum, which  as yet lives only by imbibition."   Professor Von Baer
thought that the corpus luteum was the lining membrane  of the vesicle in
a state of hypertrophy, and Dr. R. Lee believes it to be a deposit external
to the lining; but the extensive researches of Dr. Paterson, published in
the fifty-third volume of the Edinburgh Journal, have,  I conceive, decided
the question in favour  of Dr. Montgomery.
   148. Shortly after the  evolution of the ovum, the  size of the ovary is
found to be increased, especially at a certain part which is prominent, and
about the size of a nut.  At an early period after conception, this small
tumour is of a bluish-red or purple colour, owing probably to the effusion
of blood attendant on the rupture  of its  coats, and having numerous ves-
sels filled with florid blood ramifying on  its surface.   In some  part of this
coloured surface of the tumour, a cicatrix, depression, or aperture,  may
be discovered, being the point at which the ovum, escaped from the ovary
into the fallopian tube.
   149. These external appearances, however,  are inadequate to prove
the  presence of a true  corpus  luteum; they require  confirmation  by the
results of an internal  examination.   " Upon slitting open the ovarium at
this part,"  says Dr. W.  Hunter,  " the  corpus  luteum appears  a round
body, of a very distinct nature from the rest of the ovarium.   Sometimes
it is oblong or oval, but more generally  round.   Its centre is white,  with
some  degree of transparency; the rest  of its substance has  a yellowish
cast, is very vascular, tender, and friable, like glandular flesh.   Its larger
vessels cling round its circumference, and then send their smaller branches
inwards through its substance ;" which substance, according to Dr. Allen
Thompson, " has a lobular structure, the lobules radiating in a somewhat
irregular manner from the centre to the circumference.   The central part
of the corpus  luteum frequently remains hollow for  some time  after its 
GENERATION. — CONCEPTION.                 103

           Fig. 40.
production, opening exteriorly by a narrow passage  from the part where
the rupture of the vesicle originally took place;  at other times, this pas-
sage is closed more early, and there remains nothing but an indication of
its place, in a depression in the centre of the most projecting part of the
corpus luteum.  The lobules of the corpus luteum, examined with the
microscope, exhibit merely a granular  structure, and are not formed of
acini, as some have described them, so  that there is no reason to consider
them bodies of a glandular nature."

                               Fig. 41.
Corpus luteum, from Dr. Montgomery.
   150. The following measurements of the ovaries and corpus luteum,
at the third month of pregnancy, are given by Dr. Montgomery:

      The unimpregnated ovary.            Ovary containing a corpus luteum.
Length ....   1 inch 5 lines.   Length ....   1 inch 3 lines.
Breadth    ...     "  7£ "     Breadth   ...     "   9   "
Thickness  ...     "  5£ "     Thickness ...     "   7£  "

   The corpus  luteum, at the end of the third month, measured " in the
longer axis, seven lines  and  a half;  in  the shorter, six lines and a half;
in thickness, six  and a half;  and, measuring along the shorter axis, the
glandular structure is,  at the part deepest  in  the ovary, two lines and a 
104
GENERATION.— CONCEPTION.
half thick, and at the outer part one line; the central cavity measures
three lines in diameter."
   151. For a short time after the escape of the ovum, the corpus luteum
is said to increase in size, then to remain  stationary, and afterwards to
diminish  slowly.   After the third or fourth  month the central cavity con-
tracts, and  its sides coming in contact give it the appearance of an irre-
gular white line, somewhat radiated.   After delivery, the corpus  luteum
shrinks, absorption takes place, and it disappears, though at  what time is
not  quite  certain.  Dr. Montgomery has observed  it five months after
delivery; but Dr. Paterson's investigations  would lead to the conclusion
that it seldom remains so long.
   152. The number of corpora lutea corresponds exactly to the number
of children; as Dr. W. Hunter remarked, "  where there is only one child,
there is only one corpus luteum, and two in the case of twins."  Meckel
examined two hundred females of the class mammalia,  and found  this
correspondence exact.  But further, not only does each  impregnated
vesicle give rise to a corpus luteum, but nothing else does, at least in the
human subject; so that the presence of a  corpus  luteum is a proof of
impregnation.*
   153. Abnormal deviations. — There are  certain  appearances  in  the
ovary, called "false corpora lutea" which have been  occasionally mis-
taken for true ones, but which  may be distinguished  by careful observa-
tion.  False corpora lutea, according to Dr.  Paterson, may arise," 1, from
the bursting and subsequent filling with blood of a vesicle, as in menstru-
ation (§ 109): 2, from partial effusion of blood into a vesicle, either with
or without  rupture of it: 3, by re-absorption of the fluid of a morbidly
enlarged  Graafian vesicle, giving rise to a  puckered  cyst: 4, from effu-
sion of blood into the tissue of the ovary, the apoplexy of that  organ:
5, tubercular deposits: 6, cysts filled with yellow fatty matter."  In con-
tradistinction to the true corpora lutea, as already described (§  149),  it is
observed, that " they in general have an irregular form.  They want the
central cavity lined  with a  distinct membrane, or the  central puckered
cicatrix.   They have no concentric radii.   They are frequently numerous
in both ovaries."f
  * Dr. Carpenter says, " there is no correspondence between  the number of corpora
lutea found in the ovaries of a woman, or of cicatrices on their surface, and the number
of children she may have borne. The number of corpora lutea must  always be less,
when there have been many conceptions;  but the number of cicatrices may be greater;
for several causes, such as the escape of unimpregnated ova, or the bursting of little
abscesses, may give  rise to such appearances." Principles of Human  Physiology, 2d
Am. Ed., p. 597. — Editor.
  •j- " The true corpus luteum is further distinguished by its capability of being injected
from the vessels of the ovary;  which is not the case with tubercular deposits, or other
substances which may simulate it."  Carpenter's Human Physiology, Am. Ed., p. 596.
   " M. Raciborski, from his experiments and dissections relative to the formation of
the corpora lutea, draws the following conclusions:
   "1. The corpora lutea are the result of a true hypertrophy of the granular layer which
covers the internal  membrane of the Graafian vesicles.  The anatomical elements of
these two parts are  absolutely the same, only the granulations of the corpora lutea are
much more numerous, and involve many more oily  globules of a yellow  colour.
   "2. The transformation of the internal tunic into corpus luteum commences before
the rupture of the vesicle, at the moment when it is ready to give passage to the ovule.
   '«3. as  soon as the Graafian vesicles are ruptured, the transformation of the internal
membrane into corpus luteum acquires an extraordinary activity.  But  there are here
two  essential differences remarked  according as the expulsion of the  ovule has been 
CHAPTER IV.
                         UTERO-GESTATION.

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

                                    Fig. 42.
spontaneous, as it occurs at each menstrual and rutting period, or according as it has
been attended with sexual intercourse and conception.
  "In the females  of most of  our domestic animals, as the pig, cow, sheep, &c, this
difference does not exist. Whether these animals have or have not had connection with
the males, the expulsion of the ovule is always  followed by the formation of corpora
lutea, represented by fleshy masses of a yellow or reddish colour.  It is different, how-
ever' with women.  If the expulsion of the ovule is not  followed by conception,  as
happens at the ordinary menstrual period, then these granulations increase in size and
number • but this activity of nutrition soon stops, and proceeds no further than the
formation of a thin membrane of a more or less deep yellow colour, applied against the
proper membrane of the vesicle; this membrane surrounds a cavity in which may gene-
rally be found traces of a clot of blood.  If, on the other hand, conception coincides
with the expulsion of the ovule,  the elements of the granular tunic augment so in num-
ber and volume that in a short time they form a pretty voluminous mass, which of itself
fills the whole cavity of  the vesicle.
  "4. In all women delivered at the full time, we find a corpus luteum such as we have
described.   But what is very remarkable, is the rapidity with which the corpus luteum
decreases and becomes atrophied as soon as delivery takes place.  Thus a corpus luteum
which, on the second or third day after delivery, would have a medium diameter  of
seven-tenths of an inch, by the tenth day  would  be reduced more  than one half,  and,
by the end of three months, a small scarcely-coloured particle, not exceeding a line in
diameter, could alone be detected.
  " 5. It results from this,  that in women it is very easy to distinguish, by the inspec-
tion alone, cases of the spontaneous expulsion of ova from those in which the expulsion
has been followed by conception."   Edinburgh Med. and Surg. Journ., April, 1845. From
Bulletin de VAcadimie Roy ale de  Medecine.
  " It is an important fact to notice, that, whereas a spurious corpus luteum comes  to
maturity in two or three days, the true corpus luteum goes on progressively increasing
for some weeks.   This assertion is based on the fact,  that the walls of a false  corpus
luteum are thickest immediately after the cessation of the menstrua;  whereas  true
corpora lutea, examined  a month after the fcetal development has commenced, are found
increasing."  Dr. F. Renaud, Monthly Journal of Med. Science, August, 1845.—Editor. 
106                      UTERO-GESTATION.
  It has already been stated, that conception is accompanied or imme-
diately followed by congestion of the uterus; its vessels are filled with
blood, and enlarge gradually, until  they become of great size.   Many
which did not carry red blood  before, and therefore were invisible, are
now evident;  and the whole form an intricate net-work on  the  surface
and in  the substance of the organ.   Not only are the arteries (fig. 42)
distended, but, to  meet this increased labour imposed upon  them, their
coats are actually  increased in thickness, so much so as to preclude their
return to their former condition after  the object of their temporary enlarge-
ment is fulfilled.   This explains why we always  find them  more or less
enlarged and tortuous, in women who have borne children.
  The coats of the veins are much thinner, and admit of still  greater dis-
tension ; this is so marked in that part of the uterus to which the placenta
is attached, that they have received the name of uterine sinuses.
  The lymphatics  undergo a proportionate development,  and  in the latter
months of pregnancy may easily be  traced.  Mr. Cruikshank, I believe,
has the credit  of first demonstrating  them.
  155. The nerves of the uterus (fig. 43), which are very small in its
unimpregnated state, increase in size, until at the full terms they form
large cords, which send off numerous branches to accompany the  uterine
vessels,  and which, anastomosing  freely  with  each other,  exhibit  an
appearance of network, similar  to that observed in the vessels.   Their
substance is actually increased, nor do they recover their pristine size
after delivery.
                               Fig. 43.
   VVe are much indebted to the labours of Hunter, Tiedemann, and
recently of Dr. Lee, for the additions they have  made to our knowledge
of the nerves of the uterus. 
UTERO-GESTATION.
107
  156.  Great as these changes are, they are equalled, if not surpassed, by
those which take place in the proper tissue of the uterus.   In proportion
as space is required for the foetus, on account of its growth, the  fibres are
loosened,  and separate from each other, leaving between them large inter-
spaces, which afford space for, and are occupied by, the enlarging blood-
vessels  and nerves.  The amount of distensibility is very great, and fully
equal to the accommodation of the foetus, during the term of intra-uterine
life.  Nor is this distension accompanied by much thinning of the parietes:
according to Meckel, they increase in thickness  during the first three
months, and afterwards diminish to the end of gestation; but even then
they are from one to two-thirds of an inch thick, and even more about the
insertion of the placenta.  To explain this, it is supposed that new matter
is superadded  during gestation, and  removed after delivery; and this
opinion is confirmed by the difference in weight between a virgin uterus
and one  at the full term, emptied of its  contents; the former weighing
one ounce, the  latter about twenty-four.  Even when deprived of its extra
quantity of blood by firm contraction after delivery, it is many times larger
than before conception.
   157. The increase in the size of the womb  commences at the fundus,
immediately after the descent of the ovum, and, as this is developed, the
body enlarges; last of all, and not before the fifth month, the cervix.
   During the first four months, the entire organ is contained in the cavity
of the  pelvis;  soon after which time  the fundus may be felt, in thin
females, above  the symphysis pubis;  about the fifth month it reaches mid-
way between the pubes and umbilicus, and gives a roundness and fulness
to the lower part of the abdomen; at the end of the sixth month, it is as
high as the umbilicus, which it protrudes; during the seventh month, it
ascends midway between the umbilicus  and the  ensiform  cartilage;  at
the end of the  eighth month, it reaches the ensiform cartilage and fills  the
abdomen, having the intestines above and behind it.
   During the  ninth month, although it somewhat increases in size, yet,
from the  yielding of the abdominal  parietes, it does not ascend, but on
the contrary is  somewhat lower than previously. Its capacity is immensely
increased ; according to the calculations of Levret, its superficies may be
estimated at 339 inches, and its cavity will contain 408 inches;  its length
being from 12 to 14 inches, its breadth from 9 to 10, and its depth, antero-
posteriorly, from 8 to 9 inches.
   158. A considerable change takes place in the cervix uteri; it becomes
somewhat swollen, but soft, elastic, and cushion-like; the os uteri loses
in some degree its  defined form, and is dilatable; the canal  through  the
Fig. 44.                           Fig. 45.
Cervix uteri at three months.           Cervix uteri at six months. 
108
UTERO-GESTATION.
cervix, during the early months, is closed by the glutinous  secretion of
the follicles, and these glands are themselves enlarged, so as  occasionally
to be felt rolling under the finger.
   During the first three months, the os uteri is lower than usual in  the
pelvis, owing to the  increased weight of the uterus,  and directed a little
more forwards; as the uterus  rises above the brim of the  pelvis, it is
directed backwards, and, after the fifth month, the cervix is drawn out by
the expanding uterus and shortened.   At the  sixth month it is said to
lose one-fourth of its length (fig. 45); at the seventh it  is only half its
original length;  at the eighth it loses another quarter (fig. 46); and at the
Cervix uteri at eight months.
ninth the neck is obliterated (fig. 47): so that upon making an examina-
tion, we find the vagina  closed superiorly by the rounded lower end of
the uterus, but no protruding cervix.

                               Fig. 47.
Cervix uteri at nuie months.
   159.  The figure of the uterus at the full term is oviform (fig. 42), the
larger end being uppermost, and  rounder in proportion than the lower
end.  Some variations in shape are observed from the pressure of neigh-
bouring parts, the position of the patient, or of the foetus.  Occasionally
the uterus stretches unequally, so as to constitute true obliquity, one side
being more developed than the other.  Such cases  are not common, nor
do we know much of their effect upon labour; but I am told that the
celebrated Tiedemann is about to publish a monograph on the subject,
which I doubt not will throw light upon it.
   The axis of the uterus, at the end of gestation, is commonly more per-
pendicular than that of the brim of the pelvis; but this want of agreement
is  rectified at the time of labour by the uterine contractions, which tilt the
fundus forwards.
   160.  The lining membrane of the uterus participates  in the  general 
UTERO-GESTATION.
109
congestion of the uterus at the time of conception.  It  becomes  turgid
with blood ; its villi, according to Von Baer, elongate, and over and be-
tween them is spread a thin layer of pulpy semi-fluid matter, secreted by
the mucous  membrane:  this is the decidua (fig. 48).  It was noticed by
                               Fig. 48.
 Burton, but described  particularly by W. Hunter, and  called after him
 the  decidua of Hunter.  The pulpy  matter, after a  short time, acquires
 consistence, and in its  appearance and  connection with the subjacent
 membrane resembles the coagulable lymph thrown off by mucous  mem-
 branes in  a state of disease.  It lines the entire cavity of the uterus,
 closes it inferiorly, and, according to John Hunter and Breschet, sends
 off a short  process into the  fallopian  tube, through which, they say, the
 ovum descends.
   Dr. Sharpey, of London, whose microscopical researches  are so well
 known,  on  investigating the  membrana decidua of a bitch, came to the
 conclusion  that it was not a secretion from the lining membrane of the
 uterus, but  that membrane itself  altered  and modified.*  This view has
 been confirmed by Bischoff.  " Having had the opportunity of examining
 the uterus of a woman  supposed to have  been  impregnated about three
 weeks before death, he was  enabled  to  demonstrate  quite satisfactorily
 that the  membrana decidua in the human female, as in the bitch, is merely
 the ordinary mucous membrane of the uterus considerably developed, and
 that it consists  essentially of enlarged uterine follicles and their blood-
 vessels, together with an unusually large quantity of secretion which these
 follicles  have  poured out.  The  internal  surface of the  uterus presented
 an appearance quite different from its ordinary  one, being finely villous ;
 and this was especially evident on placing it in water, or examining per-
 pendicular  sections of it.  The surface  itself,  when looked  upon from
 above, appeared as if perforated by a number of small apertures, or covered
 with numerous white points; and these,  when examined by the micro-
 scope, are  found to be  the  openings of cylindrical glandules.   These
 glandules or follicles were from 1^ to 2 Paris lines in length, were  heljl
together by  a transparent material, and terminated each by a blind extre-
mity which rested on the fibrous tissue of the uterus.   They ran a some-
what waw  course, but never branched or anastomosed.  Previous to
               * Muller's Physiology by Baly, part iv., p. 1578.
                                 K 
110
UTERO-GESTATION.
impregnation, it seems to be exceedingly difficult to discover these glands
in the mucous membrane of the uterus.   Probably they then exist  in  a
very undeveloped state, but immediately on the occurrence  of conception
increase rapidly, and exude an abundant secretion.  Of these glands and
their secretions (together with blood-vessels) the membrana  decidua, and,
later on, the  placenta, essentially  consist.   The statement  that a mem-
brana decidua exists in the fallopian tube as well as in the uterus, in cases
of fallopian impregnation, Bischoff combats, by observing  that so far as
has yet been seen, the lining membrane of the  fallopian tube contains no
glands by which the formation of a structure  corresponding to an ordi-
nary membrana decidua could be effected.  A similar view to the above
with regard  to  the membrana decidua  has  been advocated also by
M.  Cowiz, in the "Archives d'Anatomie  Gen.  et de Physiologie," for
Sept. 1846.*
  It is rough externally at an early period, and smooth internally, and so
far resembles serous membranes, that it is a shut sac and contains a small
quantity of fluid.  Its colour is reddish or whitish  gray.   Its thickness
varies in different places;  it is thicker near the  placenta, and thinner  near
the cervix uteri; it also becomes thinner after the third month, in propor-
tion as pregnancy advances.  It adheres but loosely to the mucous mem-
brane at an early period, but firmly during the  latter months, so much so
that Von Baer states that it cannot be separated without bringing away
the lining membrane also; this, however,  is not always the case.   The
medium  of its connection with the  uterus is  chiefly  the small vessels
which are supplied to it by that organ, and which are arranged in loops
round its villi; they are very numerous near the placenta, but more scanty
at the cervix.
  161. A very important observation on the structure of the decidua  vera
has been made by Dr.  Montgomery, in his valuable work on the " Signs
of Pregnancy."   " Repeated examinations," he remarks, " have  shown
Fig. 49.
me that there are on the external surface of the decidua vera (fig. 49), a
great number of small cup-like elevations, having the appearance of little
bags, the bottoms of which are attached to, or imbedded in, its substance ;
they  then  expand or belly out a little, and  again grow  smaller towards
* Ranking's Abstract, vol. iv., p. 336. 
UTERO-GESTATION.
Ill
 their outer or uterine end, which in by far the greater number of them is
 an  open mouth when  separated from the uterus; how it may be while
 they are adherent, I cannot at present say.   Some of them, which I have
 found  more deeply imbedded in  the decidua, were completely closed
 sacs.   Their form  is circular, or nearly so; they vary in diameter from
 the twelfth to the sixth of  an inch, and project about  the twelfth of an
 inch from the surface of the decidua."  In a note Dr.  Montgomery sug-
 gests that these " decidual cotyledons" serve " as reservoirs for nutrient
 fluids  separated from the maternal blood, to be thence absorbed, for the
 support and development of the ovum."
   162. When  the ovum arrives at the uterine extremity of the fallopian
 tube, it must either push the membrana decidua before it, or pierce it, in
 order to enter the cavity of the uterus.   Opinions have been much divided
 as to which of these two operations takes place;  Dr. W. Hunter, Dr. R.
 Lee, and M. Breschet say that the ovum passes into the sac of the deci-
 dua ; but Lobstein, Burdach, Velpeau, and, I believe, most recent writers,
 conceive that the sac remains entire, but that the  ovum passes behind it
 to the  situation where it fixes itself, and that its free surface (that part, I
 mean, which is not in contact with  the uterus) is covered by the displaced
 decidua, to which  the name of decidua refiexa has been given, to distin-
 guish it from the decidua vera, and which was first  observed by Dr. W.
 Hunter.   As the ovum  expands, so does the decidua refiexa, until at the
 end of gestation its inner surface is in contact with the inner surface of
 the decidua vera, just  like (if I may be pardoned a very homely simile)
 the layers of a double night-cap when put on the bed.  That space of
 the uterine parietes from which the decidua was  detached by  the ovum,
 increases with the enlargement of the uterus, and is occupied subsequently
 by the placenta; but between this organ  and  the uterus, a new layer of
 membrane — the decidua serotina—is  deposited,  resembling the decidua
 vera, to which it is united at the circumference of the placenta.
  The  decidua  refiexa becomes  thinner as pregnancy advances, and is
 ultimately expelled, more or less entire, with the fcetal membranes, whilst
 the decidua vera may remain for  some time, and be then discharged in
 shreds with the lochia.
  163. We know that  the decidua is formed before the descent of the
 ovum, and therefore independent of it; and it is  stated by most authori-
 ties that in cases of double uterus, both contain  decidua, and, in extra-
 uterine foetation, the uterus is  lined by the  decidua.  There are, however,
 exceptions to the latter; for in the cases published by Dr. R. Lee, in the
 Med. Gazette, June 5,  1840, the  decidua surrounded  the  ovum in  the
 tube, and was not  present in the uterus.
  164. Abnormal  deviations. — The  decidua  occasionally exhibits  the
 effects  of inflammation ; it may be hypertrophied or increased in thick-
 ness by layers of adventitious membrane, and pus has  been found on its
 surface.  In its  substance, calcareous depositions and spiculae of bone
 may sometimes be  detected.   It  may adhere  firmly to the lining mem-
brane of the uterus, and,  persisting  after delivery,  may  constitute  the
nucleus of a mole, &c.
  165.  We have  seen  that on leaving the ovary, the ovum is received
into the fallopian tube; that its further transmission is effected by mus-
cular motion and the ciliary movements of the villi of the mucous mem
        8 
112
UTERO-GESTATION.
rahWrt  tw t-hat,there is reas°n t0 believe (Judging ^m the ovum of the
devefo  ed   m     PaSSag6      gh  ^ tube' an  additional cove™g «
   It is difficult to determine the period (even if it  be regular) at which
the ovum arrives in the uterus.   One thing appears certain; that  several
Gays elapse  from the moment of impregnation.   One of the earliest ova
on record is that described by M. Velpeau (fig. 50, natural size; fig. 51
opened and magnified), which could not have been  more  than fourteen
days old, unless the midwife who gave it to him, and who was  herself
the subject of the miscarriage, deceived  him; and she appears to have
had no reason for so doing.*

                 Fig- so.                       Fig. 51.
   166.  When  the  ovum arrives at the uterus, it consists of two  mem-
 branes, the chorion and amnion ; in the interspace between which is con-
 tained  the vesicula  alba  or umbilicalis, and  a gelatinous substance, the
 tunica media of Bischoff.  Internal to the  amnion, we  find the  liquor
 amnii, and the embryo.  Each of these parts we shall now examine in
 detail.
   167. The Chorion is the outer envelope proper to the  ovum, and cor-
 responds to  the membrane lining the egg, in oviparous  animals.   It is
 found covering the ovum at the earliest period at which this has been seen
 in the uterus, surrounding it loosely, and forming a shut sac.  It is smooth
 on its inner surface, but externally it is covered over with short cylindrical
 villi.   As  the  ovum advances in  age, these villi diminish  in  number,
 assume a vesicular appearance, and terminate in delicate  rounded extre-
 mities.   The interspaces are larger and more smooth.   About the begin-
 ning of the second month  the villi divide  into branches, which arise from
 short thin stems, and terminate either in thin filiform or vesicular enlarge-
 ments.   The process of obliteration thus  commenced, continues until no
 villi remain, except  at that part  of the chorion which  is  in contact with
 the uterus: the  other part presenting the appearance of a thin, colourless,
 transparent membrane.
  The umbilical cord is inserted  into some part of the inner surface  of the
 chorion; and that part of the outer surface  which corresponds to this
insertion, is that which always comes in contact with the uterine parietes,
and upon which the  placenta is formed.
  The chorion  may be  divided into two laminae,  especially where it
covers the placenta; the outer is  called the exochorion, the inner the  endo-
chorion, by Burdach, who  believed  the latter to be the vascular layer of
the allantois.   From  the endochorion,  according to Bischoff, are derived
the vessels which run to the villi.   The chorion itself appears to be des-

  * Dr. Allen Thompson has given an excellent notice of early ova observed by himself
and others in the Edin. Med. and Surg.  Journal, vol. iii., p. 119, to which I beg to refer
the reader. 
UTERO-GESTATION.                      113
    titute of vessels, unless, as Dr. W. Hunter suggested, we regard as such
    the white filaments observed near the edge of the placenta.   The intimate
    structure  of the membrane is cellular, and in many places bears a strong
    resemblance to that of vegetables, each cell containing a distinct nucleus:
    the villi participate in the same texture, but their cells are  filled with a
    granular matter.
      The strength of the membrane is greatest in early ova;  at the termina-
    tion of pregnancy it is considerably weaker than the amnion:  at an early
    period it  is equally strong in all parts, but afterwards it is stronger near
    the placenta.   It is covered externally by the decidua  refiexa, and inter-
    nally it is separated  from the amnion  by a layer  of gelatinous  matter,
    which is afterwards condensed into a thin membrane called tunica media
    by Bischoff, who first described it.
      168. Abnormal deviations. — Inflammation may attack  the membrane,
    giving rise to vascularity,  opacity,  thickening, or the effusion of fluid
 .   between it and the amnion.  Occasionally false membranes are deposited
    upon it, and the villi  may be the seat of hydatids.   Dr. Montgomery has
    a preparation in his  museum, in which the cord is inserted into the part
    of the chorion covered by the decidua refiexa, instead of into that attached
    to  the uterus.  The  foetus of course perished for want of  nourishment.
»   Hemorrhage sometimes  occurs into the space between the  chorion and
    amnion.
      169. I have already mentioned that during the first months of gestation,
    an albuminous or gelatinous mass of varying consistency is found between
    the chorion and amnion.   It is often mixed with flocculi or threads, and
    occasionally presents a reticulated appearance.  " When put into spirits,"
    Wagner  observes, "this mass assumes the appearance of the cellular
    tissue  that is found between the muscles, and seems in fact to bear the
    same  relation to the  amnion  and chorion, as the  intermuscular cellular
    membrane does to the fasciculi between which it  lies."   The space  it
    occupies is, in early ova, considerable ;  but it gradually diminishes as the
    two membranes approximate, and in proportion the interposed matter  is
    condensed into an  extremely delicate membrane like the arachnoid, termed
    by Bischoff and Wagner  the tunica  media.   By Velpeau  it  is called the
    "corps reticulaire," and  he considers  it to be  the allantois; but this
    opinion is rejected by other physiologists.
      170. The Vesicula alba, or umbilical vesicle (fig.  54),  is also con-
    tained in the interspace between the amnion and chorion.  According to
    modern investigations, it is constantly present as a normal formation, in
   the earlier months  of gestation, and is connected with the intestinal canal
   of the foetus.  It is in fact the vitellus  surrounded by the blastoderma,
   upon which the embryo is first formed;  and it bears a perfect analogy to
   the yelk of the egg, except  that it is not  ultimately enclosed within the
   abdomen of the foetus.   In very early ova, it is large in proportion, of  a
   rounded or oval form, and lying upon  the intestine, with which it com-
   municates.  In a short time, however, the inner end becomes  narrow, and
   forms a pervious canal or duct through which its contents  may be trans-
   mitted.  M. Velpeau found it pervious in almost every ovum  of six weeks
   old that he examined;  and he  states that he not only saw vitellary matter
   in the intestine, but that he could press the fluid from the vesicle through
   the  duct into the intestine.  The length of the  duct varies  in different
                                  k2 
114
UTERO-GESTATION.
ova, and its calibre diminishes as gestation advances, until, in the second
month, it is impervious and  thread-like, but may still be traced to the
loop of intestine  contained  in  the  sheath of  the  umbilical cord.   The
vesicle contains a yellowish-white or yelk-coloured fluid, in which nume-
rous globules are suspended.   Its parietes consist of two laminae,  an
external vascular, and  an  internal  mucous layer.   It possesses two ves-
sels, the omphalo-mesenteric artery and vein, which ramify upon its sur-
face and on the duct.  As  gestation  advances, the vesicle is emptied,
shrinks and remains flat and collapsed to the termination of pregnancy.
  Its use is evidently to contain nutriment  for the foetus, before the de-
velopment of the placenta.
  171.  The Amnion (fig. 54).—In  the quotation from Dr. Barry's paper
(§ 146) descriptive of  the changes which take place  in the ovum after
impregnation, it will  be remembered, that the amnion was stated  to  be
formed by the coalescing of the  layer of small vesicles formed on the inner
surface of the membrane which invests the yelk, with the " mulberry-like
structure formed  in the centre of the yelk, but passing to its  circumfer-
ence."  M. Coste calls the amnion a " true epidermis of the blastoderma,"
and states  that it is detached from the external surface of  the embryonic
spot.  The membrane thus formed, envelopes the embryo very closely at
an  early period, and is continuous with the common integument of the  «
fcetus, at the open abdominal parietes.   At  a later period it is distended
with fluid, and so separated from the fcetus; and after being reflected upon
the funis, of which it forms the  outer coat, it terminates at the umbilicus.
In  the progress of gestation, the amnion approaches the chorion, until at
last it is in contact with it, or rather with the tunica media.  It is thin and
transparent, but of a firm texture, resisting laceration much more than the
other membranes.  Its external surface is somewhat flocculent, but inter-
nally, it is quite smooth, like serous membrane, and, like it, it secretes a
bland fluid.  Neither vessels nor nerves  can be demonstrated  in the am-
nion in a state of health, though it may be presumed to possess them.
  172.  Abnormal deviations.—The researches of M. Mercier have  estab-
lished the fact that this membrane may be the seat of inflammation, and
that in  such cases it  becomes  vascular, and secretes  a disproportionate
quantity of fluid.   It is not  quite certain whether its quality  is  changed
from diseased action.   The  membrane may also become thickened and
opaque.
  173.  The Placenta. —Let us now consider the chorion at a more ad-
vanced period of gestation, and we shall find  that a new organ has been
developed on that part of it which is in contact with the uterus.  This organ
was first called the placenta, I believe, by Fallopius: it is a spongy vas-
cular mass, existing in  some form in all mammalia, as an appendage of
the chorion.  It is of considerable size at the termination  of utero-gesta-
tion, its diameter  being six or eight inches, its circumference eighteen oi
twenty-four, and its thickness from one inch to  one and a half.   In general
it is of a rounded or  oval  form.   Internally, its surface  is smooth and
shining, from its being covered by the chorion and amnion, beneath which
the radiations of the  umbilical vessels may be  discovered.  The chorion,
whicn covers  its  inner surface  immediately, is firmly attached  to it, and
sends processes  between  its lobes  and lobules, whilst the amnion lying
over the chorion is but loosely attached.  The  outer or uterine surface, if 
UTERO-GESTATION.
Fig. 52.
 the  placenta be "in situ" or removed  carefully, is uniform  and level
 though not exactly smooth, being covered by the decidua serotina ; if this
 be peeled off, the lobes and lobules into which the placenta is divided,
 are evident, and we find processes of the decidua serotina entering these
 divisions.  The vessels of one lobe have very rarely any direct commu-
 nication with those of another.
   174.  As to the formation of the placenta, we observed that  the villi
 of the  chorion  diminish gradually in number, and finally disappear from
 every part of its surface, except where it is in contact with the  uterus, at
 which  part they become, as  it were, concentrated, and grow with great
 luxuriance,  in consequence  of the  development within  them  of vessels
 derived from the inner layer of the chorion (the endochorion), or from
 between the two layers.  These vessels go on enlarging and multiplying,
 interlacing  and anastomosing with each  other, until  they with  their con-
 necting (or separating) sheaths  of villi or  decidua serotina, form the mass
 of the  placenta.   The vessels  are  divided into  arterial and  venous
 branches.   The two umbilical  arteries at  their insertion into the internal
 surface of the placenta, divide and subdivide into  radiating  branches,
 which plunging into its substance are minutely divided  and distributed to
 the different lobes.  It is generally stated that the ultimate radicles of the
 arteries terminate directly in the radicles of  the umbilical vein,  without
 the  intervention of capillaries; but there is  room  for doubt  upon this
 point.   The radicles of the umbilical vein coalesce, until the large vessels
 formed by them  unite in forming the umbilical vein,  which is enclosed in
 the  sheath  of the funis umbilicalis with  the  arteries.   The  arteries  are
 extremely tortuous,  and the veins are without  valves.   It may be doubted
 whether the placenta is supplied with nerves, but it  is pretty certain that
 it possesses lymphatics.*
   175.  The situation of the  placenta may be ascertained with tolerable
 accuracy, by the use of the stethoscope before delivery, and the exami-
  * " The formation of the placenta commences by the penetration of the ramified villi,
 or  filamentous  processes of the chorion, into the  tubuli of the decidua; the villi thus
serve as roots, which suck up  and convey to the embryo the nourishment secreted for
it by the maternal structures."  (Carpenter's Human Physiology, p. 603.)—Editoe. 
116
UTERO-GESTATION.
nation of the perforation in the membranes afterwards.   By some writers,
it  is stated to be at the fundus, or a little on one side of it:  by others at
the posterior or anterior surface :  it would seem from the researches of
M. Naegele, jun. to be most frequently on the left side ; next, on the right
side of the uterus.   He states that the stethoscope indicated  the placenta
to be attached  to the left side, in two hundred and thirty-eight cases out
of six hundred;  and to the right side of the uterus, in one hundred and
forty-one  cases.  In twenty no sound was perceptible ; in one hundred
and sixty it was weak, or diffused so as to  be  uncertain; in  seven  the
placenta was attached to the fundus ; in thirteen to the anterior wall; and
in eleven  cases there was placental presentation.
   176. A much controverted question  now  demands our  attention: viz.
Whether  there be  direct vascular communication between the placenta
and uterus ? and if not, how is the  aeration of  the foetal blood effected ?
I am afraid we cannot  as  yet decide the point in dispute.  It was for  a
long time believed that the blood-vessels of the uterus and placenta com-
municated with each other, and  that an interchange of  blood took place,
so that the fcetus obtained fresh blood from the mother for its own  nutri-
tion.   This opinion was supported by Cowper, Noortwyk,  Haller, Senac,
and in modern times by Flourens.
   177. The researches of the Monros, Hunters, Wrisberg,  and others,
however, very satisfactorily disproved the existence of this vascular con-
tinuity.  The labours of the Hunters in particular threw great light  upon
the anatomical  relations between the blood-vessels of the  mother and
fcetus.  " They satisfied themselves," says Dr. J. Reid, in his paper in
the Ed. Med. and Surg. Journal, No. cxlvi., "that the umbilical arteries
terminate  in the umbilical veins, and not in the vessels of the uterus,"
and that the blood  in the umbilical arteries " passes from them  into the
veins, as in other parts of the body, and so back again into the child."
They further observed, that numerous small curling arteries, the largest
being about the size of a crow-quill, passed from the inner surface of the
uterus, that they penetrated the  decidua, and opened  into the intestines
between the foetal blood-vessels of the placenta.  Prolongations from the
uterine sinuses were also traced through the  decidua, and  were observed
to terminate in the placenta in the same  manner as the curling arteries, so
that " in the umbilical  portion of the placenta, the arteries terminate in
veins by a continuity of canal; whereas in the uterine  portion, there are
intermediate cells, in which the  arteries terminate, and from which  the
veins begin.  It was therefore  concluded, that the blood  of the mother
was poured by the curling arteries into a kind of cellular tissue, filling up
the intervals between the ramifications of the fcetal placental vessels, from
which it returned to the uterine  sinuses of the mother  through their pla-
cental prolongations, after having acted upon  the  blood of  the  fcetus
through the thin walls of the umbilical placental vessels."
   178. On the other hand, Dr. Robert  Lee concludes " that the placenta
does  not consist of two parts, maternal and fcetal, and that there is no
communication  between the uterus and placenta by  large arteries and
veins.   The whole of the blood  sent to the  uterus by the spermatic and
hypogastric arteries, except the small portion supplied to its parietes, and
to the membrana decidua by the inner membrane of the uterus, flows into
the uterine veins and sinuses, and after circulating through  them, is re- 
UTERO-GESTATION.
117
turned to the general circulation of the mother  by the spermatic and
hypogastric veins without entering the substance  of the placenta.   The
deciduous membrane being interposed betwreen the umbilical vessels and
the uterus, whatever changes take place in the  fcetal blood, must result
from  the indirect exposure of this fluid, as it circulates through the pla-
centa, to the maternal blood in the  great uterine sinuses."  Lauth, Vel-
peau, Seiler,  Coste,  Radford, Ramsbotham,  Millard,  Noble, &c.  agree
with Dr. R. Lee in doubting the existence of these  utero-placental vessels,
and assume  that the placenta is to be considered exclusively as the fcetal
organ.  Dutrochet's theory of endosmose and exosmose has been adduced
to explain  the nature and process of the interchange of blood,  but I do
not believe that it is considered satisfactory by many persons.
   179.  The investigations of  Weber, Eschricht, Owen, and Reid, seem
rather to  carry us back to a modification of the opinions  promulgated
by the Hunters.  According to Weber, the large vessels which leave the
uterus to pass into the decidua, are deprived of all except their innermost
tunics, which are as soft and tender as coagulated lymph.  The veins form
a network, and  have this peculiarity, that they become wider, the  more
deeply they penetrate  between the lobules.  Thus the veins themselves
form cells or sinuses into which the fcetal villi  project.   The delicate and
yielding coat of the vein is  borne inwards by each villus pressing upon
its  exterior, and so is itself the  covering of all the villi which compose
the fcetal  lobules, and which seem to project into  its interior.  Eschricht
supposes that the utero-placental vessels divide and subdivide in the pla-
centa like the arteries and veins in the other parts of the body.  Wagner,
in his Physiology, agrees  pretty nearly with Weber, and describes the
utero-placental vessels as winding like a network around the tufts of the
chorion containing the vessels of the embryo.
   The  last author to whom I shall refer is  the late Dr. J. Reid, from
whose essay I have  already quoted, and whose industry and acumen ob-
tained for him a distinguished  place  among the physiologists of the
present  day.  In August,  1840,  he carefully  examined the uterus of a
woman  who  had died  in the seventh month of pregnancy.   " On sepa-
rating the adhering surfaces of the uterus  slowly and  cautiously under
water, I satisfied myself, but not without  considerable  difficulty, of the
existence of the utero-placental vessels described by the Hunters.   After
a portion of the placenta had been detached in this manner, my attention
was attracted towards a number of rounded  bands passing between the
uterine surface of the placenta and the inner surface of" the uterus.  These
bands were  generally observed to become elongated, thinner, and  of a
cellular appearance when  put upon the stretch, and  were easily torn
across;  while at other times, though much more rarely, they could be
drawn out in the form of tufts from the mouths of the uterine sinuses.
On slitting up some of the  uterine sinuses with the scissors, these tufta
could be seen ramifying in their interior,  and were more or less elongated;
many of them appearing only to dip into the open mouths of the sinuses,
while others  proceeded from a quarter of an  inch to  an inch from the
open mouths of the sinuses by which they had entered, and in some case*
they extended themselves  into one  of the neighbouring sinuses."   The
parts were then injected as well as was possible, and when  the branches
of the tufts  contained in  the uterine sinuses were filled with injection, 
118
UTERO-GESTATION.
" their continuity with the umbilical placental vessels was clearly ascer-
tained ;" and  an examination with the microscope  proved their identity
with the umbilical vessels in the placenta.  As to their anatomical rela-
tions  to  the  sinuses: " these tufts were found to protrude into the open
mouths of certain of the uterine sinuses only;  and it need scarcely be
added, that they were observed  only in those sinuses placed next the
inner surface of the uterus, and not in any of the deeper sinuses.   These
tufts were surrounded externally by a soft tube similar to the soft wall of
the utero-placental vessels, which passed between the margin of the open
mouths of the uterine sinuses and the edges of the orifices in the decidua,
through which the tufts protruded themselves into the sinuses.   The size
of these  tufts varied considerably.   Some of  them  appeared to fill up
completely the open mouths of the  sinuses by which they entered, while
others filled them only partially.  On examining these tufts as they lay in
the sinuses, it was evident that,  though they were so far loose and could
be floated about, yet they were  bound down firmly at various points by
reflections of the inner coat of the venous system of the mother  upon their
outer surface."  "In this uterus we ascertained that while some of the
utero-placental veins contained  no  prolongation  of the  foetal-placental
vessels, in others these passed along their interior and projected into the
uterine sinuses.  On tracing  those utero-placental veins, which contained
no fcetal vessels, as far as the  placental surface of the decidua, the inner
coat of the venous system was seen  to  be prolonged upon some of the
tufts of foetal-placental vessels in their immediate neighbourhood.   On
tracing one of the larger of  the  curling arteries through the decidua, it
was also observed,  that when it reached the  placental surface of  that
membrane, the inner coat of the arterial system of the mother, was pro-
longed upon some of the tufts of the foetal-placental vessels which projected
into their orifices.   Those numerous branches of the fcetal-placental ves-
sels which  reach the placental surface of the  decidua, and do not pass
into the uterine sinuses nor into the orifices of the utero-placental vessels,
are attached by their apices  to the placental surface of that membrane."
After an elaborate  description of the  structure of the tufts  and vessels of
the placenta,  Dr.  Reid  observes, "the  interior  of the placenta is thus
composed of  numerous  trunks and branches (each including an  artery
and an accompanying vein), every one of which, we believe, is closely
ensheathed in prolongations  of the  inner coat  of the vascular system of
the mother, or at least in a membrane continuous  with  it.   If we  adopt
this view of the structure of lihe placenta, the  inner coat of the vasculai
system of the  mother is prolonged over each individual tuft, so that when
the blood of the mother flows into the placenta through the  curling arteries
of the uterus, it passes into  a large  sac formed by the inner coat  of the
vascular system of the mother, which is intersected in many thousands of
different  directions, by the placental tufts  projecting into  it like fringes,
and pushing its thin wall before them  in the form of sheaths, which closely
envelope both the trunk and each individual branch composing these tufts.
From this sac the maternal blood is returned by the utero-placental veins,
without having been extravasated, or without having left her own system
of vessels."   " The blood of the mother contained in this placental sac,
and the blood of the fcetus contained in the  umbilical vessels, can easily
act and re-act upon each other through the  spongy  and cellular walls of 
UTERO-GESTATION.
119
 the placental vessels and the thin sac ensheathing them, in the same man-
 ner as the blood in the branchial vessels of aquatic animals is acted upon
 by the water in which they float."  These  ample  quotations will, I be-
 lieve, give the reader a just view of Dr. Reid's observations and opinions,
 and I may add that on  a  recent visit to Edinburgh, Dr. Reid had the
 kindness to show me one of the portions of uterus and placenta on which
 his investigations were made, and there was no difficulty in demonstrating
 the tufts dipping into the uterine sinuses.   No doubt, further observations
 are  necessary for the perfect elucidation  of  the subject; but  I  certainly
 think that as far  as our knowledge extends it is in favour of the  opinion
 adopted by Dr. Reid and the later physiologists.*
   180. Abnormal deviations. — The placenta is liable to malformations
 and  displacements, and  to a series of diseases, some of which have  been
 ably described by my friend Professor Simpson of Edinburgh.
   1.  It may be the seat of sudden or  gradual congestion ending in reso-
 lution or in effusion of blood " into the substance of the  organ, upon its
 uterine or fcetal  surfaces,  or between the  membranes."  Dr.  Simpson
 suggests, that perhaps  the so-called tumours, tubercles, or white spots,
 &c. of the placenta, of various authors,  may in fact be coagula of blood
 in various stages of transformation.   The symptoms  to which placental
 congestion and apoplexy give rise, depend  for their  clear manifestation
 upon the extent of the hemorrhage.  In moderate cases, there is a degree
 of uneasiness and weight  in the region of  the uterus, and sometimes a
 fixed or  intermittent pain, which may extend down  the  thighs.   When
 the hemorrhage is severe, it will be attended by the usual  symptoms of
 loss of blood.   The result to the fcetus in many cases is  death, and thus
 the congestion may cause abortion.
   2. Inflammation  may  attack the placenta, either  of its parenchyma or
 membranes, or  all  together, and it  may either  affect one  lobe only, or
 several at the same  time.
   * In the 154th No. of the Edinburgh Medical  and  Surgical Journal, we have the fol-
 lowing very candid and honourable "statement" by Dr. Reid:  "In a paper ' On the
 Anatomical Relations of the  Blood-vessels of the Mother to those of the Foetus in the
 Human Species,' printed in the 146th No. of this Journal, I have made a remark which
 I am  anxious publicly  to correct.  It is  mentioned in a foot-note, that I believe that
 the representation of the manner in which the foetal placental vessels are distributed,
 as given by Wagner, in his Icones Physiologicae, Fas. 1, Tab. xi. Fig. 2, and stated to
 have been furnished by Weber, is far from being correct. I had lately the satisfaction
 of visiting Weber, who  not only very kindly showed  me all his preparations, but gave
 me some portions  of his  beautifully injected  placentae.  I am  now perfectly satisfied
 that the representation he has  given is perfectly correct.  In  calling in question the
 correctness of Weber's representation, I was  at the time under the impression, from
 an examination of the  engraving mentioned, — which, however, greater attention paid
 to Fig. 8 might have corrected,—that it was meant to imply, that  the corresponding
 artery and vein did not  run in the same sheath, but coiled about, sometimes apart from
 each other; for, being  taken from a dried preparation, the  sheath or villus in which
 they are enclosed is  not represented, and it was this supposed error which alone led
 me to make the criticism mentioned  above.  I had not at  this time seen Wagner's
 Lehrbuch der Physiologie, in which a detailed description of this structure is given. If
 I had supplied in fig. 2, by the aid of my imagination, the walls of the villus surround
 ing the convoluted artery, and its accompanying vein, I would not have questioned its
 accuracy, for I was maintaining, as the result of my  own observations, that they were
 enclosed in the same sheath.  I make this statement,  not so much from the importance
 of the  subject, for it relates merely to a minor question of anatomical detail; but having
 erroneously called in question, chiefly from a misapprehension on my part, the accu-
racy of an observation made by a most distinguished anatomist and most estimable man,
I am anxious to correct  it."   Edin. Med. and Surg. Journ. No. cliv. p. 141. — Emioa, 
120
UTERO-GESTATION.
  It may issue in the effusion of lymph either into its substance or upon
its fcetal or uterine  surfaces.  In  the former case we have the  yellow
induration  of the placenta;  in  the  latter, adhesions between the uterus
and placenta; and, when the fcetal surface is the seat, there may be in-
crease of the liquor amnii, lymph on its surface, or, possibly, adhesion to
some part of the fcetus.  Another termination of placentitis is in the pro-
duction of  purulent matter, in the substance or upon the surfaces of the
placenta.   The most constant symptom of placentitis, is pain in the ute-
rine or lumbar regions, and in some cases there  is violent vomiting; in
others, rigors succeeded by febrile symptoms.   Inflammation of the pla-
centa may  cause the death or malformation of the embryo, and place the
mother in some danger.   For more minute details I beg to refer the reader
to Dr. Simpson's learned  essay in the Ed. Med. and Surg. Journal, vol.
xlv. p. 265.
  3.  The placenta may be hypertrophied or atrophied in part or the whole
of its substance.
  4.  It may be the seat of cartilaginous or calcareous degeneration, or of
other morbid products.
  5.  It may give rise to hydatids.
  181.  The Umbilical  Cord, funis or navel-string,  is the connecting
link between the fcetus and placenta (fig.  52), terminating with  the func-
tions  of the latter at birth.  It is visible at  the earliest period of pregnancy.
It arises from the centre of the placenta most frequently, but occasionally
from its edge  (battledore placenta), and is formed  by the umbilical arteries
and vein, embedded in (the Whartonian) gelatine, and enclosed within a
sheath of the chorion internally, and of the amnion externally.   Besides
the vessels, it contains the duct  of the umbilical vesicle and  the urachus,
the omphalo-mesenteric vessels, and, at an early period, the fcetal intestines
at its fcetal extremity.  At first, the  cord is thin and cylindrical, the ves-
sels running a straight course through it;  from the third to the ninth week,
it appears to be divided by two or three  vesicular swellings, which ulti-
mately disappear.   After  this time, the vessels run  in a  spiral  form, the
arteries  around the vein, from left  to  right, and form  in their course a
number of small loops or knots.   The vein has no valves, and its  calibre
is equal to that of  both  the arteries.  The  cord is  also supplied with
lymphatics, as has been proved by the injections of Fohmann and Mont-
gomery.'  It is  probable, though not  as  yet demonstrated, that  it may
possess  nerves also.
  The length of the cord varies much;  it is very rarely less than eight
inches, though such cases are on record, and it is sometimes five or six
feet long.   Out of 500  cases,  selected  from the writings of  Osiander,
Adelmann, and Henne, with some  additional measurements of my own,
I find the most common length to be eighteen inches; none were  under
Iwelve,  nor above fifty-four inches.*
  By most writers, the pulsation of the artesia  of the cord is considered
  * " Mr. J. B. Thompson relates in the London Lancet, June 4, 1842, a case in which
ihe funis was only seven and  a half  inches long.  Mr. Stone has met with a case, in
which the funis was still shorter, being only six inches; and Mr. Wm. Collyns, (Pro-
vincial Medical Journal, Aug. 6, 1842,) another, in which  the funis was scarcely that
length."—Am. Journ. Med. Sciences, Jan.  1843.
  Dr.  Tyler Smith exhibited to the Westminster Medical  Society (Jan. 1850), a funis
yhich measured fifty-nine inches and a half in length. — Editor. 
UTERO-GESTATION.
121
to be dependent upon the heart; but Osiander contends that they are to
a certain degree independent, and some  facts which he adduces, appear
to afford confirmation to his opinion.
   After the birth of the child, the pulsation ceases in  about fifteen or
twenty minutes, and that portion of the cord which  remains attached to
the umbilicus dies, and gradually withers, until it falls off, in the majority
of cases, on the fifth or sixth day.
   In ordinary cases the funis lies free and loose in the cavity of the amnion,
^-bove the head of the child;  but occasionally,  owing to the movements
of the child at an  early period, it may be coiled round its neck, tied in
knots, or escape below the head, so as to prolapse during labour.   The
coiling round the neck happens about once in nine or ten  cases; or, ac-
cording to the examples I  have collected, 204 times in 1920 cases.   It is
commonly enumerated among the causes of  delay in labour, on account
of the shortening of the cord which it occasions, and sundry other evil
effects are attributed to it,  which I believe to be altogether imaginary, for
the coiling does not occur except when the cord is longer than usual, so
as to leave enough of it free.  For more minute  details I take the liberty
to refer the reader to an essay on the subject  in my Researches on Ope-
rative Midwifery, &c.
   182. Abnormal deviations.—1.  The vessels of the cord may divide  at
some distance from the placenta: 2, instead of two arteries and one vein,
there have been found two veins and one artery, one vein  and one  artery,
or three arteries: 3, two cords have been attached to one  placenta with a
single child :  4, the cord may be tied in double  or  single knots:  5, the
vessels  are sometimes partially or wholly closed:  6, cases are on  record
of the absence of funis and umbilicus: 7, in an acephalous  fcetus born in
the Western Lying-in Hospital we found the cord inserted into the neck,
near the angle of the jaw, from whence  the vessels  passed  down behind
the clavicle and sternum, through the chest into the abdomen, where  they
were lost: 8, when the umbilical ring is imperfectly closed,  the sheath of
the cord sometimes contains a portion of the intestines:  9, in cases of
twins, the placenta and cords are generally distinct and without  commu-
nication, but occasionally a cross branch passes from one to the  other:
10, the  cord  may be inserted into a part of the chorion, covered  by the
decidua refiexa, instead of that part upon which the placenta is to be de-
veloped:  11,  the cord may be so much twisted (at an early period) as to
diminish the  calibre  of the vessels, and to  impair  the nutrition  of the
embryo :  12,  the vessels may become varicose, or the sheath of the cord
may contain  hydatids:  13, the coats  of the vessels may give way, and
hemorrhage ensue:  14,  the cord may be torn across,  by  the mother's
falling or receiving a violent concussion.
   183.  The Allantois " arises on the fore part of the posterior extremity
of the mucous layer which is closing to form  the intestine, as a growth
of the intestine, which  proceeds very rapidly.  It passes out where the
ventral laminae are still unclosed, in the region of the umbilicus, and in
birds and mammalia, reaches either mediately  or immediately the inner
surface of the  exochorion.  By the constriction of the navel it is separated
into two portions which communicate; that within  the body of the  em-
bryo is the sacculated urinary bladder with the  urachus  or tube of com
munication.   It receives its vessels from the hypogastric, which are spread
                                 L 
122
UTERO-GESTATION.
out as a vascular layer, especially upon that portion of its surface which
faces the exochorion.   According to Burdach (as we have seen) the ves-
sels form a distinct layer, the endochorion."  I  have  preferred quoting
this concise description from an article  in  the Brit, and For. Review, as
giving a  good account of the opinions held by most recent physiologists,
to embarrassing the reader by a  detail  of  the different hypotheses which
have been broached on the subject.
   184. The Liquor Amnii is the name given to the fluid secreted by the
amnion and contained in its  cavity.   At first, it is small in quantity, clear
and transparent;  but afterwards it  increases in  quantity,  and becomes
slightly opaline.   Dr. G. O.  Rees has published, in No. 6 of Guy's Hos-
pital Reports, an analysis of some amniotic fluid which he  obtained in a
case where premature labour was induced.  He found  its specific gravity
1008-6 and in 1000 parts, it contained
       Of water.......983-4
       Of albumen, with traces of fatty matter     .    .     5-9
       Albuminate of soda, chloride of sodium    .    .     6-1
       Animal extractive, soluble in water and alcohol,
         urea, chloride of sodium     ....     4-6
       with traces of alkaline sulphate.

Towards the  end of gestation the albumen diminishes.
   The amount at the  full time varies from half a pint to  several quarts;
but the average quantity is about a pound.  The  fluid is usually stated,
and I believe truly, to be a secretion from the inner surface of the amnion:
but Meckel attributes it to the maternal vessels, especially in the earlier
months.
   The uses of the  liquor amnii are very intelligible and important:  1, it
is probable that it serves for  nutriment to the  fcetus, at least during the
early  months: 2, it preserves an equable temperature for  it, during  its
intra-uterine life: 3, it diminishes the impression from sudden movements,
shocks, &c. and  thereby prevents injury: 4, during labour it protrudes
the membranes, and is the primary agent in dilating the os uteri.
   185. Abnormal  deviations.—It may be very scanty, or, in the opposite
extreme, excessive.  The latter deviation from its natural state is probably
the result of inflammation, and occasions some mechanical inconveniences
to the mother, and risk to the child  during gestation, whilst at the  time
of labour, it seems to enfeeble the  uterus during the first stage.   The
quality of the fluid may be  changed, though it  rarely decomposes.   Its
colour is sometimes yellow or brown.
   186.  The Embryo.—If the reader will take the trouble to turn back to
§  146, he will find that in the quotation from Dr. Barry, the last change
there described as  occurring after impregnation, was the disappearance of
the germ vesicle.   When the vesicle bursts in the hen's egg, the formation
of the germ-membrane, or blastoderma,  commences, according to  Pur-
kinje, and it is completed by the fifth  day, according to  Von  Baer.   In
mammalia, however,  it appears to exist, previous to the bursting or dis-
appearance of the vesicle; at least  it  is visible immediately the vikllus
becomes transparent after that occurrence.  Between this membrane and
the chorion, there is a thin layer  of  albumen, and at some point we find
an aggregation of  granules, forming the cumulus of the blastoderma.   It 
UTERO-GESTATION.
123
 is at this part that the embryo is  developed, lying as it were upon the
 membrane.  The form of the germinal membrane gradually changes, be-
 coming more oval.  It consists of three super-imposed laminae or layers,
 at least at  the central  point or  cumulus; and upon this  separation into
 layers, rests the modern theory of development, as first proposed  by Dol-
 linger and Pander, and afterwards  illustrated by Von Baer, Rathke, Bur-
 dach, &c, &c.   "Above, and most extended," says the author of the
 very able article in the Brit, and For. Review, from whom I have already
 quoted,  " is the serous layer;  below and least extended  is the mucous;
 between the two, and later in  its appearance, is the vascular layer.  In
 one or other of these,  as distinct primitive forms, there lies concealed that
 which is essential, in the different organs and tissues of which the body is
 composed, and in virtue of which they admit of being referred to  distinct
 original groups.  On  the serous layer, arise the organs of animal life—
 the brain and spinal cord, organs  of sense, skin,  muscle, tendons, liga-
 ments, cartilage, bone;  on the mucous, the organs of  vegetative  life, the
 intestinal  canal, lungs, liver, spleen, pancreas, and other glands.   The
 heart and vascular system arise from the vascular  layer, if this is  to be
 considered as a separate one.   To which division the generative  system
 is to be primarily referred, is still undetermined."  This  is the view ge-
 nerally accredited, but Dr. Barry seems to think it doubtful.  He has not
 observed this " splitting of the germinal membrane," nor does he conceive
 that the membranous layers originate the embryo, but the reverse; that
 the " previously existing germ, by means of a  hollow process, originates
 a structure having the  appearance of a membrane."
   In the centre of the blastoderma, where it is  supposed to divide into
 the serous and mucous layers,  there is  observed  a clear  space, the area
 proligera or pellucida, in the centre  of which and in the transverse axis
 of  the vitellus,  there is a  mass of globules loosely connected together,
 forming the primitive streak or trace  of Von Baer, and around  this  the
 area vasculosa  is developed.   I may mention that these changes have
 been observed in the ova of different mammalia, as well as in the egg;
 and there is every probability that the human  ovum undergoes identical
 mutations.
   The appearance of the primitive trace is observed in eggs at about the
 fourteenth hour  of incubation, and in the human ovum may probably be
 referred to the second  or third week.
   To  proceed with  the next changes: " The globules of the primitive
 streak seem next to be resolved, and  then there is a change of appear-
 ances.  On the  sides of the streak are two lamina dorsales, which bound
 a median furrow; and below this furrow is the chorda dorsalis, which is
 the axis of the future embryo, and the origin of the  spinal column.   That
 portion of  fluid  which  separates the chorda dorsalis from the lamina dor-
 salis is the future cord  and brain.   The chorda  dorsalis thickens  at the
 fore part, to form the first appearance of skull, and  the fluid between the
 dorsal laminae is in larger quantity, in correspondence with it; so that the
 central parts of the nervous system and their coverings  are laid down at
the same time, and  grow simultaneously.  The separation between the
spinal cord and brain is a very early one, and is coincident with  a bending
 downwards towards the yelk, of the anterior part of the laminae dorsales,
 which defines the limit between the  skull and column, brain and cord." 
124
UTERO-GESTATION.
  Next follows the closing of the laminae dorsales over the fluid which is
the rudiment of brain and  cord.   The brain, therefore, as Valentin re-
marks, ought not to be considered as growing from one end of the cord.
"At first there is only a single cerebral vesicle; for in the brain, as well
as in the cord, granules accumulate  first on the periphery, the central part
continuing to be fluid.  The  single vesicle is then elongated, and next
appears constricted in certain regions, so  as to form three cells, which
communicate.  The anterior cell corresponds to the cerebrum, the middle
cell to the corpora quadrigemina and neighbouring parts, and  the posterior
cell to the medulla  oblongata  and neighbouring parts."   "The deposit
of granular  matter  which  accompanies the  further development  of the
brain and cord, is seen on that side of both which corresponds to the vis-
cera, sooner than on that which corresponds to the  spine."
  " Twto  other laminae (lamina ventrales of Von Baer) are  in the mean
time proceeding from the axis of the embryo, one on each side.   They
grow out laterally, and  tend  to converge in the median  line, as did the
dorsal lamina; but they form a larger curve, and follow a different direc-
tion ;  that is, they converge to meet below the axis, and they do so meet,
except in the umbilicus."
  187.  After the rudiments of  organic life have been  commenced in the
central  portion of the serous layer, a fold of its peripheral portion arches
over the dorsal  surface of the embryo, "so as to represent  a sac whose
opening is at the edge of the fold."   The opening gradually decreases
until the opposing folds of membrane are  in contact, and then vanishes,
leaving  the fcetus surrounded by two  membranes.  The one next the fcetus
is the amnion; the other is gradually separated from the amnion, and joins
the serous laminae of the blastoderma; this  is the "false amnion," of Pan-
der, or the "serous  covering" of Von Baer.   This  mode  of formation of
the amnion,  has been observed by Von Baer in the dog, sheep, and pig;
and his  observation  has been verified by Dr.  Allen Thompson.
  The membrane which surrounds  the vitellus or yelk is very vascular;
it becomes oval in shape,  and more pointed where it is  in contact with
the embryo,  until at length it contracts into a narrow duct, thus forming
the vesicula alba and duct.
  The allantois, as  already mentioned, arises from the lower end  of the
intestinal canal on  a  little vesicle, and increasing  in  size, encircles the
embryo  along with the umbilical vesicle.
  188.  The  heart  of the  embryo, which  is the product  of the vascular
layer of the  blastoderma, is formed  at an early period; at first it appears
as a twisted  canal;  at the under side it receives two omphalo-mesenteric
veins, and in the situation of the future bulbus aorta it divides into four
vascular arches, which first uniting into  the aorta, again divide, run  down
near the vertebral column, and give off the  omphalo-mesenteric arteries,
which ramify on the blastoderma and umbilical vesicle.
  189.  Thus, then, we have seen the embryo developed  in the layers of
the blastoderma5 and formed  by a gradual closing in of the laminae to-
wards the median line; thus the brain and  spinal marrow, which are its
earliest rudiments, are covered in, and  in  like manner the parts anterior
to the spine, as the thorax, abdomen, &c. are formed.   We are indebted
to compative anatomy for opportunities of observation; but there  is no
doubt that the same process takes place in the human ovum.  Professor 
UTERO-GESTATION.
125
Wagner has given a. description of a human ovum of about three weeks
old, part of which I shall take the  liberty of quoting:  "Such ova, still
surrounded by decidua, measure about seven lines in length; in the naked
chorion, they are about five lines long.   The chorion at this time, is beset

               Fig. 53.                         Fig. 54.
externally with small cylindrical hollow villi.   The embryo itself is two
lines long.  It is plainly surrounded by an amnion which lies loosely, but
still pretty closely about it, and obviously proceeds from the abdominal
laminae.   The embryo  is curved, and presents anterior cerebral vesicles
or hemispheres, pretty well developed (figured rather large in figs. 53,54,)
and considerable corpora quadrigemina immediately behind them;  there
is the distinct appearance of an eye, and a rounded offset from the me-
dulla oblongata, indicates the acoustic vesicle;  several bronchial arteries
and fissures are also conspicuous, the last of them, however, not  com-
pletely formed.   The oval aperture is just above the upper bronchial fis-
sure.   The anterior and posterior extremities are curved leaf-like processes,
still of very small dimensions."  The abdomen is yet an open cleft, in
which, but projecting beyond it, is the heart,  "of very large relative di-
mensions, and consisting of a simple atrium or auricle, and ventricle;
behind  the heart is the  liver, and  under the liver the  intestine, which is
attached by means of a  distinct mesentery."  Where the large and small
intestines meet, the  canal makes  a sweep in the umbilical vesicle.   On
either side of  the mesenteric lamina, we find the primordial kidney,  com-
posed of short caeca. The allantois is seen extending from the lower part
of the intestine.
   190.  During the second month, we find the extremity larger and  more
projecting; the body curved, the head disproportionately large, and bent
downwards, indications of the nostrils, and a gaping oral aperture.   The
abdomen is closed about the fifth week, except at the umbilical  aperture,
through which a loop of  intestine still escapes.  The os  coccygis resembles
a tail, bent forward, and of considerable size.
  The forehead  is  more vaulted,  because  of the development of the
hemispheres of the brain; the spinal cord is cylindrical, of nearly uni-
form thickness, and terminating  in a blunt extremity;  posteriorly it is
open.   " The medulla oblongata makes a bend forwards at the top of
the neck, and then ascends perpendicularly into the capacious  cranium,
where the corpora quadrigemina present  themselves; as two large  semi-
globular masses, having behind them a pair of narrow lateral laminae, the
rudiments of  the cerebellum.  The medullary stem or crus cerebri passes
under the corpora quadrigemina, and again bending downwards, the cor-
pora striata and optic thalami are evolved upon it."
 
126
UTERO-GESTATION.
  The first points of ossification appear  about the seventh week, in the
clavicle and  lower jaw; the vertebral arches are not yet  closed in, and
the ribs appear like little streaks.   The only trace  of muscular fibre is in

              Fig. 55.                              Fig. 56.
the diaphragm.  The heart at this time begins to change  its form, and
the inter-ventricular septum to  form.  The liver is very large, and gra-
nular.   The  stomach is assuming somewhat of its  normal form; the
urinary bladder is enclosed, but the anus is imperforate.
  After this  period,  the different parts are developed with  tolerable
rapidity; the separate portions  of the brain are evolved, and the organs
of sense acquire their external characters; the eyelids, nose, and ears are
formed.  About the seventh month, the membrana pupillaris is ruptured,

                               Fig. 57.
and the pupil becomes visible.   The cranium continues cartilaginous for
some time, then points of ossification are seen, which radiate until each
Done is nearly complete. 
UTERO-GESTATION.
127
   The upper and lower extremities increase, the hands and feet are  de-
veloped ;  the  fingers and toes separate, and the  nails become distinct
about the sixth or seventh month.
   In front of the coccyx we find the anus, which at first is imperforate;
and anterior to it, the organs of generation, in form at first of  a conical
tubercle, which is subsequently developed into the penis or clitoris, while
the skin at the sides is prolonged into the  scrotum or  labia.   The  testes
are originally placed on each side of the vertebral  column, but afterwards
descend along the iliac vessels  to the inguinal  ring, through  which they
pass, carrying with them a portion of the peritoneum to form  their tunica
vaginalis.
   The liver and kidneys  are completed before the termination of preg-
nancy, and soon commence the performance of their functions; for the
meconium is found to be coloured by the bile even in premature children,
and urine is frequently voided during delivery.
   [The formation  of the  ovum, and the development of the embryo, are
among the most incomprehensible subjects to a student; at the risk,  there-
fore, of some  repetition of what is said upon these points by the author,
I  here introduce  the following quotation, with the accompanying illus-
trations, from  Dr. Rigby's work on Midwifery, in which the subjects are
very clearly and concisely treated. — Editor.
   "Embryo.—There is, perhaps, no  department of physiology  which
has  been  so remarkably enriched by  recent discoveries, as that which re-
lates to  the primitive  development  of  the ovum and its  embryo.   The
researches of  Baer, Rathke, Purkinje,  Valentin,  &c, in Germany; of
Dutrochet,  Prevost, Dumas, and Coste, &c, in France;  and of Owen,
Sharpey, Allen Thompson, Jones, and Martin Barry in England, but more
especially those of the celebrated Baer, have greatly advanced our know-
ledge of these subjects, and led us  deeply into those mysterious  processes
of nature which relate  to our first origin and formation.
   " These researches have all tended  to establish one great law, connected
with  the  early development of the  human embryo,  and that of other
mammiferous  animals, viz.,  that it at first possesses a  structure and ar-
rangement  analogous to that of animals in a much lower scale of forma-
tion; this observation  also applies of course to the  ovum itself, since a
variety of changes  take place in it  after impregnation, before a trace of
the embryo can be detected.
   " At the earliest periods, the human ovum bears a perfect analogy to
the eggs of fishes,  amphibia, and  birds:  and it is only by carefully ex-
amining the changes produced by impregnation in the ova of  these  lower
classes of  animals,  that we have been enabled to discover them in  the
mammalia and human subject.
   " As  the bird's egg, from its size, best affords us the means  of inves
tigating these  changes, and  as in all  essential respects they are  the same
in the human ovum, it will be necessary for us to lay before  our readers
a  short  account of its structure and contents, and also of the changes
which they undergo, after impregnation.   In doing this we shall merely
confine ourselves to the description  of what is applicable to  the human
ovum.
   " The egg is known to consist of two  distinct parts,  the vitellus or yelk
surrounded by its albumen or white ;  to the former of these we now more
       9 
128
UTERO-GESTATION.
  a. The  granulary mem-
brane forming the periphery
of the yelk.   b.  Vesicle of
Purkinje embedded in the
cumulus, c. Vitellary mem-
brane,  d. Inner and outer
layers of the  capsule of the
ovum.  e.  Indusium of the
ovary.
                   Section of a hen's egg within the ovary.

particularly refer.   The yelk is a granular albuminous  fluid, contained in
a granular membranous sac (the blastodermic membrane), which is covered
by an investing  membrane called  the  vitelline  membrane or yelk-bag.
The  impregnated vitellus is retained in  its capsule in the  ovary precisely
as the ovum  of  the  mammifera is  in the Graafian vesicle.   The whole
ovary in this case has a clustered appearance, like  a bunch of grapes, each
capsule being suspended by a short pedicle of indusium.
  " In those ova which are considerably developed before impregnation,
the  granular blastodermic membrane is  observed to be thicker,  and the
granules  more aggregated at that part which corresponds to the pedicle,
forming a slight elevation with a depression in its centre, like the cumulus
in the proligerous disc of a Graafian vesicle.   This little disc  is the blas-
toderma,  germinal  membrane, or cicatricula;  in the  central  depression
Fig. 59.
  a. Vitelline membrane.
b. Blastoderma.  From T.
W. Jones.
just mentioned is an exceedingly minute vesicle, first noticed by Professor
Purkinje of Breslau, and named after him:  in more correct language it is
the germinal vesicle.
   " According to  Wagner, the  germinal vesicle is not surrounded by a
disc before impregnation;  and it is only after this process that the above-
mentioned disc of granules is formed.   By the time  the ovum is about
to quit the ovary the vesicle itself has disappeared, so that an ovum has
never  been found  in the  oviduct  containing a germinal vesicle, nothing
remaining  of it beyond the little depression in the cumulus of the cica-
tricula.
   " The rupture of the Purkinjean or germinal  vesicle  has been supposed
by Mr. T.  W. Jones to take place before impregnation; but the observa-
tions of Professor Valentin seem to lead to the  inference that it is a result
of that process, and must be therefore looked upon as one of the earliest
rhanges which take  place in  the  ovum or yelk-bag  upon  quitting  the
ovary.*
  * We said, "one of the earliest changes."  Mr. Jones considers that "the breaking
up of the surface of the yelk into crystalline forms," is the first change which he has
observed. 
UTERO-GESTATION.
129
  "During its passing through the oviduct (what in mammalia is called the
fallopian tube), the ovum receives a thick  covering of albumen, and  as it
descends still farther along the canal the membrane of the shell is formed.
  " On examining the appearance of the ovum in mammiferous animals,
and especially the human ovum, it will be found that it presents a form
and structure  very analogous to  the ova just described, more especially
those of birds.  It is a minute  spherical  sac, filled with an albuminous
fluid, lined with its blastodermic or germinal membrane, in which is seated
the germinal vesicle or vesicle of Purkinje.   When the ovum has quitted
the ovary the germinal vesicle disappears, and on its entering the fallopian
tube it becomes covered with a gelatinous, or rather albuminous covering.
This was inferred  by Valentin, who considered that 'the enormous swell-
ing of the  ova, and their passage through the fallopian tubes,' tended to
prove  the  circumstance.   (Edin. Med. and  Surg. Journ.  April, 1836.)
It has  since been demonstrated by Mr. T. W. Jones  in a rabbit seven
days after impregnation.   The vitellary membrane seems, at this time, to
give way, leaving  the vitellus of the ovum merely covered by its spherical
blastoderma, and  encased by the layer of albuminous  matter which sur-
rounds  it.
   " From  what we have now stated, a close  analogy will appear between
the ova of  the mammalia and those of the lower  classes, more especially
birds, which from  their size afford us the best opportunities of investigat-
ing this difficult subject.
   "In  birds,  the covering of the vitellus  is called yelk-bag; whereas, in
mammalia  and man it receives the name of vesicula umbilicalis.   Its albu-
minous covering,  which corresponds to the white and membrane of the
shell  in birds, is called chorion: by the time that the ovum has reached
the uterus, this outer membrane  has undergone a  considerable  change;  it
becomes covered with a complete down of little absorbing fibrillae, which
rapidly increase in size as  development advances, until it presents that
tufted vascular appearance, which we have already mentioned  when de-
scribing this membrane.                                ,
   "The first or primitive trace of the embryo is in the  cicatricula or  ger-
minal membrane,  which contained  the germinal  vesicle before its disap-
pearance.  In the centre of this, upon its upper  surface, may be  disco-
vered a small dark line :* ' this  line or primitive  trace is swollen at one
extremity,  and is placed in the direction of the transverse axis of the egg.'
   "As development  advances,   the cicatricula expands.   'We  are in-
debted  to  Pander,'f  says  Dr. Allen  Thompson  in his admirable essay
above quoted, 'for the important discovery,  that  towards the twelfth or
fourteenth  hour, in the hen's egg the germinal membrane becomes divided
into two layers of granules, the  serous and mucous layers  of the cicatri-
cula ; and  that the rudimentary trace of the embryo, which has at  this
time become evident, is- placed  in the substance  of the uppermost or se-
rous layer.' 'According to this  observer,  and according to  Baer, the part
of this layer which surrounds the primitive trace  soon becomes thicker;

  * Allen Thompson on the Development of -the Vascular System in the Fcetus of  Ver
tebrated  Animals.  (Edin. New Philosoph. Journ.  Oct. 1830.)
  f Pander,  Beitrage zur Entwickelungs-geschichte  des  Hiinchens iin Eie.  Wuri-
burg, 1817. 
130                       UTERO-GESTATION.
Fig. 60.
and  on examining this part wTith care, towards the eighteenth hour, we
observe that a furrow has been formed in it, in the bottom of which the
primitive trace is situated; about the  twentieth hour this furrow is  con-
verted into a canal open at both ends, by the junction of its margins (the
plica primitiva of Pander, the lamina dorsales of Baer): the canal soon
becomes closed  at the cephalic or swollen extremity of the primitive trace,
at which part it is  of a pyriform shape, being wider here than at any other

                                Fig. 61.
  a. Transparent area. b. Laminae dorsales.  c. Cephalic end.  d. Rudiments of dorsal
vertebrae,  e. Serous layer. /. Lateral portion of the primitive trace,  g. Mucous layer.
h. Vascular layer,  k. Laminae dorsales united to form the spinal canal.
part.   According to Baer and Serres,  some time after the canal begins to
close, a semi-fluid matter is deposited  in it, which on its acquiring greater
consistence, becomes the rudiment of the spinal cord; the pyriform ex-
tremity or head is soon after this seen to be partially subdivided into three
vesicles, which being also filled with a semi-fluid matter, gives rise to the
rudimentary state of the encephalon.'  'As  the formation of the spinal
canal proceeds,  the parts of the serous layer which surrounds it,  espe-
cially towards the head, become thicker and more solid, and before the
twenty-fourth hour we observe on each side of this canal four or five small
round opaque bodies; these bodies indicate the first formation of the dor-
sal vertebrae.
   " ' About the  same time, or from the twentieth to the twenty-fourth hour,
the inner layer  of the germinal membrane  undergoes a farther division, 
UTERO-GESTATION.
131
                               Fig. 62.

                                   .......   a


a. Serous layer.
6, c. Vascular layer.
d. Mucous layer.
e. Heart.
and by a peculiar change is converted into the vascular  mucous layers.'
(A. Thompson, op. cit.)  It will  thus be seen, that the  germinal  mem-
brane is that part of the ovum in which the first changes produced by im-
pregnation are observed.   The  rudiments of the  osseous and nervous
systems  are formed  by the  outer or serous layers;  the outer covering of
the fcetus or integuments, including the amnios, are also  furnished  by it.
* The layer next in order has been called vascular, because in it the deve-
lopment of the principal parts of the vascular system appears to take  place.
The third, called the mucous layer, situated next the substance of the yelk,
is generally in intimate connexion with the vascular layer, and  it is  to the
changes which  these combined layers undergo,  that the intestinal, the
respiratory, and probably also the glandular systems, owe their origin.'
(A. Thompson, op. cit. p. 298.)
   " The embryo is therefore formed in the layers of the germinal  mem-
brane, and becomes, as it were, spread out upon the surface of the ovum:
the changes which the ovum of mammalia undergoes appear, from  actual
observation,  to be  precisely analogous  to those in the inferior animals.
(Baer, Prevost, and Dumas.)  From the primitive trace, which was at
first merely a line crossing the cicatricula, and which now begins rapidly
to exhibit the  characters of the  spinal column, the parietes of the head
and trunk gradually approach farther and farther towards the anterior sur-
face of the abdomen and  head until they unite ;  in this way the sides of
the jaws close in  the median  line of the face, occasionally leaving the
union incomplete,  and thus appearing to produce in some cases the con-
genital defects of hair-lip and cleft palate.   In some way the ribs meet at
the sternum ;  and it may be supposed that sometimes this bone  is left defi-
cient, and thus may become one of the causes of  those rare cases of mal-
formation, where the child  has been born with the heart external  to the
parietes of the thorax.  In like manner the parietes of the  abdomen and
pelvis close in the linea alba and symphysis pubis, occasionally leaving
the integuments of the navel deficient, or, in other words, producing con-
genital umbilical hernia, or at the  pubes a non-union of its symphysis with
a species of inversion of the bladder, the anterior wall of that viscus being
nearly or entirely wanting.
   " The cavity of the abdomen is therefore at first open to the vesicula
umbilicalis or yelk, but this changes as  the abdominal parietes begin to
close in; in man and  the mammalia merely a part of it, as above men-
tioned, forms the intestinal canal, whereas, in oviparous animals, the  whole
of the yelk-bag enters the abdominal cavity, and serves for an early nutri-
ment to the  young  animal.  Another change connected with the serous
or outer layer of the germinal membrane is the formation of the amnion
 
132
UTERO-GESTATION.
The fetal rudiment, which from its shape has been called carina, now
begins to be enveloped by a membrane of exceeding tenuity, forming a
double covering upon it; the one which immediately invests the fcetus is
considered to form the future epidermis ; the other, or outer fold, forms a
loose sac around it, containing the liquor  amnii.  Whilst  these changes
are taking place in the serous layer of the germinal membrane, and whilst
the intestinal canal, &c, are forming on  the anterior surface of the embryo,
which is turned towards the ovum, by means of the inner or mucous
layer, equally important changes are now observed in the middle or vas-
cular layer.  ' In forming this fold,' says Dr. A. Thompson, 'the mucous
layer is reflected  farthest inwards; the serous layer advances least,  and
the space between them, occupied by the vascular  layer,  is filled up by a
dilated part of this layer, the rudiment  of the heart.'  (Op. cit. p.  301.)

       Fig. 63.
    a.
                    b. Is a portion of the convexity of the amnion, upon which at a. is
                  the fundus of the diminutive human allantois.
                    c. The duct of the vesicula umbilicalis, dividing into two intestinal
                  portions ;  and besides this duct are two vessels which are distributed
                  upon the vesicula umbilicalis  and form a reticular anastomosis  with
                  each other.—From Baer,


   " Whilst this rudimentary trace of the vascular system is  making its
appearance, minute vessels are  seen ramifying over the vesicula umbili-
calis, forming, according to Baer's observations, a  reticular anastomosis,
which unites into two vessels the vasa omphalo-meseraica.   (British  and
Foreign Med. Rev. No. 1.)   These maybe demonstrated with great ease
in the chick: the cicatricula increases in extent;  it becomes vascular,  and
at length  forms  a heart-shaped  network of delicate vessels, which unite
into two trunks, terminating one on each side of the abdomen.
   " The umbilical vesicle now begins to separate itself more  and more
from the abdomen of the fcetus, merely a duct of communication passing
to that portion of it which forms the intestinal canal.   The first rudiment •
of the cord will be found at this separation ; its fcetal extremity remains
for a long time funnel-shaped, containing,  besides a portion  of intestine,
the  duct  of the  vesicula umbilicalis,  the vasa  omphalo-meseraica (the
future vena portae), the umbilical vein from the  collected venous radicles
of the chorion, and the early trace of the umbilical arteries.   These last-
named vessels ramify on a delicate membranous sac of an elongated form,
which rises from the inferior or caudal extremity of the embryo, viz., the
allantois; whether this is formed by a portion of the mucous layer  of the
germinal vesicle,  in common with the other abdominal viscera, appears to
be  still  uncertain: in birds  this may  be  very easily  demonstrated as a
vascular vesicle arising from the extremity  of the intestinal canal;  and in
mammalia, connected with the bladder by means of a canal called ura-
chus; from its sausage-like shape, it has received the name of allantois.
   " The existence of an allantois  in the human embryo has been long
inferred from the presence of a  ligamentous  cord extending from  the
fundus of the bladder to the umbilicus,  like the  urachus in animals.   But
from tne  extreme delicacy of the allantois, and  from its function ceasing
at a very early period, it  had  defied all  research, until lately, when  it  has
 
UTERO-GESTATION.
133
been satisfactorily demonstrated in the human embryo by Baer and Rathke.
It occupies the space between  the chorion and  amnion, and  gives  rise
occasionally to a collection of fluid between these membranes, familiarly
known by the name  of the liquor amnii spurius, which, strictly speaking,
is the liquor allantoidis.
  "The function of the allantois is still in a great measure unknown.   In
animals it evidently  acts as a species  of receptaculum urinae during the
latter periods of gestation ; but it is very doubtful if this be its use during
the earlier periods.  It does not seem  directly connected with the process
of nutrition, which at this time is proceeding so rapidly, first by means
of the albuminous  contents  of the vitellus,  or vesicula  umbilicalis, and
afterwards by the  absorbing radicles  of the chorion; but, from  analogy
with the structure  of the lower classes of animals, it would appear that it
is intended to produce certain changes in  the rudimentary circulation of
the embryo, similar  to  those which, at a later period of pregnancy, are
effected by means  of the placenta, and  after birth, by the lungs, constituting
the great functions of respiration.
   " In many of the lower classes of animals, respiration (or at least the
functions analogous  to it) is performed by  organs situated at the inferior
or caudal extremity  of the animal: thus, for instance, certain insect tribes,
as in hymenoptera, or insects with a sting,.as wasps, bees, &c.; in diptera,
or insects with two wings, as the common  fly; and also  the  spider tribe,
have their respiratory organs situated in the  lower part  of the abdomen.
In some of the Crustacea, as, for instance, the shrimp, the organs  of respi-
ration lie under the  tail between the fins, and floating loosely in the water.
Again, some of the mollusca, viz., the  cuttle-fish,  have the respiratory
organs in the abdomen.  We  also know  that many animals, during the
first periods of their lives, respire by a different set of organs to what they
do  in the adult  state;  the most  familiar  illustration  of this  is  the  frog,
which, during its tadpole state, lives entirely in  the water.
   "As the growth of the embryo advances, other organs, whose function
is as temporary as  that of the allantois, make their appearance: these also
correspond to the  respiratory organs of a lower class of animals, although
higher than those  to which we have just  alluded,—we  mean  branchial
processes or gills.   It is  to Professor  Rathke (Acta JYdtura Curios., vol.
xiv.),  that  we are  indebted for pointing out  the interesting fact, that
several transverse  slit-like  apertures may be detected on each side of the
neck of the embryo, at a very early stage of development.  In the chick,
in which he first observed it, it takes place about the fourth day of incu-
bation : at this period the neck is remarkably thick, and  contains a cavity
which communicates inferiorly with  the  oesophagus  and stomach,  and
opens  externally on each side by means of the above-mentioned apertures,
precisely as is observed in fishes, more especially the shark tribe; these
apertures are separated from each other by lobular septa, of exceedingly
soft and delicate structure.   Rathke observed the same structure in the
embryo of the pig and other mammalia; and Baer  has since  shown  it
distinctly in the human embryo.   It  is curious to see how the vascular
system corresponds to the grade of development then present:  the heart
is single, consisting  of one auricle and one ventricle;  the aorta gives off
four delicate,  but perfectly simple branches, two of which go to the right,
and two to the left side;  each of these little arteries passes to one of the 
134
UTERO-GESTATION.
lobules or septa at the side of the neck, which  correspond to gills, and
having again united with three others, close  to what is the first rudiment
of the vertebral column, they form a single  trunk, which afterwards be-
comes the abdominal aorta.   In a short time these slit-like openings begin
                                Fig. 64'.
o. Branchial processes
  b. Vesicula umbilica
  lis. c.Vitellus. d. Al
  lantois.  e. Amnion
  From Baer.
to close; the branchial processes or septa  become obliterated, and indis-
tinguishable from the adjacent parts ;  the heart loses the form of a single
heart;  a crescentic fold begins to mark the future division into two ven-
tricles, and gradually extends until the septum between them is completed.
It is also continued along the bulb of the aorta, dividing it into two trunks,
the  aorta proper and pulmonary artery; at the upper part the division is
left  incomplete, so that there is an opening from  one vessel to the other,
which forms the ductus arteriosus.*   A similar process takes place in the
auricles,  the foramen ovale being apparently formed in the same  manner
as the ductus arteriosus; these changes commence in the human  embryo
about the fourth week, and are completed about the seventh.
  "At first the body of  the  embryo has a more elongated form  than
afterwards, and the part which is first  developed  is the trunk, at the upper
extremity of which a small prominence, less thick than the middle .part,
and separated from the  rest of the body by an indentation, distinguishes
the  head.  There  are as yet no traces whatever  of extremities, or of any
other prominent parts; it is straight, or nearly so, the posterior surface
slightly convex, the  anterior slightly  concave, and rests with its inferior
extremity directly upon the membranes, or by means  of an  extremely
short umbilical cord.
  " The head now increases considerably in proportion to the rest of the
body ; so much so,  that at the beginning  of the  second month, it equals
nearly half the size of the whole body: previous to, and after this period,
it is usually smaller.   The body of the  embryo  becomes  considerably
curved, both at its upper as well as its lower extremity, although the trunk
itself still continues  straight.   The head  joins the body at a right angle,
so that the part of it which corresponds to the chin is fixed directly upon
the upper part of  the breast;  nor  can  any traces of neck be discerned,
until nearly the end  of  the second month.
  " The inferior extremity of the vertical column, which at first resembles
the rudiment of a tail,  becomes shorter towards the middle of the third
month, and takes a curvature forwards under  the rectum.   In  the fifth
  * In making these  observations upon the formation of the ductus arteriosus, we must
request our readers to consider this as still an unsettled question.
 
UTERO-GESTATION.
135
week the extremities become visible, the upper usually somewhat sooner
than the lower, in the form of small blunt prominences,—the upper close
under the head,  the lower  near the  caudal  extremity  of the vertebral
column.  Both are turned somewhat outwards, on account of the size of
the abdomen ; the upper are usually directed  somewhat  downw-ards, the
lower ones somewhat upwards.
   " The vesicula, umbilicalis may  still be  distinguished  in the  second
month as a small  vesicle,  not larger than a pea, near the insertion  of the
cord, at the navel, and external to the amnion.   From the trunk, which
is almost entirely  occupied by the abdominal cavity, arises a short, thick
umbilical cord, in which  some of the convolutions of the intestines  may
still be traced.  Besides these, it  usually contains, as  already observed, the

                                                           Fig. 65.

  Diagram of the foetus and membranes about the fourth week.       Ij^jS^ES^L
  a. Vesicula  umbilicalis, already passing into the ventricular      S/~2^^^mm^r r
fcnd rectum intestine at g.  b. Vena and arteria omphalo-mese-      Ml rf"3wuP||JH^ R
raica. c.  Allantois springing from the pelvis with the umbilical    e^^^^M^/M
arteries,   d. Embryo,  e. Amnion. /. Chorion. From Cams.      ~^£ii^jT\i«y^


two umbilical arteries  and the umbilical vein, the urachus, the vasa om-
phalo-meseraica, or vein and  artery of the vesicula  umbilicalis, and per-
haps, even  at this period,  the duct of communication  between the intestinal
canal and vesicula umbilicalis, the fcetal extremity of which, according to
Professor Oken's  views, forms the processus vermiformis.
   " The hands seem to be fixed to the shoulders without arms, and the

                                 Fig. 66.
Diagram of the foetus and membranes about the sixth week.
o. Chorion,  b. The larger absorbent extremities, the site of the placenta.
e. Allantois.  d. Amnion,  e. Urachus.  e. Bladder.  /. Vesicula umbili-
calis.  g. Communicating canal between the vesicula umbilicalis and in
testine. h. Vena umbilicalis. t, t. Arteriae umbilicales.  I. Vena omphalo-
meseraica.   k. Arteria omphalo-meseraica.   n. Heart,  o. Rudiment of
superior extremity, p. Rudiment of lower extremity. From Cams. 
136
UTERO-GESTATION.
feet to adhere to the ossa ilii; the liver seems to fill the whole  abdomen;
the ossa innominata, the ribs, and scapulae, are cartilaginous.
   "In a short time the little stump-like prominences of the extremities
become longer, and are now divided into two parts, the superior into the
hand  and the fore-arm, the inferior into the foot and  leg;  in one or two
weeks later, the arms and thighs are visible.   These parts of the extremi-
ties which are formed later than the others, are at first smaller, but as they
are gradually developed they become larger.  When  the limbs begin to
separate  into an upper  and lower part,  their extremities become rounder
and broader, and divided into the  fingers and toes, which at first are dis-
proportionately thick, and until the end of the third month  are connected
by a membranous-substance analogous to the wTebbed feet of water-birds;
this membrane gradually disappears, beginning  at the extremities  of the
fingers and toes, and continuing the division up to their insertion.   The
external  parts  of generation, the nose,  ears,  and mouth, appear after the
development of the extremities.  The insertion  of the umbilical cord
changes its  situation to a certain degree;  instead  of being  nearly at the
inferior extremity of the fcetus, as at first, it is -now situated  higher up, on"
the anterior surface of the abdomen.   The comparative  distance between
the umbilicus and  pubis continues  to increase, not only to the  full period
of gestation, when it occupies the middle point of the length  of the child's
body, as pointed out by  Chaussier, but even to the age  of  puberty, from
the relative size of the  liver becoming smaller.
   " Though the head appears large at first, and for a long time continues
so, yet its contents are tardy in their development, and until the sixth month
the parietes of the skull are in great measure membranous or cartilaginous.
Ossification commences in the base of the cranium, and the bones under
the scalp are those in which this process is last completed.
   " The contents of the skull are at first gelatinous, and no  distinct traces
of the natural structure of the brain  can be identified  until the close of
the second month ; even then it requires to have been some time previously
immersed in alcohol to harden its texture.   There are many parts of it
not properly developed until the seventh month.  In the medulla spinalis
no fibres  can be distinguished until the fourth month.   The thalami ner-
vorem opticorum, the  corpora  striata,  and tubercula quadrigemina, are
seen in the second month ;  in the third, the lateral and longitudinal sinuses
can be  traced, and contain blood.  In the fifth we  can distinguish the
corpus callosum ; but the cerebral mass has yet acquired very little solidity,
for until  the sixth month it is almost semi-fluid.  (Campbell's System of
Midwifery.)
   " About the end of the third, during the fourth, and the beginning of
the fifth  months, the mother begins to be sensible of the movements of
the fcetus.   These motions are felt sooner or later," according to the bulk
of the child, the size  and shape  of the pelvis, and the quantity of fluid
contained in the amnion; the waters being in larger proportionate quantity
the younger the fcetus.
   " The secretion of bile, like that of the fat, seems to begin towards the
middle of pregnancy, and tinges the meconium, a mucous secretion of the
intestinal tube, which  had hitherto been  colourless, of a yellow colour.
Shortly after this the hair begins to grow, and the nails are formed  about
the sixth or seventh  month.  A very delicate membrane (membrana pu- 
UTERO-GESTATION.
137
pillaris), by which the pupil has been hitherto closed, now ruptures, and
the pupil  becomes visible.   The  kidneys, which at first were  composed
of numerous glandular lobules (seventeen or  eighteen  in number), now
unite, and form  a separate viscus on each side of the spine;  sometimes
they unite into one  large  mass, an intermediate portion extending across
the spine, forming the horse-shoe  kidney.
   " Lastly, the testes, which at first were placed on each side of the lum-
bar vertebrae, near the origin of the spermatic^essels, now descend along
the iliac vessels  towards the inguinal  rings, directed by a cellular cord,
which Hunter has called Gubernaculum testis: they then pass through the
openings, carrying before them that portion of the peritoneum which is to
form their tunica vaginalis.
   " The length of a full-grown fcetus is generally about eighteen or nine-
teen inches; its weight between  six and seven pounds.  The  different
parts are well developed and rounded; the body is generally covered with
the vernix caseosa ;* the nails are horny, and  project beyond  the tips of
the fingers, which is not the case  with the toes;  the head has attained its
proper size and  hardness; the ears have the firmness of cartilage; the
scrotum is rugous,  not  peculiarly red,  and  usually containing the testes.
In female children, the nymphae are generally covered  entirely by the labia,
the breasts project,  and in both  sexes frequently contain a milky fluid.
As soon as a child is born, which has been carried the full time, it usually
cries loudly, opens its eyes,  and moves its arms and legs briskly; it soon
passes  urine  and faeces,  and greedily takes  the  nipple.    (Naegele's
Hebammenbuch.)
   " Thus then,  in  the  space  of forty weeks, or ten lunar months, from
an inappreciable point,  the fcetus  attains a  medium length of about
eighteen or nineteen inches, and  a  medium weight of between six and
seven  pounds."]
   191. It was formerly asserted  that the position of the child  in utero
during the early months was  sedentary, facing anteriorly;  and that to-
wards the end  of gestation,  owing to the greater weight of the head, and
to its voluntary efforts, it  made a revolution, so as  to present with the
head.   This, however, is not the  case.  With some exceptions, the posi-
tion of the child is unaltered from an early period of pregnancy to ;ts ter-
mination, whether the head  be upwards or downwards.  The arms are
generally folded over the chest, the knees  drawn up to the abdomen, the
back  curved, and the head bent upon the chest so as to  occupy as little
space as possible.   In ordinary cases, the face and anterior surface of the
child,  neither look forward as was formerly supposed, nor in  the direction
of the transverse diameter  of the  pelvis,  as is sometimes stated,  but
obliquely, so that in the first and  second position the back of the fcetus is
turned  partly forwards, and  the chest in the third and fourth.   This point
having been established by observation, we are enabled in many cases to

  * The vernix caseosa is a viscid fatty matter, of a yellowish white colour, adhering
to different parts of the child's body, and  in some cases in such quantity as to cover
the whole surface; it seems to be a substance intermediate between fibrine and fat,
having  a considerable resemblance to  spermaceti.   From the known  activity of the
sebaceous glands in the foetal  state, and from the smegma being found in the greatest
quantity about the head, arm-pits, and groins, where these glands are most abundant,
there is every reason to consider it as the secretion of the sebaceous glands of the skin
during the latter months of pregnancy.
                                  m2 
138                       UTERO-GESTATION.

ascertain the position  of the  infant before labour has  commenced, by
means of the stethoscope, according as the pulsation is heard at one side
or other of the abdomen, and more or less clearly.

                                Fig. 67.
  192.  Various causes  of the position  of the fcetus in utero have been
mentioned,  such as gravitation, voluntary  movements, &c.   Professor
Simpson has entered into an elaborate  investigation of the subject, and
has arrived at the following conclusions:—" 1. The usual position of the
fcetus, with the head lowest and  presenting over the os uteri, is  not  as-
sumed till about the sixth month of intra-uterine life, and becomes more
frequent and more certain from that time onwards to the full term of utero-
gestation.  2.  Both the assumption and maintenance of this position  are
vital and not physical acts, for they are found  dependent on the existence
and continuance of vitality in the child ;  concurring with its life, but being
lost by its death.   3. In human  physiology  we do not know or recognize
any vital power or action, except muscular  action,  capable  of producing
motions calculated to alter  or regulate  the  position, either  of the whole
body or of any of its parts;  and further, the motory muscular actions of
the fcetus are not spontaneous or voluntary, but reflex or excito-motory in
their nature, causation, and  effects.   4. The  position of the fcetus with
the head placed over the os uteri, is  that position  in which the physical
shape of the normal and fully-developed fcetus  is best adapted to  the
physical shape of the normal and  fully-developed cavity of the uterus.
5. This adaptive position of the contained body to the  containing cavity
is the aggregate result of reflex  or excito-motory movements on the part
of the foetus, by which it keeps  its  cutaneous  surface withdrawn as far as
possible from the causes of irritation that may act upon  it as excitants, or
'hat happen to restrain its freedom of position or of motion." 
UTERO-GESTATION.
139
3| to 4
193. The length of a full-grown fcetus is from 18 to 22 or 24 inches.
     The longitudinal diameter of its head (l2) is from 4  to 4|
     The transverse  ....
     The occipito-mental or oblique (3 4)
     The cervico-bregmatic  (5 6) .
     The trachelo-bregmatic
     The inter-auricular
     The fronto-mental (7 8)
     The transverse diameter of the shoulders
     The transverse diameter of the hips
                               Fig. 68.
31
4.3
   5
to 4^
to 4
   3
   3*
to b\
to 5
 In general, it maybe observed that all the measurements are less in female
 than in male children.*
   The weight of a full-grown child at birth varies in the same and in dif-
 ferent sexes.   Rcederer found  the weight in Germany, to  be from seven
 to eight pounds.  Dr.  Jno. Clarke,  in the Lying-in Hospital, Dublin,  as-
 certained the waight of the majority, to be about seven pounds, but that
 it varied  from four to eleven pounds.  In  France, the average weight is
 less; according to Camus, it is  six pounds and a quarter, and observations
 at La Maternite have confirmed this estimate.  In Brussels, it is six pounds
 and a half; but in Moscow, nine pounds  and one fifteenth.   Dr. Beck
 states that the average weight in America exceeds seven pounds.f
   194. The umbilicus  changes its relative position  as the development of
 the fcetus proceeds, until at birth, it is near the middle of the entire length
  * Dr. Meigs (Obstetrics; the  Science and the Art,  p. 63) makes the occipito-frontal
 diameter four inches and ten-twelfths of an inch.  " I speak," he remarks, " with great
 confidence  as to the above estimate, for I have carefully measured and recorded the size
 of three hundred crania of mature children that I received in the course of my obstetric
 practice."
  The bi-parietal diameter, being the mean derived from the measurement  of one hun-
 dred and fifty crania, he makes three inches and eleven-twelfths of an inch.
  The occipito-mental diameter, being the  mean derived from the measurement of one
hundred and twenty-six crania, he makes five inches and a half. — Editor.
  f The variations in weight are  surprisingly great in all countries; and it is highly
probable that the average in this respect, if it could be correctly ascertained, would not
be found to differ .in different countries so much as is stated above.  In the United
States, it is not customary in private practice either to measure or weigh the infant at
the time of birth,  except when the size is unusual; hence all general statements of the
kind are derived from  alms-houses and hospitals, which can hardly be considered to
represent fairly what obtains among the mass of the people. — Editor. 
140
UTERO-GESTATION.
of the child.  According to Chaussier, Bigeschi, and others, this relative
position of the umbilicus is a test of its maturity, being distant  from the
central point in  proportion to  its immaturity.   But it  seems doubtful
whether  its position is so  exactly  central in mature children  as these
authors state ; for M. Moreau has recently measured  five hundred children,
born at the full term in La Maternite, Paris, and of  this number, he found
only four in whom the umbilicus was exactly central.   In the remainder,
the point  of insertion of the funis fell on an average from eight to ten lines
below the middle.   In  a few children born  about the  sixth or eighth
month, the umbilicus was central.
   195. The characteristics of the  maturity and perfection of a child at
birth, according  to Fodere and Capuron are, its  ability to cry as soon as
it reaches the atmospheric  air,  or shortly after;  to  move its limbs with
facility and more or less strength,  its body being of a clear  red colour;
the mouth, nostrils, eyelids, and ears,  perfectly open ;  the bones of the
cranium  possessing some solidity, and the edges of the fontanelles not far
apart; the hair, eyebrows,  and  nails, perfectly developed ; the  free dis-
charge of the meconium a few hours after birth, and finally, the power of
swallowing and  digesting,  indicated by  its seizing the nipple or finger
placed within its mouth.
   The child  may be  considered immature, when its length  and volume
are much less than those of an  infant at  the full  term;  when it does  not
move its limbs, or makes only feeble motions; when it seems unable to
suck, and has to be fed artificially ;  when its skin is of  an intense  red
colour, and  traversed by  numerous bluish vessels;  when the head is
covered with down, and the nails are not formed ; when the bones of the
head  are  soft, and the fontanelles widely separated; the  eyelids, mouth,
and nostrils  closed;  when  it sleeps continually,  and an artificial  heat is
necessary to preserve it; and when it discharges its urine and meconium
imperfectly.
   There are  cases on record of  children prematurely born at the fifth and
sixth  month  of gestation,  attaining maturity; but  ordinarily we do  not
consider  a child ' viabW until about the seventh month of  utero-gestation.
   196. The  proportion of the sexes in Europe, according to the learned
M. Quetelet, is*about 106 males to 100 females, nor does it appear that in
this part of the world, climate has much influence.  At the Cape of Good
Hope, female births predominate among the free inhabitants,  and the op-
posite  among the slaves.  A country life  seems to favour  the production
of male progeny; and the  relative ages of husband and wife exert a de-
cided influence, for in proportion as the husband is younger than the wife,
girls predominate, and within  certain limits, a disproportion the other "vyay
has the opposite effects; or as Mr.  Sadler has expressed it, upon a mean
number of births, the  sex of the child  is that of the parent whose age is
in excess.*
  * Dr.  G.  Emerson, of Philadelphia, has carefully investigated the influences operating
to change the number of births,  and also the relative proportion of the sexes at birth;
he includes them under two heads :—
  1st.  The Seasons.—The following general results relative to this point were obtained
from estimates based upon 65,542 births in Philadelphia.   The greatest number of con-
ception's occurred during the winter and spring months; the maximum being 17,645 in
the spring months.  The smallest number occurred in the summer and autumn months,
the minimum being 15,200 in the summer quarter. 
UTERO-GESTATION.                       141
  The number of twin cases at La Maternite was 444 in 37,441 cases, or
1 in 84 ; in the Dublin Lying-in Hospital 2101 cases in 134,908, or about
1 in 64 ; in the same number 29 triplet cases occurred, or 1 in 4652; and
one case of quadruplets.
  The  mean proportion of still-born children in the cities of Europe is
about  1 in 22 births:  the extreme variation is from 1 in 11 at Strasburg,
to 1  in 36 at Stockholm.
  In the Lying-in Hospital in this city from its  establishment in 1757 to
1836 there occurred 8021  still-born  children in 134,908 cases, or about
1 in 17.
  The number of still-born males is  greater than that of females: in West
Flanders and at Berlin in the  proportion of 14 to 10.
   197. The  Physiology of Fcetal  life is  simply that of organic nutri-
tion ;  at first by superficial  imbibition, afterwards probably by absorption
by the villi of the chorion, and ultimately by the  changes made in or addi-
tions to the fcetal blood,  in the placenta.
   The sources of nutriment during the earliest  period of embryonic life
are the vitellus, or the fluid in the umbilical vesicle, and possibly the gela-
tinous matter (tunica media) between the amnion and  chorion.   After the
formation of the amnion, its fluid may possibly contribute to this end.   Dr.
Montgomery, as we have seen, suggests that the milky fluid contained in
the decidual  cotyledons, may  also be available for this purpose.
   There is no doubt of the functions of the placenta: there the blood of
the fcetus  is  renovated from that of the  mother, in  the same way as the
blood  of  fishes is aSrated by the water passing through the gills.
   Whether in the earlier months absorption is  carried on by the  surface
alone, or whether, as Velpeau  suggests, a portion of the liquor amnii finds
its way into  the stomach,  may be difficult to  decide, but  that a  certain
amount of digestion is carried on, is impossible to doubt.*

  The greatest excess of male conceptions is shown to be  in the winter season, when, the
total being 17,184, the males were 9,007, and the females 8,177.   The excess  of male
conceptions for the other three quarters or  seasons, varies but little from the minimum
excess,  which occurs in spring.
  2d. The plenty or deficiencies of food, purity or impurity of the air, over-working, and
whatever tends to exalt or to impair the vital  energies of the people.   In many parts
of Europe, where the  general population is over-worked and under-fed, the excess of
male births is very small; being throughout France and  Prussia under 6 per cent., and
in England about 5 per  cent.   In Philadelphia, where the general condition of the
population is very favourable, the male births exceed the female about 7 per cent.  In
the rural districts of the United States, and especially in the newest  settlements, the
preponderance  of boys at birth is believed to be not less than 10 per cent.  An opposite
result is found  when fatal  epidemics alarm and depress the public mind.  Thus, among
Uic children born in Philadelphia, whose conception occurred during the prevalence of
the  cholera in 1832, there  was a  preponderance of females.   The same result was
shown in the births which took place in Paris, nine months after the cholera prevailed
there in 1832.  The births, at a somewhat later period  after the visitation of  the epi-
demic, exhibit an increase in the amount of males, in consequence, it is presumed, of
the parents being endowed with vital energies above the average, as is shown by their
exemption or recovery from the disease.—Transactions of the American Med. Association,
vol. iii.  p. 93.—Editor.

  * Since it has been ascertained that the blood of the mother does not circulate in the
vessels of the foetus, but that this enjoys a sort of independent existence, the subject of
foetal nutrition  has become one of great obscurity.  The occurrence of well-authenti-
cated cases in which children have been born without placenta, funis, mouth or  anus,
or any absolute connexion  with the mother whatever, proves that they may be nourished
by the fluids imbibed or absorbed By the cutaneous surface 
142
UTERO-GESTATION.
   198. Before describing the circulation  in  the fcetus, there  are  certain
anatomical peculiarities which demand our notice : —1. There is a supple-
mentary vein, situated  at the thick edge of the liver, and leading from the
umbilical vein to the  vena cava ascendens,  called the ductus venosus:
2. The septum between the  auricles is imperfect, having in its centre a
valvular oval aperture  called the foramen ovale:  3. The pulmonary artery
soon after its origin gives off a branch, the ductus arteriosus, which enters
the aorta just below its arch.   The general effect of these peculiarities  is
to render the heart virtually a single one, to provide for the quiescent state
of the lungs, and to modify the distribution of fresh blood.
   Different opinions have been given as to the course  of the  blood in the
fcetus:  I shall  mention only two, Sabatier's  and Winslow's.   Sabatier's
figure-of-8 circulation  is thus  described by Dr.  Flood:—" The blood of
the fcetus is conveyed from the placenta by the umbilical veins to the liver,
through which it circulates, and then  passes into  the inferior cava.  A
portion  of  it,  however,  is  transmitted  in a  comparatively pure  state,"
through the  ductus venosus, " which opens into the left hepatic vein, and
then into the  inferior  cava.  From  the inferior cava  the blood ascends
into the right  auricle,  then by the foramen ovale  into the left  auricle, left
ventricle, and arch of the aorta.  A portion of the blood thus  carried into
the aorta descends into its thoracic part; the rest, after circulating through
the head and upper extremities, returns by the superior cava to the right
auricle,  and passes thence into the right ventricle and  pulmonary  artery.
A small part of this blood goes to the  lungs  by right  and left branches ;
but the rest, conveyed by the ductus arteriosus,  joins  the  blood that we
left descending through the thoracic  and abdominal aorta, and all that is
not employed in  the  nutrition of  the body and lower  extremities, is
returned by  the hypogastric arteries to the placenta."   The object  of this
theory is to show that the head and  superior  extremities receive a  supply
of purer blood, which they  are supposed to need for their development;
but there are great objections in  the  way:—1. Even supposing the pure
blood was  conveyed in the manner stated, it  is too  small in  quantity to
answer the purpose, being only one-fifth of the whole: 2. Supposing  it
to be  sufficient, the presumed effects are not produced, the intestines, ribs,
&c, being just as perfectly formed  at birth as the brain: and 3. No such
transmission of pure blood across the auricle, through  the foramen ovale,
can take place, because of the effects of gravity, the descending current
from the superior cava, and, above all,  because of the  active contraction
of the right  auricle.  We  must therefore adopt  Winslow's explanation,
  A distinguished physiologist observes on this subject that, " The most plausible opinion
he can form on this intricate subject is, that the mother secretes the substances, which
are placed in contact with the foetus, in a condition best adapted for its nutrition ; that
in this state  they are received into the system, by absorption, as the chyle or the lymph
is received into the adult, undergoing modifications in their, passage through the foetal
placenta, as well as in every part of the system where the elements of the blood must
escape for the formation of the various tissues.
  " With regard to the precise nutritive functions executed in the fcetal state, and first,
as concerns  digestion, it is  obvious that this cannot take place to any extent, otherwise
excrementitious matter would have been thrown out, which by entering the liquor amnii,
would be fatal to its important functions, and probably to the very existence of the foetus.
Yet, that some digestion is effected, is manifest from the presence of meconium in the
intestines, which is probably the excrementitious matter  arising from the digestion of
the mucous  secretions of  the alimentary canal."—Dunglison's Human Physiology, 4th
edition, vol. ii. p. 497. — Editor. 
UTERO-GESTATION.
143
which  assumes that the heart is virtually single and  the  blood mixed.
According to him, " The blood of the system  generally passes  from the
superior and inferior cava into the right auricle.  One part of this is trans-
mitted through the right auricle.  One part of this is transmitted through
the right ventricle and pulmonary artery, and thence (except a supply for
the nourishment of the lungs) through the ductus arteriosus into the de-
scending  aorta;  a  second and larger part, passes through the foramen
ovale into the left auricle, then into the left ventricle and arch of the aorta,
the branches of which supply the head and upper extremities.   The con-
tinued stream passes into the descending aorta, mixing with that already
described;  and all of it that is not employed in the nutrition of the body
and lower  extremities,  is reconveyed by the umbilical arteries  to the
placenta."
   199. The circulation of the  fcetus is independent of that of the mother,
though it may be sympathetically affected.  By the stethoscope we hear
the fcetal heart, which is found to beat from 120 to 150  times a minute:
at the same time I  must say, that it is not easy to  reconcile this with the
fact repeatedly verified  by myself,  that  the  pulsation of the cord when
prolapsed, or when felt during the operation  of turning, is much  slower.
I counted these pulsations the  other day, and they amounted to 80, at the
time when, I  believe, the fcetal heart had been  heard pulsating as usual.
   200. After birth remarkable changes take  place.  From  the  painful
impressions on the  surface and senses, efforts are made by the child, which
cause  inspiration and end in  crying, by which means the lungs are more
or less inflated, and space is  afforded for the pulmonary circulation, which
supersedes the use  of the foramen ovale  and ductus arteriosus: the blood
from the lower extremities cannot pass through the umbilical arteries, and
does pass through the ascending cava into the  right auricle and ventricle
and thence into the lungs, where it undergoes analogous but more perfect
changes, to those effected in the placenta, and  is distributed to the body
generally.   By degrees, the  foramen ovale closes, and the  ductus arterio-
sus, ductus venosus,  and umbilical  arteries are obliterated;  the adult cir-
culation is then established.
   Digestion takes place on the reception of food, the liver becomes more
active, and the usual excretions of the kidneys  and intestinal canal  occur.
   Before birth, the only sense in exercise was that of touch, but imme-
diately afterwards, those of sight and hearing are called into activity, and
at a later period those of taste and smell.  A considerable time  elapses
before the sensuous impressions  are  correctly  appreciated, yet every day
adds  its quota of instruction, and hourly experience at length  produces
accuracy.
   The brain,  which was perfectly quiescent during  gestation, is now the
focus for the impressions produced upon the senses, and the seat of such
intellectual  operations  at  can  take  place at so early a  period, and the
nervous system generally, is the centre to which all  organic operations are
referable.
  201. In conclusion, I shall briefly notice the so-called laws of develop-
ment.
  The first of these is the law of unity of organization, in virtue of which
" the progressive phases of the embryo,  correspond to the abiding forms,
which  are preserved in the total organism of animated  nature  as  tvpical
        10 
144
UTERO-GESTATION.
of its gradative evolution ;  and that as the embryo of each higher animal
passes rapidly through the forms  of the animals inferior to it in order to
attain its maturity and specific rank of being, that of man is transitively
the compendium of all; not, indeed, without a difference, since in each
instance, the changing form of the embryo bears the impress of the transi-
tional and incomplete character, while it ever preserves the promise  and
prophecy of the being into  which it is to be finally evolved."   This law
of transitive development, so  eloquently described by Mr. Green in  the
extract I have quoted from his Hunterian oration,  has been established by
the researches of Wolff, Otto, Meckel, and other German physiologists;
but it is only just to  state that the idea was familiar to our great natural
philosopher John Hunter, who remarks,  "If we were capable of following
the progress of increase of the number of the  parts of the most perfect
animal, as they are formed in succession," from the very first, to  its  state
of full  perfection,  we  should  probably be able to compare it with some
one of the incomplete animals themselves, of every order of  animals in
the creation, being at no  stage different from some  of those inferior orders;
or, in  other words, if  w?e were to take a series of  animals from the more
imperfect  to  the perfect, we should  probably find an imperfect animal
corresponding with some stage of the perfect."
   In accordance with this  law,  we find  the fcetal nervous system  at  the
earliest period resembling that of the annelides, then that of the inverte-
brata,  and afterwards  that of fishes, reptiles, birds, &c.   The  same may
be  said of other organs, and we  have  already given an  example in the
case of the uterus  (§ 91).
   More striking illustrations may be derived from  certain abnormal devia-
tions, of which Mr. Green remarks,  " and it did not escape Hunter, as a
consequence  of the  same law, that  congenital  defects, hitherto  compre-
hended • under the  vague designation of monstrosity,  are to be explained
by the  development of the embryo being interrupted at some early stage
of its regular evolution, and that the defective form which is the result, is
analogous to the form and structure of an inferior  class."
   Thus we have  the law exhibited  in  the successive transitions of  the
fcetus until its arrival at its perfect state;  and, if possible,  more strikingly
illustrated by those exceptions, where it fails to attain this perfection.*
  * One of the most  remarkable of these congenital defects is the " spontaneous  am-
putation of the fcetal  limbs in utero," so well described by  Dr. Montgomery of Dublin.
Since the publication of his paper in the year 1832 (Dublin Journal of Medical Science
vol. i. p. 140), the subject has attracted a good deal of attention in Europe, and also in
this country, and several very interesting cases have been detailed: in some, it seems
to have  been  caused  by the umbilical cord encircling the limbs and acting as a liga-
ture ; in other cases the origin of the ligature has been ascribed by Dr. Montgomery to
organized lymph. Professor Gurlt, of the Royal School of Medicine at  Berlin, in a
paper published by him in 1833, regards, "these threads as prolongations of the  egg
membrane  from which the foetus grows, whether this skin (or membrane) be taken as
the navel bladder or the amnion," and " objects to their being considered as  formed by
organized lymph," as supposed  by Dr. Montgomery.   " The prolongations  of  the
membrane," Gurlt thinks, "are  afterwards, by the constant motions of the foetus,
twisted into slight but firm cords, or threads, which may involve different portions of
the fcetal limbs, (as we sometimes find the umbilical cord several times round the neck,
or othe" parts of the child's body,) so as to stricture them, and cause their separation;
in this way he explains the presence of the ligatures concerned in  the production of
spontaneous amputation."
  For further information on this curious  subject the reader is referred to  Dr. Mont-
gomery's essay, contained in his invaluable work on the "Signs and Symptoms of
Pregnancy." — Editor. 
SIGNS OF PREGNANCY.
145
  202.  The other law I shall notice has also received its most impres-
sive elucidation from certain exceptions: it is called the law of symmetry,
conjugation, or  affinity, founded upon the  general observation that all
formations proceed from the  circumference to the  centre.   According to
M. Serres, the body generally, and each organ, whether single or double
at birth, is originally divisible into two parts, that each half grows towards
the mesial line, where it meets its opposite and is joined to it, as we saw7
in the case of  the  dorsal and ventral laminae.  If the law of progression
be equally observed  by both  halves, the organ resulting from their union
will be  perfect;  if the growth be unequal, deficient, or excessive, the re-
sult will be deformity by defect or excess.   Again, connected with this
law of symmetry,  and perhaps causing its deviations, is the fact that de-
velopment of each part of the body is to a certain extent dependent upon
its vascular supply;  if this be deficient or  in excess, so  most probably
will be  the other.
  203.  We are now able to classify  to a  certain extent the deviations
from  the  normal formation of the fcetus, viz. into those whose deformity
results from an  arrest of the transitive development, those arising from
irregularity of symmetrical growth, and those dependent upon vascular
irregularities.  Others still remain,  however, the larger  class probably
depending upon diseased action in the organs or structures of the fcetus
or of  its dependencies, and some which it is very difficult to  explain at
present.
                           CHAPTER V.

                      SIGNS OF PREGNANCY.

  204.  Having now described  minutely the process of utero-gestation,
let  us examine  the signs  and symptoms  to which it gives rise, and by
which it may be detected.   I need say but little as to the importance of
such an inquiry, or of the responsibility which is incurred by a physician,
when his opinion is demanded.   The honour, and therefore the happiness
of a female, may depend upon  his decision, the peace of families may
rest upon it, and  the inheritance of  property be controlled by it.  The
limits of this work oblige me to treat the question rather as a physiological
than a  medico-legal  one ;  but although much is omitted which might be
available in the latter point of view, all that is adduced applies equally to
both.   In all such cases, the reader is to remember that he may not merely
be requested to investigate  a case of doubtful pregnancy where no shame
is  evolved,  but  that  he  may be consulted in cases where pregnancy is
concealed by unmarried women,  or by married women under certain cir-
cumstances, to avoid disgrace;  and  on the  other hand, where it is pre-
tended  in order to secure  an inheritance, to extort money, or to delay
punishment.   In considering each "sign" I shall endeavour  to state its
value  as evidence, as well as to describe its  characters as a symptom.
  205.  The signs of pregnancy have been variously classified, and  no
doubt in a formal treatise a scientific  classification is necessary;  but in a
                                    N 
146
SIGNS  OF PREGNANCY.
brief summary like the present, it appears to me that it will be more use-
ful to take them rather in the order of time in which they are developed,
by which means the student will find grouped together, the early evidences
of pregnancy, and  again, those indicative of more advanced gestation.
  206.  The general condition of a pregnant woman is plethoric, the pulse
is  quicker and fuller, the quantity of circulating fluid is said to be  aug-
mented, and its quality  altered by the increase of fibrine, judging from
the prevalence of the buffy coat in blood taken under such circumstances.
  Well-marked sympathies are excited  in distant organs  which often
amount to distressing irritation, and the nervous system may suffer both
primarily and secondarily.   Variations in temper and disposition are of
frequent occurrence, as well as caprices of taste.   The chylopoietic viscera
are often  deranged, and the secretion from  the kidneys  altered.   The
skin may change its colour, and become sallow or discoloured in patches,
though  in some cases it  becomes  more florid, with occasional eruptions
on  the  face.   Some  women become fat  during pregnancy, others lose
flesh.
  But in some particulars, the deviations  from the ordinary state are more
remarkable, and constitute the special signs  upon which our  diagnosis
must be grounded; these we shall now notice, previously remarking that
the diagnosis of early pregnancy is no easy task, but one which requires
the greatest care and discrimination.
  207.  Cessation  of menstruation. — One  of the first circumstances
which leads a female to suspect that  she  is pregnant, is the non-appear-
ance of the catamenia at the proper time, and if at the second period they
are still absent, it is deemed conclusive, or nearly so.
  No doubt this is  one of the most unvarying, as it is one of the  earliest
results  of pregnancy.  But, strictly speaking,  it is not  conclusive, inas-
much as the discharge may recur for some months after  conception, or
even monthly during  the whole period of utero-gestation.   Such cases
have been recorded by Maureceau, Puzos, Desormeaux, Johnson, Frank,
Dewees, Kennedy, Montgomery, &c, and several such have occurred to
myself.*
  Again, conception may take place previous to menstruation, or imme-
diately after ceasing to give suck, before it has  had time to occur.   Nay,
some cases are on  record where women  menstruated only during gesta-
tion.
  Lastly, the catamenia may be arrested by disease of various kinds, and
it is even possible for pregnancy to occur in such cases.
  If then, menstruation  may be suspended by other causes  on the one
hand, and may continue, notwithstanding pregnancy, on the other hand,
it is evident, that by itself, the  cessation of menstruation  is not a proof of
conception,  although it is of considerable value (inversely as to  the fre-

  * Dr. Meurer has recorded a remarkable instance of  menstruation during pregnancy
in a woman, setat. 27,  who was pregnant for the fourth time when he  wrote.  " She
always has  had her menses  regularly during pregnancy, and only during that  time.
They come on without  any illness; and she has  always borne healthy children, at the
full period.  While unmarried, and except during pregnancy, she  never menstruated,
but she was never unwell from it.  Her general appearance is rather masculine; it
appears, therefore, that in her, as in all viragos, the sexual functions require a powerful
excitant, such as pregnancy, to cause them  to be energetically performed."—London
Medical Gazette, Nov. 1840, from Med. Correspondenzblatt, Bd. 9, No. 31.—Editor. 
SIGNS  OF PREGNANCY.
147
quency of the exceptions)  as evidence, especially combined with  other
signs.   I may add that in cases  of concealed pregnancy, the  woman
sometimes stains her linen with blood, in order to simulate this discharge.
   208. Morning Sickness.—The intimate sympathy between the uterus
and stomach, is  shown by the irritability of the latter soon after concep-
tion.  Most women suffer more or less from nausea  and vomiting, espe-
cially on rising in the morning; hence it is termed " the morning sick-
ness."   The irritability may commence immediately after conception, as
in two cases mentioned by Dr. Montgomery; but more generally it sets
in about the fifth or sixth week, and ceases soon  after the third  month.
The daily attack lasts but a short time, from ten minutes to an hour, after
which the patient completely recovers, and is able to take food.
   As an evidence of pregnancy, its recurrence at the regular time and in
the  Usual manner, is of great value when combined with other symptoms,
but the exceptions and irregularities are sufficiently  frequent to render it
more doubtful if taken  alone;  for it may be  altogether absent, and  yet
the  patient be pregnant, or  if present, it  may occur at unusual times, or
with extraordinary violence : with some women it occurs during the night
only, with others it lasts during  the entire day, and  may continue through-
out  the period of gestation.  On the other hand, it may be  present  as
morning sickness, from various  causes, and yet the patient not be  preg-
nant.
   Dr. Ramsbotham remarks, that  when vomiting " is  entirely  absent,
Mtero-gestation does not proceed with its  usual regularity and activity;"
and so far my experience agrees with his, that irregularities in this  parti-
cular  are  frequently followed by  deviations in the other symptoms  of
pregnancy.*
   209. Salivation.—The irritation  caused by pregnancy may affect  the
salivary glands, and induce salivation, although it  is not of very frequent
occurrence.   It is enumerated by Hippocrates and the  earlier writers  as
one of the signs of pregnancy; but recent authorities consider it of less
value.  Cases, however, are mentioned by Dewees, Montgomery, and
others.  Several  such have occurred  to  myself, in which it commenced
at an early period, was very profuse, but unaccompanied by swelling or
tenderness, and  ceased  spontaneously,  in  one case, about  the fourth
month, in another about the fifth, and in a third  about the  eighth.   As
Dr.  Montgomery has  observed,  it  is  " easily  distinguished  from the
ptyalism induced by mercury, by the absence of sponginess and soreness
of the gums, and  of the peculiar fcetor, and by  the presence of preg-
nancy."
   210. Mammary Sympathies.—About two months after conception, the
attention of the female is attracted to the  state of the breasts.   She feels
an uneasy sensation of fulness, with throbbing and tingling pains  in their
substance and at the nipples.   They increase  in size and firmness, and

  * " This  remark does not entirely correspond with my experience," remarks  Dr.
Huston, in a note to a former edition.   " I have known many women proceed regularly
through their pregnancy, and be safely delivered of healthy children, without experi-
encing the least degree of morning sickness.  But where a woman labouring under this
disturbance is suddenly relieved, before the usual time for its cessation, there is reason
to apprehend some mischief to the ovum, the more especially if she has been  exposed
to any mental or other cause capable of strongly impressing  the  nervous or vascular
system." — Editor. 
148
SIGNS OF PREGNANCY.
have a peculiar knotty glandular feel;  the areola darkens, and after some
time, a milky fluid is secreted.
   But it must be recollected that the breasts  may enlarge from other
causes;  this happens with some women at each menstrual period, when
the  catamenia are suspended, or after they cease; and at such time a
milky fluid may be secreted.  Distension of the  uterus from hydatids or
other causes, is accompanied by a change in the breasts.   On the other
hand Gardien  and Mahon have  remarked, that when menstruation takes
place during the early months of gestation  the swelling  and pain of the
breasts are absent, and Dr. Montgomery mentions a case in which no al-
teration took place until after delivery, in consequence of the delicate state
of the patient's health.
   In the virgin state the  colour of the nipple and areola differs compara-
tively little from that of the surrounding skin; it  is generally a few shades
darker, but sometimes scarcely that.
   But after conception a great change is observed in most women, though
less  marked in those of very light complexions.   The first alteration per-
ceptible is " a soft and moist  state of the integument, which appears raised
and  in a state of turgescence, giving one the idea, that if touched by the
point of the finger, it would be found emphysematous;  this state appears,
however, to be caused by infiltration of the subjacent cellular tissue, which,
together with its altered colour, gives us the idea  of a part in which there
is going forward a greater degree of vital action than is in operation around
it, and we not unfrequently find  that the little glandular follicles or tuber-
cles, as they are called by Morgagni, are bedewed with a secretion suffi-
cient to  damp  and colour the woman's inner dress."   The above is an
extract from Dr. Montgomery's work, to which, and the plates  accompa-
nying it, I beg to refer the reader.   This  first change in  the  areola takes
place at  an  early period ; Dr. Montgomery states that he has recognised
it at  the  end of the  second month.   " During the  progress of the next
two months, the changes in the areola are  in general perfected, or nearly
so ; and then it presents the following characters; a circle round the nipple,
                              Fig. 69.
whose colour varies in intensity according to the particular complexion of
the individual, being usually much darker in persons with black hair, dark
eyes,  and sallow skin, than in those of fair hair, light-coloured  eyes, and 
SIGNS OF PREGNANCY.
149
delicate complexion.   The extent of the circle varies in diameter from an
inch to an inch and a half, and increases in  most persons as pregnancy
advances, as does also the depth of the  colour."  " In the centre of the
coloured circle, the nipple is observed partaking of  the altered colour of
the part, and appearing turgid and prominent, while the surface of the are-
ola, especially that part of it which lies more immediately around the base
of the nipple, is studded over and rendered unequal by the prominence of
the glandular follicles, which, varying in number from twelve to twenty,
project from the sixteenth to the eighth of an inch; and lastly, the integu-
ment covering the part appears turgescent, softer, and more moist, than
that which  surrounds it, while on  both  there are to be observed  at this
period, especially in women of dark hair and eyes, numerous round spots
or small mottled  patches of a whitish colour, scattered  over the outer part
of  the areola, and for about an inch or more all  around presenting an ap-
pearance as if the colour had been  discharged by a shower of drops falling
on the part."  Dr. Montgomery fixes the time of this peculiar appearance
at  about the fifth month, at which  time  the breasts have become full  and
firm with large veins ramifying on their surface.   After the sixth month, a
number of  silvery streaks like cracks may be observed, the result of over-
distension.
   To these well-marked changes in the areola and nipple there are many
exceptions ; the colour, which is in  general the most prominent alteration,
may not deepen so decidedly;  and many cases of  women of  light com-
plexions occur, in whom it scarcely  differs from the surrounding skin.
Besides, as Dr. Ingleby has well remarked,  " when the colour of  the in-
tegument around the  nipple has been  once  modified by  pregnancy and
nursing, it  is no longer, I think, a conclusive criterion."   Again, in other
cases the sebaceous glands are but  slightly developed ; but I have almost
invariably  observed the puffy state of the areola in  first pregnancies.  If
the fcetus die, the changes are  arrested and gradually decline.
   On the other hand, something resembling  the deepened colour of the
areola, as well as enlargement of the  mammary gland, is  said to be pre-
sent, when the uterus is distended  from  other causes;  and I have  repeat-
edly seen the follicles developed in patients neither pregnant nor nursing.
Upon the whole, however, the changes  in the breast and nipples are cer-
tainly the most unequivocal of all the early signs of  pregnancy.
   211. Milk in the breasts, although a popular evidence,  much relied
upon, can scarcely be  considered  of any value  at all.   It  is true, we do
 often find it at an early period, and generally at a later;  yet it occurs so
 frequently without pregnancy, that no certain conclusions can be drawn
 from it.  For instance, Baudelocque mentions the case of a girl of eight
years old,  who milked  her breasts in the presence of the Royal Academy
of Surgerjr, October 16th, 1783, and Belloc another;  in both, the secre-
tion was apparently the result of the application of a child to the breasts.
A similar case, but in a woman, is  related by Mr. Semple in the North of
England Med. and Surg. Journal,  vol. i. p. 230.  Milk is also occasion-
 ally secreted at each return of the  catamenia, and may remain very long
after weaning.  Fodere mentions that  he has frequently known it secreted
at the final  cessation of menstruation.*
   * Some very remarkable cases of  mammary secretions, both in the male and unim-
pregnated female, are cited in Dunglison's Human Physiology. — Editor.
                                  n2 
150
SIGNS  OF rREGNANCY.
  212. From what has preceded, the student will have gathered that the
diagnosis of pregnancy in the early months must be more or less doubtful.
No single sign can be relied on  as  conclusive; it  is only when two  or
three are present, and occur in proper sequence, that we can feel certain.
For example:  if a patient miss one or two periods, we may have grounds
for suspicion, and these will be strengthened if morning sickness occur in
the second  month; but if  to these be  added  enlargement of the breasts
and darkening of the areola, the  case  will  be pretty certain.*   In  many
cases, too,  we may derive  assistance from the character and circumstances
of our patient.   It is not,  however, until the latter half of gestation tha
we obtain positive evidence, which can neither be simulated nor evaded.
This we shall now consider.
  213.  Enlargement of the abdomen.—The gradual distension of the
uterus has  already been described (§ 157) as tolerably equable, enabling
us to  estimate the period  of pregnancy by the height to which it has  at-
tained in the abdomen.  During the  early months,  although  it  be not
perceptible above the pubis, yet the abdomen increases by degrees, owing
to the intestines  being pushed up from the pelvis.  This enlargement,
however, is variable, owing to the distension  of the intestines by gas or
faecal  accumulation.   In  some cases, the abdomen  even  becomes flatter
at first, from the sinking of the uterus in the pelvis; but it soon increases
again, and  by the end of the third month it is visibly but equally enlarged.
During the fourth month, the  womb ascends above the symphysis pubis,
and  may be felt as a rounded tumour, which goes on augmenting till it
occupies the whole abdomen.   When  it reaches the umbilicus, it pushes
it forward,  so that in the  sixth and seventh months, it is more level with
the surrounding skin, and afterwards it projects beyond it in most women.
  The feel of the abdomen distended by the uterus is very different from
the impression it gives when the  distension is caused  by fluid, flatus, &c.
The uterine tumour is firm, hard, elastic, and defined, preserving its form
in all positions of  the body, though more  remarkable when the patient is
upright; whereas in  ascites the defined tumour is wanting, the fluid obeys
the law of  gravitation, and  the abdomen  has not the same firm elastic
feel.  The  best mode of examining the uterine  tumour, is to make the
patient first stand up, and then lie down; this will demonstrate the form
of the womb better than keeping in one position ; and after lying for some
time, the uterine parietes become relaxed and less firm.   Percussion will
distinguish between pregnancy and tympanites.
  Nevertheless cases do occur which are very embarrassing; for the uterus
itself may  be  distended by air, fluid, or hydatids, and then the form of
the uterus  and abdomen will be the same as in pregnancy.   In such cases,
our guide must  be the history of the  case, and further investigation into
the contents of the uterus.  I  have already described the changes which
take place  in the cervix (§ 158).
   214. Quickening. — This term was applied to the mother's perception
of the first  movements of the fcetus, under the  erroneous belief that it was
its  first movement, as it then became alive or quick.  We know that  the
fcetus is alive from tne moment  of conception, and have little doubt but
  * According to recent observations,  certain alterations in the urine, believed to be
peculiar to pregnancy, are to be regarded ns among the earliest indications of that con-
dition—tnese are described under the head of Kiesteine, in \ 226. — Euitoe. 
SIGNS  OF PREGNANCY.
151
that movements take place at a much earlier period.   By modern writers,
then, the term  is applied to the first perception of movement on the part
of the  mother, which generally  occurs  about four  or four and  a half
months after conception, though  some feel it earlier, and others not till
afterwards.   Dr. Montgomery observes,  "Experience has shown that  it
happens from the tenth to the twenty-fifth week; but according to my ex-
perience, the greatest number of instances will be found to occur, between
the end of the  twelfth and  sixteenth weeks after conception, or adopting
another mode of calculation, between the fourteenth and eighteenth week
after the last menstruation."  Out of one hundred cases, Roederer found
that eighty quickened at the fourth  month, and of the remaining twenty,
some at the third and some at the fifth.
   The sensation is at first like a feeble pulsation ; and though so slight,
is often accompanied by sickness  of stomach  and faintishness, or even
complete syncope.   By degrees it becomes  stronger and more frequent,
until   the  movements of  the  different  extremities  are  distinguishable.
Authors are not agreed as to the explanation of quickening, or why the
movements are felt at the fourth month or thereabouts, and not earlier.  I
think, upon the  whole, that the most probable explanation is the one
which the late Dr. Fletcher, of Edinburgh,  used to give in his lectures.
" The  movements of the fcetus while the uterus is  in the cavity of the
pelvis are not perceived, because the uterus is not supplied with nerves of
sensation,  and it is surrounded by parts similarly deficient;  but when it
emerges from the pelvis, it comes in contact  anteriorly with the abdominal
parietes, which are liberally supplied with sensitive nerves, and which by
contiguity of substance, feel the movements,  and thus the woman becomes
conscious  of them."  This view is strengthened by  the fact-, of which I
have  been  repeatedly assured, that the  movements, unless wrhen  violent,
are felt in front only.
   Its value as  a sign of pregnancy is somewhat impaired by the  interval
which frequently intervenes between the first faint sensations and their re-
petition ;  by the late  period at which they are felt  in  some cases; and in
a medico-legal point of view, by our being dependent upon the evidence
of the patient herself; or the patient may be deceived by flatus in the
intestines.   On the other  hand,  cases occur where  no sensation is per-
ceived by  the mother.   " Of this fact," says Dr.  Montgomery,  " the
writer can speak with certainty, having  now in several  instances, by ap-
plying his hand to the abdomen, distinctly felt the motions  of the fcetus
in utero, while the mother had no perception of them."
   215. The movements of the fcetus may be felt by the practitioner some
little time after quickening, by placing  the hand, especially if it be cold,
upon the abdomen; and  the  impression will of course be in  proportion
to the vigor of the motions.*  At an advanced period, it would not be
easy to mistake them ; but we may be deceived at an earlier period ; Dr.
Blundell relates a case of a woman who possessed the power of simulating
these movements by the action of the abdominal muscles.
   * Dr. Simpson stated,  at a late meeting of the Edinburgh Obstetrical  Society, a va-
riety of observations and experiments showing that, contrary to the commonly received
opinion, the mere application of cold (as a cold hand,  &c.) to the surface of the abdomen
of a pregnant woman, had not the effect of exciting,motions in the foetus.  The appli
cation of portions of ice even, of the  size of the hand, had no such effect. —Monthly
Journ. Med. Sci., July 1830.—Editor. 
152                     SIGNS OF  PREGNANCY.
  Dr.  Tyler Smith  describes two abdominal movements in  the  latter
months of pregnancy—one  traversing irregularly over  the  abdomen,
giving a feeling of ridges or prominences to the hand, and the other like
a shock or impulse ;  the former he regards as due to the peristaltic move-
ments of the uterus, and the latter only to the  foetus, and  I must confess
I think there is  great weight  in  his arguments.   I am happy  to express
my obligations to his recent work (" Parturition  and Obstetrics "), which I
regard as  one of the most important and ingenious  that has appeared for
many years, both, as expressing more clearly, the " idea " of uterine and
ovarian physiology, and also as giving to it for  the first time the unity of
a system.
  216. Ballottement.—A vaginal examination will enable us to ascer-
tain not merely the state of the cervix, but also to decide upon the pre-
sence of a fcetus, by repercussion or ballottement, as it is  termed by the
French.   The patient should be  in the  upright position; or if she be in
bed, her shoulders should  be  raised; the  operator must  then  introduce
his  forefinger, and place it upon the cervix uteri, whilst the other hand is
employed to  keep the uterine tumour steady, then  suddenly but slightly
jerking upwards the point  of his finger, he will feel a sensation of some-
thing having receded from  it, and which  he will perceive to fall again on

                               Fig. 70.
A. Vertical section of the
   sacrum.
B. Rectum.
C. Uterus and ovum.
D. Bladder.
E. Finger in  the vagina,
   with  its extremity
   pressing up the uterus.
       This cut exhibits the manner of making this examination.—Editor.

the point of his finger in a moment or two.   The jerk of the finger upon
the head of the fcetus causes it to float upwards a little in the liquor amnii,
and its own weight makes it descend.  Dr.  Montgomery justly remarks
that " should this be distinctly felt, it is proof positive of a fcetus in utero,
there being no other condition  or  disease of the  organ, in which a solid
body can be felt in this way floating in the cavity."  Of  course it proves
nothing as to the life of the child.  The  period  when this test is most
available is during the  fifth and sixth months.
   217.  Auscultation. — M.  Mayor  of Geneva first applied, in  1818,
auscultation to the diagnosis of pregnancy; he was  followed in 1821 by
M. Lejumeau de Kergaradec,  and since his time the investigation has
been pursued with zeal and intelligence by Haus, Hohl, Kennedy,  Mont-
gomery, Naegele,  jun., &c.  M. Mayor observed only the  sounds  of the
fcetal heart, but M. Kergaradec detected not only this double sound, but
another single, whirring sound, which he  called  the "bruit placentaire"
 
SIGNS OF PREGNANCY.
153
because he  believed  it to be situated  in  the  placenta.  To these two
sounds Dr. E. Kennedy has added a third, which is heard only occasion-
ally, the pulsation in the funis.   Each of these  deserves a separate inves-
tigation.
  As to the mode of making the examination, it maybe effected with the
naked ear applied  to the abdomen, or by the stethoscope; the latter is
preferable, as it enables  us  to define  and limit the sound, and in most
instances  it  is more  convenient.   The patient, if  possible,  should be
placed on her back in bed, with the head raised, and the abdomen covered
only by the night-dress.   In this way we can obtain access to all parts of
the uterine tumour, except posteriorly, and by  turning the patient to one
side or the other, we  can  easily examine the lateral  portions.  The aus-
cultator should place himself in the easiest posture possible, especially
avoiding  a  dependent position of the head, in which case he wTould be
apt to mistake the throbbing of his own arteries for sounds communicated
from the patient.  The stethoscope should be placed lightly upon the ab-
domen, and the pressure be varied, in order to ascertain whether the
sounds are in any degree  modified by it.
   218. The Uterine Souffle, or bruit placentaire, is a single intermitting
whirring sound, heard over a certain extent of the uterine surface.  It has
been compared to the sound of a pair of bellows, to that made by gently
blowing over the mouth of a bottle, and to that heard when a shell is ap-
plied to the ear, &c.   Perhaps the best comparison is with the "bruit de
soufflet" of the heart,  which is doubtless  sufficiently familiar to all.   Dr.
E. Kennedy remarks, that it assumes all the variations of the latter sound,
viz.,  the rasping or sawing  sound,  the musical or hissing  sound, a sound
resembling  the cooing of  a dove, and a drone resembling that  of a  bag-
pipe, accompanying the sound, yet without interfering with it.
   It  is stated by Hohl and others,  to be  limited to the situation of the
placenta (§  175), and so  it is generally; but in many cases it extends to
some distance, and in others, according to Naegele, it may be heard in
almost any part of the uterus: he further states, that it may constantly be
heard at  the lower part of the uterus, by applying the stethoscope near
Poupart's ligament.   I cannot say that I have been able to verify the
latter statement, but I have found it very possible to produce a souffle in
that situation by a little extra pressure of the stethoscope.
   219. The period when it first becomes  audible is about the fourth
month, according to Montgomery, Hohl, and Naegele; Dr. E. Kennedy
states that he has succeeded in detecting  it  as early as the tenth week;
and on the  other hand, it cannot be heard in  some  cases until the fifth
month.  It  may, however, always  be  distinguished before the pulsations
of the fcetal  heart; and even when the fcetus perishes, it continues for some
time afterwards.  It is feeble when first heard, but increases  in  intensity
and strength ; the intensity, however, is subject to some variation.   It is
synchronous with the mother's pulse,  and  subject  to its varieties,  but
without impulse.  During labour its intensity  varies; in  the  upper part
of the uterus it is  frequently inaudible during a pain; after delivery it
ceases entirely, though not always instantly.
  220. M. Kergaradec, as I have  already said, placed the seat of this
sound in the placenta ; more recent  investigations, however, have decided
that  it is  situated in  the  uterus.  Dr. E. Kennedy conceives it to result 
154
SIGNS  OF PREGNANCY.
from the difference between the calibre of the arteries supplying the uterus
and the uterine sinuses: that the expanding current of blood rushing from
an artery into a larger sinus gives rise to the  sound, just as the passage
of blood through a constricted valve of the heart  or aorta, does to the
bruit de soufflet.   Other explanations have been given, but all are agreed
now that its  seat is in the uterus, and not in the placenta; and most, I
believe, that it indicates the position of the latter organ.
  221. As a test of pregnancy, its positive  value (that  is, its  being
audible) is very great, though not quite conclusive, as it  is heard some-
times in cases of disease, of which I had a remarkable instance under my
own care,  and may occasionally be produced by too great pressure of the
stethoscope upon an artery.  Neither does it prove that the fcetus is alive,
in cases of pregnancy, as it is observed to persist  for a  short time after
the death  of the  child;  it is heard also in  some  cases  of blighted ova
which have degenerated into moles.
   On the other hand, its negative evidence (our not being able to detect
it) is of much less value, as we may not be able  to hear the sound although
the patient be pregnant, probably from the placenta being attached poste-
riorly.*
   222. Pulsation of  the Fcetal Heart.— Very different from the
uterine souffle is the sound which attracted the  attention of M. Mayor, the
pulsation of  the fcetal heart.   It consists of a  rapid succession  of short,
regular, double pulsations, resembling those  of the adult heart, except in
force and  frequency.   The sound is like the  muffled ticking of a watch,
or, as Naegele remarks, like  the pulsations  of the heart of a new-born
child.   Their frequency is about double  those  of the adult, or from 120
to 140 in a minute.   M. Naegele, jun. found  that  in 600 cases  the ave-
rage frequency was 130 strokes in  a minute.   I have already stated my
inability to explain the discrepancy between  the pulsations of the heart,
and those  of the cord dependent upon it, as  to  frequency.
   The variations in strength  and rhymth of the pulsations  of the  fcetal
heart, are  very numerous  and not easily explained; no  doubt many are
caused by changes in the condition of the fcetus itself, and  others by im-
pressions received from the mother; for  although the fcetal circulation is
independent of that of the parent,  yet there  is so intimate a sympathy,
that disturbances in the maternal system  are  communicated to that of the
fcetus, some  (in case of sudden  shocks) immediately, and others (in case
of disease) more tardily.
   The situation in which the fcetal heart is heard most distinctly, is about
the middle or inferior abdominal region, more  frequently on the  left than
on the right side.   " The extent  of surface," says  M. Naegele, jun. in
  * With regard to the " souffleplacentaire," of Kergaradec, authors are not yet agreed.
Dr. Rigby remarks that "later observations have shown that it is not connected with
the placenta, but depends upon the increased vascularity and peculiar arrangement of
the uterine vessels during the gravid state."
  There is much reason to doubt whether the " souffle placentaire," or the " uterine souffle,"
does not depend wholly on compression of the maternal vessels by the enlarged uterus.
Professor Dunglison informs me, (remarks Dr. H., in  a note to a former edition,) that he
heard it in one case of fibrous tumour of  the uterus: and I am satisfied that I heard it
in a similar  case, and also in one instance from the presence of a greatly enlarged ovary.
If these observations be correct, the sound is extra-uterine, and therefore not indicative
of pregnancy farther than as that state is  likely to be connected with enlargement of
the uterus. — Editoe. 
SIGNS OF PREGNANCY.
155
 his treatise on Auscultation, translated by Dr. West, p. 41, " over which
 the  beating  of the heart is heard, cannot be accurately defined in inches
 and lines, but it is certainly audible through a larger space than most ob-
 servers have represented.   Its sounds reached beyond the linea  alba to-
 wards the other side, in one hundred and eighty-five of three hundred and
 seventy cases, in which the position of the fcetus with its back to the left
 side of  the  mother was distinctly ascertained by the ear, and afterwards
 verified by the result of the labour ; in forty-six, they were audible over
 nearly the whole abdomen ; while in one hundred and thirty-seven, they
 were confined to the left side, and did not reach the mesial line.  The heart's
 sounds  were audible beyond the mesial line, only  in forty-five of one
'hundred and eighty-five instances, in which  the back of the fcetus was
 directed to the right side ; one hundred  and fourteen times they were dis-
 tinguishable on the right side only ; but  in twenty-six they extended over
 the whole abdomen.   In all these instances in which the heart's sounds
 were not limited to one lateral half of the abdomen, their greater  intensity
 at one part  indicated the situation of the back, and  consequently the posi-
 tion of the fcetus."
    The  earliest period at which the pulsations can ordinarily be detected is
 the middle of the fourth month or the beginning of the fifth.   Dr.  E.
 Kennedy has heard them in a few instances before the expiration of the
 fourth month.  Dr. Montgomery fixes the end  of  the fifth month.  The
 earliest period mentioned by Naegele,  is the eighteenth week,  in  thirty
 out of  fifty  patients, who were examined before the middle of pregnancy.
 In  some cases they did not become audible before  the fifth month.  It is
 easy to conceive that various circumstances may impede the transmission
 of  the  sound,  and so  alter the time at which it would otherwise be first
 heard ; as,  for example, excess of liquor amnii, thickness of the  abdomi-
 nal parietes, or feebleness of the fcetus.
    223.  When the pulsation of the fcetal heart is heard, it is proof positive
 of  pregnancy, equally remote from imitation  or evasion.   The  only cir-
 cumstances at all  likely to embarrass us for a moment, are  the sounds of
 the maternal heart, which may sometimes be heard ; the sound of the con-
 traction of the  abdominal muscles;  or of the  uterine  arteries;  but the
 greater rapidity, and clearer though feebler sound of the fcetal pulsations,
 will distinguish them with facility.
     On the other hand, the pulsations being  inaudible,  is not  conclusive
  proof that the patient is not pregnant, as the  child may have died, or, as
  in  some rare cases, they may  be inaudible for a time, though the fcetus be
  living.   I know this to be the fact, though I cannot explain it.
    224. Pulsation  of the Umbilical  Cord,  or  funic souffle.  — If the
  position of the funis be favourable, as, for instance, if it be twisted round
  the neck, body, or limbs of the fcetus, or in any way placed between the
 fcetus and the anterior or lateral parietes of the uterus, it is quite possible,
  as  Dr.  E. Kennedy has shown,  to hear the pulsation of its arteries, corre-
 sponding to the fcetal  heart's action.  Both Haus and Hohl have denied
 this,  but without just reason, in  my opinion, for Dr. E. Kennedy states
 that  " in some  cases were the parietes  of the uterus  and abdomen were
  extremely thin, he has been able to distinguish the funis by the touch ex-
  ternally, and has  felt it  rolling under the finger,  and thert* applying the
 stethoscope, its pulsations have been discoverable,  remarkably strong.'" 
156
SIGNS OF PREGNANCY.
Professor Naegele, jun., agrees with Dr. E. Kennedy as to the seat of the
pulsation, and attributes it to the tortuosity of the arteries, and to the dila-
tations observed in them.   Occasionally the sound is rather a souffle than
a pulsation, but fainter than the uterine souffle, and  distinguished  from it
by its being synchronous with the pulsations of the fcetal and not the ma-
ternal heart.   Dr. E. Kennedy found that he could produce the souffle, by
pressing slightly upon the cord with the edge of the  stethoscope.
  225. We have now examined the principal signs  developed during the
latter half  of pregnancy, — to wit, enlargement of the abdomen, quick-
ening, the  motions of the child, ballottement, and the results of ausculta-
tion, and we find that whilst all  are valuable, there  is a degree of uncer-
tainty  attached to the first three which calls for a very careful estimate on
our part: that the positive evidence of the latter modes of investigation is
conclusive, but that the negative evidence, or absence of the  usual results,
is not  proof that  the  patient is not pregnant.  So that, as was before ob-
served, we ought rather to  depend upon the coincidence of two or more
of the  signs of pregnancy than attempt a  diagnosis from any one alone :
the only sign indeed which can  be regarded as itself proving that the wo-
man is pregnant  of a living child is the pulsation of  the fcetal heart.
   226. Kiesteine. — There  are  two other signs which I have deferred
noticing until now, because they require more research to entitle them to
a place among the recognised evidences of gestation, and it seemed better
that the student's attention should rather be directed to those considered
valid, than embarrassed by doubtful ones.  The first of these tests is de-
 rived  from the urine.   M. Nauche was the first who accurately described
 the change which takes place in the urine of pregnant women.  He found
 that " by allowing the urine to stand for some time, in thirty or forty hours
 a deposite takes place of white, flaky, pulverulent, gruraous matter, being
 the caseum, or peculiar principle of the milk formed in the breasts during
 gestation."   This deposite has  lately received the  name  of Kiesteine.
 M. Eguiser has published the result of his researches on the subject in the
 Lancette  Franchise,  Feb. 1839, p. 36.  He  states  that " the urine  of  a
 pregnant woman, examined in the morning, is generally of a pale yellow
 colour and slightly milky;  it first reddens  and then  turns blue the ' papier
 tournesol^ as ordinary urine.  Exposed to the contact of air, a cloudi-
 ness  is observed from the first  day, resembling fine wool;  from the first
 day also,  a white matter is deposited.   These phenomena  are not, how-
 ever, constant.  From the second to the  sixth day, small opaque bodies
 are seen rising from  the bottom to the surface of the fluid,  and then col-
 lecting together until they form a layer, covering the whole surface; this
 is kiesteine.  It is sufficiently consistent to be raised from off the fluid.
 It is whitish, opaline,  slightly granular, and resembles much the  layer of
 fat which swims on  the surface of fat broth when cool.   Examined by
  the  microscope, it  appears a  gelatinous mass  of indeterminate form.
  When it  is  old, cubical crystals  are sometimes detected."  " It persists
  thus  for three or four days ; the urine  then becomes troubled ; small por-
  tions are  detached from its surface, and sink to the  bottom,  until the layer
  is entirely broken up.   Kiesteine appears to exist in  the urine from the
  first  month  until  the period of delivery,"  Dr.  Montgomery  seems  to
  think this appearance constant, when the  deep colour and turbid con-
  dition of the urine permit of observation. 
SIGNS  OF PREGNANCY.                    157
   Dr. Guiding Bird has published a series of experiments on this subject
 in Guy's Hospital Reports, No. 10, which confirms the value of this test.
 The pellicle formed in the urine of 27 out of 30 pregnant women, and it
 was found only in two  instances  out  of a number, in the  urine of un-
 married  women.   I shall  quote his  conclusions: — 1.  "That certain
 organic matters, closely resembling, if not identical with, caseous matter,
 mixed with abundance of the earthy phosphates  in  a crystallized  state,
 are eliminated from the  blood during pregnancy; and if not otherwise
 removed are  taken up, and finally thrown out of the system by the kid-
 neys.   2.  That  certain accidental circumstances, especially connected
 with those morbid actions in which the kidney is called upon to perform
 a compensating function for the skin, as indicated by the abundance of
 azotized matter in the form  of amorphous lithate of ammonia in the urine,
 interfere temporarily with the development of caseous matter, as they do
 in checking the cutaneous and  other secretions.   3. That, taken in con-
 nexion with other symptoms, as the formation of a dark areola round the
 nipple,  and cessation of menstruation  and abdominal  enlargement, the
 formation of a caseous pellicle  in the urine affords a very valuable cor-
 roborative indication of the existence of pregnancy."
   This  subject has recently been investigated by Dr. E.  K. Kane, in
 the Philadelphia Hospital, and he has arrived at the  following conclu-
 sions:—
   1. That kiesteine  is not peculiar to pregnancy, but  may occur when-
 ever the lacteal elements are secreted without a free  discharge at the
 mammas.
   2. That though  sometimes  obscurely developed,   and  occasionally
 simulated by pellicles, it is generally distinguishable from all others.
   3. That when pregnancy is possible, the exhibition of a clearly defined
 kiesteine pellicle is one of the least equivocal proofs qf that condition;
 and
   4. That when this pellicle is  not found in  the  more advanced stages
 of  supposed pregnancy,  the probabilities, if  the female be otherwise
 healthy, are as 20  to 1 (80 to 4) that the prognosis is incorrect.* f
   227. Jacquemin's test. — This consists in  a violet colour of the mu-
 cous membrane of the vagina  and labia, dependent  probably upon  pres-
 sure above.   M. Parent Duchalet confirms  the result of M. Jacquemin's
 observations, which he states were made upon a large number of pregnant
 women, and that the change of colour was never absent.  I had lately
 an opportunity of minutely examining a  well-marked  case, and found
 that the violet colour was caused by a great number of small veins in a
 varicose  condition.                                       I
   228. Twin  Pregnancy. — The inadequacy of the  signs which  are

   * American Journal of Med. Science, July 1842.
  f Recently a new animal substance is alleged by Dr. Stark to have been discovered by
him  in  the urine of pregnant women, to which he has given the name of " gravidine,"
both  on account of its  occurring during the state of pregnancy, and of its falling  to the
bottom of the vessel as the fluid containing it cools.  " This substance," he avers, "is
a matter sui generis; a proximate substance or principle forming in some measure a
connecting link between the albuminous and gelatinous principles."  The  reality of
Dr. Stark's discovery is  disputed by Dr. Grifiith of the Finsbury Dispensary, and can
hardly be considered as admitted by the profession.   Braithwaite's Retrospect of Medi-
cine and Surgery, vol. vi. p. 241, 1842. — Editoe.
                                   O 
158
DURATION  OF PREGNANCY.
commonly stated to  indicate plural pregnancy, must have been  felt  by
every accoucheur.  Those upon which the greatest reliance is placed are,
the- disproportionate  size of the  abdomen compared with the period  of
gestation ; the flattened state of the abdomen in front, with the appearance
of being divided into  halves; the inequality of its surface;  the tumult-
uous movements of the fcetus ; the inordinate weight and distension ; and
the excessive oedema of the lower extremities.  No doubt many of these
circumstances may be observed in twin pregnancy; yet none  of them are
sufficiently distinctive, while several may arise from other causes.
  M. Hohl has  remarked that in  twin  cases the uterine souffle is heard
" over a large surface,  with greater intensity  and more varied  tone ;"  but
in ten twin cases  observed by Naegele, jun., no variation in this  sound
was observed sufficient to excite suspicion of twins.
  The only sign upon which reliance can be placed, is, as Dr. E. Kennedy
has pointed out, the hearing the pulsation of two fcetal hearts,  equally dis-
tinct, and at a distance from each other.
   " Usually," says Naegele,  " the beating of one heart  is heard  in the
left or right inferior abdominal region, while that of  the other is audible
in the superior abdominal region of the opposite side.  But it never hap-
pens, be the position of the children what it  may, that the  beating of the
two hearts  is heard  on the same horizontal plane."  It is the more im-
portant to bear in mind the different situations of the two  hearts, because
their action is often synchronous.
                          CHAPTER VI.

                    DURATION OF PREGNANCY.

  229.  What is the ordinary term of gestation, and what are the devia-
tions from it ?   Such are the questions to be briefly discussed in the pre-
sent chapter, rather in a physiological than a medico-legal point of view ;
for  full particulars, I refer the reader to Beck's Jurisprudence and Mont-
gomery's Essay on the subject.
  The first point to be settled is the ordinary term of utero-gestation; and
we  are met at  the outset by the difficulty of obtaining accurate data.   The
common mode of calculation is from a fortnight after the last menstrua-
tion ;  and the period so fixed is corrected by the time at which quickening
occurs.   In many instances this proves pretty correct;  in the majority, I
think, it is rather overrun; and, at any rate, the uncertainty as to the period
of conception, and the variation in the time of  quickening, are sufficient
to render the computation no more than an approximative estimate.
  Cases, however, occasionally occur, where conception follows a  single
coitus, and if  they were sufficiently numerous, they would settle the ques-
tion ;  but they are rare.  Dr. Montgomery relates the case of a lady who
went to the seaside  in June 1831, leaving her husband  in town.  He
visited her for  the first time November 10th, and returned to town the next
day.  She  quickened  on the 29th of January  1832, and was delivered
August 17th, exactly two hundred and  eighty days from the time of con-
ception 
DURATION OF PREGNANCY.
159
  The deductions from such cases, and from general calculation, have led
to fixing the  term of gestation at ten lunar months, or nine calendar
months and one week, or forty weeks,  or two hundred  and eighty days,
allowing for some variation either way.
  230. But then, allowing for the uncertainty  of the ordinary data, or
supposing the "point dC depart" unquestionable, are we to conclude that
the actual  duration  of  pregnancy is  determinate  and invariable?   We
know that it may be abbreviated without destroying the child, from vari-
ous causes, but then this is not the natural  course.  May it also be pro-
longed ?  So  much diversity of opinion has obtained on this point, that
it is very difficult to come to a  satisfactory conclusion.  In the celebrated
Gardiner peerage case, the most eminent accoucheurs in the country were
arranged on opposite sides.   Drs. Gooch, R. Blegborough, Davis, Sir C.
M. Clark, and Mr. Pennington, discrediting protracted gestation, and Drs.
Granville, Conquest, Blundell, Merriman, Power, Hopkins, &c, advocat-
ing its possibility.
   Dr. Dewees remarks, " I have had every evidence, on this side of abso-
lute proof, that it has been prolonged to ten calendar months, as an habitual
arrangement, in at least four females; that is, each went one month longer
than the calculations made, from an allowance of ten or twelve days after
the cessation of the last  menstrual period; and from the quickening, which
was fixed at four months."  Professor Desormeaux relates a case of a lady
whose pregnancy lasted nine months and a fortnight.  The late Professor
Hamilton, of Edinburgh, declares his " solemn conviction, that he has
met with at least  twelve cases, in the course of practice, where there could
not be the  shadow of doubt of the protraction of human pregnancy be-
yond the ordinary period."  M. Valpeau has  recorded nine cases of the
kind.
   To these authorities may be  added the names  of Hervey, Smellie, Zac
chias,  La Motte,  Le Roi, Le Bas,  Fodere,  Capuron, Gardien, Murat, &c
   Dr.  Montgomery relates  two cases in his work,  one of which cam'
under  my observation ;  in the  first the gestation continued two  hundrei
and ninety-one days, and in the second forty-one weeks and two or thref
days at least.   I have referred  to  some of the cases on record, because.
the question being chiefly of authority, positive  evidence must infinite!j
outweigh mere negation.
   231. An additional argument has been deduced from the irreguiarit'
of the period of gestation among cattle.   According to the researches o'
M. Tessier: out of 160 cows,  14 calved from 8 months to 8 months anc
26 days ; 3 at 270 days;  50 from 270 to 280  days ;  68  from 280 to 29C
days;  20  at  300,  and  5  at  308 days;  the  extremes being  thus  61
days apart.   Of 102 mares, 3 foaled on the 311th day;  1 on the 314th
1 on the 325th; 1 on the 326th;  1 on  the 330th; 47 from 340 to 35C
days;  25 from 350  to 360; 21 from 360 to 377, and one on the 394t>
day; the extremes being 83  days.   With sows, the extremes  were 15
days;  and  with rabbits (out of  139 cases) 7 days.*

  * Recently, Earl Spencer has  communicated the results of his  observations for a
number of years on cows, to the English Agricultural Society.   (Journal of the English
Agricultural Society,  part ii. 1839.)   Of 764 cases, -314 calved before the 284th day,
310 after the  285th, and only 16 after the 295th ; so that  the probable period of gesta'
tion, he thinks, ought to be considered 284 or  285 days. — Editor.
       11 
160
DURATION  OF  PREGNANCY.
   232. In  conclusion, there is no doubt that the usual period of gestation
may be anticipated  by at least two  months, without necessary injury or
death to the infant; and it appears to me  that  the evidence we possess,
as well as  the weight of authority,  is  in favour of occasional protracted
gestation;  and that,  to use the  words of Dr. Montgomery, I  " cannot
imagine why  gestation should  be the  only process, connected with  re-
production, for which  a  total exemption from any variation in its period,
should be claimed." *

  * Dr. James Reid, Physician to the General Lying-in-Hospital, London, has presented
a series of facts  calculated to  throw much light upon the  question of the duration of
pregnancy in the human female.  (Lancet, July 20, 1850.)   He gives  a summary of
twenty-five cases which he has collected during the last twenty years.   He states that
he has every reason for relying implicitly on the statements made to him by the parties.
They were either cases of single women  who dated from one coitus, or  of  married
females, whose husbands had been absent for a considerable time before and after the
last intercourse.  In no one of them was there the slightest apparent reason for decep-
tion ; and their small number for so long a space of time shows he had been careful to
select such only as he could thoroughly depend on.  The cases are as follows: —
  1.  Connection only July 27;  parturition occurred April 30 (276 days).
  2.  Catamenia terminated March 14;  connection only March 18 and 20;  parturition
 December 20 (274 days).
  3.  Catamenia,  December 13; connection immediately afterwards; quickened April
6; confined September 13 (274 days).
  4.  Catamenia, November 6; connection only November 18; confined August 20 (275
days).
  5.  Catamenia, November 7; connection only November 12;  sickness  commenced on
Oecember  12; confined August 12 (273 days).
  6.  Catamenia, January 10; connection only Febuary 2; quickened June 16 ; confined
October 31 (271 days).
  7.  Connection only November 15;  confined August 16 (274 days).
  8.  Connection only October 18; confined July 19 (274 days).
  9.  Catamenia, June 15; connection only July 1; confined April 5 (278 days).
  10.  Connection only  August 5;  confined April 25 (263 days).
  11.  Catamenia, August 4;  connection only August 6; no intercourse afterwards for
six weeks; confined May 13  (280 days).
  12.  Catamenia, August 9; connection only August 11; confined May 2 (264 days).
  13.  Connection only  October 29; confined July 30 (274 days).
  14.  Catamenia, November 7;  connection only  November 18; confined August 21
(276 days).
  15.  Connection only October 8; confined July 9 (274 days).
  16.  Connection only April 6;  confined January 7 (276 days).
  17.  Catamenia, August 15; connection only August 18; confined May 25 (280 days).
  18.  Catamenia, July 17 ; connection only July 22; quickened November 10;  confined
April 15 (266 days).
  19.  Catamenia, January 9; connection only January 10; confined October 2 (265
days).
  20.  Connection only February 11; confined November 3  (266 days).
  21.  Catamenia, May 14; connection only May  14; quickened September 10; con-
fined February 10 (272 days).
  22.  Connection only February 28 ;  quickened at 19th week; confined November 30
(275 days).
  23.  Connection only February 9; confined November 6 (271 days).
  24.  Catamenia, March 5; connection only March 12 ; sickness commenced April 14;
quickened July 6; confined December 24 (287  days).
  25.  Catamenia, September 10; connection  September 15, 16, 17; confined July  5
(292 or 293 days).
  Two only of these cases, it will be observed, went beyond the term of 280 days, and
it is requisite we should enter more fully into the details relating to them.
  In case 24, the circumstances were as follows: A young lady, under promise of mar-
riage, unfortunately allowed liberties which caused the usual result—pregnancy.   She
was then deserted by her lover, who went into the country,  and she saw no more of him
for a time.   About  eighteen  months after her confinement, an imprudent female friend 
DURATION OF PREGNANCY.
161
   But on the  other hand,  it  must be  confessed that  many of  the cases
adduced are valueless, because founded on data which  are necessarily un-
certain ;  and I should be unwilling to admit any as conclusive, occurring
in persons exposed to frequent intercourse, and calculated in the ordinary
manner.

wrote to her, informing her that the father of her child was in London, and was to be
at her house  on the ensuing  evening, but that he was to leave town on the day after.
Hoping that she should  be able to induce him to aid towards the maintenance of the
child, she  went to her friend's house at the appointed time,  March  12th, and the
parties having been left alone together for a time, intercourse again took place.  The cata-
menial period had terminated a week previously, and, at the expected time of its return,
she was alarmed at its absence.   Morning sickness commenced  April 14th, and in the
beginning of June, when  she called to  consult  Dr. Reid, there were all the well-marked
signs of pregnancy.   The movements of the fcetus were felt July  6th, and from there
being no doubt whatever, in this case, as to the precise time  of conception, Dr. R. felt
much interest in watching the  termination.  December 17th was the day on which it
was calculated, at the latest, that parturition would take place ;  but  this event did not
occur until the twenty-fourth, making the term 287 days.  The  parties had never met
after the 12th of March.
   Case 25. — A married  lady, who had  not borne a  child for the previous five years.
Her husband returned from the Continent on the evening of September 15th (five days
after the lady's catamenjal period), and he again left for a long journey on the morning
of the 17th.  All the usual signs of pregnancy occurred in October, and throughout the
whole term she confidently expected to be confined about June 21st,  as the date of im-
pregnation was so well marked.  Labour,  however, did not  commence until July 5th.
Now in this case the only objection  that could be offered is, as to the veracity of the data,
but, says Dr. R., independently of the virtuous character of the lady, my attention would
not, under other circumstances, have been so frequently directed to the precise date of
her  husband's departure; and, after  five  unproductive years, it would at least be an
extraordinary coincidence, that impregnation should have been caused by another indi-
vidual than the husband  at this precise time.   I may  add, too, that of several children
which the lady now has,  that which was born at the  period referred to certainly bears
a much stronger resemblance to the husband than either of the others.
   The following are cases narrated by other authors, in which the data were sufficiently
determined: —
   Dr. Girwood's: — The  husband arrived at home May 31;  the  catamenia should have
appeared  June 2, but did not; symptoms  of pregnancy soon after were  evident, and
parturition took place March 1 (274 days). Lancet, Dec. 1844.
   Dr. Montgomery's:—Catamenia, October 18; impregnated November 10; one con-
nection ; quickened January 28; confined August 17  (280 days).  Exposition of Signs,
Sec. of Pregnancy.
   Dr.  Rigby's:—Three  cases of  single coitus;  first, 260  days;  second, 264  days;
third, 276 days; fourth,  284 days.   American Journal,  Dec. 1847.
   Dr. Lockwood's:—Four cases of single coitus; first, 270 days; second, 272  days;
third, 276 days; fourth,  284 days.   American Journal, Dec. 1847.
   Single connection, October 10, 1840; confined August 4, 1841  (272 days). American
Journ. Med. Sciences, April 1842.
   Case of Anderson v. Whitaker, 1827 :—One coitus only, January 8; confined October
28 (283 days).
   Dr. Lee's : — Forty-one weeks after the departure of her husband for the East  Indies
(287 days).  Medical Gazette, 1831.
   Desormeaux's is a very satisfactory case. The lady was deranged, and it was thought
probable, by her physicians, that pregnancy might be beneficial.   The husband visited
her, therefore, at intervals of three months  only, so that, if conception should take
place, the risk of abortion from continued intercourse might be avoided.  An exact ac-
count of these visits was kept, and when  conception  took place they ceased.  She was
confined nine calendar months and a fortnight after  the last visit.   The exact number
of days is not given, but, taking the shortest nine months (273 days), with the addition
of the fourteen, there will be, at least, 287 days.  Did. de Med.  vol.  x.
   Dr. Dewees' case in Philadelphia:—One connection; delivered nine months and thir-
teen  days  after (say 286 days).   In this case the catamenia appeared as usual at the
proper period, one week after the intercourse.
   Dr. Beatty's: — 291 days.  Dublin Med. Journ. vol. viii.
                                         o2 
CHAPTER VII.
                                STERILITY.

  233.  Having thus completed the history of conception and utero-gesta-
tion, we shall now consider certain abnormal deviations from the ordinary
course of these functions;  and the first in order is sterility, or inability to
conceive.
  The causes of this defect  have been divided into functional and organic,
into curable  and  incurable;  into those which cause  sterility, properly so
called, and those which  merely occasion impotence.   Without adopting
any special classification, I  shall enumerate the organic and incurable cases
first, and then the curable, whether functional or organic, with their treat-
ment ; and adding other causes, not included in either class.

  Mr.  Skey's case of Caesarian operation: — One coitus only, on April 7, 1846; labour
pains commenced on January 25, 1847 (293 days).
  Dr. Mcllvain's, at Charlotte,  North Carolina: — The lady was visited by her husband
from a distance, July 1, 1847;  he remained until the morning of the 6th, and did not
again see his wife for nine  months.  Intercourse took place on the 1st, 2d, 3d, and 4th
of July.  Shortly after, symptoms of pregnancy appeared, but the lady was not con-
fined until April 23,  1848, 293 days after the 4th of July (or perhaps 296 after the 1st).
  Dr. Ashwell's: — Catamenia  terminated January 25 ;  husband left  a few days after,
and was absent six weeks.  Confined November 27 (300 days after the last intercourse).
There would be  258 days from his return; but the infant, Dr. Ashwell mentions, was
much larger than the  other children of the lady, and bore a strong resemblance to the
father.
  Velpeau gives a case (Art des Accouch.) of 310 days.   At the supposed fourth month
of this gestation, M. Velpeau affirms  that he distinctly felt both the active and passive
movements of  the foetus.
  It will be seen, therefore, by the foregoing cases,  that there are well-authenticated
instances in which the period of gestation has  been extended  beyond the usual term.
In the  cases of single intercourse, 293 days form the longest period, or eighteen days be-
yond what  is deemed  to be  the usual average duration of pregnancy in the human
female.  Now  it is a coincidence with the results of Lord Spencer's tables, that of the
764 cows whose data were  so accurately noted,  the greatest excess beyond the average
term of gestation in them (285 days) was also  eighteen days.  In the case related by
Dr. Ashwell, the exact day of impregnation is not given; it is stated that the husband
left a few days after the catamenial period, and I have put this down as six days after;
but as it is the only case which extends to 300 days, some, perhaps, may doubt the
exactness of the husband's statement as to time.
  Velpeau's case is  without dates, and rests solely on the fact of the foetal movements
being  felt  at  the fourth month; might they not have been  appreciable before  that
period ?
  With a view to ascertain the experience of those who were  most likely to have paid
particular  attention to this subject, upwards of forty of the  most  eminent  obstetric
practitioners in  London, Dublin,  and Edinburgh, were applied to by Dr. Reid.  The
large majority of these expressed a firm conviction as to the  occasional extension of the
usual  period of pregnancy by a few days beyond 280.   Several have met with one or
two cases  of protracted gestation, out of many hundred, on the  exact data of which
they could rely; others, who had  not kept notes  of their cases, could  not  positively
speak to facts,  but had no moral doubt as to the period being extended in some instances.
Some,  who have had extensive  experience in private and hospital practice, state  that
they have never met with an undoubted case of protracted gestation; whilst two affirm
tbat it is their strong  conviction, that no case ever exceeds the 280th day from concep-
tion, and one,  that it is never carried beyond the ninth calendar month.
  In order to show that no other data than the calculation from a single coitus is to be
depended upon to fix the commencement of pregnancy, Dr. Reid presents the following
►able,  the result of 500 cases, in which the  exact number of days intervening between
                                                                 (162) 
STERILITY.
163
   234.  The absence of the ovaries will render the person incurably sterile,
as will also the absence of one and disease of the other, or the disorgani-
zation of both.   Cases of this  kind  are not infrequent.   Disease of the
substance of the ovary may be extended to the Graafian vesicles,  or they
may be congenitally deficient, and  so conception  be prevented.   " The

the last day  of menstruation and that of parturition is shown.  With the exception of
about 50, they were private cases, in which the data were most correctly kept; and the
others were  selected from upwards of  1000 hospital and dispensary cases, presenting
an equal certainty as to date, in females superior to the usual class of hospital patients.
37th week.
38th week.
39th week.
40th week.
41st week. ■<
Days.
f252
 253
 254
 255
 256
 257
 258
L259

f260
 261
 262
 263
 264 ,
 265
 266,

f267
 268
 269
 270
 271
 272,
 273

r274 ,
 275
 276 ,
 277
 278 ,
 279
 280 ,

 281
 282 ,
 283
 284.
 285
 286 ,
1287
Cases.
.  4"
  1
  1
. 2
  4
. 4
  4

. 6
  5
. 3
  9
,10
  5
,10

  9
,13
  5
,13
 12
,13
 16
,21
 20
 16
 16
 22
 21
 15.

 181
 25
 14
 15
 14
,15
 llJ
23 cases.
i-48 cases.
-81 cases.
131 cases.
-112 cases.
42d week.
43d week.
44th week.
45th week.
Days.
f288 .
 289  ,
 290 .
 291
 292 .
 293
 294.
f295
 296
 297
 298
 299
 300
 301
f302
 303
 304
 305
 306
 307
 308
f309
 310
 311
 314
 315
 316
 Cases.
.17'
 9
14
 6
 3
 6J
► 63 cases.
28 cases.
► 8 cases.
6 cases.
Total, 500 cases.
  In the case which occurred 314 days after the cessation of the catamenia, it is noted
that quickening did not happen until the 6th month, proving, in Dr. Reid's opinion,
that conception had taken place later than had been thought.  Had minute investigation
been made, at an early period, into  the remaining five cases which went beyond the
44th week, it is most likely that similar facts might have been observed.
  It will be seen that the above  table agrees with that of Dr. Merriman (114 cases), in
showing that the greatest proportion of  women complete the period of gestation in the
40th week after the cessation of the  catamenia, and a very considerable number in the
41st week.
  In Dr. Murphy's table of 182 cases, the  numbers, born in the 39th and 40th weeks
were about equal, being 24 and 25;  whilst the greater proportion (thirty-two) were in
the  41st week, and 25 in the 42d week—equal to those in the 40th.
  In Dr. Reid's table, given above, the 282d day was that on which  the largest actual
proportion of the patients were delivered;  but the  number from the 274th to  the 2S2d 
164
STERILITY.
most frequent variety of ovarian disease," says Dr. Davis, in his Obstetric
Medicine,  "which we may suppose calculated  to  produce this effect, is
that  of an obviously morbid  enlargement of the vesiculae Graafian®, ac-
companied by a degenerated structural condition of their parieties."
  235. The fallopian tubes may be congenitally deficient or imperforate,
though such cases are extremely rare.   Their canal may be obliterated from
acute or chronic inflammation, or their fimbriated extremities may become
adherent to the ovaries.   Even though not imperforate, yet the  canal may
be filled with adventitious matter.  In all these cases, sterility is the con-
sequence, because the access of the spermatozoa  to the ovary is prevented.
  236. The  uterus maybe absent, of which numerous cases are recorded.
If present, its  cavity may be  partially or  wholly obliterated, as was  no-
ticed by Morgagni, Baillie, and Mott; these cases are of course incurable.
The canal of the cervix may be impervious, or its mouth covered by mem-
brane, as in Delpech's case and several others;  but though sterility results
so long as it  continues, it is within reach of treatment,  and has been cured
by puncturing.
  Diseases  of the  uterus,  such as carcinoma,  polypus, prolapsus,  &c.
are  enumerated  among  the causes of sterility, but erroneously, I think.
Madame Lachapelle, Dr. Davis, and  others, have related  cases of con-
ception and delivery notwithstanding  the existence of scirrhus and even
open cancer.
  M. Chopart  mentions a case of complete prolapse, which proved no
bar either  to intercourse or conception.  Many cases of polypus disco-
vered  during labour or causing abortion, have been met with; two oc-
curred to myself a short time ago.
  Inversion of course involves sterility; and the same may be said when
the cavity of the uterus is occupied by fluid or solid matters, and  the os
uteri closed,  as in physometra, hydrometra, moles, &c; but these belong
to the  curable causes.
  237. The  vagina may be absent,  imperforate,  or  partially  adherent.
Some of these  cases are curable by careful  incision and separation, as in
Dr. Physic and M.  Amussat's cases.   Again, it may be the seat of callo-
sities, cicatrices, tumours, &c.  and by them be  partially closed, offering
an obstruction to copulation;  but they also may generally be relieved by
an operation.   Extreme narrowness  of the canal is seldom the cause of
impotence, as it is  generally overcome; but extreme shortness is consi-
dered  as  occasionally an incurable cause, though I rather think without
sufficient reason, as, though short, it may not be sexually disproportionate.  m
Closure of the orifice of the vagina by membrane, is an effectual impedi-
ment to coition, and  until removed,  to conception; but  partial closure
may admit of conception.  A short  time  ago I attended  a lady  in  her
confinement, in whom the hymen was perfect, the perforation barely ad-

day ran so near to each other that we must rather take that as the average period. If
we allow a range of from two to six days after menstruation, as elapsing probably be-
fore conception takes place, it will then appear that about the 39th week after impreg-
nation is most probably the ordinary duration of pregnancy;  and this will coincide
with the result of the table taken from cases of single coitus.
  In  a  note to a former edition of this work, Dr.  Huston states that he has known at
least two instances in which he had the strongest reasons for believing  that it extended,
ii, one case two weeks, and in the other three weeks, beyond the usual period, or nine
calendar months. — Editor. 
STERILITY.
165
mitting the tip of my finger, and the membrane was strong enough to re-
sist the pressure  of the head for a considerable time.
   238.  The variety of dysmenorrhcea in which lymph is secreted, is  con-
sidered  by Denman  and others to preclude conception ; this, however, is
not universally the case, and the disease in many cases is curable.
   Congestion, erosion or ulceration  of the cervix uteri, uterine leucorrhcea
when excessive, and perhaps vaginal leucorrhcea, may also be included
among the  curable  causes of sterility.    The  same  result obtains tempo-
rarily, in cases of irritable uterus and some diseases of other organs.  Mr.
Whitehead  has lately suggested that the uterine mucus, instead of being
alkaline, as in its healthy state, may be rendered acid by certain affections
of the uterus, and as the researches of M. Donne have shown that sperma-
tozoa lose their vitality sooner in acid mucus, this may be a frequent cause
of sterility.*
   Unsuitable marriages,  whether  as to  disparity of age or  constitution,
often prove unfruitful:  cases are on record of parties who together were
sterile, being both fruitful with other individuals.
   Excessive sexual indulgence often defeats its object.
   239.  I have thus cursorily noticed most if not all the appreciable causes
of impotence and sterility in the female,  with  a slight sketch of the treat-
ment of  such as are  remediable.
   There is, however, a considerable class of unfruitful marriages of which
no explanation can  be given; we can  only  conjecture, that the  ovaries
or fallopian tubes  are defective,  or  that  some sexual  incompatibility
exists.
   The uterus  and vagina are within reach of an examination, and  their
condition can be minutely ascertained by means of  the finger, the specu-
lum, and bougies.f

   * On Abortion and Sterility, p. 406.
   f In a paper read before the Westminster Medical Society,  April 1849, Dr. Tilt, after
dividing the causes of sterility into those which are self-evident, those which  are dis-
putable, and  those which are of a mysterious  nature, directed the attention of the
Society to subacute ovaritis as a frequent cause of sterility.
   He pointed out the paramount importance of the ovaries in  the female organism, and
their influence over all the  functions  of reproduction: he showed that the anatomical
phenomena of  ovulation are identical with those termed inflammatory, and hence
inferred, that in morbid  ovulation the healthy process might often pass into the inflam-
matory, which would furnish  a satisfactory explanation of the increase of pains and
of heat in the ovarian regions,—symptoms so frequently met with in difficult menstrua-
tion.  He considered that subacute inflammation of the ovaries might produce all those
symptoms which are called by the common name of dysmenorrhcea, although they may
also depend on the disorder of other organs.  He also  admitted, that  the symptoms of
subacute  ovaritis might  vary according to the nature of the patient's  constitution, pro-
ducing hysterical symptoms in nervous and highly excitable  females, and morbid pro-
ducts and sterility in those, of a strumous constitution.
   Dr. Tilt proved, by the testimony of authors,  the frequency of unaccounted-for ova-
rian lesions ;  and as these lesions are admitted by all to be the  products of inflammation,
he drew from  this, as an evident conclusion, that the ovaries and their peritoneal cover-
ing were frequently subjected to inflammation, though not recognized as such during the
patient's life,  nor treated accordingly. Respecting the production of dysmenorrhcea,
Dr. Tilt admitted that while, in some  instances,  all the symptoms of that disease were
produced  by subacute ovaritis; in others, as has been  well established by Dr. Oldham,
ovaritis determines dysmenorrhoea by the inflammatory  congestion of the uterus to which
it gives rise; but he did  not agree with Dr. Rigby that membraniform exudations in the
catamenia were always the proof of ovaritis.  Having thus established that  subacute
ovaritis is a frequent cause of dysmenorrhcea, Dr. Tilt observed, that dysmenorrhoea
and sterility being admitted as concomitant facts, depending on each, or on the  same 
CHAPTER VIII.
                        SUP ERF C3T ATI ON.

   240. The  term Superfcetation has  been applied to those  cases  of ab-
normal conception in which a female, already pregnant, has been supposed
to conceive a second time before the termination of the first  gestation.
The belief in the possibility of such an occurrence is universal among the
older writers, and cases are adduced in support of the opinion, but modern
writers have been more divided in opinion ;  it is denied  by Hebenstreit,
Ludwig, Nutger, Schmidtmuller,  Blumenbach, Beck, &c.;  but admitted
by Haller, Hervey, Ploucquet, Barzelotti, Velpeau,  Burning, &c.
   241. The cases alluded to are such as the following:—1.  It is not un-
common for women to be  delivered of  a  full-grown child and a blighted
ovum at the same time, and from the  disparity between them, it has been
assumed that the period of conception was different for  each.
   2.  Again,  a woman may be delivered of two living children at one
birth, or within a few hours of each other, one of which may be fully de-
veloped while the other appears immature.
   3.  Further, the same woman has given birth to twins of different colour,
as in  the  case related by Buffon, and  quoted  by Fodere and all  recent
writers on  the subject, of a woman at Charleston,  South Carolina,  who
was delivered in 1714 of  twins, within a very short time of each other,
the one being black, the other white.   On examination, the  woman  con-
fessed that on  a certain  day, immediately after her husband left  her, a
negro entered her room, and  by threatening  to murder her in case  of re-
fusal,  obtained connexion with her.
   Dr. Mosely, in his work on tropical diseases, p. Ill, mentions a similar
case:—"A negro woman brought forth  two children at  a birth, both  of a
size,  one of which was a negro, the other a mulatto.  On being interro-
cause, he had a right to infer that subacute ovaritis was a cause of sterility, and that this
imperfection was the result —
  1. Of morbid lesions of the stroma, or of the vesicles of the ovula therein contained.
  2. Of a false membranous deposit lining the ovaries, so as to preclude the exit of the
ovula.
  3. Of lesions in the tubes destined to convey the ovula to their uterine abode. He
likewise stated that sterility was sometimes produced  by the uterine extremities of these
tubes being blocked up by a glutinous deposit.
  In concluding the enumeration of morbid lesions, Dr. Tilt remarked,  that as  our ac-
quaintance with the physiology of the ovaries dates  only from yesterday, we need not
be surprised if the knowledge of their pathology  is also in an embryotic state.
  Dr.  Tilt concluded by giving the history of three cases  in which the diagnosis of the
disease was  fully confirmed, by an accurate examination of the patient through the
rectum, and wherein the treatment recommended  brought on a cessation of the sterility
after it had lasted five, six, and seven years.  The remedial measures prescribed were,
leeches, to diminish the chronic  ovarian congestion; blisters, to break the chain of
morbid nervous action, fostered by long habits of suffering;  mercurial  ointment, com-
bined with narcotic extracts and camphor, to reduce  pain and vascular action; medi-
cated enemata were also administered with the same intention.
  The views advanced by Dr. Tilt in  the paper referred  to, are more fully developed,
and illustrated by a more extended series of observations, in a treatise which that gen-
tleman has recently published  on "Diseases of Menstruation, and Ovarian Inflfnnma-
tion, in connection with Sterility, Pelvic Tumours, and Affections of the Womb."—
Editor.
                                                             (1GG) 
SUPERFC3TATI0N.
167   *.
gated upon  the  cause  of their  dissimilitude, she said  she perfectly well
knew the cause of it, which was, that a white man belonging to the estate
came to her hut one morning  before she was up, and she  suffered his
embraces  almost instantly after her black  husband had quitted her."
Cases of the same  kind have  been  published by M. de Bouillon,  Drs.
Dewees, Trotti,  Guerarde, Delmas, Dunglison, &c.
   4.  Lastly, cases have occurred where the  birth of a mature child was
succeeded,  after the lapse of some months, by the  birth of another.
Several such cases  might be cited.  In the Recueil de la SocietS d>Emu-
lation, there is one of M. A. Bigaud, of Strasburg, art. thirty-seven, who
was delivered of a  lively child on the  30th of April.   The  lochia and
milk  were soon suppressed.   On the 17th of September of the same year
(i. e. about four and a half months after the first delivery) she brought forth
a  second apparently mature and healthy child.   On the  death  of the
woman the  uterus was found to be single.
   In the case related by Desgranges, of Lyons, the woman was delivered
on the 20th of January 1780, of a  seven-months  child ;  and on July 6th,
1780, five months and sixteen  days  after the former birth, she gave birth
to a second, which had apparently reached its full time.
   The  late Dr.  Maton published a similar case  in vol. iv. of the Trans.
of the College  of Physicians,  London.  Mrs. T.,  an Italian lady,  but
married to  an Englishman, was  delivered of a  male  child at Palermo,
November  12,  1807.   On  the 2d  of  February 1808, not  quite three
calendar months after the preceding  accouchement, she was  delivered of
a  second male  infant.   Dr. Maton assured Dr. Paris that "both the
children were born perfect; the first, therefore,  could not  have been a
six-months  child."   Other cases maybe found quoted by Beck, Velpeau,
and Cuming.
   242. Upon the strength of these cases, it is assumed that a second im-
pregnation may be effected, although  the uterus be occupied by the results
of a previous conception.  Our first  object  is therefore to ascertain how
far the cases considered in themselves warrant such a conclusion, and then
whether, if the cases are not otherwise explicable, we are bound to adopt
this theory as the true explanation.   First, then, I would observe that the
first and second class of cases can be easily  explained without having re-
course to the doctrine of superfcetation at all.  When twins are conceived
from one  intercourse, it not  unfrequently  happens  that one ovum is
blighted, and sometimes rejected, sometimes retained, and occasionally
the appearanoe of the ovum when subsequently expelled will be found to
correspond  to the period of pregnancy,  at which symptoms of uterine
disturbance and threatened abortion  appeared.   Again, nothing is more
common in  twin pregnancy, than to find one more fully grown than the
other, and nothing more easily  explained.  So that neither of these cases
are any support to the doctrine, because they are susceptible of another
and more simple explanation.
   The third class, where children  of different colours  are brought forth,
is equally unavailable, for, at the  utmost, they only prove  that a double
conception may  occur from connexion with two individuals, if such inter-
course take place with a very short interval.   If such cases occurred with
an interval of four or five months  between the birth  of the children, the
case would  be altered;  but I am not aware of any such on record. 
168
SUPERFCETATION.
  It must be confessed that the fourth class of cases is very difficult of
explanation, and they are the  only ones  of  any force in support of the
theory.   It has been supposed, that in such cases, both children were be-
gotten at the  same moment,  but  that the tardy birth of the latter was
owing to its slower development:  but this explanation requires previous
proof that a slow growth of the fcetus involves a protracted gestation.
  Another explanation has been proposed, based  on the fact, that when
pregnancy has occurred with a double uterus, one cornu only is occupied
by the child.   It may in such cases  be possible (so it is argued) for the
woman to conceive a second  time, and  the child to occupy the vacant
cornu, although previously pregnant; and in support of this  view, a case
is adduced which  occurred to Mad.  Boivin, and which  is related  in M.
Cassan's thesis " On double Uterus and Superfcetation."   " On the 15th
of March,  1810, a woman, aged forty,  gave birth to  a female infant,
weighing about four pounds.   As the abdomen still remained bulky, Ma-
dame Boivin introduced her hand, but could find nothing in the uterus.
But the examination led her to suspect that there was another fcetus, either
extra-uterine, or contained in  a second cavity  in the womb.   At length,
on the 12th of May, a second  female infant was born, weighing not more
than about three pounds, feeble, and scarcely able to respire.  The mother
assured Madame Boivin that she had had  no  connexio'h with her husband,
(from whom she had been some time separated,) except thrice in two
months, viz., on the 15th and 20th of July 1809, and on the  16th of Sep-
tember following."  In this case there can be little doubt of the existence
of a double uterus, and  it would be difficult  to disprove  that  the second
child was not the fruit of the last  conception,  and, if so, a clear case of
superfcetation;  but, even granting  so much, it  only proves the possibility
of such  an event when  the uterus is double,  and it would  not only be
very bad logic to assume that the uterus was double in all cases when two
children  are born at considerable intervals; but it would be  inconsistent
with facts, for it is expressly  stated  that in  the case of M. A. Bigaud,
already quoted, the uterus was found, after her death, to be single.
  243.  Thus, whilst we  need not deny that a double uterus may afford
an opportunity for  a double conception, at distant periods, we cannot ad-
mit one such case  as explaining all the cases of that kind on  record;  and
with respect to such, we have  made no advance towards  an  explanation.
Admitting this, are we necessarily to adopt the hypothesis of superfceta-
tion ?  I think not, because the real  difficulties of such a theory appear
insurmountable; and if so, our ignoaance of the  true explanation is no
argument for the adoption  of  a false one.   The physical difficulties are
those which depend on the changes induced by impregnation.  The reader
will find that it wTas stated  (§ 160) that shortly  after conception, the uterus
is lined by the deciduous membrane, a  shut sac, closely adherent to the
lining membrane of the uterus throughout, and covering the orifices of
the os uteri and of the Fallopian tubes; that the canal of the cervix uteri
is, during pregnancy, plugged  with thick  tenacious mucus secreted by the
glands.   Now if this be the  case, and  if it be an essential  condition of
generation (§ 143) that the spermatozoa pass through the fallopian tubes
to the ovaries, it is evident that the  theory of superfcetation  involves so
much apparent physical impossibility, that it must be rejected, unless  it
can be shown how the spermatozoa can obtain  access to the ovaries when
the uterus is (as it  were) hermetically closed. 
EXTRA-UTERINE PREGNANCY.
169
  In coming to this  conclusion, I  must honestly confess that I have no
better explanation to offer of such cases as Dr. Maton's; but surely it is
more philosophical to acknowledge our ignorance and patiently to wait
for additional information, than in our impatience of a state of uncertainty,
to adopt a theory involving such difficulties.
  244.  In conclusion, I would say, 1. That  the  theory of superfcetation
is unnecessary to explain the birth of a mature fcetus and blighted ovum ;
of a mature and immature fcetus, born together or within a month of each
other ; or of  foetuses of different colours, as they may reasonably be sup-
posed to be the product of one act  of generation, or of two nearly con-
temporaneous.   2. That in  cases of double uterus, it is possible  for a
second conception to  take place, and  (judging from the subsequent birth
of the second child, in the only case on record) at a later period than the
first.  3. That in the remaining cases, where  one mature child succeeded
the birth of another after a considerable interval,  we have no proof of a
double uterus in any, and positive proof that in one  case it was single,
and that to the  explanation of these cases, no theory, as yet  advanced, is
adequate; that of superfcetation  being opposed  by physical difficulties,
which are insurmountable in the present state of our knowledge
                           CHAPTER IX.

                   EXTRA-UTERINE PREGNANCY.

   245. From certain causes, with which we are but partially acquainted,
it  sometimes happens that the ovum, instead of passing into the fimbriated
extremity of the fallopian tube on the bursting of the Graafian vesicle, and
being thence transferred into the uterine cavity, in the gradual manner al-
ready described, is arrested in some part of its progress, where an effort
is  made to supply the place of the uterus, and afford  space and nutrition
for the fcetus.   This, however, can only be partially successful, and the
fcetus ultimately perishes for want of nourishment.  To this misplaced
gestation various names have been given, — " Extra-uterine pregnancy,"
"  Conceptio vitiosa," " Grossesse contre nature,"  " Exfoetation," &c.
   This abnormal  deviation from ordinary gestation was known, but not
minutely, to the ancients.  Albucasis relates a case of fcetal bones being
extracted from an abscess, which  had formed near the umbilicus, and
similar examples were recorded by Cornac, F. Plater, Cordaeus, Horstius,
Primrose, Hildanus, Riolan, jun., &c.   In more modern  times  very nu-
merous and well-authenticated cases have been published, and have been
carefully collected and referred to by Dr.  Campbell in his learned essay
on this subject, to which I have been principally indebted for this chapter;
and if I need any excuse for the freedom with which I have availed my-
self of his labours, it must be found in the fact, that his assiduity in col
lecting, and care in referring to the numerous cases on record, as well as
the accuracy of his reasoning and the excellence of his practical recom-
mendations, have  left little or nothing for me to do but to follow in  his
steps.
                                  p 
170
EXTRA-UTERINE PREGNANCY.
  246.  All the varieties of extra-uterine pregnancy may be  reduced to
three:
  1. Ovarian fcetation, when the ovum  is detained in the ovary:  2.
Tubular fcetation, when the fallopian tube is the seat of the arrest; and,
3. Interstitial fcetation, when the ovum enters the parieties of the uterus,
but is detained in an interspace of the fibres before it arrives in the uterine
cavity.
  Dr. Campbell has added another variety, which he calls the ovario-tubal,
a compound of the two first, when the sac containing the fcetus is formed
by the ovary and fallopian tube jointly.  A fifth species, ventral fcetation,
is enumerated by most authors, where the ovum is found in the abdominal
cavity;  but I think Dr. Campbell is right in supposing such cases to have
originally belonged to one or other variety previously mentioned, and for
which a separate section is scarcely necessary.
  A brief notice of each  variety, warn the details of a case or  two, will
be necessary before considering the symptoms and termination, &c.  For
reference to cases, I beg to refer  the reader to Dr. Campbell's book.
  247.  1.  Ovarian fcetation. — By some writers  the existence of this
species  of extra-uterine gestation is considered as rather doubtful, on ac-
count of the facility afforded for  the escape of the ovum after the rupture
of the Graafian vesicle; but the  evidence of facts is too  strong to be re-
sisted.
  The earliest example  on record is to be found in the Philos. Trans, vol,
ii. p. 650, communicated by the Abbe de la Roque.  It occurred in 1682:
the right ovary wras enlarged to the size  of a hen's egg, and  lacerated
through its whole length.. The fcetus was found in the abdominal cavity,
in the midst of a large quantity of blood.
  The following instance I quote from Dr. Campbell; it occurred in the
practice of Dr. Granville, and, from his high character, no doubt can be
entertained  of its  accuracy.  "  The  subject of the  case was a lady, aet.
39, the mother of seven  children. Until Dec. 1818, when she conceived,
the  catamenia were regular; and from this period till June 9, 1829, the
time of  her decease, she experienced various and severe sufferings, and
there were occasional discharges of a  colourless fluid  ' per vaginam.'
After death a considerable tumour, soft and moveable, was perceived im-
mediately above  the pubes, and  rather to  the left of the linea alba.  On
reflecting the abdominal parietes, blood to the amount of several pounds
was observed to fill every space  which the viscera did not occupy.  The
tumour  alluded to  was about four times the size of a hen's egg; and dis-
played the same general black-reddish hue of all  the ambient parts.  A
blood-vessel, the size of a large crow-quill, which  penetrated the dense
portion  of the tumour, was traced upwards to the descending aorta, and
was ascertained to be  a branch of the left spermatic.   A smaller and much
shorter vessel  arising  from the tumour, was also found  to communicate
with the spermatic vein, thus establishing a complete circulation to and
from the parts.  The  inferior and left half of the  tumour presented a sur-
face, consisting at two or three points of diaphanous membranes, through
which a fcetus of about four month's growth was readily discovered.  The
left ovarium was the seat of the  tumour, which, as it gradually enlarged,
distended the  tunics of  that organ in the same progressive manner, in a
ratio with its  own size.   As the fcetus, however, increased  further, the 
EXTRA-UTERINE PREGNANCY.
171
ovarium burst in three places;  and thus the membranous sac forming the
tumour partially protruded into the abdominal cavity.   During this de-
structive process, that part of the parietes of the  ovarium to which the
placenta was attached was also lacerated, so as to tear the adhesion of the
mass, thereby producing sudden and fatal hemorrhage.  The right ovary
was sound."
  248. 2. Tubal fcetation.—When the arrest  of the progress of the
embryo takes place at the fimbriated extremity of the fallopian tube, we
frequently find that the ovary forms part of the walls of  the cyst in which
the fcetus is  contained, though it is not always easy to point out the exact
locality of the arrest.   " In some instances," says Dr. Campbell,  " it may
be presumed that in the  incipient stages of gestation, the ovulum is con-
nected with only one of these appendages, either  the ovary or the tube ;
and  that the second  organ, whether ovary  or tube, becomes involved
merely in  consequence of its state  of activity, its progressive enlargement,
and  the pressure exerted  by  the ovum, together with the  consequent
morbid excitement."  Such cases  constitute the "ovario-tubal gestation"
of this author, and to this class he conceives  to belong those which have
been recorded as examples of " ventral fcetation."

                               Fig. 71.
  249.  But of all  the varieties  of extra-uterine gestation, that where the
embryo is contained in the tube itself, is the most frequent.   Riolan pub-
lished  the  first well-attested  example,  and he was followed by Littre,
Sanctorinus, Poteau, &c, &c.   The following example is taken from the
Transactions of a  Society for the improvement of Medical and Surgical
Knowledge, vol. i. p. 216.   "A married woman in her second pregnancy,
in consequence of a  bilious complaint  to which she had formerly been
subject, used some remedies  she had  been wont to employ, and  also a
warm bath.   She had been obstructed  but one period, and paid so little
attention to this circumstance, that  she  did not make it known, either to
her husband  or to the ordinary medical  attendant.  On May 13,  1791,
the  morning  subsequent to her having used the  bath, she was suddenly
seized, without any previous  exertion, with a violent pain in the  lower
part of the abdomen, followed by syncope, from which she soon recovered.
A moderate bleeding and an opiate diminished, but  did not entirely sub-
due, the pain, which now attacked the loins as  well as the abdomen, and
recurred in violent paroxysms,  accompanied by vomiting, yawning, and
fainting.  On the 16th she was  somewhat easier; but towards  evening
there was an aggravation of her  sufferings, accompanied by cold sweats. 
172                 EXTRA-UTERINE PREGNANCY.
coldness of the lower extremities, interrupted articulation, great restless-
ness, with want of pulsation at the wrist, and she expired.
  "Autopsy.—Nearly a gallon of blood was found effused into the abdo-
minal cavity, a laceration of an inch and a half in length about the middle
of the  right fallopian tube; an  embryo of the  sixth or  seventh week in
the blood;  the uterus lined with decidua, and its cavity filled up with
gelatinous  matter."
  I cannot but notice in this place two cases published by Dr. R. Lee, in
Med. Gazette, vol. xxvi. p. 436, because of the peculiarity of the situation
of the  membrana  decidua: — "A lady died suddenly in 1829, from in-
ternal hemorrhage, produced by  rupture of the right fallopian tube, which
contained an ovum.   On. opening the tube, and examining the different
parts of the ovum, I found a deciduous membrane everywhere surround-
ing the chorion,  and closely adhering to the inner surface of the tube, as
the decidua usually does  to the lining membrane of the uterus  in ordinary
gestation.   Within the decidua the  chorion, placenta, amnion, and em-
bryo were distinctly seen."  Again, " on the 18th July, 1836, Mrs. K----,
after suffering  some time with symptoms of inflammation and retroversion
of the uterus, was seized with great faintness, and soon expired.  A large
quantity of fluid blood was found in the abdominal cavity, and the right
fallopian  tube was extensively lacerated near  its fimbriated extremity.
On removing the uterus and its  appendages from the body, and carefully
examining the ovum contained in the right  fallopian tube, it was  evident
that a  deciduous membrane everywhere surrounded the chorion, and  ad-
hered to the inner surface of the tube.  The uterus was  considerably  en-
larged, and its inner surface was coated with a very thick layer of yellowish-
white  soft  substance, like common adipose  matter, and  bearing  no
resemblance to  the deciduous membrane.  There was  no trace of  any
arterial or venous canal, in this coating."
   250. 3. Interstitial fcetation.—This form is the rarest of the three
or five;  but the  following case leaves not  a doubt of its existence.   It
occurred in the practice of the late  Mr. Hey of Leeds,  and by him was
communicated to Dr. W. Hunter.   " The patient, aged 35, of a healthy
constitution, was seized when two months advanced in her second gesta-
tion, with  pains resembling colic, which were subdued by  appropriate
remedies: but in the sixth month, they  returned with much greater vio-
lence, and were more diffused  than formerly."   They were repeatedly
alleviated, but as frequently returned.  When the  term  of gestation  was
completed, the movements of the child ceased.   Pains came on, but with
little  effect, and vomiting, which  produced great  emaciation, and ulti-
mately proved fatal.  "Dissection exhibited adhesions between the omen-
tum, intestines,  peritoneum, and a  large  peculiar sac, which occupied
nearly the  whole abdominal  cavity.  Besides  a well-formed fetus,  free
from any mark  of decomposition, the cyst, which was  a line and a half
in thickness, contained a quantity of chocolate-coloured fluid and some
purulent-looking  matter.  The  umbilical  cord  passed from the foetus
through a narrow aperture into  a cavity whose  walls were an inch and a
half in thickness, but of much  smaller dimensions than that  which  con-
tained  the  fcetus.  This smaller cyst, which must have been the uterus,
contained a placenta of a size so unusual, that it filled three-fourths of the
cavity of the organ; both together weighed two pounds and a half avoir- 
EXTRA-UTERINE PREGNANCY.
173
dupois.   No trace  of cicatrix could be detected  in  the uterine parietes.
The membrane of the ovum, after lining the uterine  cavity, was reflected
to form the inner lining of the cyst which lodged the fcetus."
   251.  Causes. —- After the  instances I have quoted in illustration of each
variety, we  may  now proceed to  inquire as to the causes of extra-uterine
gestation, which, however, are by no means easy of discovery.  It is pos-
sible that either congenital malformation or pathological changes may retain
the fecundated germ  in the ovary, or prevent its entrance into the fallopian
tube, or arrest its progress after its entrance.   Narrowness or obliteration
of the tube  may  effect this.
   In addition, interstitial fcetation has been attributed  to  narrowness of
the uterine orifice of  the fallopian  tube, or an  unusually large  interspace
between  the fibres, or to a partially cornuated uterus.
   But these causes, it is evident,  are mainly conjectures.*
   252.  Symptoms. — The  symptoms vary a good deal.  So long as the
part in which the embryo is  lodged can accommodate it, there may be but
little disturbance, and nothing to  afford grounds for a  correct diagnosis.
In other  cases, the local symptoms resemble those in disease of the uterus
or ovaries.   In the greater number of  cases, there is much suffering from
an early period.  Certain of the  signs of pregnancy may be present, but
a degree of irregularity  in  their intensity  will  frequently  be observed.
Thus the catamenia may be present or absent, and if present either scanty
or profuse ;  and not seldom  there is  hemorrhage, or  a discharge of clots,
which have  been mistaken for portions of the placenta.  The mammary
sympathies are excited in most cases, and the changes in the areola take
place.   The patient may or  may  not suffer from nausea or vomiting, and
in some cases at  an early period the fcetal  movements have been felt by
the patient.   The increase of the abdomen generally differs from that in
ordinary pregnancy, being more to one side,  and  the pain or uneasiness
may be  limited to the spot where  the tumour is felt.  M. Chaussier lays
great stress  upon a sense of  weight and uneasiness, deeply seated in the
pelvis, and occasionally, extending to the kidneys.
   An examination per vaginam reveals a great deviation from the  state of
the organs in ordinary gestation.   The os uteri may be high or  depressed,
but it is very seldom  drawn out  or  dilated;  in fact, it is generally as it
wras before impregnation, or nearly so.
   * Velpeau seems to think that .occasionally too great density, or preternatural thick-
ness of the covering of the ovule, or envelope of the ovary, may detain the ovum and
prevent its entering  the fallopian tube at the proper time, and thus become the cause of
extra-uterine pregnancy; and likewise various pathological conditions of the tube, as
paralysis, spasm, excision, or insufficient length, engorgement, contraction, or inflam-
mation and ulceration of its mucous membrane, &c.   Astruc believed that unmarried
women were more liable to this accident than others, and it is supposed  to be caused
by fear or other strong mental emotions, of which two striking instances are mentioned
by MM. Lallemand and Baudelocque, in which it seemed to be caused by fright.  Dr.
Rijj;by very properly observes on this subject, that "it must always remain a matter of
great obscurity as to the immediate causes of extra-uterine pregnancy, more especially
of the ovarian and ventral species; ami the more so as we are  still ignorant of the
mechanism by which the fimbriated extremity of the fallopian tube grasps the ovary
immediately over the impregnated vesicle of De Graef at the moment of conception.
In many cases we are inclined to  believe that this function of  the fallopian tube is de-
stroyed by adhesion  between it and the ovary, a circumstance of not uncommon occur-
rence ; but from the alteration in  the shape and size of these parts, as also from exten-
sive adhesions  which are usually found after death in such cases, it will ever be difficult,
and perhaps impossible to prove it." — Editor.
                                  p2 
174
EXTRA-UTERINE PREGNANCY.
  253. When the cyst in which the ovum is contained bursts, however,
a series  of new and alarming symptoms  are  superadded.  The patient
complains of great uneasiness or pain suddenly occurring, languor, debility,
and exhaustion to an extreme degree ; there is sometimes a sanguineous
discharge from the vagina, with dysuria, tenesmus, irritable stomach, &c.;
in short the patient exhibits the symptoms of collapse from loss of blood.
  In tubal fcetation, these symptoms generally come on more suddenly
than in the other varieties, so as at once to excite suspicion of a rupture
of some internal organ having taken place.
  In interstitial fcetation,  the symptoms are a modification of those in the
other varieties.   In some, there are abdominal pains and sanguineous dis-
charges, in others these are absent; but in all  the cases on record the tu-
mefaction and fcetal movement were confined to one side of the abdomen.
It is also remarkable, that in all, the child appears to have lived to the term
of utero-gestation.
  254. I have already stated that matters may go on more or less quietly
for some time, not without injury to the health of the mother, but without
danger to her life.   However, the crisis must come sooner or later, when
the cyst gives way and symptoms of collapse set in, followed by those of
inflammation.   This crisis may be hastened by various circumstances, such
as violent action of the abdominal muscles, and the consequent pressure
upon the tumour, sudden shocks, or blows upon the abdomen, coughing,
vomiting, &c.   The rupture of the cyst may be followed shortly by fatal
results, owing to the shock to the system, the hemorrhage, subsequent in-
flammation, or from one or more of these consequences combined.
  255.  But there are many exceptions to such prompt terminations.  The
patient may survive the shock, hemorrhage, and subsequent inflammation,
and the parts may accommodate themselves to  the presence of the fcetus,
so that the patient will recover a certain amount of  health, and suffer but
little local  inconvenience;  nay, she may even again conceive and bear
children ; " nine women  conceived once during the retention  of the ex-
tra-uterine fcetus ; two twice;  one three times; one four times ; one six
times, and one  seven times."
   The period during which the fcetus may be retained before the mother's
death or its own expulsion varies much.   Dr. Campbell gives  the follow-
ing account of  seventy-five cases: it was retained  "three months in two
instances ;  four months in one;  five months in  one; nine months in two;
fifteen  months  in  three; sixteen months in two ; seventeen  months  in
two;  eighteen  months in seven ; one year in five ; two years in eight;
three years in seven ;  four years  in four;  five years in one ; six years  in
two ;  seven years in three ; nine years in one ; ten  years in three ; eleven
years in two ; thirteen years in one ; fourteen years in two ;  sixteen years
in one; twenty-one years in one; twenty-two years  in one;  twenty-six
years in two •, twenty-eight years in one ; thirty-one years in one ;  thirty-
two years in one ;  thirty-three years in one ;  thirty-five years in two; forty-
eight years in  one1"; fifty years  in  one; fifty-two years in one; fifty-five
years in one, and fifty-six years in one case."
   These cases  afford a striking instance of the power of the human frame
to adapt itself  to new and apparently adverse circumstances.   In many
cases, after some time, an effort is made to get rid of the foreign body  by
artificial openings;  thus the fcetus may be passed piecemeal  through the 
EXTRA-UTERINE PREGNANCY.
175
 abdominal parietes, the  colon, rectum, or vagina.  In some rare cases,
 fcetal bones have made their way into the bladder.
   256. Experience alone could  have convinced us of the possibility of
 the fcetus living in these misplaced gestations ; yet it may continue to draw
 nourishment and exist for  any period within the full term of gestation.
 " In ninety-eight cases," says Dr. Campbell, " in which we can  decide,
 or nearly so, on the stage of pregnancy, the fcetus in seventy-nine patients
 died at the close of nine months, or soon thereafter;  one in the eighth;
 seven about the seventh; one in the sixth; two  in the fifth ;  two in the
 fourth ; five in the third, and one at the end of the first month."
   The development during the life of the fcetus appears to proceed at the
 ordinary ratio, and subject to the laws of normal gestation; the placenta,
 cord,  and  membranes are obvious before decomposition takes place; but
 the placenta is generally thinner than usual.  Authors have differed as to
 whether the ovum receives an additional covering or not, analogous to the
 decidua;  but the evidence adduced  by Dr. Campbell and Dr. R. Lee's
 recent researches  seem conclusive  in the affirmative, and it is probable
 that this membrane, which closely resembles the decidua, may perform
 an  office similar in the  nutrition of the fcetus.   The  part to which the
 placenta is attached, receives an  increased vascular supply for the occa-
 sion.
  Almost  all writers have  described the uterus in these  cases as lined
 with (so called) deciduous membrane, though in some cases much hyper-
 trophied; but in one  of Dr. Lee's  cases it was absent, and he doubts,
 whether when present,  it  possesses  " an  organised vascular structure,
 similar to that of the true decidua."
  257. Treatment.—If we are satisfied of the nature of the case, the first
 indication is to prevent or postpone the laceration of the cyst in which the
 ovum  is contained, and which so  often proves fatal.   With  this view,
 undue exertion of every kind is to be avoided, and all circumstances likely
 to excite uterine irritation.  No pressure should be made upon the tumour,
 and any uneasiness in it should be  allayed as promptly as possible by
 vensesections, leeches, or opium.
  When the  rupture takes place,  marked by the  sudden giving way, col-
 lapse,  and  exhaustion, &c, the second indication is to moderate the effu-
 sion and support the strength, for which purpose  the  patient  should be
 placed on a hard bed, with her head low, and the abdomen firmly com-
 pressed by a binder,  over which cold  should be applied by means of
 pounded ice in a bladder.
  Acetate  of lead may be of service, with suitable stimulants and broths.
  Should we succeed in relieving the  state of collapse, we must next
 combat the inflammation which will set in, by the abstraction  of blood,
 calomel and opium, blisters, &c.
  As the child dies soon after the rupture of the cyst in  most cases, we
 must next  endeavour, by quietness and the  absence  of  excitement and
irritation, to aid the natural powers  in accommodating  themselves to the
new circumstances of the case.  The bowels must be kept free by gentle
laxatives, and any renewal of the pain must be met by the application ot
a few leeches or an anodyne.
  If we find after a time that any effort  is made to remove the foetus by
the  formation of an abscess or fistulous communication and diseaarge of
       12 
176
PATHOLOGY  OP THE FCETUS.
foetal bones, it may in  some cases be advisable to assist the process by
enlarging the opening  in the abdominal, vaginal, or rectal parietes;  but
this should be done with great judgment and care, as serious hemorrhage
may ensue, and we are never to forget that nature is generally competent
to complete the processes she commences.
  Any subsequent inflammation  must of course be treated  in the usual
manner.
                           CHAPTER X.

        PATHOLOGY OF THE FCETUS. —SIGNS OF ITS DEATH.

   258. When describing the contents of the gravid uterus, a short notice
of the principal pathological changes to which they are exposed wras ap-
pended, so that I need not recapitulate them here.  They, however, with
the diseases to which the fcetus  is obnoxious, constitute an important de-
viation from normal gestation.   The latter remain for notice at present.
   Abundant observation has proved, that the fcetus is  liable to almost all
the forms of disease  which attack the child ;  that many of them are quite
independent of the maternal state ; but  that in addition it maybe affected
secondarily through her.   Amongst the examples  of  the latter, must be
classed those cases  of premature births which occur  during epidemics,
and where the fcetus  appears to have participated  in  the disease  of the
mother, as in the  observations of Roederer, Wagler, Schmurrer, and Rus-
sell.  I have observed a considerable quickening of the action of the fcetal
heart,  some  days  after pregnant women have been attacked with fever.
   According to Duettel, Schweig, Zurmeyer, &c. children born of mothers
suffering under intermittent fever  have  exhibited the same disease imme-
diately after birth.
   Many cases have been recorded by Hildanus, Bartholinus, Mollenbroc-
cius, and, in later times, by Van Swieten,  Mead,  Baker, Lynn, Jenner,
&c. of children born with small-pox.   Measles have also  been observed
in new-born infants  by Osiander, Stark, Girtanner, Orfila, &c.  Nor are
they exempt from other diseases of the  skin, as erythema, strophilus, pem-
phigus, &c.
   259. There is scarcely any internal organ which has not been observed
to be  the seat  of inflammation.  The presence of hydrocephalus is the
result  of inflammation  (acute or chronic) of the arachnoid.   Hoogween,
Veron, and  Cruveilhier have recorded cases  of pleurisy.   Mende and
Koelpin  have observed abscesses of the lungs;  Zierhold oedema,  and
Wrisberg scirrhous induration ;  Husson, Chaussier, and Billard have dis-
covered tubercles, Cruveilhier lobular pneumonia, and Lobstein calcareous
deposition in these organs.   Brachet,  Chaussier,  Duges, Billard, Carus,
Simpson, &c. have observed cases of peritonitis, Chaussier of enteritis, &c.
  Of  the cause of such attacks we know little or nothing.
  260. Chronic diseases are  even more numerous: the fcetus may suffer
from a general hypertrophy or atrophy;  may be attacked  with various 
PATHOLOGY  OF THE FCETUS.
177
forms of syphilitic  disease; may labour under worms, calculus, dropsy,
jaundice, or  hernia, and the pancreas,  liver, or kidneys may exhibit or-
ganic or pathological changes.
   The bones and joints are notunfrequently diseased; thus, for instance,
children are  born with rickets, as related by Osiander, Carus, Otto, and
others; with caries, as  observed  by Carus and Joerg;  or  necrosis, as in
M. Billard's  case.   Numerous cases of fractures and dislocations of dif-
ferent bones are on record.
   261. This brief and imperfect sketch will suffice to prove the truth of
the statement made at its  commencement, that the fcetus does not enjoy an
exemption from disease whilst "in utero;" unfortunately we possess neither
the means of detecting nor of curing  these affections.  The  subject is
nevertheless  one of great interest:  to enable any of my readers to pursue
the investigation further, I shall subjoin the names of  some of the authors
who have written expressly upon it.   Murat, Diet, des Sciences Med.; art.
Fcetus.  Osiander,  Handbuch der Entbindungskunst.  Joerg,  in  his
works.   Carus, Zur Lehre von Schwangerschafl und Geburt.  Mende,
Ausfilhrliches  Handbuch  der gerichtliche Medizin.   C.  W. Hufeland,
Die Krankheiten der Ungebornen, 1837.  Meissner, Kinderkrankheiten,
1829.  Hardegg,  De morbis Fcetus Humani, 1827.  Billard, Mai. des
Enfans nouveauxnes,  &c.   Bergk, De  morbis Fcetus Humani, 1829.
Zurmeyer, De morbis Fcetus, 1832.  J. Grcstzer, Die Krankheiten des
Fcetus, 1837.  Prof.  Simpson, Essay  on Peritonitis, Ed. Journ. vol. 1.
p. 39 ;  and on Hernia, vol. lii. p. 17.  M. Groetzer's work is an excellent
summary of the labours  of his predecessors, and Professor  Simpson's
Essays are equally admirable for their  research, careful observation, and
logical  deductions.*
   262. Death of the fcetus.—But  although we may not  be able  to
detect disease  in  the  fcetus, it is often of great  importance  to ascertain
whether it be dead or alive, and it is therefore desirable if possible to de-
termine what are the signs of its death.   The question may be of conse-
quence to the medical jurist, and is always to the obstetrician as influencing
our decision  as the best time for operations.
   The diagnosis of a dead fcetus is confessedly very difficult: since  the
time of Mauriceau the subject has been  investigated by many writers, and
still, notwithstanding the powerful aid afforded by the stethoscope, many
cases are exceedingly doubtful; and for obvious reasons, since most of
the symptoms  upon which we must rely,  depend upon the sensations of
the mother, and sensations are notoriously delusive.
   263. The  signs which  are given as evidence of the  child being dead
are: the cessation of its movements; the subsidence or flaccidity of the
abdomen ; the recession of the umbilicus; the loose feel of the uterine
tumour, and  its rolling about in the abdomen ;  a sensation of dead weight
and coldness in the abdomen ;  the breasts suddenly becoming flaccid, and
their  secretion  suppressed; the health  being deteriorated; the appetite
bad ;  the countenance sunk; a dark areola round the eyes; foetid breath;
repeated rigors, &c.
   264. Taken separately none of these  signs are certain; the movements

  * An excellent  monograph on the subject of  fcetal  pathology is contained in the
" American Journal of Medical Sciences," for August 1840, and continued in the same
journal, Oct. 1811; by William Roberts, M. D., of New York. —Editor. 
178                  PATHOLOGY  OF THE FCETUS.
of the fcetus maybe suspended for some days without its being dead , the
degree of tension of the abdomen varies much in the course of pregnancy,
especially in women who have had several  children ; the uterine tumour
is occasionally felt as a weight (as it were a foreign body) by women who
bring forth the child  alive ;  the coldness is a mere sensation, and  there-
fore of little value, a dead fcetus not being really colder than a living one ;
and  the health may be deteriorated,  and a dark shade appear under the
eyes from  many causes besides  the death of the fcetus.  The breasts,
however, seldom become flaccid, after having been tense, from any cause
but the death of the child.
  Besides, it is a matter of common  experience, that women retain a dead
fcetus " in utero" for weeks or months, and exhibit few or none of these
symptoms.  In  such  cases  women have even fancied that  they felt the
fcetal movements up to the time of labour without any change in the ab-
domen, breasts,  or general health.
  265.  But although taken singly,  none of these signs are conclusive,
yet cases occur  in wThich the concurrence of several is  nearly so.   Sup-
pose, for example, that in the sixth month of pregnancy, a patient should
find the motions of the child, which  up to that period  had  been lively,
cease, and soon  after observe that the abdomen  and uterine  tumour had
lost their tense  and rounded  form,  at the  same  time  feeling the latter
weighty and rolling loosely in the lower belly, and finding the breasts,
which had been tense, firm, and  glandular, subside and become flaccid.;
we should undoubtedly have almost  proof of the death of the child.
  The value of these  signs in short consists in their concurrence, and in
their contrast to  the patient's previous condition and sensations.
  266.  We have found the  value of auscultation  in detecting pregnancy
by proving the life of  the fcetus, and  it may very naturally be asked, what
evidence does it afford of its death ?  in  other words, the hearing the pul-
sations of the fcetal heart proves the child to be alive;  does their being
inaudible prove that it is dead ?   1 have already stated that in some cases
although the child  be  alive, yet the sound of its heart is inaudible, or tem-
porarily suspended, and such cases of course prevent a directly affirmative
answer to the question.  Again, much depends upon the tact  and expe-
rience of the auscultator;  one  person may detect a pulsation that  is in-
audible to another: to pronounce, therefore, that a fcetus is dead because
we  do  not at any one visit hear the heart, would be too hasty a conclusion.
  But if after hearing the heart pulsating distinctly, we find  it gradually
or suddenly become inaudible, and continue so, the evidence will be very
strong, and if in addition the  principal  symptoms above enumerated be
present, there can  be little doubt of the  death of the fcetus.
  267.  Thus far we have considered the signs of the death of the fcetus
during utero-gestation previous to labour; when this process commences,
other and more distinctive evidence is accessible.
  On the rupture of the membranes, when the fcetus has been some time
dead, the liquor is frequently changed, being of a dark colour, and of
thicker consistence than usual; but if the death be recent, no such altera-
tion will be found.*
  * " The liquor" has been repeatedly seen, not only " thicker than usual," but actu-
ally foetid, although the child was alive and healthy.  In such cases, it arises probably
from decomposition of a portion of blood which is extravasated by a partial separation
of the placenta,—or,  perhaps, of a small fragment of the placenta itself.—Editor. 
ABORTION.—PREMATURE  LABOUR.               179
  Great stress is laid upon the state of the scalp and bones of the cranium,
and, I believe,  justly.   After the fcetus  has  been dead some time, if the
finger be pressed upon the scalp, it is felt to be emphysematous, crepitating
under the  touch, and a portion of the cuticle will peel off.   The bones of
the  skull also overlap more,  and feel loose wTithin the scalp.
  When present, these signs are, I believe, conclusive, but the latter  only
will be found if the death be recent.   It is stated by Dr. Parr and others,
that no tumour is formed upon the head of dead children; but from some
observations I have made, I am not quite sure of the fact.  The absence
of pulsation at  the greater fontanelle, and  its diminution from the collapse
of the bones, is admitted to be an important sign.
  268.  In face presentations, when the child is dead, the lips are flabby,
the tongue flaccid and motionless, and the  presenting part slightly swelled.
In breech presentations, the sphincter of a living child resists  or contracts
upon the finger, but when dead, it is relaxed.  The discharge of meconium
is of no value  in  breech presentations, and of very little in any other.
When the arm protrudes, it shortly becomes livid and cold, and the pulse
at the wrist  often imperceptible, but this  does not prove the child to be
dead.  The peeling of the epidermis is conclusive.   In prolapse of the
funis, the pressure to which it  is exposed,  very soon destroys the child,
and in most cases the presence or absence of pulsation in it, is a satisfac-
tory test of the life  or death of the child.   Dr. E. Kennedy, however,
records a very instructive exception  to  this  rule: the cord had been  pro-
lapsed for an hour, and during a pain no pulsation was perceptible ; when
the pain subsided, he " drew the funis backward towards the sacro-iliac
symphysis, and then was able  to detect  a  very indistinct  and irregular
pulsation, which corresponded to a slight fcetal pulsation over the pubis."
The forceps were in consequence applied, and the child was saved.
  269.  Dr.  Collins and Dr. E. Kennedy regard the evidence afforded by
the stethoscope during labour of the  child's life or death as conclusive, or
nearly so ; certainly the information thus  obtained of the changes which
occur in the fcetal circulation is extremely valuable, and the gradual dimi-
nution in frequency and force of the b-eart's action, and its  ultimate  ces-
sation, will probably justify our belief in the death of the child.  It must
be  remembered that it  is not simply the absence of pulsation that is to
determine our opinion, but its cessation  after having been heard.
                           CHAPTER XI.

                 ABORTION. —PREMATURE LABOUR.

  270.  The expulsive action of the uterus may be exerted at any period
of gestation, though it appears  more  easily excited at or previous to the
third month, on account of the frailty of the connexion between  the ovum
and decidua.   It is  also more liable to occur at the beginning  of each
month, corresponding to a menstrual period, than  during  the interval, in
accordance with the  periodicity peculiar to the female generative  system. 
180
ABORTION.—PREMATURE LABOUR.
  If it occur before the sixth month, it is called an abortion, subsequent
to this period, premature labour.   It is always an " untoward event," and
may exert an unfavourable influence upon the health of the female, but it
cannot be considered as  dangerous, unless it be accompanied by great
hemorrhage, and even in  such cases it is rarely fatal.
  271.  Frequency.—Dr. Collins met with at least 393 premature cases
in 16,414;  Dr.  Beatty met with  21 premature cases in 1200.   In  my
own report,  65 cases of abortion  are  recorded  in 1705 deliveries; Ma-
dame Lachapelle records 116 cases in  21,960 cases  of pregnancy; M.
Deubel  35 in 420;  making in all 530 premature cases in 41,699 deliver-
ies, or 1 in 78 \.
  Mr. Whitehead has recently  published some statistics of abortion,  of
which I shall give an extract.   " Two thousand married women in a state
of pregnancy, admitted for treatment at the Manchester Lying-in Hospital,
were interrogated in rotation respecting their existing  condition and pre-
vious history.  Their average  age  at the time of inquiry  was  a small
fraction below 30 years.   The  sum  of their  pregnancies, already termi-
nated, was 8681, or 4.38 for each;  of wThich rather less than 1 in 7 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, consequently, be  rather more  than 1  in  7."   Of 747, all
had 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  the preceding  state-
ments it appears that more than 37 out of every 100 mothers, experience
abortion before  they reach the  age of 30 years.  As to the pregnancy
most likely to be prematurely terminated, Mr. Whitehead states that of
226 women  pregnant for the second time, 20 or 8.8 per cent, had aborted
of the first, and of 230 pregnant for the third time, 58 or 25.20 had pre-
viously  aborted.   Of  602  cases, abortion   occurred  at the  following
periods: in  35  at 2 months, in 275 at 3 months, in 147 at 4 months, in
30 at 5 months, in 32 at 6 months, in 55 at 7 months, and in 28 at 8
months.*
  272.  Causes. — The  causes  of abortion  may  be either  maternal  or
ovuline.
  1. The maternal causes may arise from the condition of the mother,
or they  may be accidental.   That certain states of the  constitution, or of
the  general  health,  render the patient obnoxious to this  accident, there
can be  no  doubt;  and Denman  is probably correct in attributing many
cases to this, rather than to the specific cause assigned ; for as he observes,
" that about  which  the  patient was  employed, when  the first symptom
appeared, is fixed upon as the particular cause, though probably she was
before in such  a state that abortion was inevitable."   The habits of life
have also a  considerable  influence, for we find abortion most frequent in
the extremes of society.
  On the other hand, it is wonderful with what tenacity the ovum is re-
tained by persons of delicate constitution, and under very trying circum-
stances ; thus women far  gone in consumption conceive, complete the
term of utero-gestation,  and are delivered  of healthy children.  And
* Whitehead on Abortion and Sterility, pp. 245-6. 
ABORTION.—PREMATURE  LABOUR.
181
Mauriceau mentions a case (Obs. 242) of a woman who fell from a win-
dow in the third  story of a house, in the  seventh  month of pregnancy,
and broke one of the  bones of her fore-arm, dislocated her wrist, and
bruised herself very much ; yet she fulfilled the period of pregnancy, and
was delivered of a living child.   Dr. Davis also relates the case of a lady
who was thrown from her horse, when three or four months pregnant, and
much bruised, yet without interruption to gestation.
   So that we cannot pronounce a priori that delicate women will abort,
although it is undoubtedly a cause far from uncommon.
   When this constitutional or local susceptibility is extreme, a very slight
shock indeed will be sufficient to cause the accident; thus  one lady will
miscarry after having a tooth  drawn, another from making a false  step
going down stairs, &c.;  and in a case I lately attended, it  seemed to be
brought on by the lady's reading an account  of a railroad catastrophe.
   273. Certain local disorders are said to  cause abortion, as leucorrhcea,
uterine irritation,  a patulous state of the os uteri, diseases of the  rectum.
bladder, &c.
   Mr. Whitehead mentions that of  747 women, the sum of whose abor-
tions amounted to 1222, the assigned causes  were as follows: —

   " Inward weakness," impaired health, and acute disease     .   911
   Accident,  mental perturbation, &c.   .....   222
   No assignable cause  ........   90
   This " inward weakness," to which so many attribute their miscarriages,
is, in fact, leucorrhcea, arising from  disease of the  lower portions of the
uterus.   Out of 378 cases an examination  showed that 275  were  thus af-
fected with inflammation and  superficial erosion of the cervix, varicose
ulceration, oedema, fissured ulceration,  induration  of the cervix, endo-
uteritis, follicular  ulceration, syphilitic disease, &c, thus confirming the
statement of M. Boys de  Loury and Dr. Bennett as to ulceration  being a
common cause of abortion.
   The  same consequence may follow febrile complaints; thus a patient
will often  miscarry during  the course of typhus fever, small-pox, scarla-
tina, measles, &c.; but it is possible that the miscarriage in these cases,
may result from the death of the fcetus, and not directly from the disease.
In this way probably.it  is, that syphilis gives rise to  abortion  or premature
labour.
   274.  Among the accidental  causes of  abortion may be enumerated
blows, falls, violent concussions, excessive or sudden exertions, straining,
severe coughing, &c. which in most cases  act by separating partially the
ovum from the uterus.
   Mental emotions, anger, joy, sorrow, good or bad news suddenly told,
may excite the uterus to action, and effect the expulsion of its contents.
   Lastly,  a female may acquire a habit of aborting.  Each occurrence
predisposes to a repetition of the accident at about the same  period;  and
after it has happened several times,  it is extremely difficult  to  carry her
safely over that period.   Thus Dr. Young of Edinburgh had  a  patient
who miscarried thirteen times in succession, and  Dr. Schultze  one to
whom the same accident happened twenty-two times, at or about the same
period of gestation.  I was myself consulted a short time ago by a lady
who stated that in  less than three years she had miscarried ten or twelve
                                 Q 
182               ABORTION.—PREMATURE LABOUR.
times during the second month of gestation.  It is remarkable, that these
patients seem to have  as  great an  aptitude for conceiving as for mis-
carrying.
  Dr. Tyler Smith (p. 127) has divided the causes of abortion into excen-
tric, centric, and special, so far as the mother is concerned.   The former
includes the causes already mentioned which act by irritation of the mam-
mary, trifacial, vesical, and  uterine  nerves; the second, those which  act
through the medium of  the  blood, as scrofula, syphilis, the exanthemata,
&c.; and the third includes cases of disease.
  275.  2.  The ovuline  causes of miscarriage may be stated generally, to
be anything which compromises the life of the child, whether the ovum
be thereby  detached or not.   Thus certain pathological conditions of  the
amnion, chorion, or decidua, the erroneous insertion of the funis, diseases
of the placenta, separation  of the ovum,  &c.  must necessarily interfere
with the perfect nutrition of the fcetus, and perhaps cause its death and
subsequent expulsion.   Or  the fcetus may  die  of some of the  diseases
mentioned  in the last chapter.   As a rule, it may be stated, that the death
of the fcetus will be followed  by its expulsion,  but the period of this  oc-
currence varies very much;  a  few days  only may elapse,  or it may  be
months, or, in a few rare cases, years.  I think also, that the. evidence  we
possess, shows the much greater frequency of the ovuline than the mater-
nal causes  of abortion; and if so, we must conclude, that as it  is better
that a blighted  fcetus should be thrown  off, so abortion  in many, if not
most instances, is a salutary effort, when  not complicated.
  The occurrence  of hemorrhage from internal or external  causes, is not
an unfrequent cause  of abortion, partly from the injury done to the fcetus,
and partly from the distension and  irritation of the uterus.  The blood
may be effused between the  uterus and decidua, between the decidua and
chorion, between the chorion and amnion, into the substance of  the pla-
centa, or into the cavity of the amnion.   It has also been poured into  the
peritoneal cavity, probably through the fallopian tube, as noticed by Botal,
Ruysch, and Smellie.
  276.  Symptoms.—When threatened with a  miscarriage, the patient
generally experiences a. sense of uneasiness, languor, and weariness, with
aching or pain in the back ;  after these preliminary symptoms have lasted
for  some time, those of  labour supervene, and in most cases they do  not
differ much from those of labour at the full term;  the pain may even be
as great.
  A slight  discharge of mucus or  blood from the  vagina is observed,
pains are felt in the back, extending round the loins to the abdomen, and
down the thighs, recurring at regular intervals, and increasing in strength
and frequency.   The stomach frequently becomes irritable, and discharges
its contents.  The pulse is  quickened,  the skin  hot, voluntary efforts  are
made in aid of the uterus, and ultimately the contents of the womb, or a
portion of them, are expelled.
  277.  But although these symptoms are generally present, yet  the pro-
gress of different  cases is so dissimilar, that we must enter a little  more
into detail.   Occasionally cases occur wrhere the ovum slips out  of  the
uterus (so to speak) with scarcely any pain, little or no hemorrhage, and
followed by a speedy recovery.  We see this chiefly in persons who have
acquired the habit of aborting.   Other patients oresent the ordinary symp 
ABORTION.—PREMATURE  LABOUR.
183
toins of lacour as enumerated above, but which subside after a time, with-
out the expulsion of anything from the uterus, until the expiration of the
full term of utero-gestation, when the birth of a full-grown child is accom-
panied by the expulsion of a blighted fcetus, the case  being one of twin
conception.
   Again, the  pains of labour may come  on with more or  less  flooding,
and after some time the fcetus alone be expelled, the shell of the ovum
being  retained.  The latter is generally detached after a time, or it may
be dissolved,  and discharged along with the  lochia.   So  long  as it re-
mains, hemorrhage is to be feared ; and in many cases where it dissolves
by putrefaction, uterine phlebitis is excited ; such cases, therefore, excite
great anxiety, and require careful treatment.
   Lastly, very alarming hemorrhage may precede or accompany abortion.
I cannot say that I ever met with a case in which it proved fatal, though
I have seen  life reduced  to the lowest ebb.   It is also important to re-
member, that flooding scarcely ever continues after the expulsion of the
ovum.
   278. The flooding may be caused by external  accidental circumstances,
such as blows, falls, &c. or  it may result from some condition of the ovum
or its vessels beyond our cognizance ; it may be internal for a time and
afterwards escape, or it may be discharged per vaginam from  the begin-
ning.
   There is of course no difficulty in the diagnosis in  the latter case; but
it  is not always easy to  detect internal  hemorrhage.   In general, the
patient becomes pale,  exhausted, and faint, with a dark shade under the
eyes, and a  quick, weak  pulse.   She complains  of  headach, lassitude,
slight  shiverings,  occasional dull  pains  in the  pelvis, weight about the
rectum, perhaps a difficulty in voiding urine, tightness of the epigastrium,
&c. with reaction at intervals.
   The uterine tumour, if above the pelvis, will be found unusually tense,
and larger than the supposed period of pregnancy would warrant.  After
a time, the distension of the uterus excites contraction,  then the mem-
branes give way, and the  blood escapes.  The fcetus is of course lost.
The intensity of the symptoms, and the injury  to the mother are in pro-
portion to the amount of flooding, which, in fact, constitutes the primary
danger of an abortion.
   Generally speaking, the flooding is less, the nearer the gestation is to
its completion.
   279.  Treatment. — The  first question that occurs to us when called in
to a case of threatened miscarriage, is, whether  it can be averted.  If we
possessed any means  of ascertaining the state of the ovum and foetus, the
question would probably be, whether it ought to  be averted ; for'certainly
when the fcetus is dead or seriously injured, it is much  better that it should
be cast ftff.   But we do not possess this  knowledge^ and must therefore
content ourselves with the conviction, that if the  vital relation between the
ovum and uterus  be compromised, it will be expelled, and in the mean
time use the most  suitable means to arrest, if possible, the progress of the
case, or to avert danger from the mother.
   If the hemorrhage be very slight, and the pains very trifling, our efforts
may be successful; but if the pains  have continued  for  some time, and
are accompanied  with  bearing down, and especially if there be much 
184              ABORTION.—PREMATURE LABOUR.
flooding, there is little hope of success.  If the patient be robust and
plethoric, it will be advisable to take away blood from the arm ;  and she
should repose on a hard bed, lightly covered with clothes, in a cool room,
and be kept in perfect quiet, mental and bodily.  All causes of irritation,
excitement, or distress, must be removed, and stimulants  of every kind
avoided.   We may then  attempt to suspend the uterine action, by means
of opium or some of its preparations, in full doses.
   In such  cases I have latterly succeeded several times by means of the
tincture  of Indian hemp, as prepared by Mr. Donovan of this city, in
doses of five to ten  drops three times a day.
   The acid mixture, cold to  the vulva, or an  enema  of cold water, will
be useful,  if  the  discharge increase.
   If our attempt thus to  arrest  miscarriage fail, we must then act accord-
ing to the  circumstances  of the case.  If there be little hemorrhage, and
the pains increase and expel the ovum, little treatment will be necessary.
   280.  If the fcetus  alone be expelled, we may wait awhile (if no flood-
ing occurs) to see if the uterine efforts will detach the secundines; if not,
perhaps we may be able to reach the lower portion of them with the finger,
and gradually withdraw  them; if this  fail, we may frequently succeed
with the ergot of rye.*
   But there are  many cases  in which  none of these plans will  succeed.
Are we then to leave the  case to nature ?  We know that after a  time the
shell of the ovum will putrefy, dissolve, and  be discharged ; but experi-
ence too  often  proves, that  this  process involves  considerable  danger:
danger of  hemorrhage first, and afterwards of uterine phlebitis.   I shall
speak of the treatment in cases of flooding, presently;  and with regard to
the danger of uterine phlebitis  from absorption  of a putrid ovum, it is
sufficiently imminent to warrant  interference, if we are called early enough.
The French recommend a pair  of long thin forceps, with which the ovum
is to be seized and  removed; but  against such  an instrument there lies
the serious objection, that we cannot be certain of not injuring the uterus,
unless we  introduce the finger also.  The late Mr. Wainwright,  of Liver-
pool, published a short paper in one of the journals, in which he recom-
mended extraction of the ovum by introducing the hand into the vagina,
and one, or at most two,  fingers into the uterus.
   That this is practicable, and  in certain cases advisable, I know by ex-
perience, having repeatedly practised it; but it must be remembered that
it is not free  from danger, and before we  have recourse to  it, we  should
be satisfied that the natural powers will not act, even under the  influence
of ergot.   Further, if done at all, it should be before the secundines have
putrefied,  or irritative fever set in.f
   * The use of the ergot of rye under these circumstances is not without inconvenience;
for although it be true that " flooding constitutes the primary danger of abortion," in-
tense pain and nervous excitement are not unfrequent attendants, and ergot never fails
to aggravate the sufferings of the patient in these respects.  Time,  rest, and opium,
are the grand remedies in abortion, for which there are no substitutes.   Where the
strength of  the patient  and condition of the circulation allow of it, bleeding, in the
early stage,  if it do not prevent abortion, will rarely fail to mitigate the violence of its
attendant circumstances. — Editor.
   | Dr. Rigby advises the mode recommended by Levret as preferable to the employ-
ment of the  fingers, viz., to throw up " a powerful stream of warm water by  means of a
syringe."  Dr. Dewees employed  a wire crotchet for  the removal of the  secundines
when they were not thrown off spontaneously, or by the use of ergot.   This  instrument 
ABORTION.—PREMATURE  LABOUR.
185
   281. Thus far I have spoken of the treatment of the simpler forms  of
abortion, let us now proceed to consider  those cases which are complicated
with flooding.   When it is  considerable, there  is little or no chance of
preventing miscarriage, and as the danger  from hemorrhage  ceases with
the expulsion of the ovum, our endeavours must be directed to moderate
the discharge, until that event takes  place.  The most  direct means  of
restraint we possess is the plug; but this must never be  used, if internal
hemorrhage may take place to such an extent as to destroy life: in other
words, not if the uterus be empty, and the patient far advanced in preg-
nancy.   If the uterus be filled with its natural contents, or be only slightly
distensible, even  though  empty, we can  restrict the amount of loss  by
filling the  vagina, and stopping  the external  outlet.   For this purpose
Dewees recommends a sponge ; but  I have found a silk handkerchief or
tow much better.  The vagina must  be filled completely, and after six or
eight hours the plug should be withdrawn, and if necessary a fresh one
introduced.*
   Cold should  be applied  to the vulva, by means  of a cloth dipped in
cold water and suddenly applied : it may be removed after the shock is
produced,  and  re-applied at intervals.   I have  also  seen great  benefit
from enemata of cold water.
" consists of a piece of steel of the thickness of a  small  quill at its handle, and gradu-
ally tapered off to its other extremity, which is bent to  a hook of small size."  In the
                                  Fig. 72.



accompanying drawing, (fig. 72,) the instrument is represented of one-third the proper
size.  Various other contrivances to effect  the same object have been proposed at dif-
ferent times;  the best, because the safest and  most  efficient, in my estimation, is  the
"placental forceps" of Dr. Henry Bond  of this city.  This instrument is well repre-
                                  Fig. 73.
sented in the accompanying drawing (fig. 73).  " It is about ten inches long, curved
laterally on a radius of about twelve inches, and the blades are about one inch and a
half longer than the handles.  The blades terminate in an oval expansion nearly half
an inch wide.   The handles and blades, including the edges of the oval expansion, are
rounded or bevelled off, so as to preclude all probability of wounding or pinching any
of the surrounding soft parts.  The inner part of the oval expansion is made concave
and rough, so as to maintain a secure grip upon the body embraced.  The curvature is
intended to be such, that when introduced with the finger as a director, in cases where
the perineum is rigid, there shall be no unnecessary or inconvenient pressure on this
part, or on the urethra.   The outside of the oval part of the blades is made slightly
convex and smooth, without a fenestra, so that in passing them through the os uteri,
and expanding them so as to embrace the placenta, there shall be the least  danger of
abrading  or lacerating that part."  (Amer. Journ. of the Med. Sci., April, 1844.) —
Editor.
  * Where, however, there is the least prospect of saving the foetus, the plug is inad-
missible ; for by preventing the blood from flowing out of the uterus, it will most pro
bably  penetrate between it and the ovum, and thus produce a greater degree of sepa
ration. —Editor.
                                     q2 
186
ABORTION.—PREMATURE LABOUR.
   Opium in small  doses is very useful, nor does it suspend  the uterine
contractions.*
   Doctors Dewees  and  Conquest  recommend  the  acetate  of lead, and
others, large doses  of dilute sulphuric  acid in  infusion  of roses;  but I
cannot say that I have obtained much success from them.
   282.  AVhen the plug is removed, we should carefully examine the os
uteri, so as to ascertain if the ovum is descending:  if we are able to reach
the lower end of it,  it is often possible by a little dexterity to hook it
down.   If it be beyond our reach, we may replace the plug, or give ergot
to excite the  uterus to action.   Borax is highly esteemed  in  Germany,
and has been recommended by  Dr.  Copland, for its influence  in exciting
uterine contraction; it may either be given alone or  combined with the
ergot.
   283.  In the majority of cases, the natural efforts or the means just re-
commended, will succeed in expelling the ovum ; but in some they fail,
and the  patient may be  reduced to  the verge of death by the flooding,
which is kept up by the  presence  of the ovum.  In such  cases a  more
direct  interference  has been  recommended.  M. Levret advises warm
water injections into the vagina and uterus ; Dr. Dewees the use of a wire
crotchet, and some  French writers (as  already mentioned) the use of a
delicate pair of forceps.f   For  my own part, I decidedly reprobate such
instruments, when the same benefits can be  obtained by  the  finger, as
recommended by Mr. Wainwright.   I  have several times  had occasion
to perform this operation in extreme cases, and I have been able to do so
with perfect success, as far as  the extraction of the ovum is concerned,
and without any  unpleasant consequences.
   But let me be quite understood by my junior readers: such an opera-
tion at an early period of gestation  is  not without  danger, and requires
delicacy, gentleness, and tact:  to have recourse to it in any but extreme
cases would  be  unpardonable  rashness; but  I should  deem it just as
wrong, to allow a patient to die of  hemorrhage, without having had re-
course to it.
   284.  The after-treatment of patients who have miscarried  requires great
care.   The popular belief is, that abortion is more dangerous than labour,

  * " In the management of cases of threatened abortion," says Dr. Lever, (Lond. Med.
Gaz., 1849,) "it is my rule, if possible, to get a thorough knowledge of the immediate
or exciting cause of the hemorrhage or pain, or both ; secondly, before using opium, to
ascertain the state of the  os uteri, and especially whether the anterior part of the neck
has lost its plumpness and firmness,  and has become soft and baggy.  If  with the dis-
charge we have a patent state of the os uteri, and  if the neck be  soft and loose,  the
exhibition of opium will do harm, by retarding the emptying of the uterus, which must
sooner or later take place. But while I do  not advocate the use of this drug under the
circumstances related, I can speak loudly in its praise after the abortion has occurred,
especially if such have  been attended with  a large loss of blood: it will then allay ex-
citement, tranquillize the circulation, and procure sleep.  These remarks, however, do
not altogether apply to  those  cases which menace from accident, or from mental causes,
or those which may be said to be due to habit.  In these, with the application of cold,
perfect quietude, and unstimulating diet, I  have known the exhibition  of opium by the
mouth, or, what I prefer,  a cold starch injection with  opium, thrown into  the bowels,
and repeated every night, or more often according to existing circumstances, followed
by the best results." — Editor.
  f Dr. Dewees, it is believed, never employed the "wire crotchet"  for the removal
of the ovum, but solely *o bring away the secundines after the rupture of the ovum, and
the escape of the foetus. —Editor. 
ABORTION.—PREMATURE LABOUR.
187
and I am not sure that it is far wrong.   No doubt exists  that women are
as liable to puerperal diseases after abortion or premature labour, as after
delivery at the full time,  and they require as careful management.
   The patient should rest in bed the usual time, and then return gradually
to her usual  occupations.  Attention should  be paid to the lochia that
they be not checked, and to the bowels.  The diet for some days should
be bland and unstimulating.
   285. The prophylactic treatment of abortion or premature labour, re^
quires in the first place, the removal or avoidance of all possible causes;
and secondly, the adoption of all means calculated to strengthen the con-
stitution.
   The  state  of the  stomach and bowels must be carefully regulated, the
diet be light and  nutritious, and  exercise  taken in the open air, but not
so as to occasion  fatigue.  If the  patient be robust, the pulse full and
quick, and some threatening symptoms present, a small bleeding may be
useful; but if she be weak and  cachectic, we must have recourse to tonics.
   If the  patient have previously miscarried,  as she approaches again the
same period, she  must  take  more rest, lying on a sofa or  bed, lightly
covered, the  greater part of the day, until the period be passed.  Rest,
more or less absolute, is  one of the most powerful prophylactic  means we
possess.
   Cold sponging, the use of  the  "bidet,"  or cold  bathing, as recom-
mended  by Mr. White of  Manchester, is highly beneficial,  provided we
guard against too great a shock.
   When the habit of miscarrying has  been acquired, one  of the  most
effective  means of breaking it, is to give the uterus a long rest, by sepa-
rating the woman and her  husband for several months. *
   * This habit is sometimes so firmly fixed  as  to be very difficult to overcome. Dr.
Huston states, in a note to a  former  edition, that he has succeeded in some very obsti-
nate cases by confining the patient to a sofa, commencing some time before  the usual
period of miscarriage and continuing several  weeks after the time had gone by — care-
fully avoiding the erect position and all  unnecessary muscular exertion, and using at
the same time injections daily of opium, in sufficient doses to prevent uterine action —
the quantity varying from two to five grains in the state of powder, suspended in muci
»age.  By these means a  condition of tolerance on the part of the uterus may be ac-
quired, which will allow gestation to go to the full period.—Editor. 
PART  III.
          PHYSIOLOGY OF THE UTERUS — PARTURITION.


                           CHAPTER I.

              CLASSIFICATION. —DEFINITIONS, ETC.

  286. We have now  arrived at  the last great function of the uterine
system—that of Parturition, with its abnormal variations.
  It consists in the expulsion  of the fcetus and its appendages  from the
cavity of the uterus, and  effects the separation of the child and the mother.
  It occurs, as we have  seen already, at the end of nine calendar months
and a week — ten lunar months—forty weeks, or 280 days, a  few  days
being allowed either way.
  287.  The magnitude  and importance of the event, and the regularity
with which it takes place, have induced physiologists of all ages to assign
causes for it, but as yet without success.
  Thus it has been supposed that  the uterine action is excited by the
struggles of the foetus for want of adequate nourishment, or from the con-
straint of its position,  or from the endeavour to breathe : by others it has
been  attributed  to  the  acrid nature  of  the  liquor amnii.  Buffon has
likened the process to the dropping of ripe fruit.   Hervey, Burdach, and
others attribute it to the uterus having obtained its maximum of irritability
at the exact  time that the fcetal development is complete.   It  would be
easy to  fill pages with similar explanations, but  these may suffice:  they
are all either more elaborate expressions of the fact, or mere hypotheses.
  288.  But though all search has hitherto failed  in discovering the ex-
citing cause  of labour, it has established the fact, that the periodicity
which we found to characterize  the other.uterine functions, prevails here
also.  #For example, abortion or  premature labour, when not the result of
external accidental causes, occurs very generally at a monthly or what,
but for conception, would have been a menstrual period.
  Again, as remarked by Stark and others, the normal period for parturi-
tion corresponds to a menstrual period ; on this principle Kluge  calculates
the duration of pregnancy in every case at 280 days, and so much  more
or less, as impregnation took place immediately  before or after  menstrua-
tion.  Speaking generally, labour  may be looked for at about the  tenth
period after the last appearance of the catamenia.
   Lastly, in extra-uterine gestation, an  attempt  at  labour occurs very
generally at the same period.
   So that taking the monthly  discharge as the the type of utero-ovarian
periodicity, we may observe that it continues, though at times less demon-
                                                         (188) 
                 CLASSIFICATION.—DEFINITIONS,. ETC.             189

strably, throughout the whole period of the functional activity of the sexual
system.
  After a most ingenious and  elaborate investigation, Dr. Tyler Smith
considers that he has proved that "ovarian excitement is the law of par-
turition in all its forms of ovi-expulsipn."  " When the ovarium is severed
from the rest of the sexual apparatus, as in the mammalia and human fe-
male, the ovarium is connected  with the rest of the parturiant canal  by a
series of reflex arcs.   By means of the spinal excitor nerves of the ovaria,
that portion of the spinal  centre which  presides over the  actions of the
uterus is, at the end of utero-gestation thrown into a state of excitability
or polarity, somewhat resembling the general spinal excitability of tetanus.
It is curious that at this time, besides the ovarian excitement of the  cata-
menial period which ushers in parturition, there is upon the surface of the
ovarium the cicatrix (corpus luteum) left by the ovarian  phenomena of
conception, but  which speedily disappears after delivery.   The uterine
nervo-motor system  being thrown  into  such a state of persistent  excita-
bility that the uterus firmly contracts equally upon its contents, the fcetus
itself, hitherto defended by the liquor amnii, becomes an ordinary excitor,
and the reflex actions of labour are gradually  established.  The equable
contraction of the uterus  preceding labour is, in effect,  just as  though
the membranes had been  punctured in the operation of inducing prema-
ture delivery, and the head of the foetus brought  to exert pressure  upon
the os and cervix uteri."
  Admitting that ovarian  excitement thus excites uterine action, I do not
think Dr. Smith  has satisfactorily explained the cause of that excitement
occurring regularly at the tenth  menstrual period rather than at any other.
  289. Classification of Parturition. — The basis of all classification
must be the definition  of natural labour, inasmuch as the other classes and
orders are but deviations from, or complications of it; but upon this defi-
nition writers are much at variance.   Some  make the  efficiency of the
expulsive force  the sole question, and include under natural  labours, all
such as are terminated  by the natural powers.   Thus Hippocrates, Smellie,
Baudelocque, Rigby, &c. &c. include face, breech, and foot presentations
in this class.   Others conceive  that the presentation ought  to  be taken
into consideration, and  therefore  Denman, Blundell, Davis,  Ashwell,
Ramsbotham, &c. &c. limit natural labours to head presentations.
  I prefer the latter arrangement,  because I deem it better that what we
take as natural labour, should present as nearly as possible a perfect  type.
Now the elements  of labour are three : —1, the expulsive force ; 2, the
child or body to be expelled; and  3, the passages through which it is to
be  expelled.   If these be equally adapted to  each  other, the natural ob-
jects of the labour will  be attained, viz. the delivery of a living  child
with safety to the mother; and  the labour  may well be termed natural.
But this result does not obtain except with head presentations, or at least
not in anything like the same proportion ; for in breech cases 1 in 3^ are
lost, and 1 in 2^ in foot  presentations, which is far more than when the
head presents.   This alone would, I conceive,  be a valid reason for limit-
ing natural labour to head presentations; not that the natural powers alone
may not terminate the  labour with other presentations, but that the average
mortality is much higher.
   Again, I think that the  preponderating frequency of head oresentations 
190             CLASSIFICATION.—DEFINITIONS, ETC.

ought to have  much weight in  determining the most  natural form  of
labour; and  I  find  that in 327,802 cases  the  head presented 321,502
times, whereas  breech presentations occur only once in 52^ and  footling
cases once in 90j cases.
  290.  For these reasons, therefore, we shall include only head presenta-
tions under the term natural labour, and this will constitute the first great
class of labours;  the second will include  deviations from it,  in conse-
quence of inequality or inefficiency in  any one of the elementary condi-
tions of parturition, such as inefficient force, defective passages, or abnor-
mal presentation; each of these will constitute a sub-division into orders.
  Besides these abnormal deviations from natural labour, there exist many
which  do not  fall  under any  natural classification,  but which  may  be
grouped together as a series of complications, without any necessary  rela-
tion  to  the  character  of the labour.   So far  then our arrangement will
stand thus:
          Class I.  Natural labour.
         Class II.  Unnatural labour.
              a.  From abnormal condition of the expulsive force.
            Order 1. Tedious  labour.
                  2. Powerless labour.
               b.  From abnormal condition of the passages.
                  3. Obstructed  labour.
                  4. Distortion of pelvis.
             -  c.  From abnormal condition of the child.
                  5. Malposition and malpresentations.
                  6. Plural births.  Monsters.
          Class III.  Complex labour.
            Order 1. Prolapse of funis.
                  2. Retention of the placenta.
                  3. Flooding.
                  4. Convulsions.
                  5. Lacerations.
                  6. Inversion of the uterus.
  This arrangement is nearly the  same as that given by Dr. Merriman in
his valuable "Synopsis of Difficult Parturition;"  and I think  it will  be
found to include all the important deviations from natural labour.   I  have
not made any distinction dependent upon the kind of assistance  required
in certain difficult labours (as, for instance, the " manual or instrumental
labours " of some authors),  but I shall interpolate a few chapters on  ope-
rative midwifery after treating of pelvic distortions; and add  a chapter
or two in conclusion, on some of the more formidable diseases of childbed.
  291.  Presentations.—We understand by the presentation, that part
which presents itself at the brim  of the pelvis.   Some writers, especially
the French,  enumerate a great  variety  of presentations, all of which, I
'hink, may be advantageously included under four heads.
     1.  Presentations of the head.
     2.       "        "   breech, including the hips and loins.
     3.       "        "   inferior extremities, including the knees and
                              feet.
     4.       "        "   superior extremities, including the shoulder,
                              elbow, and hand. 
                CLASSIFICATION.—DEFINITIONS, ETC.             191

  Others, such as the back, belly,  sides, &c, are so extremely rare, if
they occur at all at the full term, that it would be superfluous to treat of
them separately.   Their practical management would be the same as for
presentations of the shoulder or arm.
  The following table will give some notion of  their  relative frequency,
in the practice of the same individuals:
Author.	Total No. of Cases.	Head presenta-tions.	Breech presen-tations.	Inferior extre-mities.	Superior extre-mities.
Mad. La Chapelle .... Dr. Churchill.....	20,517 15,652 10,387 2,947 640 2,452 839 691 16,414 1,182 4,666 1,640	19,810 14,677 9,748 2,735 619 2,225 786 645 15,912 1,105 4,266 1,119	372 349 61 78 2 17 14 242 28 59 35	238 255 184 40 3 8 21 7 187 15 29 22	80 68 48 19 1 4 4 4 40 4 12 9
  292.  The  diagnosis of different  presentations  may be thus generally
stated.   The head  may be known  by its hardness, by the sutures and
fontanelles.
  The breech, by its softness, by the cleft between the buttocks, the anus,
os coccygis, scrotum or vulva.
  The knee, by its rounded form, by the condyles of the femur.
  The foot, by its  long form, its  being at right angles with the  leg, the
nearly equal length  of the toes, the narrow heel, &c.
  The elbow, by the olecranon process rendering the joint  sharper than
the knee.
  The hand, by its  shortness, the unequal length  of the fingers, and the
divarication of the thumb.
  293.  Positions.—The position, is the relation which  some part of the
presentation bears to a given  part  of the pelvis; thus the positions of the
head  are  determined  by the  relation of the  fontanelles to  the  foramen
ovale and sacro-iliac synchondroses;  or, in more general terms, the po-
sition may be said to be the relation of the extreme points of certain
diameters of the child, to the extreme  points of the pelvic diameters.
These we shall examine in detail  in the next chapter.
  294.  Stages  of Labour.—For the convenience  of description, it has
been the practice to divide the process of labour into so  many  parts or
stages, some making three, others four, five, or six: I shall content my-
self with three ;  the first, extending  from the commencement of labour to
the passage of the head through  the  os uteri, the second  terminated by
the birth  of the child, and  the third  occupied by the expulsion of the
placenta.
        13 
CHAPTER II.
                  MECHANISM OF PARTURITION.           W

  295. Before describing the phenomena  of natural labour,  it will be
better to investigate the mechanism by which  the expulsion of the child
is effected, and with this view we shall first examine the elementary agents
of parturition, separately, and afterwards their joint action.   These pri-
mary conditions or agents, are, 1, the expulsive force;  2, the passages;
and 3, the child.
  296. 1. The expulsive force.—The uterus is in all cases, the main
agent in  the expulsion of the fcetus, and in  some, the  sole power  em-
ployed ; as, for instance, when the death of the mother precedes the birth
of the child; or when the mother is delivered in  a state of syncope or
asphyxia, as related by Haller and Henke;  or in cases of prolapsus uteri,
as mentioned by Wimmer, Chopart, &e.
  We have heretofore seen that the uterus,  if not muscular, possesses at
least the  characters  of  muscularity, that it  is composed  of regular  and
irregular  layers of fibres ; at the time of labour these fibres contract, be-
come shorter and  thicker, and by their joint action diminish the size of
the uterine cavity.  The contractions are periodical, with distinct intervals,
and each  one is called " a pain."  They were so  named, no doubt, from
the suffering they occasion, but in obstetric  language, the term " pains"
refers to the uterine action, and not to the suffering.
  The  contractions  commence in the cervix,  according  to  Muller,
Michaelis, and Wigand, and there is reason  to believe, some time pre-
vious to  the beginning of real labour, and  without suffering, for in most
cases, at the commencement of labour, we find a slight degree of dilatation
of the os uteri, without any complaint on the part of the patient.  After
this  unconscious uterine  action has continued for a time, it is attended
with pain, and which marks the commencement of labour.  The suffering
increases  with  the increase  of the pains.  They are seated at first in the
loins, and gradually extend  round to the abdomen and down the thighs.
From their acute, stinging character, these pains, which  are limited to the
first  stage, are called " cutting  or grinding pains:" during the second
stage, ihe suffering is less acute, though not  less severe, and the uterine
contractions being aided by voluntary efforts, the pains are called " forc-
ing or bearing-down pains."  The former occasion the patient to cry out,
but the outcries are suppressed during the second  stage, from the neces-
sity of holding the breath, to fix the chest as a "point d^appui."
   The cause of the suffering is, first, the forcible  distension of the cervix,
next, the  pressure  of the fibres during contraction upon the nervous fila-
ments, and, lastly, the dilatation of the passages.
   The amount of suffering depends a good  deal upon the temperament
oi the patient, and  upon the habits of life;  among savages it appears
slight, but it is excessive in civilized life.
   297.  Each  uterine contraction has a peculiar character; slight at  first,
it  gradually increases until  it arrives at its maximum  of force, remains
                                                         (192) 
MECHANISM OF  PARTURITION.
193
stationary for a short time, and then quickly subsides: and this is charac-
teristic of the entire labour, for the pains which are slight at first, go on
increasing in  frequency and  force, until, having arrived at the maximum
degree of power, all obstacles yield before them, and delivery is accom-
plished.
  Another remarkable peculiarity is their periodicity; each pain is followed
by a distinct interval of rest and ease, diminishing as the labour advances,
but in a regular  manner.  M. Saccombe has given an exact record of the
frequency and duration of the pains, in one case, in his " Elemens de la
Science des Accouch." p. 202, which I shall  extract.   Between 10 and
11 o'clock, a.m. the patient  had seven pains, and from 11 a.m. to mid-
day  eleven pains, as follows:
				minutes		seconds
From the 1st	pain to the	2d	the interval	was 15	and its duration	21
2	<<	3	k	14	k	27
8	<«	4	«	10	<<	27
4	««	5	ii	8	<<	29
5	M	6	ii	7	u	32
6	II	7	k	6	ii	35
7	(1	8	ii	6	ii	36
8	((	9	n	6	ii	40
9	II	10	«i	6	u	42
10	II	11	u	5	i<	45
11	II	12	ii	6	ii	45
12	((	13	ii	5	ii	47
13	II	14	ii	5	ii	49
14	II	15	ii	5	ii	55
15	<l	16	ii	4	<<	V 2
16	II	17	ii	4	ii	I'M)
17	II	18	ii	4	ii	V27
18	((	19	u	4	ii	1'33
  At this period the waters escaped, and the head was  soon expelled.
M.  Saccombe remarks that " it results from this observation: — 1.  That
the interval  between the pains, is in inverse  ratio to  their duration.  2.
That the duration of each pain, is in direct ratio to its  intensity; that is to
say, in proportion as the  interval between the pains gradually diminishes,
so  does  their duration increase, and  in  proportion as their duration  in-
creases, so does their intensity."   The same conclusions equally apply to
the severer pains of the second stage.
  298.  The pains, as I have already said, commence in the cervix, and
gradually involve both the body and fundus ;  their first effect, as Wigand
has observed, being to elevate,  as it were, the presenting part, and  after-
wards to force it down.   During a pain, the uterus becomes hard, round,
and prominent, with the  fundus tilted forwards ; when the pain subsides,
it softens, but does not quite recover its former flaccidity.
  It is impossible to estimate exactly the amount of force  exerted by the
uterus ; it is always in proportion to the resistance, although the  mode in
which it is  exerted varies: in  some  cases it overcomes the obstacles by
rapid and energetic  pains, in other cases, the same end is attained Dy a
longer and slower process.
  The first  stage of  labour is completed by the uterine action alone, but
during the  second stage, it is aided by the voluntary muscles, especially
those of the abdomen, which press directly upon  the uterus, and by the
depression of the diaphragm, which diminishes the  cavity of the abdomen.
                                 R 
194                 MECHANISM  OF PARTURITION.
The additional effort made during the second stage, is owing to the in-
creased amount of resistance to be overcome.
   Towards the termination of labour, expulsive efforts are made by the
vagina, and these are still more evident in the extrusion of the placenta.
   299. Uterine action is not directly subject  to  the control of the will,
although mental emotions exert a considerable influence  upon  it.   For
instance, labour may be  brought  on  by mental excitement;  and, on the
other hand, anger, fear, surprise, &c, may suspend the pains.   Betschler
relates a case where the labour was arrested by the  fright occasioned by
a violent storm, and  many of my readers  are  familiar with  the  case re-
lated by Baudelocque, in which the pains ceased each time that the pupils
who were to witness  the  case came in sight of  the patient.  A temporary
suspension of labour on the arrival of the accoucheur (especially if sud-
den and unexpected), is a very common occurrence.
   I have spoken of the voluntary exertions made during the second  stage
of labour: these, it is true, are at first under the command  of the will,
but at a more advanced period, it  is  scarcely possible for the patient to
withhold the co-operation of these muscles.
   Dr. Tyler Smith thus sums up the motor actions of the uterus at p. 48
of his work:  " Volition may be said to affect the process only indirectly.
Emotion has a direct influence, but it is accessary rather than essential to
its performance.   Reflex action is the great physiological power, which
being absent, the function of parturition could not be properly performed.
Peristaltic or immediate action is the basis or radical element upon which
the other causes of motor action operate."
   300. 2.  The Passages.—Let me recall in a  few words  to the reader's
recollection the diameters of the pelvis:  those of the brim being — the
antero-posterior 4 to 4^ inches, the transverse b\ inches, and  the oblique
4f to 5 inches; the relative  proportion of these gradually changes in the
cavity, until at the lower outlet the transverse is 4 inches, and the antero-
posterior 5;  in other words, that which was the longer at the upper outlet,
is the shorter at the lower. From these diameters a deduction of a quarter
of an  inch  in the antero-posterior, and half an  inch in  the transverse
diameters,  must  be  made,  on account of the  soft  tissues  clothing the
pelvis.
  I also  remarked before, the  great changes in the axes of the pelvis,
which form an obtuse angle with each other, that of the brim looking up-
wards and  forward,  and that  of  the outlet downwards  and forwards.
Lastly, I pointed out, as an important mechanical  agency, the  inclined
planes of the  cavity of the pelvis, the direction of which  is  downwards
and forwards.*
  * As no correct idea of the mechanism of  labour can  be acquired unless attention is
paid to the several planes of the pelvis, and the variations produced in the direction of
these planes by changes in the position of the body, and by disease, we have taken the
liberty to introduce here  an extract from Dr. Meigs' " Obstetrics—the Science and the
Art," which, with the accompanying illustrations, places this subject in a very clear
light.
  "Plane of the Superior Strait.—The plane of the strait is an  imaginary super-
ficies, the anterior margin of which is at  the symphysis pubis, its posterior  margin at
the promontory, while the rest of its margin touches the inner lips  of the  linea ilio-
pectinea.
  " When the woman stands erect, or lies at length on the back, the plane of this strait
dip? at an angle of 50° to the axis of her body. 
MECHANISM  OF  PARTURITION.
195
   301.  Now what mechanical effects are these peculiarities calculated to
produce upon  the passage  of the fcetal  head?  1.  It is evident that as
certain diameters only of the child's  head correspond to certain others of
the  pelvis,  the  gradual change  in these must be followed  by a similar
change  in the position of the head;  because the expulsive force  presses

   " Inclination of the Plane.—It must clearly appear that the plane of the superior
strait dips at a variable angle in various positions of the trunk of the body; for if the
subject be standing, it dips  as  above at 50°, but if the trunk be inclined forwards, the
dip will be lessened; or if the trunk be inclined far backwards, it may be increased.
Now this is an important item of obstetric knowledge, since upon it is founded advice
as to the decubitus of the patient, whom we may direct to extend her trunk or to flex
it more or less, as we may desire to bring the plane of the superior  strait into a posi-
tion that may favour both the entrance of the  presenting part into the strait, and its
passage through it.
   " The  figure is  designed to show that the plane of the strait may give different angles
with  the spine, according  as  the spine is  brought more  forward, or carried farther

                                     Fig. 74.
backwards over the opening.  Thus e e e is a cirolo of which the diameter b/represents
the inclination of the plane of the upper strait, equal to an angle of 135° fa, which is
the ordinary altitude of the spinal column  or  axis of the trunk.   If the patient lying
upon her back should have her shoulders raised, so as to carry the spine forward to c,
equal to 22.30°, the angle would be reduced to 112.30°.  But if the shoulders should
be still more elevated to d, the axis of the trunk would be at right angles to the plane
of the  strait bf.
  " The same  effect as to the inclination of the plane of the strait is produced in the
patient, lying on her side, whenever she bends her head and trunk forwards: and,  in-
deed, in labours, we 6ee women  constantly  prompted by an instinctive  sen&e of the
utility of it, bending the trunk quite over the abdominal strait, to which, moreover,
the old nurses  and experienced crones urgently exhort them.  A child's head, that  in 
196
MECHANISM OF PARTURITION.
the head  forwards,  and  it can  only advance by making this  adaptation.
2. The change in the direction of the axes,  and the effect of the inclined
planes,  more especially of the curve of the sacrum, must necessarily effect
a change  in the  direction in which the  fcetal head  moves, in fact, they
alter it from that of  the axis of the brim, to that of the outlet.
one inclination of the plane should be driven against the symphysis pubis, would with
a lesser inclination of it plunge at once to the bottom of the pelvis.
  "Justus  Heinrich  Wigand, the lamented author of the celebrated  volume entitled
Die Geburt  des Menschen, was deeply impressed with the importance of a careful atten-
tion to the inclination of the  plane in labours.  He often made use of his knowledge
of it as a foundation of his prognosis.   I have copied these outline figures from the
second edition of his work, by Froriep.  They represent the female torso in profile.
Each figure has marked upon it  six lines, of which the two horizontal ones extend pa-
rallel  to each other, from the promontory  of the  sacrum and  the symphysis pubis
respectively.
  " In a well-formed pregnant female, the profile will resemble the outline figure, pro-
vided the child be not very large, nor the liquor  of the amnios excessive in quantity.
As in fig. 75,  the back bone will not be excessively curved.  A line drawn horizontally
Fig. 75.
Fig. 76.
forwards from the top of the sacrum will pass out at the navel, and equal angles will
be formed by a line drawn from the top of the sacrum to the symphysis pubis, which
indicates the inclination of the superior strait, and one drawn from the same point to
the scrobiculus cordis.  A line from the scrobiculus cordis to the symphysis pubis, will
be perpendicular to the one first mentioned.
  " Inspection of such a  figure  might well serve to establish a favourable prognosis;
since, cseteris paribus, any untoward circumstances would be very little to be expected
with so perfect a form, proportion, and arrangement of parts.
  " Figure 76 is a copy of Wigand's figure 3d, in which he proposed to represent  the
profile of a pregnant woman of apparently perfect form, but the inclination of whose
superior strait is excessive, as may be seen by observing the line drawn from the top of
the sacrum to the top of the symphysis pubis.  In such a patient the plane of the strait
looks almost backwards, and the indication of Conduct would  be to cause her to bend  her
body strongly forwards, flexing her thighs very much upon the pelvis.   Such a direction
alone might suffice to correct the excessive inclination of the plane, whereas, if she should
lie on the back with the shoulders low, and the limbs extended, the presenting part could
hardly fail to  be driven upon the top of the ossa pubis.  In this figure the back is much
more  curved than in the former one.  The horizontal line, from the base of the sacrum
to the symphysis, rises far above the navel, and the upper triangle or  that of  the scro- 
MECHANISM  OF  PARTURITION.
197
  But  in order that  this  adjustment of  position  and  alteration  of  the
diameter may be effected, two  things are necessary, first, that  the pains
should continue (with intervals), and, secondly, that the  fcetal head should
correspond  to  the  size of the  pelvis; for if it be  too small, it will want
the due resistance,  and may be driven through the pelvis irregularly, and
if it be too  large, it will not pass  at all.
bicle is much smaller than that of the pubis.  The line falling from the scrobicle to the
pubis retires, whereas in the former figure it is perpendicular.  In this figure the  per-
pendicular line from the base  of the sacrum is far in advance  of the upper dorsal
vertebrae.
  " The contemplation of these ingenious profiles of the admirable German cannot fail
to increase the tact and knowledge of the student, to whom the study of them is warmly
recommended.
  Here is Wigand's Fig. 4, in which is the profile of a woman with a pelvis  so deformed
as to imply a necessity for the operation of perforation, on account of its vitiated  con-
                                    Fig. 77.
jugate diameter.  The angle formed by the back part of the sacrum and spinal column
is much too small.  The bend is quite different from the gentle curve seen in the first
profile.  The scrobicle  projects very much  over the symphysis pubis, as by the line
uniting them may be seen.   The horizontal line from the base of the sacrum comes out
just above the navel.  The line from the scrobicle to the base of the sacrum, and that
from the sacrum to the  pubis are not equal — as in the first and more perfect figure.
The chord line from the promontory to the coccyx retires, and the whole of it is in rear
of the upper part of the spinal column.
  "Wigand's 5th figure (Fig. 78) represents a pregnant woman, the conjugate diameter
of whose superior strait does not exceed one inch or one inch and a half; and which, ac-
cording to most of the German accoucheurs, indicates a resort to the Caesarian operation.
  " The belly is quite pendulous over the pudenda.  The plane of the  strait makes a
very sharp angle with the  horizontal line which comes out high above the umbilicus.
The back is  extremely hollow, in consequence of the sinking of the  sacral promontory
down towards the pubis, and the line from the scrobiculus cordis to  the ossa pubis re-
treats strongly in a backward direction, leaving the breast to hang far over the pudenda
in front.   The curve of the sacrum is sharp, and the compensating curvature of the
upper part of the vertebral column is highly characteristic of this malformed pelvis,
and is an evil omen to the unfortunate woman.
  " Such are some of Wigand's outline figures.  I believe that the  study of them will
be very useful to the  student.  It takes many years of practice,  and a great clinical
experience and close observation  like Wigand's, to enable one to become possessed, at
a glance, of  the peculiarities of the  case.  He, however, was a Master in our art, a man
                                       r2 
198
MECHANISM OF PARTURITION.
   302.  Our estimate of the passages, however, would be incomplete, if
we did not regard the uterine cavity as  forming one extremity of them.
The long axis of the child's body is almost always in accordance with the
long axis of the uterus, but previous to labour, the latter is not in accord-
who devoted his time to its improvement, and spent the last moments of his truly mis-
sionary life in labouring to complete the beautiful volume from which I have taken his
drawings.  It is a privilege and an honour to evoke such a man from his too early grave,
in order that he, though dead, may yet speak in this distant land.
                                    Fig. 78.
  " Plane  of the Inferior Strait. — The plane of the inferior strait is usually re-
garded as bounded by the inner lips of the two tuberosities of the ischial bones, the
rami of the ischia and pubis, the ischio-sacral ligaments, and the  point of the coccyx.
In this way we speak of the plane of the inferior strait as one plane only;  whereas,
there are, in fact, two such planes, an anterior and a posterior.
  " This figure exhibits the contour of the outlet.  The line c d represents the trans-
verse diameter.  The letters eeaed show the anterior semi-circumference, while cfbfd

                                    Fig. 79.
show the posterior  semi-circumference of the outlet.   Now from e d to a is an inclined
plane, and from c d to b is another inclined plane.  These planes  intersect each other
at an angle of 140°, and they ought to be distinguished as the anterior and as  the pos-
terior inclined planes of the perineal strait.
  " In midwifery it will be found that as the child descends, in order to escape from
the womb, it first impinges upon the posterior inclined plane, which it depresses first,
and then begins to  depress the posterior edge of the anterior inclined plane.   When it
has succeeded in depressing the edges of the  two planes, it  escapes betwixt  them,
whereupon they resume their place like two valves, whose  floating margins had been
first violently separated, and then allowed to close again."—Editor. 
MECHANISM OF  PARTURITION.
199
ance with the axis of the brim, but rather more perpendicular: the uterine
contractions, however, remedy this by tilting  the  fundus uteri forwards,
and  so place the  child in the right  line of direction for  entering the
pelvis.
  303. Having said thus much of the passages generally, let us endeavour
to estimate the obstacles which the head meets in its progress: the first
of these is the cervix uteri.   The  resistance  it offers appears to  be the
effect  partly of  muscular action, and partly of its elastic cellular  tissue ;
but, as Dr. Murphy has observed, more generally of the latter than the
former, unless there be much irritation.   The  dilatation is evidently in the
first instance  purely mechanical, and effected by repeated  efforts, rather
than by great  force at one time, but afterwards the dilatation is  aided by
muscular action.   This will be rendered clear by considering the  process
more in detail.   During the last  few weeks  of gestation, the cervix be-
comes slightly softened and dilated, and the result of the first pains which
retract or elevate the child, is to press down a pouch of membranes filled
with liquor amnii (" the  bag of the waters").    This forms a firm,  equable
wedge, adapted to any size  or form  of the  os uteri,  and  which, as the
uterine fibres  of the body and fundus are stronger than those of the cer-
vix, must be  forced down  into and through  the os uteri with each  pain,
dilating it to the size of  the wedge thus formed, and continuing the pro-
cess until the  membranes give way.  So far, all is mere mechanical dila-
tation, but if a prolonged and careful examination be made,  when the
child's head is substituted for the  wedge of membranes, it will be found,
that the contractions of the fibres of the cervix which at  first narrow the
os uteri, do at length retract it over the head more and more each time,
until,  at length, the combined retraction of the os uteri and propulsion of
the head, force  it altogether through the cervix.  This is particularly as-
certainable  in certain cases, when the  anterior lip  is unusually long  in
dilating.   Besides the effective way in which this arrangement attains its
object, it has other advantages;  the os uteri is dilated by the bag of the
waters with far less pain, than by the fcetal head.
  The second obstacle is  the  bony circle of  the  brim  of the pelvis, into
which the head can only pass, by the adaptation of certain of its  diameters
to those of the pelvis,  and even then, the apposition is so exact  that it re-
quires a degree of compression, or " moulding" of the head, to facilitate
its entrance.  This is  further aided by the head being placed obliquely  in
every  way, and it  is  at length effected by repeated pains.  When this
moulding  is  completed,  and the  due position attained,  the  head  is
 gradually propelled into and through the cavity, receding somewhat after
«ach pain, and  again  advancing, in a somewhat spiral direction, until it
arrives at the  third obstacle, or  lower outlet,  closed in by ligaments,
muscles, cellular tissue,  &c. and external to these the perineum.   These
tissues resist  long, and  their dilatation is very painful;  they are  first
softened by mucous discharge, and then relaxed (how I know not), long
before there is direct pressure upon them: afterwards, they are subject  to
alternate pressure by the head and relaxation,  until being fully distended,
they yield, and the head directed forward by the curve of the sacrum, is
applied  directly to the  vaginal  orifice, and  gradually,  very gradually,
forced through it.
   With first children the mucous  membrane of the vagina is more or less 
200
MECHANISM OF  PARTURITION.
everted, and  frequently torn, without the injury extending to the peri-
neum.
  The amount of resistance varies in different subjects: it is greatest with
first children, and in women of advanced age;  it is also  greater in the
second than  in the first stage, but more rapidly overcome, owing to the
greater force  employed.   The facility with which  the head traverses the
pelvis, depends partly upon the force, and partly upon the amount  of
compression which it will bear: this is very considerable, though it is less
if the sutures be ossified.
  304. These obstacles constitute the natural  division of labour into
stages; the first terminating when the os uteri  ceases to impede the de-
scent of the head, and the second with the passage  of the child through
the lower outlet, as already mentioned.
  The length of each stage is of  course in proportion to the resistance,
and inversely to the power employed: but in natural  labours it is as about
2 or 3 to 1 (at least in first labours), i. e. if the whole labour be 12 hours,
the first stage will probably be 8 or 9 hours: but, of course, this will vary
much, and, within certain limits, without injury.
  When, however,  the entire labour is indefinitely prolonged, the relative
proportion of the two stages is  altogether destroyed, and  either may  be
many times as long as the other.   We  shall speak of this by and by.
Of the third  stage (expulsion  of the placenta) I shall treat under natural
labour.
  305. 3. The Child. — I have not much to add of the mechanical in-
fluence of the child in the process of labour, inasmuch as  it is altogether
passive.   The measurements of the child's head are as follows:

       1. The longitudinal diameter from
       2. The transverse
       3. The occipito-mental or oblique
       4. The cervico-bregmatic   .
       5. The trachelo-bregmatic  .
       6. The inter-auricular
       7. The fronto-mental

                               Fig. 80.
4	to 4| inches	
3£	" 4	a
	5	a
4	" 4£	a
3|	" 4	a
	3	it
	H	a
   Ine first of these diameters corresponds to the oblique diameter of the
brim and antero-posterior of the lower outlet; the second to the antero-
posterior diameter of the brim and transverse of the lower outlet in ordi- 
MECHANISM OF  PARTURITION.
201
nary cases ; the third to the antero-posterior diameter of the lower outlet
in face  presentations: the others to certain  diameters  of the pelvis,  to
which the head is only transitorily applied.

  The transverse diameter of the shoulders is from 4| to h\ inches.
         "         «      «   hips       "     4  " 5    "
  These diameters being at  right  angles with the long diameter of the
head, it follows that when the latter corresponds to the longer (or antero-
posterior) diameter of the outlet, they will be exactly in apposition with
the long diameter of the brim.
   306.  The diameters are pretty regular in well-developed infants, and
correspond very closely to those of the clothed pelvis.  Yet certain adapt-
ations facilitate the transit of the  child: viz. the  compressibility of the
head and body of the child, which it is  calculated will  permit it  to  be
forced through a  pelvis whose antero-posterior diameter at the brim is
only three inches.  And  further, the head enters and passes through the
pelvis obliquely both as to its longitudinal and transverse axes, i. e. one
fontanelle and the anterior part of the presentation  is lower than their op-
posites,  thus diminishing the longitudinal transverse  diameters from a
quarter to half an inch.
   This appears to be the proper place to notice some very interesting  re-
searches, published by Prof. Simpson,  of Edinburgh, in the Edin. Med.
and Surg.  Journal for Oct. 1844, on the different size of the head in male
and female children, and  the consequences which result to the mother and
child.
   He  states that  the  head of the  male at birth is larger than that of  the
female, in its circumference, by $ths of an inch, in its transverse diameter
by ^th and in the inter-aural diameter by  fths of an inch.
   Now it appears from the following table, that the proportion of males
is greater  than that  of females in some very important deviations  from
natural labour.
	Total Cases.	Males.	Females	Proportion.
	119	. 65	54	148 to 101
	28	17	11	153 " "
	88	54	34	161 " "
	34	23	11	207 " "
	44	31	13	240 " "
	24	16	8	200 " "
	74	50	24	200 " "
  From a large collection of facts bearing upon and illustrating the dif-
ferent  questions, the author has drawn the following conclusions of the
dangers consequent upon this slight excess of  size in male children.
  "1. Of the mothers that die under parturition and its immediate con-
sequences, a much greater  portion has given birth to male than female
children.
  2. Among labour presenting morbid complications and difficulties, the
child is much oftener male than  female.
  3. Among the children of the mothers that die from labour or its con 
202
MECHANISM OF  PARTURITION.
sequences, a larger proportion of those that  are  still-born are male than
female ; and on the contrary, of those that are born alive, a larger propor-
tion are female than male.
  4. Of still-born children, a larger proportion are male than female.
  5. Of the  children that die  during the  actual progress of parturition,
the  number of males is much greater than the number of females.
  6. Of those children born alive, more  males than females are seen to
suffer from the morbid states and injuries resulting from parturition.
  7. More male than female children die in the earliest periods of infancy,
and the disproportion between the mortality of the two sexes gradually
diminishes from birth onwards until some  time subsequently.
  8. Of the  children that die in utero and before the commencement of
labour,  as large a. proportion are female as male.
  9. In laborious labour with the head presenting, in proportion as the
order of labour rises in difficulty, the amount of male births in them rises
in number.
  10.  Of the morbid accidents that are  liable to happen in connexion
with the third stage  of labour, as many take place with  female as with
male births.
  11.  More dangers and deaths occur both to mothers and children in
first than in subsequent labour.
  12.  The average duration of labour is longer with male than with female
children."
  The long axis  of the child in general corresponds to the  long axis of
the uterus, though occasionally it is somewhat oblique:  this,  according to
Desormeaux, occurs once in 249 cases, according to Meckel once in 287,
and to Osiander once in 300 cases.
  307. Having now considered these elementary powers or conditions of
labour separately, we are prepared to  examine them in action;  in other
words, to ascertain the Mechanism  of Parturition.  Nothing can be
more simple, but  certainly nothing more erroneous than the views held by
the older writers  on midwifery.   They concluded that the head passed
through the pelvis, in the same position as that in which it emerges from
it, that is, with its long diameter antero-posteriorly.  The first writer who
corrected this opinion was  Sir Fielding Ould of this city, who wrote in
1742, and who stated that in the first part of its progress the face is turned
to one side or other of the  pelvis, " so  as to have the  chin  directly on one
of the shoulders."  Dr. Smellie in 1752 corrected the error of Ould with
regard to the contortion of the child's neck, but in other respects agreed
with Sir F. Ould.  Similar opinions were promulgated in 1770 by De-
leurye in France,  and subsequently by Schmitt and Mampe in Germany.
  The next step in advance was made  (without inter-communication) by
Saxtorph of Copenhagen, and  Solayres de Renhac of Montpellier, who in
1771 published two essays, which agreed in this fact, that the long diame-
ter of the head of the child in natural  labour, entered the pelvis in a di-
rection neither parallel to the  conjugate, nor to the transverse diameters
of the brim, but parallel to one of  its oblique diameters;  that is, with the
sagittal suture running in a line directed at one extremity to the sacro-iliac
synchondrosis behind, and to the foramen  ovale anteriorly.  They further
showed that of the two oblique diameters, the long axis of the head, in a
very large proportion, occupied the  right, or that running  between the 
MECHANISM OF  PARTURITION.
203
right sacro-iliac synchondrosis and left foramen ovale.   M. Baudelocque
adopted  the opinions of his master, Solayres de Renhac, as the basis of
his arrangement, and through his great influence, the doctrine of the oblique
position of the head has been generally diffused and received.
   There were, however, many points which needed revision and correc-
tion ;  and for the full demonstration of that which was true, and the cor-
rection of that which was erroneous, and the addition of many new ob-
servations, we are indebted to the labours  of the celebrated Naegele of
Heidelberg, who in 1818 published his essay on the Mechanism of Partu-
rition,  which  was translated into our language by Dr. Rigby in 1827.
The more closely his opinions have been tested by experience and careful
observation, the more clear does their correctness appear.
   Having  so high an estimate of the labours of M. Naegele, the reader
will  not be surprised at my adoption of his descriptions in the present
volume ; and  it would give me great pleasure, if on my recommendation,
all my readers would peruse his excellent essay.
   308. We have already stated (§293) that the position of the head, is
the relation which its diameters bear to those of the brim of the pelvis;
or, in other words, the situation of the extreme points of the longitudinal
diameter of the head compared with  the extreme points of the oblique
diameter of the brim.   Now the former are sufficiently well indicated by
the anterior and posterior fontanelles, and the latter by the foramen ovale,
right and left, and the sacro-iliac synchondrosis, right and left.
   Thus  then, according to Naegele, the head may present at the brim in
four positions: in the first, the posterior fontanelle corresponds to the left
foramen ovale; in the second, to the right foramen ovale ;  in the third, to
the right sacro-iliac synchondrosis; and in the fourth, to the left sacro-
iliac synchondrosis: the anterior fontanelle of course corresponding to the
opposite extreme of the oblique diameter.
   These numbers do not correspond with those affixed to the presentations
of other writers,  but in  order that  no confusion may arise, I shall extract
from the Brit,  and For. Review, a table of corresponding numerals of dif-
ferent authors.
Numbers affixed to Presentation by						Description of Presentation.
>. ■a S	•a e <w g.2J &	Baudelocque. Dubois. Gardien. Davis. Dewees.	h3		s a £j O .a i CO	• Anterior part of Cranium pointing to
1 2	1 2 3 4	1 2 4 5 3 6	1 2 3 4 5 6	1 2 4 6 3 6 7 8	3 4 6 5 7 8 1 2	Right sacro-iliac synchondrosis. Left do. do. Left foramen ovale. Right do. Promontory of sacrum. Symphysis pubis. Right os ilium. Left do.
  209.  Now let us trace the progress of the head in the different  posi-
tions. 
204
MECHANISM OF PARTURITION.
  In the first position, it is, as I have stated,  placed obliquely, corre-
sponding to the left oblique diameter of the brim, the posterior fontanelle
being towards the left foramen ovale or acetabulum, and  the anterior to-
wards the right sacro-iliac synchondrosis, the two fontanelles being at first
on a level;  consequently the sagittal suture will run nearly in the oblique
                                Fig. 81.
diameter of  the  brim, but rather nearer  to  the  sacrum than the pubis,
because the anterior half of the presentation  is almost always lower than
the posterior.   If the finger be at  this time introduced  into the  centre of
the os uteri, it will impinge upon the right tuber parietale, upon which the
tumour is formed.
   By the action  of the uterus, the  head  is forced downwards into the
cavity, preserving in  some cases  merely the obliquity it possessed at the
brim; but in most cases, it assumes an oblique position  as regards its
longitudinal axis, one fontanelle, generally the posterior, being lower than
the other;  this is more remarkable  as the head advances.  In other re-
spects, the position of the  head and the presenting part is unaltered in the
cavity, the posterior fontanelle still  corresponding to the foramen ovale,
and not, as frequently stated, to the  arch of the pubis.
   When the  head arrives  at the lower outlet, Naegele observes,  " by con-
tinued pressure of  the uterine contractions, the  posterior fontanelle  gra-
dually moves itself by  slight  degrees, repeated  at  equal intervals, in a
direction from  right to left (frequently more or  less from  above down-

                                Fig. 82.
 
MECHANISM OF  PARTURITION.
205
wards), and the occipital bone advances from the side of the pelvis under
the arch of the pubis.  It is not, however, the centre of the occiput that
advances under the pubal arch, but the head approaches the os externum
with the posterior and  superior part of the right parietal bone, and re-
mains in this position, until it has passed through the outlet of the pelvis
with the greatest  circumference which it opposes to it, when it then turns
itself with  the face  completely towards the right thigh of the mother."
That the head really passes thus obliquely through even the external parts,
may be proved by .tracing the sagittal suture, which will be found running
obliquely from left to right,  and by examining  the tumour of the scalp,
which after delivery  extends  behind and above the tuber parietale, upon
which  the  primary  tumour formed by  the  circle of the  os  uteri was
situated.
   310.  When the head is in the second position, its longitudinal diameter
corresponds to the right  oblique diameter of the pelvis, and it is placed
obliquely as in the former case, acquiring the second obliquity as it de-
scends ; and it passes through the pelvis and lower outlet precisely in the
same mode as in the first position, only that the slight rotation is from
right to left, and that when expelled, it completes the quarter-turn, bring-
ing the  neck under the arch of the pubis.
   311.  In  the third position the  anterior fontanelle corresponds to the
left acetabulum, and the posterior to the right sacro-iliac synchondrosis,
at nearly the same level, until the pressure occasions one or other (gene-

                                Fig. 83.
rally the posterior) to descend.  The sagittal suture  divides the os uteri
obliquely and unequally, and the tumour of the scalp is found upon  the
tuber parietale of the left side, and  rather anterior to it;  and the finger,
passed in the centre line, impinges upon it.
   " As soon as the head is engaged  in the cavity of the pelvis," Naegele1
observes, " the great fontanelle turns towards the descending ramus of the
left os ischium, and both can be felt at an equal height as to each other.
As soon as the head experiences  the resistance which the inferior part of
the pelvic cavity opposes to  it, or,  in  other words, the oblique surface
which is formed by the lower end of the os sacrum, by the os coccygis,
the ischiatic ligaments, &c. by which it is  compelled to move from its
position  backwards, in a direction forwards, it turns by degrees with its
                                  s 
206
MECHANISM OF PARTURITION.
great diameter into the left oblique diameter of the pelvic cavity; i. e. the
posterior fontanelle is directed to the right foramen ovale, and as the head
approaches nearer and  nearer to the inferior aperture, it is the posterior
and superior quarter of  the left parietal bone, which is  felt in the cavity
of the pelvis, opposite to the pubal arch; so that when the point of the
finger is  introduced  under and almost perpendicular to  the  symphysis
pubis, it  touches nearly the middle of the superior and  posterior quarter
of the  left parietal bone; and  this is  precisely the part, as the head ad-
vances further, which first distends the labia,  with which the head first
enters the external passage, and the spot upon which the swelling of the
integument forms itself."  Thus, the head is changed from the third po-
sition into the second, and so passes out,  the face, according to Naegele,
generally turning towards the left thigh of  the mother.

                                Fig. 84.
   312. In the fourth position the posterior fontanelle corresponds to the
left sacro-iliac synchondrosis, and  the  anterior fontanelle to the  right
foramen ovale; and as the head is pressed through the cavity of the pelvis,
changes, analogous to  those just described, take place, but in the opposite
direction, that is, the head is turned from left to right, so as to bring the
posterior fontanelle towards the left foramen ovale ; in  other words, that
as the  head is changed from the third to the second position, so from the
fourth  it changes into the first.  It then passes out, exactly as it did when
presenting in the first position.   The primary tumour will lie on the right
parietal bone, anterior to the tuber; but the pressure of the lower outlet
wTill extend it over the tuber, to the upper and back part of this bone.
   313. When the head presents in the third or fourth position, if the
pelvis be unusually large, or the fcetal head  unusually small, or even with
a pelvis and head  of ordinary proportions, if the pains come on very vio-
lently when the head is at the upper outlet, the changes into the second
and first positions may not take place, owing to the absence of sufficient
resistance or adequate time, but the head  be driven through the pelvic
cavity  and lower outlet in the position (or nearly so) in which it presented
at the brim, the upper and anterior part of the left (third position) or right
(fourth  position) parietal bone, and a portion of the superior part of the
fmntal of  the same side, corresponding to the  arch of the pubis, and the
posterior part of the right or left parietal bone, and part of the occipital, 
MECHANISM OF PARTURITION.
207
sweeping over the perineum.   As the head passes out, the forehead looks
upwards, under the arch of the  pubis.   Naegele states, " Of ninety-six
cases of the third vertex position, which I  observed with  particular care,
and described in my note-book, I remarked the head  three times to come
through the external passages with the head upwards or forwards."
   This  occasions more  suffering, and some  delay,  as the  longitudinal
diameter of the head  is  presented to the lower outlet without  adaptation
or modification.*
   314.  Until very  recently, the  passage of the  head with the forehead
under the arch  of the pubis was believed  to be the ordinary termination
of presentations in the third or fourth position;  but since  the publication
of Naegele's work has directed more careful attention  to this  point, abun-
dant proof has been obtained " that what has been considered as a regular
phenomenon, is a deviation, and exactly that which has been esteemed a
deviation from the usual course and rule, is perfectly regular."   Solayres
de Renhac and W.  I.  Schmitt  noticed the  change from the third into the

  * "The mechanical form of the pelvis," says Dr.  Meigs, "is so miraculously adapted
to the wants of the economy in labour, that it has power, in a major part  of these fourth
positions, to rotate the vertex from the right sacro-iliac junction to the right acetabulum,
and thence to the pubal arch; and that without any assistance given by the accoucheur.
  "It is true that this favourable rotation sometimes requires  the aid of the hand, or
even of an instrument.  It also occasionally happens, that neither the hand alone, nor
any instrument, can enable the surgeon to bring the vertex round to the front.   In such
case, it slides into the hollow of the sacrum, and the labour is thenceforward rendered
more painful and more  difficult.
  " When, in fourth positions, the vertex can rotate first to the acetabulum, and then
to the arch, the labour is not seriously retarded; but when the posterior  fontanelle gets
into  the hollow of the  sacrum, and will not suffer rotation, then the flexion becomes
greater and greater as the fontanelle slides down along the point of the sacrum, along

                                   Fig. 85.
the face of the coccyx, and down the mesial line of the perineum, until having pushed
off the perineum 4.10, the occipito-frontal diameter, the vertex slips over the fourchette,
and immediately turns over backwards, in strong extension, which allows the forehead,
eyes, nose, mouth and chin successively to emerge from underneath the crown of the
pubal arch, to complete the  birth of the head.  The annexed figure of a head in an
occipito-posterior position, shows these truths clearly enough.
  " This is the mechanism in all cases of birth in occipito-posterior positions, without
rotation to the front;  and the student will clearly understand that it must be so, since
the length of the line from forehead to vertex is too great to permit it to be otherwise."
Obstetrics, — the Science and the Art. —Editor.
         14 
208
MECHANISM OF  PARTURITION.
second  position; but for the minute explanation we are indebted to M.
Naegele.
   315.  As to  the comparative  frequency of the four positions: there is
no doubt of the greater predominance of the first; it occurred to Naegele
in the proportion of 69 per cent,  of all his head presentations ; to Madame
Lachapelle in 77 per cent.;  to Madame Boivin in 80 per cent., and to M.
Halmagrand in the ratio of 74 per cent.
   The fourth position is  also confessedly the least frequent, occurring to
M. Naegele in  the ratio of .03 per cent.; to Lachapelle and Halmagrand
in .04 per cent., and to Madame Boivin in  .05 per cent.
   There is a  great difference of statement, however, as to the comparative
frequency of the second and  third positions; thus Naegele, in 1290 cases,
only met with the second position in one instance, or in the proportion of
.07 per  cent.    M.  Halmagrand describes it as  occurring in 5 per cent.;
Madame Boivin in 19 per cent., and Madame Lachapelle in 21 per cent.
On the other  hand, Naegele  found 359 cases of the third position in 1210
cases, or  29  per cent., while Madame Lachapelle gives only .077 per
cent, of such cases,  and Madame  Boivin  only  .05.   Dr.  Simpson ob-
served  accurately the  position in 335 cases of cranial  presentation,  and
found the  first position in 256 cases, the second in 1, the third in 76,  and
the fourth in 2  cases.
  It is  extremely difficult to explain  these  discrepancies  satisfactorily.
M. Naegele conceives that the examination was  not made until after the
change from the third into the second position had been effected; and he
thinks that this  opinion is confirmed by the  fact  that the frequency of the
second position of authors, agrees with the  frequency with which he  has
observed the head to present in the third position.   The researches of my
friends Dr. Breen, Professor Simpson, &c. have led them to coincide with
Naegele, and correctly so in my  opinion.
   316.  Diagnosis. — The  diagnosis of the  positions  of the head  is a
matter of some difficulty, and requires  delicacy of tact and  experience ;
of course, the difficulty is greater before the os uteri is dilated.  Naegele*
has laid some  stress upon the fact, that the movements of the child^ are
felt more on one side than  the other; so that when this happens on the
right side, as is most frequent, we  may presume the head  to be  in the
first position, and when on the left side, in the second.   That this obser-
vation is correct, my experience  leads  me  to believe;  but it  affords no
means of distinguishing between the first  and  fourth, nor  between the
second and third positions.
   The stethoscope has also been called in to our  aid, and in many in-
stances  the information it affords is conclusive.   We cannot always dis-
tinguish a head from a breech presentation  by it; but  if by other means
we can ascertain that the head  presents, it is possible by this means to
detect the position earlier than by any other.  " Thus," M. Naegele, jun.
observes,  " if  in a case of vertex presentation, the pulsations of the fcetal
heart are distinctly heard in the left inferior  abdominal region, diminishing
in intensity as  the ear leaves this part, but extending  upwards and for-
wards, and continuing audible as far as the linea alba, or even beyond it,
it may be  presumed  that the head occupies the first position.  We are
warranted in  supposing that the head is situated  in the  second  position if 
MECHANISM OF  PARTURITION.
209
the heart's pulsations are most distinctly heard in the right side of the abf
domen."*
   Careful observation of the movements of the child and of the stetho-
scopic phenomena, have also led to the conclusion that in some cases the
child takes up its position at an early period, and does not change it  till
birth ;  whilst in other cases the  changes are frequent, but diminish  to-
wards the eighth month.  The fcetal heart will  always be found to corre-
spond with the motions of the child as felt by the mother.
   317.  We possess  an unfailing test  of the correctness of  our diagnosis
in the tumour of the  scalp, or " caput  succedaneum," as it has been
called.   It is formed  by the pressure of the  head against the opening
through which it has to pass, i. e. first against the  lips  of the os uteri, and
secondly against the circumference of the vaginal orifice, and it always
forms on the lowest or presenting  part, so that the  primary tumour indi-
cates the part of the head which presented at the os uteri, and the primary
and  secondary together,  that  which occupied the lower  orifice.  The
tumour itself consists most  frequently of serum, sometimes with blood
mixed, and in a few cases of blood alone.
   We have already seen, that, in  the first position, the primary tumour
occupies the right tuber parietale, and the secondary, in addition, the pos-
terior and superior arch of the parietal bone, with a part of the occipital
bone occasionally:  in the second position, it occupies the left tuber parietale
primarily, and the posterior angle secondarily:  in the third, the  primary
tumour is somewhat  anterior to the tuber parietale ; but by the change to
the second position the tuber and  posterior  part of the bone become the
seat of the secondary tumour: and in the fourth, the primary tumour is
anterior to the right tuber  parietale, but the secondary tumour  includes it
and the posterior part of the bone.
       * A Treatise on Obstetric Auscultation, translated by Dr. West, p. 71.
s2 
CHAPTER III.
           PARTURITION. —CLASS I. NATURAL LABOUR.

  318. Definition.—The term " natural labour" is applied to those cases
in which the head presents, and descends regularly into the pelvis; where
the process is uncomplicated, and concluded by the natural powers within
twenty-four hours (each stage being of due proportion), with safety to the
mother and child, and in which the placenta is expelled in due time.
  Slight  differences will be found in  the definitions  given  by different
authors;  for instance, Dr. Power limits the time to six hours ;  Dr. Cooper
to twelve; whilst Dr. Breen extends it to thirty hours.   Dr. Burns also
includes the fcetus having  arrived at the full term;  but these variations
are of comparatively little importance.   Within the litaits I have laid down
there will be found room for great diversity in the peculiar features of each
case, and experience teaches us that scarcely any two labours are exactly
alike.  First labours are in general more tedious than subsequent ones, at
least when the resistance is chiefly from  the soft parts.
  319. The following table will show the proportional  duration  of la-
bours :
Authors.	<*• o 5S g	"° to * i .Sj3	3 o JS	9 O	i 9 O	1S
	— CO SO	Ceo	ex	0O		2 o 5*
			c	a	a	<
Dr. Merriman ....	500	206	398	442	450	
Dr. Collins.....	15,850	13,012	15,084	15,346	15,586	264
Dr. Maunsel ....	839	347	647	734	793	36
Dr. Beatty.....	1182	577	958		1114	69
Dr. Churchill ....	1285	366	760		1119	166
Dr. Granville ....	640	.	515	above IS	hours	104
Drs. McClintock and Hardy	6634	3882	5280	5706	5852	269
  In addition to these specific details, I may mention that  Dr. Smellie
calculated that 990 in 1000 are natural labours: Dr. Leake 900 in 1000:
Dr. Bland found 1792 cases of natural labour in  1897 cases: Dr. Jos.
Clarke 9748 in 10,199: Dr. Merriman 2607  in 2735: Mr.  Lever 4266
in 4666 : and Professor Assalini (quoted by Merriman) out of 269 cases
reports 205 as " quick and easy."
  320.  It will be observed that I have inserted a parenthesis in the defi-
nition, to the effect that each stage should be in due proportion  to the
other (i. e. the first to the second as 2 or 3 to 1), and this  I have done to
guard against the error of making time (or the entire duration of the labour)
our sole standard, instead of symptoms;  for a labour  may be natural as
to time (i. e. completed within 24 hours), and yet if the first stage be very
short (say one  or two hours), and  the second  prolonged  (say 20 hours),
the character of the labour may be altogether changed, and the formidable
symptoms of powerless labour be  developed.
                                                        (210) 
NATURAL LABOUR.
211
  321.  Precursory Symptoms.—Before  describing the ordinary course
of labour, it is necessary to point out certain symptoms which indicate its
approach.  These vary in intensity in different women: in some they are
but slight, and may perhaps pass unnoticed;  in others they are very well
marked.  The most important are,—1, the subsidence of the abdomen:
2, frequent  micturition:  3,  griping and  tenesmus:  4,  painless uterine
contractions: and 5, mucous discharge from the vagina.   Let us examine
each of them briefly.
   322.  1. Subsidence of the abdomen.—We have heretofore seen (§ 157)
that at the commencement of the ninth month, the fundus uteri reaches
to the ensiform cartilage ; but that during the last month  it subsides: this
is especially remarkable during the last fortnight, and is sufficiently marked
to attract the attention of the patient.   The uterine tumour becomes ap-
parently less, and sinks forward.  It may probably be owing partly  to the
lower end of the uterus sipjking into the pelvis, and partly to some  relax-
ation of the uterine tissue permitting a greater amount of lateral expansion,
and a consequent diminution in its  height.   The tilting forward is owing
to  a relaxation  of the abdominal  parietes,  and increases in successive
pregnancies: sometimes, though rarely, it is so excessive as to require
the support of a bandage, and even to retard the first stage of labour by
deranging the axis of the uterus.
   323. 2. Frequent micturition.—In proportion to the enlargement of the
uterus, is the pressure  exercised by  it upon the  neighbouring viscera.
During the last  month, when it  sinks  down into the pelvis, and falls for-
ward,  the pressure upon the bladder  is considerable, and its capacity is
so much diminished ;  rendering a frequent evacuation of its  contents ne-
cessary.  In addition, there is a certain amount of sympathy between the
uterus and bladder,  and an increase of irritability in the latter, on account
of which it is less tolerant of the presence of urine than under ordinary
circumstances.  Its  value  as a  sign  of approaching labour, however, is
lessened by the fact  that it occurs  from the same causes, just before the
uterus rises out of the pelvis, and that it  may be present during several
weeks in the latter part of gestation.
   324. 3. Griping,  tenesmus or diarrhoea.—Similar mechanical and sym-
pathetic effects of advanced gestation  to  those just noticed, may be pro-
 duced in the rectum and large intestines, and the result will be an irritable
 state of the bowels,  occasional griping pains, and a desire to go to stool,
 when but little is  passed.  It must ever be remembered  that this frequent
 passing of a small quantity of fluid  feces, is quite compatible with a great
 accumulation of faecal  matter above  the seat of the irritation, and may
 often be relieved by a free evacuation. It is an uncertain sign of the ap-
 proach of labour.
   325. 4. Painless uterine contractions.—During the last  month of ges-
 tation,  and especially towards its termination, patients frequently notice a
squeezing sensation  in the  abdomen,  which lasts for a  little time, then
subsides, and is not attended with pain.  As was remarked by Leroux,
if the hand be placed upon the  abdomen, the uterus will be felt tolerablj
hard, well-defined, and tilted forwards.  This partial contraction appears
in some cases to be excited by the movements of the child.  I have never
observed it till towards  the termination of pregnancy, except in  cases of
threatened abortion or premature delivery.  Velpeau states that the  cervix
uteri may also be  felt alternately relaxed and contracted. 
212
NATURAL LABOUR.
  It appears extremely probable that by this painless mechanism, is effected
that change in the cervix and os  uteri which have been observed to take
place previous to actual labour.
  326.  5. Mucous  discharge from the  vagina.—This is called  "the
shows," by nurses: it is generally observed about twenty-four hours pre-
vious to the commencement of actual labour, and evidently prepares  the
passages for  the  transit  of the fcetus.  The  quantity and  quality  vary:
sometimes the fluid is thin, in other cases thick and viscid, (which Wigand
says is more favourable,) becoming thinner at the time of labour;  some
women have  it profusely, others scantily.   It is generally colourless until
labour has set in ; but during the dilatation of the os uteri, striee of blood
are mixed with it, arising from the rupture of some of the small vessels
of the cervix uteri.
   327.  Of these precursory symptoms, it will be remarked, that the first
and third only indicate an advanced period of gestation; the fourth,  ac-
cording to my experience, that labour is not far off;  but the  fifth is  the
only one which shows that it is close at hand.
   In addition to  these more marked symptoms, many minor ones might
be  enumerated;  such, for instance, as swelling of the labia  and lower
extremities, cramps in the thighs  and legs, the improvement of the appe-
tite and spirits, diminution  of the  dyspnoea, a sense  of greater lightness
and facility of walking, &c.; but  these being unequal and uncertain,  are
therefore of less value.
   328. Symptoms of Labour. — I shall now proceed to  the  description
of labour in  each stage; first  detailing the phenomena, and  afterwards
prescribing  the  requisite management.   Before I proceed, I should wish
to impress upon  my junior readers, the  extreme importance of  carefully
and minutely studying the subject of natural labour, not merely in books,
which  must  necessarily be imperfect, but at the bedside of the patient.
No case of labour, however simple, can  be attended without some  addi-
tion to  our knowledge, if we are vigilant: almost all recent improvements
in practice have arisen, and  I believe nearly all future ones will arise, from
a more perfect knowledge of the natural process, and a more  correct  ap-
preciation of the natural powers.
   As I have already treated of the mechanical and vital agencies employed
in effecting delivery,  I shall now  confine myself to  a practical considera-
tion of the results.
   329. The commencement of labour is dated by the patient from  the
moment that the uterine contractions become painful, and correctly so,
provided  the entire uterus  be engaged, if they recur regularly, and con-
tinue without suspension.  But this is not always the case ; the uterus  not
unfrequently at first  acts  partially,  irregularly, and inefficiently:  such
efforts  are called "false or spurious pains."   They  arise from various
causes, such as over-fatigue, indigestion,  constipation, cold, &c, and  are
occasionally  excited by the motions of the  child.  A little careful obser-
vation will enable us to distinguish them from true pains, as they  com-
mence  about the fundus, and are of limited extent, recur at  irregular
intervals, are  not attended with  the  mucous discharge from  the vagina
(§ 326), and  do not dilate the  os uteri, or protrude the  "bag of  the
waters :" on the other hand, true  pains  generally commence in the lower
part of  the uterus,  and are  first  felt in the back, extending gradually to 
NATURAL LABOUR.
213
the front, recurring with regularity though increasing in frequency, dilating
the os uteri, and protruding the membranes.
   As these false pains may occur at any period of gestation, and some-
times bring on labour prematurely, or when at the full term occasion
distress and loss of rest, it is always desirable to relieve them: this may
generally be  done by rest, if the patient have been fatigued, or by aro-
matic purgatives followed by an opiate, if the stomach  and bowels are
deranged.
   330.  The true pains recur at regular intervals, gradually increasing in
frequency and power; and each pain from its commencement augmenting
in intensity, until having arrived at its maximum, it remains stationary for
a  short time, and then subsides: thus presenting, as it were,  a type of the
entire course of the pains.
   The  pains exhibit, however, different characteristics according to the
stage of labour, and have  therefore been divided into two kinds, " cutting
or grinding pains,"  and " bearing-down or forcing  pains."  The " cut-
ting or grinding pains" are indicative of and confined to the first stage
of labour, during  the dilatation of the os uteri.  They are short, severe,
and not very  frequent, obliging the patient  to  suspend her occupation,
and partially arresting respiration ; but not inducing any voluntary efforts.
They are generally (but not always) seated in the back, gradually extend-
ing round  the loins to the abdomen and thighs.   The suffering they occa-
sion is very considerable, and although (except in some irritable subjects)
it is less than that which accompanies  the stronger pains of the second
stage, yet it appears  more difficult to bear, and the patient gives utterance
to groans and loud outcries.  The outcry which attends upon the cutting
pains, is an excellent  diagnosis mark of the first stage of labour, and in
some cases we are obliged to depend upon it alone.
   331. During the first stage we generally find  the patient more irritable
and restless  than  subsequently, moving from one place to  another, and
changing both  occupation and position frequently: she is low-spirited and
fearful, weeping from dread rather than suffering, anticipating evil, and
scarcely to be comforted.   This distressing state disappears, however,
as the  labour  advances.   In some  cases the  despondency which  has
darkened the last few  months of pregnancy, is exchanged for cheerfulness
and courage the moment labour sets in.   In general I have remarked,
that, whatever the mental condition may have been during pregnancy, and
even the first stage of labour, the violent pains, severe suffering, and hard
work of the second stage, occupy the mind as well as body,  to the exclu-
sion of desponding anticipations, and, as it were, rouse up all the patient's
energy and courage to meet the exigencies of the case.  A singular de-
viation from mental integrity, apparently from extreme suffering, has been
the subject of a valuable  essay by my friend Dr. Montgomery,—I allude
to the partial and temporary delirium which occurs occasionally, just as the
head is  passing through the os  uteri or  os externum.   It  seldom lasts
more than a few minutes, and in one  case  I attended, the patient was
conscious of talking incoherently, but felt quite unable to arrest herself.
   332.  During the  first stage of labour, and especially at  the  time the
head passes through  the os  uteri, severe  rigors occur; not from cold, as
they are observed equally when the patient is warm, but as  a prelude to
a pain.   The surface is generally of the usual temperature and free  fron. 
214
NATURAL LABOUR.
perspiration, at least till near the end of the stage.  The pulse is seldom
permanently quickened until the second stage;  although, as Hohl has re-
marked, if it be carefully examined it wTill be found to become more fre-
quent during  the first part  of a pain,  then to remain  stationary  for a
moment, and afterwards to subside.
  During this stage also, the stomach is apt to become irritable  and dis-
charge its contents, probably from sympathy with the uterus, rather than
from mechanical pressure, as the abdominal muscles are as  yet  inactive.
This is always beneficial, as it not only removes indigestible matters which
may be in the stomach, but certainly relaxes the cervix uteri.
  333. If the hand be placed upon the abdomen when the pains  come
on, the uterine  tumour will be  observed to contract, become hard, and
tilt  itself  forward, so  as ultimately to  bring the axis of its cavity into
complete  accordance with that of the brim ; and after  remaining in this
state for a longer or ishorter time it relaxes, but does  not quite return to
its  pristine flaccidity.
  The results of auscultation are very  interesting:  M. Hohl in his work
" Die geburtshulfliche exploration," pt. i. § 105, thus  describes them:
" If we direct our attention to the changes of tone which the uterine pul-
sations present, wre shall find them generally stronger, more  distinct, and
varied in  tone during labour, and this is especially the case just  before a
pain comes on.  Even if the patient wished  to  conceal her  pains, this
phenomenon,  and  more especially the rapidity of the beats, would enable
us to ascertain the truth.  The moment a  pain begins,  and even before
the patient herself is aware of it, we hear a sudden short rushing sound,
which appears to proceed from the liquor amnii, and  to be partly produced
by the movements of the child which seems to anticipate the coming on
of the contraction ;  nearly at the  same moment all the tones  of the arterial
pulsations become  stronger; other tones, which have not been heard be-
fore, and  which are of a piping resonant character, now  become  audible,
and seem to vibrate through the stethoscope, like the sound of  a string
which has been struck and drawn tighter while in the  act of vibrating.
The whole tone of the uterine  circulation rises in point of pitch.  Shortly
after this, viz., as the pain becomes stronger and more general, the uterine
sound  seems, as it were, to become more and more distant;  until, at
length, it  becomes very dull or altogether inaudible.   But as soon as the
pain has reached its  height and gradually  declines, the sound  is again
heard as full as at the beginning of the pain, and resumes its former tone,
which in the intervals between the pains, is as  it was during pregnancy,
but somewhat louder."—(Rigby.)
  334. An internal or vaginal examination reveals to us the condition of
the  passages, the state of the os uteri, and  the rate of progress.  At an
early period, the vagina will be found cool, moist or dry, and  undilated,
of nearly  the calibre  it was before labour commenced; as it advances,
however, even during the first stage, the entire canal becomes more flaccid,
and if  not dilated, at least relaxed and  dilatable.   The os uteri is high
up, but not always  in  the same  situation;  in first labours it is nearer to
the  promontory of the sacrum than the  symphysis  pubis, in subsequent
confinements this is often reversed.   The lips of the orifice are sometimes
soft and thick, in other cases hard and thin;  the former dilate more readily,
and the latter generally become  softer and thicker before dilatation takes 
NATURAL LABOUR.
215
place.   At the commencement of labour the orifice will readily admit the
point of the forefinger, and by the repeated pains it is gradually widened
so as to allow the child to pass.  -The rate of dilatation is  slowest at the
beginning;  it is  said, and  I believe truly, to take  as much or more time
to dilate the os uteri to the size of half-a-crown, than to complete the pro-
cess ; and for a very evident reason, viz., the want of a mechanical dilat-
ing force (§ 302); the bag of the waters not being protruded until some
progress has been made.
   If the finger be  maintained in the orifice during a pain, we feel the
circle tighten and become hard, until  the head presses  upon the cervix ;
after which time the lips are retracted  by each contraction.  We ascertain
the progress of the labour, by carefully estimating the  advance made by
each pain.
   335. Towards the end of the  first  stage, or at the  time when the os
uteri is  pretty well  dilated, we remark  an  increase of the sanguineous
striae in the vaginal discharge and  the accession of voluntary efforts;
slight at first, but gradually increasing.  About this time  generally, the
membranes give  way, the liquor amnii escapes, and by the next pain the
head passes through the os uteri and enters upon the second stage.
   The phenomena are now somewhat  changed, especially in  their intensity.
The pains  are  more frequent and longer, the  intervals  shorter, and the
suffering greater in general; but owing to the necessity of fixing the chest
as a fulcrum for muscular exertion, the breath is suspended  during a pain,
and the  outcry suppressed except at its termination.  The character of
the outcry is therefore as good a test of the  second stage as  of the first.
At the accession  of each pain the patient holds her breath, and seizing
hold of something with her hands, brings the muscles of the extremities,
of the back, and abdomen, to aid the  expulsive  efforts  of the uterus.
These  are the " bearing-down pains"  of the second stage.
   It is not easy to explain  the change in the character of  the pains, nor
why straining should occur only in the second stage.   Wigand attributes
it to sympathy between the os uteri  and vagina, and between the abdo-
minal and  other  muscles.   It certainly cannot  be merely owing to the
presence of the fcetal head  in the vagina.
   Further, the arrest of the circulation from the suspension  of respiration,
distends the cutaneous vessels, the surface becomes florid, the face almost
purple, the veins  of the forehead, temples, and neck are distended, and
the  eyes are bright  and  prominent; the heat  of the  skin  is  greatly
increased,  and a profuse perspiration ensues.   The  pulse, which was
quiet during the  first stage, or at most quickened during a pain, is now
increased in frequency during an interval, and  the changes noticed  by
Hohl are very remarkable  during the pains; i. e. it becomes more  fre-
quent at the setting in of each pain, until it attains its maximum rapidity,
at which it  remains for a short time  stationary, and then  subsides.   At
the termination of the second stage, it will generally be found to range
between ninety and one hundred and  twenty beats in a minute.
  336.  Vomiting also frequently occurs ; but in the second stage it is as
much the result of pressure as of sympathetic irritation,  and  it is generally
favourable, as it seems to relax the soft parts.  However, as it is a symp-
tom  developed also in unfavourable cases, it may be well to observe, that
it may reasonably excite uneasiness when it comes on (during this stage) 
216
NATURAL  LABOUR.
after the sudden cessation of uterine  action;  when symptoms  of fever,
such as rapid pulse, furred tongue, heat of skin, &c, are present; when
it is accompanied by abdominal tenderness; and especially if the fluid be
sanguineous or dark-coloured.
  If the  second stage be prolonged, the patient often feels heavy  and
sleepy, and may doze between the pains,—the result of the fatigue, com-
bined with the congestion about  the face and head.  Under ordinary
circumstances this need excite no uneasiness, as the  patient  is  refreshed
by it;  but  if it be excessive  and  accompanied with headach, especially
in primipara, we must be watchful, and on our guard  against an  attack
of convulsions.
  As the head advances through the pelvis, it presses more  or less upon
the  nerves which pass through that  cavity to the lower extremities,  and
gives rise  to  spasms  and cramps, which add to  the suffering of  the
patient.  They may be partially relieved by friction.
  The pressure of the  head also  evacuates the  contents of the rectum,
but effectually prevents the emptying of the bladder.
  337. If an internal examination be made at the beginning of the second
stage,  wTe shall find the vagina dilatable, and  as  though it had been
dilated, its walls rugous and flabby, and prepared to yield to the pressure
of the  head.   The head itself will be perceived at the upper part of the
pelvis, filling it more or less completely, descending with each pain,  and
receding  at its conclusion ; the advance exceeding the recession, and the
excess marking the rate of progress of the labour.  At a later period,  the
head will be  felt on  the floor of the pelvis, where  it meets with consi-
derable resistance, but which is  overcome by the  mechanism already
described (§ 302); we observe the same repeated advance and recession,
the head  each time propelled  a little further than before, and often with a
kind of spiral movement, until after a time proportioned to the difference
between  the  force employed and the resistance, the obstacles yield,  and
the head  presses upon  the perineum, which undergoes the same process
of dilatation.
  338. At  this period of the labour, when the head  is distending  the
perineum and  dilating  the external orifice, both the  suffering  and  the
exertion  reach their  maximum point;  and yet it is beautiful  to observe
how cautiously (so to  speak)  and how securely the  process is effected.
Adequate expulsive force is called  into action; and if it were continuous,
nothing could save the patient from  injury; but each pain is just long
enough to gain upon the advance made by its predecessor; and the head
detained  for a few moments at its furthest point of advance, then recedes;
and this is repeated until the perineum is completely softened, and the os
externum dilated.  Nor is this all; the resistance offered by the  perineum
carries the  head forward, so that its lowest point (the tumour) shall press
against the os, and by the time  the perineum yields, the  orifice is suffi-
ciently wide to secure the proper direction of the head in its transit.
  At the latter part of the second stage, the pains are often what is called
" double ;" i. e. they succeed each other so quickly, that a new one com-
mences before the former has quite terminated.   At length the force con-
quers all  resistance, and with  a throe of agony the head is expelled; aftei
which  there is a short  rest, equal to two or three pains, then the  uterine
power  is  again exerted to  expel the body of the child. 
NATURAL  LABOUR.
217
  The second stage is now completed ;  the suffering, which was intense,
is exchanged for perfect ease, and the sense of relief is inexpressibly
great.   If the hand be placed  on the  abdomen, it will be found flabby,
and the uterus large,  and moderately contracted.

                                Fig. 86.
   339.  The third stage of labour includes the detachment and expulsion
of the placenta.   In some  cases, the contractions which  expel the child,
expel the after-birth.  In  most cases, however, it is partially or wholly
detached, remaining in the uterus or vagina, from whence it may be ex-
pelled by the natural powers alone, or aided by gentle traction.
   The interval which elapses after the expulsion of the child, before the
uterus again actively contracts  to expel the placenta, varies  somewhat in
different cases, apparently according to the fatigue that organ has under-
gone.   Dr.  Clarke found the  average interval to be  twenty minutes.
Out of 277 cases which I have  accurately noted in my own  private prac-
tice, I find that  in 176 the placenta was expelled  in (within) 5 minutes;
in 60 cases, within  10 minutes; in 14, within 15 minutes; in 11,  within
20 minutes ;  and in 16, within half an hour.
   Where due attention  has not been paid, the interval will be longer;
but from the  above data we may  conclude with the highest authorities,
that in natural labour, the  placenta ought to be expelled within an hour
or an hour and a half,  and that when  the interval  exceeds this, the  case
fairly comes under the order  of  " retained  placenta," of which  I shall
treat hereafter.
   When  this  interval, whatever it be, has elapsed, the uterus again con
tracts, but much less forcibly,  and by one  or two pains, the connection
between the placenta and uterus is severed, the now useless appendage is
extruded into the vagina, and by the contraction of this canal is expelled,
with a  gush of  blood  or clots  (dolores  cruenti).   The bag  of the mem-
branes  is generally turned inside out,  especially  if the  after-birth have
                                  T 
218
NATURAL LABOUR.
been extracted by pulling the cord, and the situation of the perforation in
the membrane through which the child passed, will enable us to estimate
the distance of the placenta from the os uteri; the distance of the perfo-
ration  from the  placenta being exactly the same as the distance of the
latter from the os uteri.
   340.  Management of natural labour. — Let us now turn from the
description of the phenomena of natural labour to a consideration of the
duties  of the attending accoucheur, and the mode of managing  such
cases.   I have already stated that  most of the modern improvements in
midwifery have resulted from a more  correct  appreciation of the natural
powers ; so in the management  of natural labour, the great improvement
has been the  absence of interference.   There is, in truth, but very  little
for the accoucheur to do, if the case be  natural and  the  circumstances
favourable, and very little that he needs, except patience and gentleness,
and therefore the old  practice of carrying certain instruments and certain
medicines about with him, is  strongly to be deprecated, as, to say the
least, a  needless exposure  of himself  to temptation.   All  the surgical
appliances needed are, an elastic-gum catheter (male)  and a  lancet; and
if in the country, a small quantity of laudanum.  He  ought also to be
provided with a  few  strong pins, and some  ligatures of twine  or tape;
and if there be a prospect of  much  delay, he will not be the worse  of a
book in his pocket, provided that it be not a treatise on midwifery!  But
to return : although there is little to do in a natural labour, we cannot of
course assume that any case to which we may be called is of this class,
without inquiry;  our  first object, then, when summoned to a  patient  is to
ascertain  her present  state, whether she be in labour or not,  &c.; if she
be, the presentation and position of the child, the rate of progress and
probable termination of the labour.
   341.  As to the present state of the patient, a careful examination of the
bodily functions generally, and of the pulse, tongue, skin, &c. will show
whether the patient is in ordinary health, or whether we may have to  con-
tend with any complication, as fever or organic disease; and the informa-
tion may enable us to anticipate, and  perhaps prevent  some  attacks.  A
more minute investigation must be instituted into the state  of the uterine
system,  as to the presence of real pains; their frequency, force, and regu-
larity ; the character  of the outcry, the amount of voluntary effort, the
quantity  and quality of vaginal discharge, &c.   By these symptoms, we
shall be able to form an opinion as to the existence of labour, the stage
and rate of progress,  and the preparedness of the passages, &c. and also
as to the propriety of seeking for more special information, by means of a
vaginal examination.  This will add to the information previously acquired,
a knowledge of the presentation and position.
   342.  It is not possible to fix a definite time for this examination; for in
many cases, it will depend upon the patient.   It may, however, be stated
generally, that it is satisfactory to make it as early as convenient, and that
certainly no time should  be lost after the escape of the waters, lest we
miss the best opportunity for rectifying  a mal-presentation.    Further, the
attendant should never leave his patient for more than a few minutes, un-
less he  has ascertained that all is right.   The frequency with which it
should be repeated must depend chiefly upon the rate of progress.   Dur-
ing the  first  stage (judging by the  outcry and cool skin) it is scarcely 
NATURAL  LABOUR.
219
necessary, if once we have ascertained that all is right; but during the
second stage, it may be repeated according to the rapidity of the advance,
every four, six, eight, or ten pains; and when once the head distends the
perineum, the accoucheur should keep his  finger upon the head during
each pain, so as to regulate the support necessary for the  perineum.  To
the junior student only, can any directions as to the mode of making an
examination be necessary, and  they may be  brief.  The patient should
lie upon her left side, with the hips  near to the edge of the bed, and the
knees drawn up towards the abdomen.  The forefinger of the right hand

                               Fig. 87.
(or two fingers, and in some cases, those of the  left hand) having been
well oiled or soaped, should be passed along the  perineum, and into the
vaginal orifice; it is then to be directed upwards and backwards, towards
the promontory of the sacrum, until the os uteri or the presenting part be
found.  Having done this, we shall be able to estimate the calibre, heat,
and  moisture of the vagina, the dilatability of the os uteri, the resiliency
and general condition of the cervix, as well as the  actual dilatation by the
bag  of the waters, or the fcetal head, during a pain.   If the membranes
be entire an experienced finger will in most cases detect the presentation ;
if they have given way, this will be much more easy and certain;  and if
it be the  head, by finding the fontanelles and comparing their situation
with certain parts of the pelvis (§ 307) the position may be determined.
   It is generally recommended to introduce the finger during a pain, as
less unpleasant to the patient; hut the examination must occupy both a
pain and an interval, if we hope to obtain full information.   A compari-
son of the knowledge thus obtained, with the frequency and force of the
pains, will enable us to estimate the rate of progress of the labour; and
these results, combined with the local and general condition of the patient,
will afford adequate grounds for our prognosis.  In conclusion, I would
earnestly recommend  to my  junior readers to take every opportunity of 
220
NATURAL LABOUR.
passing the catheter and making vaginal examinations in the dead subject
as well as the living.
   343. We will  now suppose  that the conclusion from these investiga-
tions is favourable, that the  patient is in good health, is really in labour,
that the head presents, and that she is making a sufficiently rapid progress,
with every prospect of a safe termination.
   It is not necessary, during the first stage, that the  accoucheur should
stay in the room with the patient, nor even in the house, if the progress
be slow;  before leaving her, however, he must be certain that all is right,
that everything is in readiness; and he must give some general directions
to the nurse.  The patient is better out of bed during the early part of the
labour, if it happen in the day-time, as she will be less fatigued, and pro-
bably less impatient than if she  lay in bed the wrhole time; she may rest
on the sofa when tired, and occasionally walk about, or pursue any slight
occupation if she be able.
   It is very desirable to keep her tranquil and cheerful, for which purpose
she should be told of all  that is  favourable  in her case, and  all subjects
calculated to depress should be avoided.  In this matter much depends
on the nurse, who should  receive proper cautions.  I am satisfied that in
most, if not in all cases, it is better to deal frankly with our patient, and
not to  make false promises in hopes of encouraging her to bear the pains.
Let her be told that all is favourable, and that, as  far as we can judge, the
labour will terminate safely for herself and her child, and she will bear to
be told, that she has yet some time to suffer.   Moreover, as it is impossi-
ble to calculate with accuracy upon the duration of a labour, an assurance
that it  will be over in a certain time will, in all probability, issue in disap-
pointment ;  and if so, in distrust either of our truth or skill.   I have dwelt
upon this the more, because nothing is more  common than for the patient
to beg of the  attendant to say how long she will have to  endure the
pains.
   During this  first stage  the patient  may be allowed her usual diet, but
without stimulants, as it is rather advantageous to have the stomach  occu-
pied.   The  bowels should be freed by medicine or enemata, if necessary,
and the urine regularly evacuated ; and it may be as well to put my junior
readers on their guard against a frequent error of nurses, in confounding
the dribbling of the liquor amnii, after the rupture of the membranes, with
" passing water."  I  need not say that this may  take place, and yet the
patient suffer from retention of urine.
   344. The patient should  be  cautioned  against making any voluntary
effort during the first stage ;  at least,  until obliged by the increasing vio-
lence of the pains, as no effort can at this time hasten the labour. " Wo-
men," says  Dr. Denman,  " may be assured  that the best  state  of mind
they can be in at the time of labour, is that of submission to the necessi-
ties of their situation;  that those who are the most patient  actually suffer
the least; that if they are resigned to their pains,  it is impossible for them
to do wrong, and that attention is far more frequently required to prevent
hurry than to forward a labour."
   Neither is it necessary, as was  formerly taught, for the  accoucheur to
endeavour to hasten the labour by manual dilatation  of,the  os  uteri or
passages; such an " abominable custom," as Denman justly calls it, would
rather have the effect of retarding the labour by the irritation it would oc- 
NATURAL LABOUR.
221
casion, and might, as  in  a case I recently witnessed, give  rise to inflam-
mation, and sloughing afterwards.
  345.  Among the matters which should be in readiness, are two or three
short pieces of tape or twine, for tying the navel string, a pair of scissors,
some strong pins, and a binder.   The latter should be made of a double
of diaper, nearly half a yard wide, and long enough to go round the hips,
and to allow for pinning  over.  These things ought to be provided by the
nurse ; but as labour sometimes occurs  unexpectedly, or the  nurse  may
be forgetful, it is well for the attendant to have a  supply of twine  and
pins, with a pair of scissors, in his pocket-case.   Towards  the end of the
first stage, it is customary for the nurse to " make  the bed," which is
done by placing a skin of leather,  or a  square of oiled silk over the  mat-
trass, to  protect it, at  that part of the bed which will be occupied by the
patient's hips; over this is placed the under-blanket and sheet, and upon
these, two or three sheets folded  square, on which the  patient is to be
placed.   These folded sheets will absorb most of the discharges, and can
afterwards  be  removed without  disturbing the  patient, leaving dry bed-
linen underneath.  The  skin or  oiled silk is allowed to remain  for some
time longer.
   346.  Soon after the second stage of labour has set in, the patient (es-
pecially if she have borne children before) should undress,  and go to bed.
The position for delivery has varied in different times, and still varies in
different countries.  In the earliest times the sitting posture  was preferred ;
and in Ambrose Pare, Deventer, and other old writers, we have a de-
scription  and plates of labour-chairs,  one of which the  late  Professoi
Hamilton used to exhibit to his class.  In China and Cornwall the patient
is delivered upon her  knees, or leaning over something.   In France and
some parts of  Germany, the woman  is placed  upon her  back, with the
knees drawn up ;  but serious objections exist to either of these plans; by
far the best and most  natural position is the one now adopted almost uni-
versally in Great Britain and in many parts of the Continent;  viz., on the
left side, the hips being close to the edge of the bed, and  the knees drawn
up  towards the abdomen.  It is usual to place a pillow between the knees
to keep them separate, but I cannot say that I think it is of any service.
The patient's night-dress  should  be drawn up underneath her, beyond the
hips, to escape soiling; and she may be allowed to grasp a sheet fastened
to the bed-post, or, what  is much better, the hand of an attendant.
   But although I  have advised that the  patient should lie down soon after
the commencement of the second stage, it is not necessary that she should
remain in the one  position the whole time, provided that  it be assumed
before the head presses upon the perineum.*
   347.  In most cases the liquor amnii escapes about the  beginning of the
second stage, but occasionally, when the membranes are unusually tough,

  * The position upon the left side, with the knees drawn up, is that almost universally
directed by American accoucheurs, and it is certainly the one which  is the most con-
venient to the practitioner, and productive of the least possible exposure of the female's
person. It is only, however, when the labour is proceeding rapidly that it is necessary
for the female to retain, uninterruptedly, the position described.  Change of position,
or even rising from the bed and sitting in an easy chair, in cases where the labour is
proceeding slowly, will conduce to the comfort of the patient, while, at the  same time,
it will often prevent injurious  consequences from the heat, pressure, and constraint re-
sulting from long continuance  in one position. — Editob.
                                  t2 
222
NATURAL  LABOUR.
they remain entire until the head has cleared the os uteri, or even, but
more rarely, until it is passing through the os externum.   When we are
quite satisfied that the head has passed through the os uteri, we may rup-
ture the membranes, by pressing the finger against them during a pain, as
their integrity is an impediment to the advance of the child after this time ;
but it should not be done hastily, nor until we are certain  that their use-
fulness is at an end.  When the patient becomes hot, the bed-clothes
should be lightened, and the room at all times be kept pleasantly cool and
fresh.  Food cannot be taken  at an  advanced period of the  labour, but
warm drink, such as whey, gruel, or tea may be allowed.
  348. When the head is  on the floor of the pelvis, the accoucheur should
take his place by the bed-side, and  examine gently during each pain for
the purpose of deciding when it  is  necessary to  support  the perineum.
The object in supporting  the perineum is twofold; first, to afford a mo-
derate  counterpoise  externally to the  pressure exerted from within, so  as
to prevent the  structures yielding under sudden  or severe pains; and
secondly, to prolong (as it were) the curve of the sacrum, and so make
certain of the head  being  carried forward to the orifice of the  vagina, in-
stead of being forced through the  perineum for want of such impulse
anteriorly.   Now to fulfil these two objects, it is clear that we need not
interfere at all until  the perineum is  fully distended and protruding; but
when we find this to be the case, then we should cover the left hand with
a soft napkin, and apply it along or across the perineum, commencing  at
the coccyx, and reaching to the anterior edge.   The  amount of pressure
needed is  but little, no attempt must be made to retard the progress of
the head; but whilst the perineum near  the  coccyx is  firmly  supported,
the more anterior portion  should be left free to yield  before the pressure
of the  head.  Neither is the skin to  be  retracted when the head presses
through the orifice,  but rather carried forward, so  as to lessen  the chance
of laceration.
  Either hand may  of course be used ;  I prefer the left, because it leaves
the right at liberty to examine, and to receive the head of the  child.
  Let  me repeat, that to make our assistance useful and not injurious the
support should be moderate, equable, and rather firmer near the coccyx
(but yielding as that bone  yields),  than towards the anterior edge ; that it
need not be afforded until the perineum protrudes; that then it should be
afforded during each pain, and until the pain has entirely ceased. I really
believe that it would be better not to touch the perineum than to make
injudicious pressure;  it has been my lot to witness  more than one case
where rupture was owing  to excessive and injudicious support.
  349. As the head passes through the vaginal  orifice, the accoucheur
should receive it into his right hand, allowing  it to make the  usual rota-
tion, and carrying it forwards as the pains expel  the shoulders and  body
of the child.  The left hand must be employed in supporting the perineum
as the shoulders press forward.   When  the head is expelled, the nurse
should be directed  to make gentle steady pressure upon  the uterus, and
to follow it down, keeping her hand firmly upon it until the binder is ap-
plied ;  by so doing, we  shall rarely  have any trouble  or delay with the
after-birth.
  When the child is born, its mouth should be examined, and any mucas
that may have accumulated in it removed. 
NATURAL LABOUR.
223
   It not unfrequently happens (§ 181) that the funis is coiled around the
child's neck, and fears have been expressed of its retarding the expulsion of
the body, or causing the rupture of the cord, or the inversion of the uterus.
These fears I believe to be unfounded, for extensive researches show that
the funis is never twisted round the neck, unless it be beyond the ordinary
lei:jth, and yet the ordinary length is sufficient to  permit the birth of the
child, after deducting  the  amount  lost in the coiling.   A very few cases
are on record of cords so short (six or eight inches)  as to require division,
before the child could be delivered;  but in ordinary cases, if we find on
examination with the finger when the head has escaped  that  the cord is
twisted round the neck, all we need do is to draw down more of the cord,
and either slip the loop over the head or shoulders.   If we cannot do this,
we must loosen the  cord as much as we can, so as to prevent the strangu-
lation of  its vessels, and then wait for the uterus to expel the child.
   350. There is generally a short interval after the head  is born before
the  pain  expels the body, and it occasionally, though seldom, happens,
that this  interval is prolonged  to the  manifest risk  of the  child, which
becomes  livid and  swollen, making vain efforts to breathe.   If it be  al-
lowed to  remain thus,  it will die of apoplexy; but,  on the  other hand, if
we extract it hastily  without uterine action, there is danger of hemorrhage.
Under these circumstances, we  have  the  choice of  two  evils, and must
choose the least; the nurse should be directed to use  friction over the
uterus, and if this fail in exciting it to action, she must  make firm pressure
on the uterus, whilst the accoucheur takes  hold of the child's  head, and §?
inserts a finger into the axilla, and gently extracts the body.   The hemor-
rhage may be prevented by pressure, but nothing can save the child  but
removal.   I have repeatedly acted thus, and without  any ill consequences.
   351. If the child  be healthy, and have not suffered  from pressure, &c.
it wTill cry as soon as it is born, and when respiration  is established, it may
be separated from the mother, rolled in flannel, and removed.   This hav-
ing been done, the hand should  be placed upon the abdomen to ascertain
(from the size of the uterus) whether there  be  twins; if not,  we may pro-
ceed to apply the binder, which  should embrace the hips inferiorly and the
whole abdomen.   It should be pinned firmly, but not too tight, and  be
kept on during the wThole time the patient is in bed.   I do not know that
we consider the binder absolutely necessary.   Dr. Davis states that he has
not used  one for fifteen or twenty years, except in  cases of flooding; it
is, however, very useful at first in maintaining a certain degree of contrac-
tion of the uterus, and giving support to the abdomen, and afterwards in
promoting a return to the natural condition of the uterine and abdominal
parietes;  for which reason I  think it deserving of rather more attention
than is usually paid paid to it, at least after the first day  or two.  I believe
that  if it be duly applied during the time the  patient keeps  her bed, she
will  avoid that loose state of the integuments  which gives rise to what is
called " pendulous belly."
   352.  When the binder is  applied, the  patient may be allowed to rest
awhile, if there be  no flooding; after which, when  the uterus  contracts,
gentle traction should be made  by the funis, to  ascertain if the placenta be
detached ;  if so, and especially  if it be in the  vagina, it may be removed
by continuing the traction steadily in  the axis  of the upper outlet at first,
at the same time making pressure upon  the  uterus;  if  the cord do not
           15 
224
NATURAL  LABOUR.
yield, the after-birth is not detached as yet, and no force must be used. A
little patience, with occasional friction to  the uterus, will be all  that is
necessary.
  After the placenta has  been expelled or withdrawn, the binder may be
tightened if necessary, and a warm napkin applied to the external parts.
The soiled sheets underneath the patient may be removed, and the night-
dress drawn down; but  no  further change should be  made for two or
three hours, as it is most  important for the patient to avoid all exertion at
this time.   In some places and with some practitioners, it is customary to
give stimulants on the completion of labour;  but it is quite  unnecessary
in ordinary cases, and may do mischief.  Rest and quiet are the best and
only necessary restoratives.   A still stronger objection exists  in my mind
against the practice of giving a dose of laudanum, unless specially called
for, as it may suspend the uterine action, and give rise to hemorrhage.
We may depend upon it that nature is fully equal to the emergency, and
that the less we interfere the better for our patient;  in the words of an
eminent writer, " Meddlesome midwifery is bad."
  Although our duties are now ended as far as the mother is concerned,
we  should allow an hour to elapse  before leaving the  house, and before
we  go, we should carefully examine the surface, pulse, uterine  tumour,
&c. and ascertain from the nurse the amount of discharge, so that we may
be satisfied that all is right, or if wrong, that we may remedy it promptly.
We ought also to visit the patient after six  or eight hours  to  see that the
progress of the convalescence (to be presently  described) is favourable.
  353.  Now let us return to the child ;  after  waiting until respiration is
fully established, or until the pulsation in the cord ceases, a ligature is to
be placed upon the funis about two inches  from the navel, and a second
a few inches  further on;  and the cord divided between the  two by die
scissors.   Some fqreign writers object to the ligature as unnecessary, and
the  case of animals has been brought forward as a proof; but  Dr. Hunter
has shown that this mode of dividing the funis prevents hemorrhage by
the  " torsion" exerted upon  the vessels, and  most practitioners of any
standing, must have met  with cases where hemorrhage occurred  in  spite
of a ligature; so that in  these countries the propriety of the practice is
generally admitted.  The second ligature is added to prevent  mischief,
if there should be  a  second child with a vascular  communication (as
sometimes happens) between the two placentae.   Dr.  Dewees objects to
this, on the ground that the loss of blood hastens the extrusion of the pla-
centa.   The end of the funis should always be examined before the child
is dressed, and if any oozing have  occurred, an additional ligature must
be applied nearer to the umbilicus.   This fragment of the funis gradually
dries up, withers, and falls off on the  fifth or sixth day generally, though
the  time may vary from the second to the fifteenth day.
  354.  Thus far I have  described the ordinary management  of ordinary
cases both  as regards mother and child; but  there are not unfrequently
slight deviations from this simple  course, and some of them, as regards
the  child, must now be  noticed.   For instance, when born it may be in
a state of defective vitality, asphyxia, or apoplexy.
  1. It may be in a state of anemia,  syncope, or asphyxia, from uterine
hemorrhage, too early detachment of the placenta, or  defective nutrition.
In these cases very feeble, if any, efforts at inspiration  take place, there is 
NATURAL LABOUR.
225
no pulsation in the cord, and the action of the heart is very weak.  There
is  consequently no  object in preserving the Utero-foetal connexion;  the
funis  should be  tied and divided, and the  child plunged into  a warm
bath: if this fail, cold effusion must be tried ; but that which I have seen
most  effectual is light and rapid friction of the body and extremities with
warm flannel, with or without  stimulants.  Tickling the nose or fauces
with  a  feather, electricity,  and stimulating  enemata have  been recom-
mended ; but I am not  aware  that they have been very successful.   In-
flation may be tried by means of a proper  tube introduced into the larynx,
or a flexible  catheter passed through  the nose, and with greater prospect
of success than  most of the other means.   Great care must be taken to
introduce the instrument cautiously  and  correctly, and  to inflate slowly
and gently.
   2.  In other cases, the child may be in a state of oppression or asphyxia
from  prolonged labour, or from  some deviation from the normal presenta-
tion,  &c.; but in such instances the pulsations of the funis, though weak,
are perceptible, the colour of the  surface  is natural, and the shape of the
head  is unaltered.  Here it would evidently be wrong to divide the cord
until  respiration has been established ; therefore, placing the infant in such
a position that there shall be no  impediment to the circulation through the
cord, we must adopt  some of the plans already mentioned, for its restora-
tion.   Friction with hot flannel, warm baths, aspersion with cold water,
stimulants to the surface, or inflation  may be in turn tried, until the child
makes  an effort to  breathe.  When it has fully recovered, the cord may
be tied  and divided.   If these means fail, we may try the  effect of loss
of blood by  cutting across the  cord and  allowing  a dessert or table
spoonful of blood  to escape before  applying the ligature.  Should this
not succeed, the case is  hopeless.
   3.  There is a third class of cases,  when the child is threatened with or
attacked by apoplexy, from prolonged labour, the  pressure  of  a narrow
pelvis, or (as already  noticed) from an interval elapsing between the birth
of the head and body.   In  such,  the heart's  action is laboured, the  pul-
sation in the cord feeble and oppressed,  the  surface blue, the face livid,
and in some cases  the  form of the head  is changed.   The treatment is
exactly the opposite of that for the first class of cases ; unless the circula-
tion be  relieved, the  infant will die of cerebral oppression or apoplexy;
therefore the first thing to be done  is to divide the cord, and allow from
half an  ounce to  an ounce  of blood to escape ; after which, we generally
find the surface paler, the pulse quicker and firmer, and an effort made to
respire; the cord may then be tied.   If respiration do not  take place,
cold  sprinkling, warm baths, friction  or inflation may be tried.
   I have only to add, that in all these cases we should not be easily dis-
couraged, but  continue  our efforts for a  considerable time, as we often
succeed after a longer time than we should have believed possible.
   355.  The tumour of the scalp, already  noticed, subsides in a very short
time, without requiring  any application in most instances;  other cases,
however, are not so tractable.  The more  simple tumours consist of serum
effused  underneath the scalp ; others, of serum mixed with blood : again,
in more rare  cases, we find blood effused  under the pericranium ; and
lastly, in addition to the blood  effused, the pericranium  appears to secrete
a ridge  of bony substance limiting the effusion.  These cephalamatoma, 
226           CONVALESCENCE AFTER NATURAL LABOUR.

which  are very  rare, are about the size  of an almond,  apparently not
painful, and may be distinguished by their persisting for several days, and
by the semicircular ridge or boundary, which can be felt by the finger.
No doubt they are  the result  of pressure; but they do  not  disappear as
do the other forms of tumour.   Spirit or stimulating lotions may be used,
and in some cases they will be successful; in others it will be necessary
to lay open the  tumour  and apply simple dressings.  The reader may
consult upon this subject, essays by Wagstaffe, Gedding, Naegele, &c,
and the works of Osiander, Michaelis, Groetzer, and Valleix.
  356.  The only remaining deviation from the normal condition of the
infant which I  shall notice, is the hemorrhage which sometimes takes place
from the navel from incomplete closure of its vessels on the separation of
the remains of the funis.   Fortunately it is not of frequent occurrence, as
it is very difficult to arrest it,  and I believe in most cases the result is
fatal.   Compresses of every kind, escharotics, and even the actual cautery
have failed.  Dr. Stewart advises that the navel should be filled with alum
or some astringent, and  a compress placed over it.   Mr. Pout and  Dr.
Radford propose to cut down upon the vessel and tie it.
  I would venture to suggest that the navel should be stretched open and
filled  with  plaster of  Paris,  either  dry  (in powder) or moistened; it
would become  solid  in  spite  of the hemorrhage, and  would, I think,
effectually plug the vessels.
                           CHAPTER IV.

            CONVALESCENCE AFTER NATURAL LABOUR.

  357.  The history of natural labour would be incomplete  did we not
say something of the state of the patient after delivery, both as to the effects
produced, the gradual restoration of the parts engaged, and the requisite
treatment.
  If we examine the condition of the patient a few hours after delivery,
we  find a considerable change both locally and generally, and which can-
not be  attributed to mere fatigue.   The  nervous system is more or less
affected; the secretions are altered, and new ones established ; the condi-
tion of the uterine system itself, and in its relations, is completely changed,
the  circulation disturbed, &c. &c.
  Let us briefly examine these peculiarities separately.
  358.  1.  The nervous shock.—The sudden  alteration  of the eye, the
diminished or increased  sensibility of the brain, the  disturbance of the
respiratory  and  circulating system,  the  altered secretions,  the great ex-
haustion, &c. are all evidences of a shock to the nervous system, the ef-
fects of which  are  thus extensively felt.   After easy labours the shock is
not very remarkable, and  the  patient soon  recovers from it; but it is too
manifest to be doubted after those of a more serious character.  I cannot
agree with those who attribute the state of the patient to fatigue, and I am
happy to have in this opinion the support of the late  Professor Hamilton 
              CONVALESCENCE AFTER NATURAL LABOUR.          227

of Edinburgh, who in his Practical Observations distinctly recognises this
nervous shock as an effect of labour.
  When it is moderate, it gradually subsides, if the patient be kept free
from all excitement and disturbance, and  obtain a few hours'  sleep.  In
proportion to the rapidity and completeness of its subsidence, will be the
return of  comfort and health to the patient.
  359. 2. The state of the circulation  and respiration. — The changes
induced in these systems  appear to be the  combined result of the nervous
shock and muscular exertion.  From  extensive investigations  I have ob-
tained the following results.  During the second  stage of labour, the
pulse (as already noted) always increases in frequency, though the amount
varies in different persons.   Shortly after  delivery it falls, nearly, but not
quite, in proportion to  its  previous frequency, i. e. it descends nearly as
much below the ordinary standard as it was above it.   After the lapse of
a few  hours, a reaction  takes place, the amount of which is nearly, but
not quite, in proportion to  the original increase and subsequent collapse.
Again, after twelve or fourteen hours it subsides, to be again increased on
the secretion of the milk ;  after which,  if the patient go on well, it gra-
dually returns to the ordinary standard.  To illustrate my meaning, let
us suppose  that during the second stage the pulse  mounts up to  120;
then,  during the  collapse,  it will  fall perhaps to 60 ; and, on reaction
taking place, it will rise to 100 or  110.   I  do not intend to give this  illus-
tration as the accurate standard of these changes, but merely as illustrative
of the alternations I have  generally observed; nor do I say that they
occur in  every case, but  only that I have noticed them  in  a  very  large
majority.
  I have  never been able  to discover any proportion, between the fre-
quency of pulse induced by the secretion  of milk, and its previous  state.
  The importance of these successive alternations will  be seen more  strik-
ingly, when we come to consider the variations from normal convalescence;
it may suffice to say, that I  have seldom seen them absent (the  pulse hav-
ing increased during the second stage) without serious cause.
  The frequency of respiration after natural labour is  in accordance with
that of the pulse, when the nervous shock has been moderate.  During
the increase of the circulation, the number of respirations per minute is
increased, and again diminished during the collapse.
  360. 3. State of the uterus, vagina, <Src.—Immediately after delivery,
the uterus contracts more or less  firmly, so as to reduce its size to about
that of an infant's  head.   This contraction is beneficial in several ways:
it prevents hemorrhage, it empties the uterine cavity,  and diminishes the
calibre of the  uterine vessels and sinuses.  After a short period of con-
traction, an  interval of relaxation ensues, followed in its turn by renewed
contractions.   The  repeated contractions  reduce  the  size of  the uterus
gradually, until about the eighth  or tenth  day, it is small enough to de-
scend into  the pelvis.  Previous  to this, it can be examined through the
relaxed abdominal parietes, and a tolerable accurate knowledge obtained
of its  condition ;  but subsequently we can only reach the  fundus at the
brim  of the pelvis; and after  another week it  disappears altogether.
Some, as  Murat and Ramsbotham, attribute this rapid diminution in size
to uterine contraction alone; others conceive, with Dr.  Hamilton, that
absorption goes on rapidly at the same time.  The decision of this aue.s 
228          CONVALESCENCE AFTER  NATURAL  LABOUR.

tion mainly depends upon another, viz. whether  during gestation new
matter is  actually added.  If so, no  doubt, contraction alone would not
be sufficient to explain the change after delivery.
  361.  The  condition  of the  cavity of the uterus is of great interest.
When examined a day or two after  delivery, the lining membrane appears
loose and corrugated, somewhat softened, and covered  more or less by
patches of the decidua.   The part  to which the placenta  was attached, is
raised above the  level  of the  surrounding parts; its surface is unequal,
resembling in this respect a granulating ulcer;  its size is wonderfully re-
duced.   The whole internal surface is of a  dark ash colour, while the dis-
charge upon it may be greenish or  brownish,  giving the appearance of a
morbid condition of the parts — indeed I have known it pronounced to be
gangrene.  The structure of the uterus, if cut into, is found  to be less
dense than natural, and the fibres more  distinct; the sinuses are still very
evident, and at the placental  insertion they  are filled with clots  of blood.
The os  and cervix uteri are covered with ecchymoses, as though they had
been  severely bruised; and sometimes small lacerations may be observed
in the margin.  The orifice remains  open for some days, but  gradually
closes.
  The vagina is speedily reduced in size after its great distension: at first
there is considerable heat and soreness; but this shortly subsides, unless
the  head  of the child have remained long  in the pelvis, or the  lochia be
acrid.  The  lower outlet, too, resumes its natural capacity in a shorter
time than would have been believed possible.
  The abdominal integuments  are longer in resuming their  natural state ;
they remain flaccid and loose  for  a considerable  time;  but if care  be
taken in the bandaging, but  little evidence, beyond the presence of the
white streaks, is afforded after a month or two, of their previous disten-
sion.
  362.  4. After-pains. — The contractions of the uterus, subsequent to
delivery, of which we have spoken, are unaccompanied by pain in primi-
parous women; but in subsequent labours they cause more or less suffer-
ing, and are called " after-pains." *  They vary a  good deal in their fre-
quency, their severity,  and  their  duration.   The  first is generally felt
within half an hour after delivery,  and they ordinarily cease  in thirty or
forty hours, though they may continue  longer.  They are not  generally
accompanied by bearing-down  efforts, nor by increased frequency of the
pulse.  During their presence the discharge from the uterus increases, and
coagula are frequently expelled.  From this latter circumstance  they have
been  attributed to the presence of coagulated  blood in the uterus, but, at
most, this is only an occasional exciting cause.   Their operation is, within
certain  limits, undoubtedly salutary; they prevent hemorrhage, diminish
the  size of the  uterus,  and  expel  its contents.   The application of the
child to the breast often brings  on or aggravates the after-pains.
  363.  5. The lochia.—The discharge  of blood which accompanies de-
livery, continues for some time afterwards, doubtless from the mouths of the
vessels exposed by the separation of the placenta ;  but after a while, the
  * As a general rule, it is true that  females do not suffer from after-pains  subsequent
lo a first confinement. Exceptions do, however, occasionally occur.  We have known
jrimiparous women to experience as severe after-pains as those who had previously
borne children. — Editor. 
              CONVALESCENCE AFTER NATURAL LABOUR.          229

character of the discharge changes, and it can no longer be considered a
mere escape of blood, but exhibits all the characters of a secretion.  This
state of the lining membrane of the uterus would lead  us to expect such
an occurrence.  The discharge is called the " lochia;"  or in popular lan-
guage,  " the cleansing."  For three, four, or five days, it continues of a
red colour, but much thinner, and more watery than blood, and not coagu-
lable ;  it then sometimes becomes yellowish, like puriform matter; but
more frequently maintaining its  serous consistence, it changes its colour
successively to greenish, yellowish, and lastly to that of soiled water.
  It has a  very peculiar odour, which can neither be mistaken nor forgot-
ten, but which it  is  impossible to describe.   The  duration  of the  lochia
varies a good deal:  in some patients it ceases naturally and without bad
effects,  a few days after delivery, and  I have repeatly observed  this with
those delivered  of still-born  or putrid infants.   Generally speaking, in
these countries it does not cease  till about the end of three weeks, or a
month ; but much depends upon the constitution of the  person.  As to the
quantity, it is impossible to fix any limits ; it depends partly upon the ex-
tent of secreting surface, and  partly upon the duration of the discharge.
As the secretion is necessary for  uterine health, the  sudden interruption of
it is generally attended with evil  consequences.
   364.  6.  The  secretions and, excretions. — From the exertions of the
second  stage of labour, the secretion of the skin is increased, so that the
surface  is bathed in perspiration.  After delivery,  this  active state of the
secretion  diminishes somewhat,  but still  continues above the  ordinary
standard ;  and very often the perspiration has a faint sickly odour.  The
skin is soft and flabby, with a slightly greasy feel.
   As convalescence progresses, the surface returns  to its natural state.
   The kidneys may retain their usual activity, or, whir h is more frequent,
have it  somewhat increased  after delivery, notwithstanding the unusual
amount of perspiration ; but this may be owing to the diet consisting prin-
cipally of fluid matter.
  The state of the bowels varies ; sometimes it is  unaltered; in others it
is the reverse of what  it was during  gestation, patients who were consti-
pated having now no need of medicine ; and those who were annoyed by
diarrhoea, having solid motions.   The latter change is by no means un-
common, and may probably be owing to the increased  secretion from the
skin and kidneys.
   7. The milk.—The enlargement  of  the  breasts  during gestation  is
generally accompanied with the secretion of a serous fluid, differing from
true milk, though in some cases (seldom with first children) true milk is se-
creted during labour, and the woman can give suck immediately afterward.
  In ordinary cases,  however,  the breasts  remain quiescent for about
twenty-four hours, but soon after that begin to  enlarge, with stings  of
pain.  At  the end of the second or beginning of the third  day, they are
perceptibly larger, heavier, and more tense ; the patient suffers from rigors,
heat of skin,  pain and soreness of the breasts, and the pulse  is quickened.
At this time the secretion commences ;  at first slowly and with difficulty ;
but afterwards more freely, and in proportion to the freedom is  the dimi-
nution of the pain and fever, until after a few days it takes place without
distress or  disturbance.   The milk at first differs from that secreted after
wards, and often  acts as a purgative to the child.
                                  u 
230          CONVALESCENCE  AFTER  NATURAL  LABOUR.
  365. Management of Women in Childbed.—I cannot do better than
follow the order in which I have noted the phenomena of childbed.
  In ordinary cases the shock to the nervous system does not require any
active treatment.   The patient should be kept in a state of perfect quiet,
the  room slightly  darkened, and very few persons except the nurse ad-
mitted.   Little talking should  be allowed, and no whispering.   Every-
thing calculated to excite mental emotion  should  be  avoided, and the
patient be kept calm and cheerful.  The horizontal  posture should be
strictly preserved,  and the patient allowed to sleep, after which the nerv-
ous system will have recovered its tone, and the patient will be free from
danger on this account.
  366. As the state of the pulse is merely symptomatic, it will be remedied
best by our successful management of the patient in other respects.  It
should be narrowly watched, and  accurately estimated, as  its  deviations
will often be the first evidence of mischief going on.
  367.  Immediately after the expulsion of the after-birth, a warm napkin
should be applied  to the vulva,  and changed at short intervals during the
day.  This will afford relief from the smarting pain consequent upon the
passage of the child.  After some hours, when the  patient is recovered,
the external parts  should be washed with tepid milk and water,  contain-
ing a small portion of spirit.   This must  be repeated twice a day, not
only for the sake of cleanliness, but to aid in restoring the parts  to their
natural state.
  A horizontal posture is peculiarly favourable to the uterine  system, in
the relaxed  state in which it is after delivery; the patient cannot assume
an upright position, without a certain amount of displacement, and a  risk
of hemorrhage.  By keeping the  patient on her back,  we  may even
remedy old displacements.  A lady had prolapsus uteri after her second
confinement, which lasted till she became again pregnant; this was men-
tioned to me when I was called to her in her third labour.   I  kept her
unusually long in bed, and subsequently on a sofa, and the parts com-
pletely recovered their natural state, so that she suffered no more from the
displacement.  In ordinary cases, the  after-pains require no treatment;
but if they should deprive the patient of sleep, we may give an aromatic
purgative or a dose of laudanum.
   The only attention which the lochia require, is, that the napkins should
be  changed sufficiently often, and applied warm, as  any sudden  impres-
sion of cold to the external parts may be followed by the  suppression of
that discharge.
   368. Directions should be given for the patient to void urine within six
or eight hours after delivery or sooner; and this should be done as nearly
in the horizontal posture  as possible.   Owing to the  distensible  state of
♦he abdominal parietes, the patient will often wait much longer, if not re-
minded ; and the  consequences may be very troublesome,  if not serious.
The bladder may become paralysed, or inflammation may spread from it
to the peritoneum.  If there should be any difficulty in  evacuating the
bladder, as  sometimes  happens, a cloth wrung out in warm water,  and
applied to the vulva, will remove it; or if not, we must have recourse to
catheterism.
   369. The state  of the bowels after delivery is of great importance ;  it is
perhaps better that they should continue quiet for twelve or fourteen hours 
CONVALESCENCE AFTER NATURAL LABOUR.          231
 after delivery, on account of the fatigue ; but after that time has elapsed,
 we should procure a discharge by medicine, if there be none spontaneously.
 A dose of castor oil,  senna, or rhubarb, may be given;  and if necessary,
 repeated.  The frequency of  repetition must be regulated by the state of
 the bowels previous to labour.  If we suspect any accumulation, we should
 not  be satisfied until the intestines are well cleared out;  and if the  patient
 do not suckle her child, purgatives will be  the more necessary,  for the
 relief of the breasts.  In the latter case, the saline purgatives will be found
 the more useful.
   370. The state of  the  surface will point out the propriety of not ex-
 posing the patient to  a draught of cold air.   She should be  allowed to
 cool gradually, and then the bed and bed-clothes so arranged as to afford
 a comfortable degree of warmth.  The chamber should be kept cool and
 fresh.  The  smaller the fire (if there be one) the better.
   371. When the breasts begin to enlarge and be  painful, relief may often
 be obtained by friction with warm oil  or fomentations, at the same time
 giving a dose of aperient medicine.   But  the best remedy is the applica-
 tion of  the child; and the sooner this is done the  better, as  the  secretion
 and escape of the milk will be facilitated,  the feverishness diminished if
 not avoided, and a good nipple more easily formed than when the  breasts
 are distended.
   It  is  better to do this, even if it  should  not be the  intention  of the
 patient to suckle her infant,  as it will afford  relief; and  by  not  suffering
 the child to do more, we insure the ultimate  subsidence of the secretion,
 which is always in proportion to the demand upon it; if this be very slight,
 it will soon cease altogether.
   372.  The  importance of presenting the horizontal posture has already
 been stated;  I shall therefore merely add, that the patient  should never
 leave her bed, even to have it made, before the sixth day; and if she can
 be persuaded to limit her exertions to this point for eight or  nine days, so
 much the better.  Far more mischief results from premature exertion, than
from all the errors in diet added together.
  373.  The  regulation of the diet is, nevertheless, of considerable im-
portance, as  excess, by inducing feverishness, may retard  the  convale-
scence.   The patient  should be confined to slops — gruel, panada,  arrows-
root, milk, whey, weak tea,  &c. — with bread or toast and butter,  or bis-
 cuit, for three or four  days.   When  the excitement produced  by the se-
 cretion of milk has subsided, if there  be no counter-indication, she may
take  some broth, and on the  seventh  or  eighth day some  chicken, or a
mutton chop, with some  wine  and water.
  In all that  concerns the diet, or the assumption of the upright position,
or making exertion, it cannot be too strongly impressed upon all, that an
excess of caution is an error on the safe side.
  374.  On  certain Variations from ordinary  Convalescence.—Al-
though the following observations are a deviation from the plan I proposed,
yet I should not feel justified in their omission, and I do not know that a
better opportunity will  offer for  them  than the present, as  they may be
usefully compared with the preceding  description of ordinary  convale-
scence.   These deviations may depend upon the constitution or the cha-
racter of the  labour, or upon  pressure exercised locally.  Even without
reference to  the  influence of the labour, there  are  certain  irregularities 
232          CONVALESCENCE AFTER  NATURAL LABOUR.
which occasion anxiety both to the patient and  her physician.   Some of
these issue in serious disease ; others, more numerous, are mere temporary
deviations from the normal course,  but  requiring familiarity and tact to
distinguish them from the more  important attacks.
   375. 1.  The nervous shock may be very  severe.   In these cases the
patient complains  of great  exhaustion; the  senses are either unnaturally
dull,  or morbidly acute, the breathing is hurried, and panting, and the ac-
cordance  between the respiration and circulation is broken.   The aspect
of the patient is that of a person in a state of collapse.   The  countenance
is expressive of suffering, anxiety, and oppression.   The pulse may be
either very slow and laboured, or unusually rapid, very small, and flutter-
ing.  There are many cases, however, where the shock, though far from
being so  severe as in the case I have supposed, is quite sufficiently  so to
excite the fears of the  medical attendant.   Reaction is long  before it oc-
curs, or it may take place imperfectly or excessively, and the patient re-
main for some time in a very weak condition.
   Under  proper treatment,  the  patient will  gradually recover from this
state  of exhaustion or  collapse, unless the shock  be  excessive and  then
death will supervene  in a few hours.   I have seen several cases of this
kind;  in one case, the labour  was  tedious, but terminated naturally;
two others were instrumental deliveries ; but in none where a post mortem
examination was obtained, was there either injury or disease discovered.
   A due  estimate of the nervous shock is of great importance in severe
cases ;  for in almost every instance the progress of the convalescence is
in inverse proportion to the amount of this disturbance.
   The  best  remedy in  these cases is opium,  either in a large dose,  or in
small and repeated ones; it not only  gives the patient a chance of sleep,
the best restorative of  all, but  even if it  fail  in this, the system will be
quieted, the respiration rendered more equable, the pulse slower and more
natural, and the relation between these two systems restored.*
   The  exhibition of stimulants (wine or brandy and water) in  moderate
quantities is  necessary; but we must be careful not fo exceed, or they will
do mischief  instead of good.   The amount of stimulants given in cases of
collapse should have reference to the probable reaction, as well  as to the
present state of the patient.   Ammonia or musk  are the best medicinal
stimulants, and they may be combined with the  opium.   The diet of the

  * These remarks of the author are deserving of the serious attention of  the young
practitioner.   " I have seen more than  one  instance," says Dr. Huston in a note to a
former edition, "in which there was reason to believe the life of the patient was sacri-
ficed from ignorance of the true character of the condition here referred  to.   If the at-
tention of the practitioner be at  the time particularly directed to puerperal fever, he is
liable  to confound the exhaustion in which he finds the patient, with the early stages
of that disease.  The cold extremities constitute the chill, while the  haggard counte-
nance, hurried respiration, and frequent pulse, are regarded as conclusive evidence of
a rapid peritonitis. Bleeding from the arm or by leeches, is the instant resort,  and a
few short hours confirm the worst anticipations, by the fatal termination, a result which
the efforts of the attendant have but too successfully aided in producing.
  " The author speaks vaguely in recommending ' Opium, either in a large dose, or in
small and repeated ones.'  Where much pain and jactitation occur, the  dose should be
large, say a grain and a half, or two, or even three  grains; but when the object is to
soothe the nervous system, and sustain the circulation, smaller doses, as half a grain or
ten or fifteen drops of laudanum, repeated every hour or two, with or without carbonate
of ammonia, wine whey, or other mild stimulants, are  appropriate remedies.   When
reaction ensues, of course these are to be laid aside.—Editor. 
CONVALESCENCE AFTER NATURAL LABOUR.          233
patient, when the effects of the shock have subsided, must be nutritious.
It may be necessary to postpone the application of the child to the breast
for some days,  or even to give up suckling altogether in some cases.
  All that has been said already upon the necessity of perfect quiet applies
with ten-fold force to these cases of extreme nervous shock.
  376.  2.  The state of the pulse.—One variation from the usual alterna-
tions of the pulse has just been noted, in cases of great nervous shock,
when it either sinks below its due  proportion, or more frequently remains
very quick, weak, and fluttering, during the period of collapse.
  In almost all the cases of flooding after labour, when I have had an op-
portunity of examining the pulse up to the time of  the occurrence, I have
found it remain quick, and perhaps full, instead of sinking after delivery.
This has been so marked in several cases, that I now never leave a patient
so long as this  peculiarity remains; and in  more than one instance  I be-
lieve the patient has owed  her safety to this precaution.  Three  cases
occurred within a very  short time of each other,  in which I  noted this
undue quickness of the pulse without any other untoward symptom; at
that  time there  was no excessive discharge, and the uterus was well con-
tracted.  In  all these, alarming hemorrhage occurred within an hour, and
was  with difficulty arrested.  I have  also  remarked an undue frequency
of pulse when  the after-pains are extremely violent; and as the uterus is
in such cases rather tender on pressure, it requires care to distinguish be-
tween this state and the commencement of puerperal fever.   This observa-
tion  will also apply to the quickening of the circulation, which takes  place
when lactation commences, and which in addition is accompanied by rigors.
A careful examination, however, will generally lead us to a correct  conclu-
sion, and the subsequent diminution of the frequency of the pulse will re-
move all doubt.  Again, the  pulse is quickened when a large coagulum is
contained in  the uterus, or if the patient  suffer from diarrhoea, or gastric
disturbance.  In some of these cases the diagnosis may be obscure, and
it may be necessary to suit our treatment  rather to the anticipated attack
than to the present symptoms ;  thus, we may give small doses  of blue pill
or calomel in combination with opium, along with medicines suited to the
peculiar symptoms present.
  All  the  observations I have  been  able  to  make, confirm Dr.  John
Clarke's remark, that no patient can be considered safe whose pulse ex-
ceeds one hundred.
  377.  3.  The state  of the  uterine system. — Instead of a gradual de-
crease in the size of  the womb, I have occasionally found on  the fifth or
sixth day that its bulk has increased, and that it has felt less firm than
previously: this, combined with increased  frequency of the  pulse, has
apparently threatened  an attack of hysteritis; nor was this anticipation
lessened, by the uncomfortable sensations of the patient, nor by the sudden
decrease of the lochia.  However, in most of these cases, I found  upon
applying hot fomentations to  the abdomen, that more or less coagula were
discharged, affording instant relief to the patient, and indicating the source
of the  symptoms.  Purgative enemata also favour the  expulsion of the
clots ; and in such cases may be given with great benefit.
  It has been  already mentioned that the uterus is not free from  tender
ness  in cases where the after-pains are severe ; and if it be rudely pressed,
the  outcry of the patient may lead us to suspect the presence  of serious
                                u2 
234           CONVALESCENCE AFTER NATURAL LABOUR.
disease.  It will be observed, however, that this tenderness is greatest dur-
ing each uterine  contraction, and  that  as  tliese contractions subside, the
soreness diminishes.
  Fomentations to  the abdomen will  generally mitigate this sensibility;
but if the after-pains be severe, and the tenderness considerable, a full
dose of  laudanum,  followed by  an aromatic purgative, will  probably
relieve both.
  The vagina may be attacked  with  inflammation, which sometimes
proves extremely distressing;  this  will form  the  subject  of a separate
notice.
  In cases where the lochia are acrid, the orifice of the vagina, with the
labia and external parts, are apt to be excoriated.  The patient may suffer
extremely either from a smarting  pain, or from itching; and it is difficult
to say which is the more distressing.  Extreme cleanliness, frequent bath-
ing, lead lotions, black wash, or vaginal injections of warm water, may
be  tried, and  will ordinarily afford  relief; if not, the  disease will gene-
rally subside with the cessation of the lochia.
  378.  4.  The after-pains. — Instead of the after-pains coming on about
half an hour or an hour after the labour, in moderate degree, and ceasing
after a short time, they occasionally commence  immediately after the  ex-
trusion of the placenta with great severity,  and long continuance.  In
these  cases the tenderness of the  uterus is marked, but when the pain is
relieved by remedies, the tenderness disappears also.  The pulse also is
quickened  for the time.   This deviation does  not depend upon  the
presence of coagula, as in the worst cases I have seen none were expelled,
but it seems rather a spasmodic contraction  of the uterine fibres.   The
best remedy is a full dose  of opium, which should be repeated if neces-
sary.   At the  same time hot flannels may be applied to the abdomen and
vulva.
  The after-pains sometimes continue at  intervals, unusually long, and
are  very severe whenever the child  is applied to the breast.  They occa-
sion distress and exhaustion by preventing  sleep, and should therefore be
relieved if possible, by cordials, aromatic purgatives, or a dose of opium.
  379.  5.  The lochia.—Variations in  the quantity, quality, or odour of
the  lochia,  not unnaturally  excite  great alarm in the  mind of the patient,
who regards any deviation  in this secretion as a proof of  serious disease.
Yet very remarkable differences do occur, without any morbid  affection
of the uterus or vagina.
  The discharge may  cease a few hours after delivery, especially after
the  birth of still-born or putrid children, without any unpleasant symptoms.
  The discharge  may continue the usual time, but in very small quantity ;
and this is commonly the case when flooding occurs during or after de-
livery.
  On the other hand, it may be excessive, though not prolonged beyond
the  usual time ;  or  without being excessive, it may continue  unusually
long.   In these cases it may be  necessary to  allow the patient  a better
diet, and to give  tonics, such as bark,  preparations of iron, &c.
  In some cases the lochia, after decreasing in  quantity for some time,
are  suddenly discharged in double quantity, and of a red  colour, but with-
out  coagula.   This generally happens when the patient is permitted to sit
up  too soon.   Or it may happen at a later period, in  consequence of 
CONVALESCENCE AFTER NATURAL LABOUR.          235
walking about too much.  A little extra rest will, however, suffice to re-
store the patient to her former state.
  Again, the  os  uteri is sometimes obstructed by a clot, and the lochia
are greatly diminished, or perhaps altogether restrained, until  the expul-
sion of the clot affords an exit to the accumulation.
  Instead of  the usual changes, from red to yellow, or greenish, the red
discharge may persist;  or after these  changes have taken place, the red
discharge may return.   In these cases, it is necessary to be on our guard,
as the change may be  the  precursor of secondary hemorrhage.   The
patient should be confined to the horizontal position, and clothed very
lightly.
   The lochia, after going through their ordinary changes, may terminate
in uterine leucorrhcea, which may become permanent.   This will be best
remedied by counter-irritation to the sacrum, and  the internal exhibition
of copaiba, iron, or ergot of rye.
   Again, the  unusual colour of  the lochia may excite alarm.  Instead of
the transition  from red, to a pale red, yellowish, or greenish colour, they
are sometimes a dark brown, and perhaps more tenacious than  usual, or
acrid,  so as to excoriate the vulva.
   Lastly, examples occasionally occur where the lochia have a very offen-
sive foetid odour, occasioning great annoyance both to the patient and her
friends.   The discharge is  generally of a  dark colour, and often acrid.
It may arise from the decomposition of a small portion of the  placenta or
membranes which were left  in the uterus or vagina,  or from the putrefac-
tion of coagula.   In such cases the vagina should be syringed two or three
times a day with warm milk and water, or a very weak solution of chloride
of lime.
   380. 6. The bladder.—"After severe labour," says Dr. Burns, "the
neck of the bladder and  urethra are sometimes extremely sensible, and
the whole of the vulva is tender, and of a deep red colour.   This  is pro-
ductive of very distressing strangury, which is occasionally accompanied
with a considerable degree  of fever.   It is long  in being removed, but
yields  at last to  a course of gentle laxatives, opiates, and  fomentations.
Anodyne clysters are of service.  An inability to void the  urine requires
the regular and speedy use of the catheter."
   381. 7. The breasts.—Variations in the  period at which the milk is
secreted are  common, but  of  no moment.  If  the vascular action be
excessive, it must be moderated by antiphlogistic remedies, such as tartar
emetic, purgatives, fomentations, &c, and by the frequent  application of
the infant.
   If, as in some  rare cases,  no secretion  should take place, the child will
require a wet  nurse, but the mother will  not suffer.
   When the nipples  are deficient or  mal-formed, we must  endeavour to
draw them out by the breast-pump; but if this  do not succeed, we must
obviate the ill effects of the  secretion of milk, by tartar emetic, saline pur
gatives, fomentations, &c. 
CHAPTER V.
PARTURITION. —CLASS II. UNNATURAL  OR ABNORMAL LABOUR.
                   ORDER 1. TEDIOUS LABOUR.
  382. Definition.—The head of the child presents, and the labour is
terminated without manual or instrumental assistance, but it is  prolonged
beyond twenty-four hours, from  causes which occasion delay in the first
stage.  The placenta is expelled naturally.
  383. Very slight experience is sufficient to show that  delay in labour
may occur in either the first or second stage, and a more extended obser-
vation will prove, 1, that when the  delay is excessive, the relative duration
of the two stages is  destroyed, so  that they bear no steady proportion to
each other;  thus, for instance, in a labour of sixty hours, the first stage
may occupy fifty-nine,  and the second only one, or vice versa:  2, that
the effects of a prolonged labour upon the constitution of the patient, de-
pends upon  the stage in which the delay occurs: and 3, that delay in the
first stage involves very little if any danger, no matter how tedious it may
be, but that  delay in the second stage, beyond a comparatively short time,
is always of serious import.  Although these deductions are not distinctly
enunciated by writers  on  midwifery, yet they appear to be involved in
their practical remarks, inasmuch as they distinguish the causes of delay
in the first stage from those in the second, as being much less dangerous.
The above conclusions, drawn  from numerical  estimates, and  supported
practically by high authority, are sufficient, I think, to justify our making
the distinction between "tedious" and "powerless" labours  to depend
upon the stage at which the delay occurs.
   384. Statistics.—Unfortunately our best statistical reports only give
the entire length of the labour, without distinguishing the stages, so that
the first table I shall give will merely show the frequency of those labours
whose duration exceeds twenty-four hours.
Authors.	Total Number of Labours.	Above Twenty-four hours.
Edinburgh Lying-in-Hospital ....	10,387 2,947 2,452 839 1,182 4,666 1,285	134 128 48 46 69 62 166
		
Dr Churchill.........		
		
  Thus,  in 23,758  cases  of labour, we  have 653  prolonged beyond
twenty-four hours, or nearly 1  in 36.
  I mav  add, that delay is  most common among first cases.
       J     >         J                      °           (236) 
TEDIOUS LABOUR.
237
  385.  The following table is intended to exhibit the relative  duration
of each stage in labours of twenty-four hours and upwards, in which the
delay occurred in the first stage, and the results to the mother and child.
The registers  of the Western Lying-in-Hospital have  furnished  the data,
and as the cases are therein entered under the inspection of Mr. Speedy
and myself, I believe they may be depended upon.
		CJ			
	3	be		a*	
03	C	a	c		
a		05	o		
O	kJ		QJ	o S o	
Cm o	O	<C	v. bo		Results to Child.
h	e	v*	c cd		
.a	o-	o	£W		
s a 55	a 3 Q	es s III	ft C	a	
	hours.	hours.	hours.		
5	24	23*	*	favourable.	favourable.
13	24	23	1	do.	12 do. 1 putrid.
2	24	22	2	do.	1 do. 1 still-born.
3	25	22 to 24	1 to 3	do.	do.
1	25	19	6	do.	do.
2	25	17	8	do.	do.
2	25	16	9	do.	1 do. 1 still-born.
1	26	25*	J	do.	do.
7	26	25	1	do.	6 do. 1 still-born.
2	26	23	3	do.	do.
3	27	26$	*	do.	do.
2	27	26	1	do.	do.
1	28	27*	*	do.	do.
3	28	27	1	do.	do.
2	28	26	2	do.	do.
1	28	25	3	do.	do.
1	28	22	6	do.	do.
1	29	28*	J	do.	do.
2	29	28	1	do.	do.
2	29	27	2	do.	do.
1	30	29*	i	do.	do.
2	30	29	l	do.	do.
1	30	28	2	do.	do.
1	30	26	4	do.	do.
1	30	23	7	do.	do.
1	30	19	11	do.	do.
2	31	30	1	do.	do.
2	31	29	2	do.	do.
1	31	27*	3*	do.	do.
1	31	27	4	do.	do.
1	32	31*	*	do.	do.
4	32	31	1	do.	do.
1	32	24	8	do.	unfavourable.
1	33	32*	*	do.	favourable.
1	33	32	1	do.	do.
1	33	31	2	do.	do.
1	34	33	1	do.	do.
1	34	30	4	do.	do.
1	34	29	5	do.	do.
1	35	84*	I	do.	do.
2	35	33	2	do.	do.
2	36	35*	J	do.	do.
1	36	35	1	do.	do.
1	36	33	3	do.	do.
1	36	31	5	do.	do.
 
jS	W
r-*	uo
»—•	OS
cr1	"
re	zn
>—>	o
	3
3	re
—	S5
	
3	o
	o
cr	3
3* ft.
<-*	sr
	re
P3	
	
	re
-*l	3
-1	jq
M	3-
Cfl	o
l-H	>-»s
K-?	
3 O	00
	
	t»
°	rr*
	
	re
	
	
CO	w
	3
cr	d-
re	I-H
o 3	r?
<~<	en
MMM                                                                                                                               tr
os ** #> oj to i-» «. to co to 0 OSMCO OS os^ co co co os to to cxJCOO^ot^OT^IS^^cocnltJ^ffi^lnSSSSS^^^toSS
Number of Cases.
Duration of Labour.
Length of first Stage.
->   M l-J   I^COMM   00 W   rf>. *. l-l ^ ©   I

p  p p  p p p  p p p  p p p  p p  p p p  p p p p p  p p p p p  p p  p p p  p p p p p  o o  o o o  o o o
g. a. &, a, &. c
O  O ©  O O i-i
OOC    OOOOOOOw    ©OOOOOOOOOOOOOOw    OOOOOaonnr?7?i?P. •  5'C'r'B'E'B'w
©o©ooooCi
0©©©00©00000
o  o o  o o o
Length of second
     Stage.
Results to Mother.
fcO
00
00 
TEDIOUS LABOUR.
239
one of the kind on record.   The reader will understand  that from  this
list I have excluded all presentations but the head, all operative cases, af
cases which were prolonged in the second stage, and all such as  were of
doubtful accuracy, but that beyond this I have in  no degree selected the
cases.   The entire  number amounts to one hundred and forty-three.  Of
these not one of the mothers died, although in some cases the first stage
was enormously prolonged, and but ten of the children, one of which was
putrid.   If the relative length of the stages be examined, it will be found
that  it  did not follow, because  the  first was very long that  the  second
should be long also ;  and in many cases (not included in the table) when
the second stage  was delayed, the first  was extremely  short.   Thus I
think that, so far as it goes, this table proves the propositions with which
I started ;  viz. that " when  the  delay is excessive, the  relative  duration
of the two stages* is  destroyed, so that they bear  no steady proportion to
each other," and that " delay in the first stage involves very little  if any
danger, no matter how tedious it may be."
   The  only apparent exception to  this rule, of which I am  aware, are
those cases in which  some mechanical impediment exists, and which be-
long to an order to  be hereafter considered.  In  these  cases mischief
arises, not from the prolonged first stage so much  as from the impediment
to the completion of  the second.  Undoubtedly a prolonged first stage is
a bad preparation for undue prolongation  or for any accidental complica-
tion of  the second.
   These conclusions I think are fairly deducible from the premises, but
there are  others which I would guard against, and these are, first, that
because no evil happened in these cases, therefore  nothing is to be done
in any case where the  delay is  in the first stage, and secondly, that the
delay was  the  result of bad management,  whereas in  most cases the
patients were not brought under our care until the greater  part of the time
had elapsed.   I do think that when we find no evil resulting from the
delay, we are  not warranted in active interference;  but I am equally con-
vinced  that when we can remove the cause of it, we are bound to do so.
   I  may add, in confirmation of my own conclusions, the statement of
Denman, " that neither mother nor child is ever in any danger (except in
hemorrhage or convulsions) on  account of the labour, before the mem-
branes  are broken," i. e. in the first stage.
   387.  Symptoms.—I  conclude, then, that  these cases of labours  pro-
longed  in  the  first  stage,  present  nothing formidable as regards the
mother, and very little as regards the child ; but yet we find that the con-
tinued  suffering produces  a great  degree  of fatigue, and  in  nervous
women  especially, the loss  of  sleep is very much felt;  the spirits are
depressed, and the patient expresses a great dread of the result.   Not
withstanding  this,  however, the condition  of the  patient is favourable.
The skin  is cool,  the pulse  quiet, the tongue clean and  moist; there is
rarely any headach;  the stomach may be more or less disturbed, but the
other bodily functions are performed  in  a  healthy manner.   The pains
recur regularly, though their extent is often limited, and their power inef
ficient,  their duration and frequency varying occasionally.   Still, a  per-
ceptible though slow progress is made.
   The strength is  seldom impaired, and the patient often gets some quiet
sleep, which tranquillises the mind, and restores the bodily powers; there
         16 
240
TEDIOUS LABOUR.
is neither fever nor inflammation, the vagina is cool and moist, and  both
urine and feces are evacuated easily and spontaneously.
  The tranquil pulse, cool skin, and loud outcry, are all indicative of the
first stage of labour, and on examination the head  is found  not  to  have
passed through the os uteri, whether or not the membranes be broken.
  The nervous shock is never in proportion to the length of the first stage
of labour, but of the second.
  388. Causes and Treatment.—The  causes which  occasion  delay in
the first  stage of labour are various, and not always peculiar or confined
to it,  and the treatment must  be adapted to each.   No doubt can be en-
tertained of the propriety of removing them, when this can be done,  even
though the delay they occasion may be innoxious.    Let us examine the
principal causes and their treatment separately.
  389. 1. Inefficient action of the uterus is a very common cause of delay,
and occurs most commonly in delicate women confined for the first time.*
It may arise from constitutional weakness, a deranged  state of the diges-
tive organs, mental depression, uterine plethora, or irritation of the os and
cervix uteri, &c.
  We find  the pains  feeble, of short  duration, limited in extent, often
seated in front, and producing little effect upon the  bag of  membranes or
cervix uteri.  When the intestinal canal is  deranged, they are  mixed up
with  griping pains in  the  abdomen, which, in many  cases, modify  or
supersede the real pains
  It should also be stated that bodily weakness or  even the presence  of
fatal  disease does not always  involve feeble uterine  effort; patients in the
last stage of consumption are  often delivered with great facility.
  390. Treatment.—The first element in  the management of these cases
is time.   We must exercise patience ourselves, and encourage our patient
to do so.  All that is calculated to cheer her  should be communicated,
and she should be occupied, if possible, and amused.   If it be  day-time,
she should not  lie down, but  may rest on a sofa, and  walk about occa-
sionally, taking the pains sitting or standing.   The  bowels must be freed
by medicine, if necessary, and for this purpose enemata of a stimulating
character may be used, as they very often also quicken the uterine action.
The  diet should be bland and nourishing, but not stimulating.
  These palliative measures will  be sufficient in many cases, in others
they are of  no use, and the patient may be exhausted from the prolonged
suffering and want of sleep ;  and the best thing we  can then do (if there
be no counter-indication) is to give a full  dose of opium, so as to suspend
the pains for a  time and procure  sleep.   If it succeed, the patient will
wake up refreshed and  strengthened, and the pains  most probably return
with  increased  strength.  A purgative  enema, administered when the
patient awakes, is often of great service.
  When the inefficiency of the pains depends  on intestinal disturbance,
it will be right  to evacuate the bowels freely before  the opiate is given, if
one be necessary.  Should there be indigestible matter in the stomach,
it is probable that it will be evacuated spontaneously.
  * It not unfrequently occurs in women who are not particularly delicate but the re-
verse,  and who apparently labour under no constitutional weakness; the  ineflBcient ute-
rine action resulting apparently, in these cases,  from some constitutional peculiarity—
often descending  from mother to daughter.  On the other hand, the  females of pome
families are remarkable for the ease with which they give birth to their children, inde-
pendently of any physical peculiarity discoverable on the closest scrutiny. — Editor. 
TEDIOUS LABOUR.                        241
  In case of plethora of the uterus or irritation  of the cervix, we shall
often derive benefit from the abstraction  of  blood, after which the  pains
generally become stronger; if they do not,  we may have recourse to the
opium for temporary relief.
  391. So far the remedies mentioned tend merely to the removal of ob-
structions to uterine action ; but as it does not follow that in all cases  this
relief is followed by vigorous  action, we have  next to seek for  some
agents which shall  act  directly upon  the uterus.   The one upon which
most  reliance  is  placed is  the ergot  of rye.  This vegetable substance
appears to have been known for a long period in Germany under the name
of Rockenmutter, Mutterkorn, &c, and to have entered into the  compo-
sition of various nostrums for hastening labour.   It is  mentioned by  Ca-
merarius in the " Actes  des  Curieux de  la Nature" for 1668; and in
1777, Desgranges published his first researches upon it, in the " Gazette
de  SanteV'   Its  introduction into British  practice was, I believe, owing
to Drs. Stearn and  Chapman, of New York, whose favourable experience
of  its effects has  been tested  by many practitioners,  and apparently with
different results.*   Desormeaux, Lachapelle, Beclard, Capuron,  Jackson,
Hall, &c, deny that it has  any effect  at  all; on  the other hand, we have
the authority  of  Bordot, Chevreuil, Gendrin,  Bigeschi, Luroth, Davies,
Blundell, Jewel, Smith, and many others, in stating that it is effective  and
beneficial.   From repeated trials, I can bear witness to its efficacy, though
it is somewhat irregularly exerted ; but I must add that I have seen it do
mischief.
   The substance itself, according to Decandolle, " is  a  peculiar species
of  fungus which  attacks the ovary of grasses, and protrudes from them in
a lengthened form, especially from  rye;"  hence the popular term "spurred
rye."f
   It is an oblong, slightly curved grain, about as thick and twice as long as
a grain of wheat, of a dark brown colour externally, but lighter, and with, a
shade of pink internally.   It  has been analysed  by Wiggins, Vauquelia,
and Wright.   The latter  chemist states its component parts as follows :
    A thick white oil.........  31-00 grains.
    Ozmazome ..........     5-50   "
    Mucilage..........9-00   "
    Gluten..........     7-00   "
    Fungin...........11-40   "
    Colouring matter........3-50   "
    Fecula...........26-00   "
    Salts.......«...     3-10   "
    Loss...........3-50   "

                                                         100-     "
  * The attention of the profession was first called to this article by Dr. Stearns of t ne
State of New York,  in a letter addressed to Dr. Ackerly, in the year 1807; and in the
year 1813, attention was further directed to it by Dr. Prescott, in a letter which he
read before the Massachusetts Medical Society.  Subsequently the high authority of Dr.
Dewees has served to bring it extensively into practice — too much so it is to be feared
for the credit of the profession and the interests of humanity.—Editor.
  •f- " Recently,  Mr. Smith (Transactions of the Linnean Society of London,  xviii., Pt.
8, p. 449, London,  1840), and Mr. Quekett, (London Lancet,  June 22, 1839,)  have
maintained that the  ergot is not a fungus, but a diseased state of the grain  occasioned
by the growth of a  fungus not previously detected; to this fungus Mr. Quekett gives
the name Ergotcctia  abortans.   By the microscope, they discovered sporules, sporidia,
or jointed bodies, which appeared to be the reproductive  particles of the fundus "—
Dimglison's New Remedies, 3d edition, p. 431. — Editor.
                                   V 
242                       TEDIOUS LABOUR.
  The chemical  analysis of ergot has thrown but little light upon  its
active principle as yet, for none  of its component principles  produce the
same effect as the substance, administered entire.
  It may be exhibited in various ways;  that which  I  have found  most
certain, is  to  mix the  bruised  or powdered grain with a little water or
milk, and simmer it for a few minutes over the  fire, then give the grounds
along with  the fluid.   Both vinous  and  acetous tinctures have been pre-
pared, but I  have not  found them  as  effectual as the powder.  Mr.
Battley has also a " liquor secalis cornuti" (so  it is called, if I remember
rightly) which seems  more certain  than the tinctures; and I have also
tried an extract which succeeded very well.
  From fifteen grains to a scruple of the  powder, half a  drachm  to a
drachm of  the tincture, and from five to ten grains of the extract, may be
given every twenty minutes, until  the effect be produced, or until we are
satisfied that it will not act.  I would not give more than a drachm,  or at
the utmost  a drachm and a half of the powder (or its equivalent in  tinc-
ture or extract); for if that  do no good, more will be useless, and may be
injurious.
  If it succeed, we find in  five or ten minutes after its exhibition, that the
pains  are stronger, longer, and more frequent;  their increased frequency,
indeed, is often remarkable, even when their force is but little augmented.
I have noticed, that  shortly after an effective dose has been taken, the
pulse  becomes slower until after the  pain is over, but that ultimately it
remains quicker.
  Besides this power  of strengthening feeble pains, the researches of Dr.
F. Ramsbotham and others have proved  it capable of originating uterine
action.
  392. So far we have spoken of its  beneficial effects; and although in
by far  the majority of cases no injury is produced by  it, yet in  five or six
cases  I have witnessed cerebral disturbance in different degrees, from a
severe headach up to  delirium, coma,  and insensibility,  follow its use.
  By others it is said  to disorder the stomach, and if given in large doses,
to cause gangrene;  but such cases must  be very rare.  I think  I  have
seen retention of the  placenta from irregular uterine contraction after the
birth of the child, fairly attributable to it.
  By Girardin, Burns, Moreau, and others, the child is stated to be  more
frequently still-born after the  use of ergot, either from some  poisonous
influence indirectly exerted upon it,  or by the  greater pressure of the
uterus upon the cord.   I have seen some cases confirmatory of this state-
ment, and  of the latter  mode of explanation,  as the uterine action was
almost incessant.
  Dr.  Beatty has published a very interesting paper showing that in cer-
tain cases the  ergot does exert a poisonous effect upon the fcetus,  and he
concludes that the child is  not safe unless the labour be concluded within
two hours from the administration of the  ergot.  More recent observa-
tions seem  to confirm this view.
  393. I think from  what  has been  said, that we may conclude that the
ergot  of rye  may be  tried, 1, when the pains  are feeble and  inefficient,
without especial cause; 2,  if the os uteri be soft and dilatable; 3, if there
be no obstacle to a natural  delivery; 4, if the head or breech present, and 
TEDIOUS LABOUR.
243
be sufficiently advanced ; and 5, if there be no threatening head symptoms,
nor excessive general irritability.
   But on the other, hand it should not be given : 1, if the os uteri be hard
and rigid;  2, if the presentation be beyond reach ; 3, if there be a mal-
presentation; 4, if the pelvis  be deformed ;  5,  if there  be  any serious
obstacle to  delivery in the soft parts;  and, 6, if there be head symptoms,
or much general irritation.
   Though in some cases,  when timely administered, it may anticipate the
use of the  forceps at a later period, it  is not likely, as some have sup-
posed, ever to supersede  the  use of  that instrument, and it is not suited
to those cases in which the crochet is required.*
   394.  Borax is said by German writers to have the power of quickening
uterine action, though it is seldom used  in this country.    Dr. Rigby says,
" We have combined these  two  medicines (ergot and borax) with the
best effects, and generally give them in  the following manner: R Secalis
Cornuti  9i—ii; Sodas subborat. gr.  x;  Aq.  Cinnamomi  gifs.  M. fiat
haustus.   Cinnamon,  which is a remedy of  considerable  antiquity, has
also a similar action upon the uterus,  although to a less  degree."
   Dr. Radford of Manchester, has lately proposed the application of gal-
vanism  in tedious  labour from want of power  in the uterus  in accidental

   * Of the power of ergot to excite uterine contractions there can be no doubt; that it
occasionally fails to do so under circumstances apparently favourable for its action, will
be admitted by all who have had much experience with it.  Why it fails, we know not;
but  that it very generally acts with decided  energy, particularly during parturient ac-
tion, is perhaps as well established now as is the action of almost any other article of
the Materia Medica.  In this  country, its too extensive employment has left no doubt
on this point.  The  only questions which remain to be settled are as to the circum-
stances under which  it is  proper to be used,  the dose, and mode of administration.
The experience of Dr. Huston, as he  states in  a note to a former edition, confirms the
observations of Doctors Patterson and Ramsbotham as to its power of bringing on pre-
mature labour, and  its fatal influence on the  child when employed for that purpose,
although he " cannot  admit that this occurs in consequence of the child being poisoned
by the ergot through  the system of the mother."
   The incessant action of the uterus, under the influence of  ergot, is very unlike the in-
termittent contractions which occur in natural labour.   This state of permanent contrac-
tion of the organ either detaches the placenta, or so compresses it as to destroy its
functions before the child is in a situation to respire.   The  appearance of the children
born under these circumstances confirms this view.
   The intelligent practitioners  of this city use the ergot chiefly during or subsequent to
labour to overcome uterine inertia, and they always avoid its administration where any
obstruction or great disproportion between the size of the child and the passages of the
mother exists.  It is  a rule with them also to abstain from its employment until the os
uteri is not only dilatable, but fully dilated, and the other soft parts in a favourable state
of relaxation.  Even when thus cautiously had recourse  to, the  child will not uhfre-
quently be dead-born.
   The dose given is from one to two scruples of  the powder, or an amount of the article
equal to that, whatever may be the preparation  employed.  Some  prefer smaller doses,
as ten or fifteen grains, repeated every fifteen or twenty minutes until the  desired effect
is produced.
   Some practitioners  always administer the powder in the form of electuary, or diffused
in water.   The best  mode of  giving the  ergot is, perhaps,  recently powdered, in hot
water, in doses of a scruple every twenty minutes, until a drachm is taken, unless the
proper effect occurs  sooner: more than that quantity is never required,  if the article
be good, and  the case one  adapted to its use.
  Experience has shown that ergot, especially when powdered, rapidly deteriorates ; —
to avoid this and at the same time furnish an article in a convenient form for immediate
use, the Pharmacopoeia of the  U. S. prescribes a wine made by macerating two  ounces
of the  ergot (bruised) in a pint of wine, of which one or two drachms are given at a
time, and repeated if  necessary.
  The oil, tincture, and extract, are rarely used. —Editor. 
244
TEDIOUS LABOUR.
»
hemorrhage, irregular contraction, and to bring on premature labour, and
he relates a case of hemorrhage in which he employed it successfully.
  Professor Simpson tried it in eight cases of protracted labour, and thus
sums up the results:—"In one instance, the pains were more frequent in
their recurrence, but shorter in their duration, during the application of
galvanism.  In five other cases, the employment of the  galvanism neithei
increased the  average frequency of the  pains nor their average duration.
In one, the pains ceased while the galvanism was applied, and returned
upon  its removal.  In  another the uterine  action ceased while the gal-
vanism was applied, and did not return  for twenty-fours afterwards."  So
far the inference is unfavourable, but the  cases  are too few to found any
positive conclusions upon them.
  I have already alluded to the beneficial effects of  stimulating purgative
enemata ; and I may add that some writers have  recommended stimulants
externally, such as mustard poultices or  friction with stimulating liniment.
I have never found them of any use.
  395. 2.  Undilatable os uteri.— With the first child the cervix uteri is
more unyielding than subsequently, and also in women of advanced age.
It may give way, however, within a reasonable time ; but in some cases it
does not, and on examination we find  the  lips  thin, hard, and rigid, or
soft, semi-pulpy, or oedematous, and  that little  progress in dilatation  is
made  during each pain.   The  pains themselves may be frequent, and very
severe, notwithstanding  the slight effects they appear to produce.  The
thick pulpy or  oedematous cervix uteri is carefully to  be distinguished from
the soft and flabby condition, which is a kind of  transition state in the or-
dinary process of dilatation, and into which the thin and rigid cervix must
pass before it  will dilate.   The pulpy oedematous cervix is as undilatable
as the  thin and  hard.   The latter is more  frequent in primipara; the
former  occurs indifferently, and  appears  to be the result of  irritation,
caused in some cases, doubtless, by too  frequent examination.
  Besides these two varieties of undilatable os uteri,  a similar  state may
be produced by cicatrices and the consequences of previous injury.
  396. Treatment. — If the case were left alone,  in  the majority of in-
stances I have no doubt that the action of  the uterus would overcome the
obstacle, at the expense, of  course, of considerable fatigue, and when the
pelvis is large  enough to admit the head covered by the cervix, of some
risk from pressure: but  in a few cases,  the os uteri resists all  the force
brought against it, and circular laceration of the  cervix takes place.  Dr.
Merriman records such  a case  occurring in the  practice  of Mr. Scott of
Norwich, and  two  others have been  published  by Dr. Evory Kennedy,
and one by Mr. Power of this city.   Within a few  weeks I have  seen a
similar one, and Mr. Lever, Dr. Davis  and Dr. Re.ardon have since re-
corded  each  another.   In  my case the pelvis was  large, and  the head,
covered by the cervix, descended into its cavity; and I believe the lacera-
tion was as much owing to the  pressure of the  cervix between the head
of the  child and the brim of the pelvis,  as to the expulsive force.
  Although these cases  be rare, yet as we possess the means of relieving
the condition of the os  uteri, it  is our duty in  all well-marked cases to
avoid the risk, taking care, however, not  to confound the early and normal
condition of the parts with  the state we  are describing.
  The most effectual  remedy is  the loss of blood, nor need we fear that 
TEDIOUS LABOUR.
245
this will produce an unfavourable  effect  upon  the  patient.   Dr. Dewees
recommends it even with delicate women ; in one case he took away two
quarts of blood, and the patient did well.  Dr. Davis has taken between
30 and 40 ounces;  but it will not in general be necessary to abstract  so
much.   Neither ought we in any case to bleed  in anticipation of the dif-
ficulty, as has been  advised.
  In most cases of  rigidity, fourteen or sixteen ounces rapidly taken from
an ample orifice in the arm will be sufficient, and  if it make the patient
feel faint, so much the better ;  after which, if she be much fatigued, rest
may be procured by means of an opiate; and  this  will generally be  suc-
ceeded by a softened, yielding condition of the parts.
  397.  Should the vensesection only partially succeed, however, or in case
it be not desirable to have recourse to it, we may then try the tartar emetic,
which I believe was first used in these cases  by Dr. Evory Kennedy  of
this  city.  It is an exceedingly valuable  remedy, perfectly safe, and  very
successful.   It  should be given in small doses so as to excite and keep
up a state of nausea, and it may be advantageously combined with a  pur-
gative,— take for instance the following formula:  R. Magnes. Sulph. §i;
Infus. Sennae sviifs; Antim. Tart. gr. iii;  Syr. Zinzib. 3fs.   M. capiat
cochlearia duo omni semihora, vel omni horn.
  Emetics were recommended by Lovvder, and by many others since his
time, founded on the observation, that the spontaneous vomiting in labour
is almost always followed by relaxation of the os  uteri;  but as the same
benefit results from exciting nausea, it is much better to avoid the shock
of vomiting.   Opium has been used to  suspend uterine action ; but it is
far  more effective when given  after bleeding.  Tobacco enemata have
been proposed and  tried ; but their effects are  so uncertain  and occasion-
ally  so formidable, that their use is  hazardous, and to  be deprecated.  Dr.
Dewees says that they do not succeed in softening  the cervix.
  Belladonna was recommended by Chaussier, from its effects in relaxing
sphincters;  but there are very  serious objections  against  its use.  Dr.
Rigby states, " for  our own part, we must confess, that although we have
seen this application tried repeatedly, it has  never produced the desired
effects;  but  has invariably brought on very troublesome and distressing
symptoms, such as sickness, faintness, headach, vertigo, &c."
  French practitioners are in the habit of using mucilaginous injections,
after the recommendation of  Gardien, nor is there  any  objection to them,
although I cannot say I have seen much good  from them.  The hip-bath
was  tried by Dr. Dewees, but without adequate benefit; it weakens the
patient, and  may possibly give rise to hemorrhage.*
  * " In practice," remarks Dr. Lever, (Lond. Med.  Gaz. Nov. 1849,) " we find women, who
have  suffered in early or unmarried life from one of the forms of dysmenorrhoea,  when
pregnant and  in labour, with the os uteri thin, sharp, knife-like, so that its edge is
scarcely to be  felt—in fact, is often overlooked by the unpractised finger.  The suf-
ferings of the patient are intense; the dilating stage of labour is protracted ; and, if
untreated or unrelieved, by the time  the os uteri is dilated nature is exhausted, uterine
effort fails, and such a case is frequently terminated either by the  forceps or by cranio-
tomy.   In most cases, these evils may be  averted by the timely employment of opium,
and the best mode of securing its good office is in the form of enema.
  " We occasionally find the first stages of labour rendered tedious by  a hardened, un
dilatable condition of the os uteri, in women who have suffered from chronic inflamma-
tion of the neck of the  uterus, or those who have worn mechanical contrivances for the
purpose  of supporting  the viscus,  and in those who, from disease,  imaginary or real,
have been submitted to  the influence of some escharotic, at the present day by far too
                                 v2 
246                       TEDIOUS  LABOUR.
   398. I believe we  shall  rarely, if ever, fail  in  softening the cervix by
some one of the remedies I have recommended, and I must beg leave to
enter my protest against more active interference, except in such extreme
cases as that related by Mr. Lever, in which the rigidity of the os uteri is
insuperable notwithstanding an ample trial of strong pains  and the usual
remedies; in such cases incision of the cervix maybe necessary and suc-
cessful, as in Mr. L—'s  case.   Dr. Smellie advised gentle dilatation of
the os uteri as well as of  the vagina, and he has been followed more re-
cently by Doctors Hamilton and Burns, but opposed by the highest English
authorities, and by all without exception, I believe, in this country.  I do
not deny that dilatation may thus  be effected; but I believe it to be haz-
ardous in skilful hands,  positively dangerous in  unpractised  ones, and
unnecessary in  all cases.
   399. Excess  of Liquor Amnii. — It occasionally happens  that  the se-
cretion of liquor amnii is in  excess, most probably in consequence of some
inflammatory state of the amnion : at least the researches of M. Mercier
and others' seem to favour this  opinion.  In other cases, a considerable
quantity of fluid is found between the amnion and chorion, thus  adding
to the  bulk of the  contents  of the uterus.  This state of  over-distension
involves no danger to the mother, though it certainly impairs the force of
the uterus, and  so prolongs the first  stage.   I  may  add that the child is
often still-born or diseased.
   400. Treatment. — We must  be cautious in  assuming this to be the
cause of delay,  and temporise until experience has proved that the  uterine
action is deficient.  If necessary, rest may be procured by opium, and if,
after that, there  is no improvement, and the uterus be unusually large, the
membranes may be ruptured ;  after which the pains become stronger and
more frequent.   Before we do this, however, we  must be  sure  that the
os uteri is dilatable, and the presentation natural.
   401. 4. Toughness of the membranes.—Generally  speaking, the  mem-
branes yield to  the pressure from  above about the time when the os uteri
is fully dilated ; but this is not always the case.   They sometimes  remain
entire  until protruded through the external orifice,  but  in  these cases
without causing delay; in other cases their adhesion to the uterus is more
firm, and they neither break nor protrude, but of course occasion  a pro-
commonly practised.  This condition of the os uteri needs no  description; the suffer-
ings of  the patient are excessive  and protracted, and, if unrelieved, may be followed by
results serious to mother, and fatal to child.  In addition to  blood-letting, applicable to
some cases, to the  warm bath, of immense value, to the exhibition of antimony and this
is of the greatest service, we find, when the latter has been exhibited, and has produced
its desired  results, relaxation  of the os uteri, and  increase of discharge, that opium,
given in a full dose, will render these permanent, and thus prove a most valuable agent
in completing a safe delivery.
  " Opium has been recommended most strongly in cases where the os uteri is callous;
but if the callosity depends upon  previous injury,  or is the result of disease, its value, in
my opinion, depends upon its power to curb uterine action until vaginal interference
removes the obstruction to the passage of the foetus.  But there is another condition
of the os uteri in  which opium acts, and like a charm:—in women who have suffered
from irritable uterus, where the vagina is generally dry and  hot, although not over-
sensitive; but the  moment the examining finger touches the os uteri, the patient shrieks
out shrinks from the attendant,  and by her cries and motions evinces the sufferings she
endures.  In addition to subsidiary measures, as the warm bath, the injection of lin-
seed tea into the vagina, great benefit is to be derived from the use of opium, either by
the mouth or by the rectum ; the latter mode of employment being the one I prefer." —
Editor. 
TEDIOUS LABOUR.
247
longed  first stage, because the liquor amnii which is  retained, prevents
the more forcible  contractions of  the uterus.
   402.  Treatment.—The delay should never, on slight grounds, be attri-
buted to this  cause, and not  unless the pains are active, and the os uteri
perfectly dilatable: when no doubt remains, the remedy is obvious, viz.
to rupture the membranes.
   403. 5. Premature escape of the Liquor Amnii.—This may occur from
weakness of the membranes, from violence, accidents, or careless  exami-
nations, and as the early dilatation of the os uteri is effected mechanically
by the  " bag  of the waters" acting as a wedge, its  absence will  delay the
operation by  making the head of the  child the dilating power, for which
it is by no means so well suited.
   404. Treatment.—If the pains be active, and the os uteri not rigid, all
that is necessary is  a little patience, as it  is merely a question of time,
involving, it is  true, longer suffering to the mother, but no danger to her
or her  child.   In all such cases,  an early examination should be made, in
order that no time may be lost, if the presentation be abnormal.
   If the  os uteri be undilatable, and with first children it is not unusual
under the circumstances, the remedies  already recommended (§  395-6)
for such a state of the parts must be employed.*
   405. 6.  Obliquity of the uterus.—The uterus may acquire an inclina-
tion one  way or the other during pregnancy, from different causes, so as
to affect the progress of the first  stage, by destroying the unity of  axis of
the uterine cavity and  pelvic brim, so that the  head of the  child is not
applied in a right direction to the brim.
   Thus the position in  which the patient lies during pregnancy, may give
the uterus an inclination to  the right or left, and the relaxation  of the
abdominal parietes may cause " pendulous belly."  I have no doubt that
obliquity may cause delay; but it is far less frequently the case than was
supposed  by Deventer, who first pointed it  out  to  his disciples.  Dr.
Denman, who  objects to Deventer's opinion, remarks, nevertheless, that
" it must, however, be  allowed,  that some labours are procrastinated by
the mere oblique position of the os  uteri."  Dr. Wm. Hunter very truly
remarks,  " As far as I have been able to  observe, the mere obliquity of
the uterus never occasions so difficult  a labour, as  to require any artificial
arrangement to bring the os  uteri into a proper situation.   In such cases,
as in many others, art can do little good, and patience will never fail."
   The mal-position of the os uteri will be detected on making an exami-
nation  : it will be found at one extreme of the transverse diameter of  the
brim, or close to the sacrum;  and when our attention is thus excited, an
examination of the uterine tumour will decide upon the existence of  the
obliquity.  The mere deviation of the os uteri from its ordinary situation
is not sufficient, because that will soon be  altered by the pressure of  the
   * As  Dr. Lever very correctly remarks (op. citat.), the too early escape of the liquor
amnii, in addition to depriving us of the efficiency of  the bag of water to prepare the
way for the passage of the child, causes the latter to be brought into close contact with
the walls of the uterus, which is therefore abnormally  stimulated, while the head is
brought into direct contact with the os internum, the most sensitive part of the uterus;
not only is the labour, in consequence, rendered more  tedious, but also more painful,
while the birth of a living child is rendered more doubtful.  Here the  well-timed,
cautious, and judicious exhibition  of opium controls excessive uterine action, alleviates
pain, and gives  a better security for the welfare of the child.—Editor. 
248                       TEDIOUS LABOUR.
pains, if the axis of the uterine cavity be  in accordance with that of the
brim.
  406.  Treatment.—Although I do believe that the completion of the first
stage may be  delayed by lateral inclination of the uterus, I cannot but
agree with Dr. Hunter that little is necessary except patience; the uterine
contractions tend, as we  have seen, to bring the  axes  into accordance,
and this may be aided by placing the  patient on the side opposite to the
inclination.  I do not think that interference with the os uteri is ever jus-
tifiable.
  Few practitioners, I fancy, will doubt that in  an aggravated case of
anterior obliquity, or " pendulous belly," the deviation  from the proper
direction must be a serious difficulty, and one that patience alone  is not
likely to remedy.  In these cases it is customary and very useful to place
the patient on her back, at least  till towards the  end of labour; but in
some cases this alone is not sufficient.   " We have found," says Dr. De-
wees, " more than once, in cases of extreme anterior obliquity,  that it is
not sufficient for the restoration of the fundus that the woman be placed
simply on her back: but we are obliged to lift up and support by  a pro-
perly adjusted towel or napkin, the pendulous belly, until the head shall
occupy the inferior strait."  I believe that this will be  sufficient  in  all
cases ; but a very  high  authority, M. Baudelocque, practised further
manipulation; in a case of the kind he attended, after placing the patient
on her back, he  says, " I  raised the abdomen with one hand to diminish
the  obliquity of  the  uterus ;  while with two fingers  of the other, after
having pushed back the  child's  head very little, I was  able to hook the
anterior edge of the  orifice of the uterus, to bring it towards  the  centre
of the  pelvis, where  I kept it during  a  few pains; and  then permitting
the woman to bear  down with the little strength  she had left,  she was
delivered in the  space of a quarter of an hour."
  407. There is a certain condition of the os uteri, the result probably
of some obliquity, although it is  not externally perceptible, which causes
considerable delay in the first stage.   I allude to those cases where, in the
progress of the dilatation  of the os uteri, its anterior lip is caught  between
the  head and the symphysis pubis and its  retraction prevented.   It may
also result from the unequal dilatation  of the anterior and posterior  halves
of the  cervix, as in  some cases, I have  found on examination during a
pain, that although the posterior lip was dilated and retracted, the anterior
was  drawn still more tightly over the crown of the head.  However pro-
duced, the effect is a delay of some hours in the first stage.   Dr. Hamil-
ton was  the first, I  believe, to call the attention of the  profession  to this
peculiarity.
  408. The remedy is simple: during an interval between the pains the
os uteri is soft and dilatable, and it is very easy with one  finger to push
the anterior lip over  the  crown of the head; and having done  this with
great gentleness, it should be maintained there by steady pressure  during
die next two or  three pains.  It will  soon be felt retracting whilst con-
tracting, and then it  will  slip  over the head altogether.   After this diffi-
culty is removed, the labour will proceed more rapidly to its termination.
  When the head fills the pelvis very tightly, it is not easy, nor in some
cases possible to raise the anterior lip, on  account of the want of space;
and  as no force  should be used, we are compelled in such cases to trust
to the gradual predominance  of the expulsive force over the  resistance. 
TEDIOUS  LABOUR.
249
And when the lip of the os uteri becomes  oedematous from the pressure,
or inflamed, as  is not very uncommon, it will  require  great  gentleness;
in fact, if not easily raised, it had better be let alone.
   409. The causes already enumerated may be considered natural ones,
which, in general, can neither be foreseen nor prevented; but we are not
to forget that delay in the first stage is frequently the  result of mismanage-
ment.  Thus  the use of  cordials on  the plea of supporting the strength,
keeping the room hot and close, putting the patient to bed too  soon, en-
couraging her to make  efforts prematurely, injudicious  attempts at assist-
ance, omitting to evacuate urine, &c, will  all  act upon  the  labour, and
retard its progress.   A well-instructed nurse will  avoid  these  mistakes;
but we may be called in after the effect has been produced, and then  a
little common sense will be our best guide.*
   410.  These causes all act upon the first  stage of labour, and although
they offer a certain amount of obstruction, and make the labour other than
a natural one, none are of such a kind as  to prevent its being completed
by the natural agents.
   Again, we have seen that the  delay is attended with no ill effects to the
mother, and little if any  to the  child; that at  most it occasions a degree
of fatigue, weariness,  and  exhaustion  (which  is soon  repaired); conse-
quently, whilst this is a sufficient warrant for endeavouring to remove the
cause, it does not justify our attempting to hasten the labour, merely be-
cause the first stage is tedious.
  . I would recommend to my readers a careful  perusal of the controversy
between  Drs.  Hamilton and Collins,  as throwing much light on the man-
agement of the first stage.    It will be found in the Dublin Journal  and
Medical  Gazette for 1839.
   * Labour  is occasionally rendered tedious, during its first stage, by the occurrence
of irregular  and spasmodic pains.  " They are recognised,"  says Dr. Lever (op. cit.),
"by their acuteness, by the want  of consentaneous action in  the uterine fibres — some
portion of the uterus, during their continuance, being hard and contracted,  while the
other portion is soft and yielding ;  there is  also no distinct or regular interval of time
between the paroxysms of pain.  If untreated or unrelieved, the strength of the patient
is exhausted before the establishment of true labour pain; or, the child, which at the
commencement presented normally with the head, may even have its position changed
to that of the shoulder, in consequence of the uterus contracting on one side only, and
thus forcing  its contents over to the uncontracting or yielding side.  In such cases, the
utility and value of opium are most marked.   It may be exhibited by the mouth or per
anum.  It will calm the spasm, subdue irregular action, alleviate pain, procure sleep;
and after this, true and regular uterine action will be established.  Manifold are the
instances of  its value I have witnessed under such  circumstances."—Editor. 
CHAPTER VI.
         PARTURITION. —CLASS II. UNNATURAL LABOUR.
                  ORDER 2. POWERLESS LABOUR.

  411. Definition.—The labour is prolonged  in  the second  stage by
causes which act on the uterine power primarily or secondarily, rendering
the pains feeble and  inefficient, or totally suppressing them.  In conse-
quence of the stage at which the delay takes place, certain symptoms
arise which render speedy delivery imperative.  The pelvis is sufficiently
roomy.
  412. We have just seen that delay in the first  stage of  labour is  unat-
tended with serious  results  to the mother, and very rarely to the child,
and we remarked that although feeble, the pains recur regularly; that the
labour advances, though slowly; that the  strength  is not  seriously im-
paired, though temporary fatigue may be  induced;  that there is  no fever
or local inflammation;  that the vagina is  cool and moist;  the  evacuation
of urine  and fasces easy; that there is no abdominal tenderness; and
lastly, that  even if unaided, the labour will be completed by the natural
powers.
  413. Symptoms.— We have now to investigate the effects of delay in
the second stage ;  and we shall find them very different.   For a time the
second stage may continue without any bad symptoms, even though un-
usually long, nor can we  fix a  definite time, after which  they are  deve-
loped ; I have known them occur after eight hours, or not until twenty or
twenty-five hours have elapsed;  but  in general,  there are symptoms of
constitutional suffering after the second stage has exceeded twelve or four-
teen hours.
   The pains, which had been regular and powerful, are observed  after this
period to become irregular, both as to recurrence and force ;  for a  while
they may be more rapid, and  then return less frequently, and evidently
with far less effect.   They may continue to grow  weaker until  the charac-
teristic bearing-down effort ceases altogether ;  and with equal suffering we
have the  loud outcry and slight force of the first, just as though the labour
had retrograded.   In some cases the character only of the pains is changed,
and not their frequency ;  in others, they return at lengthened intervals.
   414.  Other symptoms accompany or shortly follow this break-down of
the uterine action ; the shivering which was mentioned as a symptom in
natural labour, often  becomes extremely severe, so as to resemble a slight
convulsion ; the vomiting becomes more frequent  and distressing, ami
green or  bilious matters are ejected;  the  patient  is  restless, throwing her
arms about, and repeatedly changing her position ; the skin is hot, whether
moist or  dry; the  pulse rises,  and continues from  one hundred to one
hundred and forty;  the  tongue  is dry, loaded,  and furred, with sordes
about the teeth; the  mind  is disturbed, fearful, and despondent: the va-
gina  is hot, and, as well as the os uteri, tender to  the touch ; the  bland
mucous discharge is changed to a vellow or brownish colour, and is  some*
                                                       (250) 
POWERLESS  LABOUR.
251
times, though rarely, acrid or foetid;  and the pressure of the child's head
prohibits the evacuation of the bladder.
  415.  These symptoms  succeed each other much in the  order in which
they are enumerated, if the patient be not relieved; of course they vary
in degree, and in many cases some are absent; but sufficient will be pre-
sent in every case when  the second stage is excessively prolonged, to
characterize the labour.  Should the patient be so unfortunate as to obtain
no assistance, the  case goes on from bad to worse, all the symptoms are
aggravated, and new and most formidable ones are added.   The vomiting
becomes more frequent, and the matters ejected are dark-coloured; the
abdomen becomes tender, the jactitation and restlessness ungovernable,
the pulse rapid and feeble, the  skin covered with cold clammy sweat, the
tongue brown and dry; the patient  falls into a state of half-stupor, with
low muttering delirium, and ultimately death closes the melancholy scene.
   In all such cases the child is in great jeopardy, and unless the woman
be timely relieved, it will  be lost.
   That these symptoms do really arise when the second stage of labour is
protracted, from whatever cause, will not be questioned  by those whose
experience among the mismanaged  poor has been extensive ; and there
can  be no doubt that they would arise in similar cases among the higher
ranks,  were not the assistance of art enabled to anticipate  them.
  416. Causes. — I  do not profess  to be able to explain  why this series
of alarming  or fatal  symptoms should result from  delay in the  second,
rather  than in the first stage of labour; it may be that the first stage is a
more local, the second a more constitutional process; that in the latter the
different systems of the body (vascular, nervous, muscular, &c.) are deeply
involved, and that a return to their natural state, without the removal of
that which occasioned their implication, is impossible; or we may say,  if
we prefer, with the Arabian writers, that it arises " ex lege natura," that
the process must be fulfilled, or the lives of mother and child be sacrificed.
Whatever  form  of expression we  use,  the fact remains  the  same; the
symptoms which arise from delayed  second stage differ from those in the
first, and the case  may terminate fatally if unaided.
  I  have stated that these  symptoms arise because of the delay in the
second stage, and that they are the same, no matter what be the cause of
the delay.   It may be occasioned by some peculiar condition of the uterus
itself, by obstruction in the soft parts, by deformity of the pelvis; but still
we find the same series of symptoms.  As the treatment differs according
to the cause, I shall  in this chapter  refer only to those which affect the
uterus  itself,  taking the phenomena which result as the general type.
  417. Inefficient  or powerless condition of the uterus in the second stage,
as in the first, may be the result of  various circumstances, such as wTeak
constitution,  mental  emotion, disease, &c.  Women of a weak constitu-
tion, especially in  their first confinement, not unfrequently find  the uterine
powers fail, after  some hours of endurance, and that without our being
able to restore them.   These are the cases, and these only, in which there
is anything to fear from a prolonged  first stage ; for the exhaustion pro-
duced  by it, and which in healthy women is of no consequence,  may be
the cause of  inefficient uterine action in the second stage.
  In women of an irritable nervous  temperament, there is also occasion-
ally a failure  of uterine powers in the second stage. 
252
POWERLESS  LABOUR.
  Mental emotion, though it has less influence in the second  stage than
in the first, may nevertheless  suspend the power of the uterus; and al-
though in most cases it returns after an interval of freedom from pain, yet
in others it does not, and bad symptoms set in.
  Disease of the uterus, even when offering no  physical impediment to
delivery, may yet so interfere with the joint action of the muscular fibres,
as to render  the  pains of little avail.  Whilst this is confined to the first
stage, it is of little import; but the uterus may complete that  stage, and
yet  be seriously affected by  the  continuance of the same cause  in the
second;  then the consequences are more  serious.  Thus rheumatism of
the  uterus, which so often stimulates  the false pains and aggravates the
suffering of the real ones, may at length interfere with the forcing pains,
so much as to detract from their efficiency, or to render them  almost nu-
gatory.
  Again, tumours in the uterus offer a mechanical impediment to the con-
traction of the organ, besides their interference with the conjoint action
of the fibres, and in some very rare cases, they have been known to render
the  labour powerless.
  Other uterine affections acting upon a certain condition of the constitu-
tion, may render the organ unfit  or unable  to  complete the  process of
delivery, and the delay being in the second stage, the symptoms already
described will be developed, though the time at which they appear varies
very much.
  I need not say that mismanagement will greatly aggravate this tendency
in all cases;  and in some, good and judicious care may possibly avert it,
  418.  Treatment. — The cause  of the  bad  symptoms of powerless
labour is, as we have said, the delay in the second  stage, but the reason
of our interference is not the  delay, but the urgency of the symptoms, so
that if the labour should  be prolonged, and no ill consequence arise, we
should not be justified in interfering further than to remove the cause.
  Of course  a case of powerless labour presenting  the  formidable array
of symptoms I have described, will very rarely occur in the hands of a
judicious practitioner, as he would previously decide upon the propriety
of interfering ;  but we may be called to consult  upon such cases.   Our
duty then, will  be to examine the condition  of the  patient carefully and
minutely ; the pulse, tongue, head, abdomen, and, above all, the genital
system, so as to appreciate correctly the present state of the patient;  and
not this only, but we must calculate  as  accurately  as possible from the
history of the symptoms, duration of the labour, &c.  the rate at which
the  patient is running down.  These investigations are for the  purpose of
solving three important questions.—1. Whether interference be necessary.
2. What mode  of interference is preferable:  and 3. The best time for
interference.
  419.  1. The necessity for terminating the  labour is grounded almost
solely upon the condition of the  mother.   If we find the pulse perma-
nently quickened (say 100 or upwards), a  degree  of fever present, the
head not advancing from the pains having lost their force, with more or
less of the other symptoms I have described, we may  be pretty certain,
either that the natural efforts will not terminate the labour; or, supposing
tnat possible, the condition of the patient will be so much deteriorated in
the time required, as to render the delivery by the  natural powers more 
POWERLESS  LABOUR.
253
dangerous than the employment  of art.   In forming a conclusion upon
this point, the estimate  of the " rate of progress" of the  labour will  be
of great value.
  420. 2.  The time at  which we ought to interfere will depend chiefly
upon the  rapidity of the  accession and increase of the unfavourable
symptoms, and also upon the condition of the child.   For example, if
the patient be getting rapidly worse, and the bad  symptoms  increasing
formidably, the only object will then be to determine upon the quickest
mode of delivery : but, on the other hand, if her state be less threatening,
demanding  less  promptitude, then we may take  into consideration the
condition  of the child, and according as we believe it to be alive or dead,
we may venture upon a short delay or  deliver immediately.
   I have already enumerated in detail (§261) the signs of the life or
death of the  child: the most important of which are, the  results of aus-
cultation, the movements of the child felt  by the  mother, and  the elastic
feel of the integuments  of the head.   The positive evidence of the  first
two, is quite conclusive ; i. e. when the fcetal heart is heard or the move-
ments felt, there  can be no doubt that the child is alive; but their negative
evidence  is  not  so  conclusive.  We  may conclude that the child has
died during labour, if after having heard the pulsations of the fcetal heart
distinctly, we have found them gradually become weaker, and at length
permanently  inaudible ;  if the movements,  at first lively and  distinct,
have ceased ; and if the tumour of the scalp has  acquired a flabby em-
physematous feel.  The feeling  of the cuticle is valuable, but rather as a
proof of  the child  having been dead some  time.   Now  what is the
practical use to be made of  a knowledge of the  child's being living or
dead?  1. If the child  be dead, there need be  no delay;  the  moment
we are satisfied either that the natural powers will not be able to terminate
the labour, or that the condition of the mother demands assistance,, we
may instantly interfere,  and we are free to consider the mother's  interests
only as to the mode of doing  so.  2. If the child  be  living, and the
symptoms not very urgent, a short delay  may be allowed, so  as to give
fair play to the natural powers ; or if  immediate relief be desirable, wre
should give the child a chance if possible, by employing means which do
not necessarily involve  its  destruction.   But  I  would repeat, that the
saving of the mother's life being our first object, if the symptoms demand
it,  we must  discard all consideration  of the child, even if it be  alive;
although this must not be done without seriouS deliberation.
   421.  3. The modes of delivery at our command are, 1, the vectis; 2,
the forceps;  3, the crotchet.  We may lay it down as an  axiom that that
method of delivery is best, by which labour can be terminated most easily,
and with the greatest safety to the mother and  child..  If there be space
enough between  the fcetal head and the pelvis, the vectis may be tried, as
a tractor;  but the forceps is a much better  instrument, for if it  can be
applied without force (and in  no other case should it ever be attempted), we
hold the power of delivery in our own hands, and  unless the patient be
too for gone or the operator deficient in dexterity, but little  time will be
lost and  no mischief be done  to mother or child.  Even  taking  the
statistics among the poor and worst managed part of the community, the
mortality to the mother is 1  in 21, and to the  child 1 in 5, which is less
than that attendant upon other operations.
                                 w 
254                    POWERLESS LABOUR.
  I have therefore no scruple whatever in recommending a trial with the
forceps  before using the crochet, in every case where there  is  sufficient
space,  except where  the  child  is dead,  or wrhere  extreme dispatch  is
necessary.
  If the state of the  mother preclude all consideration for the child,  or
if it be  dead, then the perforator and  crochet may be used, the great ad-
vantage of this operation being  the facility of delivery when the bulk of
the head is reduced, and its disadvantage, the damage done to the child.
I shall speak more in detail about these operations by and by.
  422.  If the case be  from the beginning under our own care, and our
interference be well-timed and ably executed, in all probability the patient
will recover well; but  if she have been neglected and allowed to run
down before  assistance  was rendered, unpleasant consequences may fol-
low, as, for instance, the nervous shock may be severe or even fatal; the
patient  sinking twelve  or  twenty-four hours after delivery, without ever
rallying after the operation.
  Again, from the long-continued pressure of the head of the child upon
the soft tissues of the pelvis,  inflammation may  arise, and unless subdued
may terminate  in abscess  between the vagina and rectum; in  slough-
ing of the vagina with or without perforation of  the  bladder or rectum ;
or the contusion of the  parts may be so severe  as to cause the  patient  to
sink; or lastly, peritonitis or  hysteritis may be developed somewhat later.
  Such serious consequences, which  are. unfortunately but too frequent,
indicate the necessity not  merely of terminating  the  labour by judicious
and timely aid, but also of attending minutely to the local condition of
the patient for some time after delivery.    Especial directions should be
given to the nurse to  syringe  the vagina two  or three times a day with
tepid milk and water, to bathe the external parts  with a weak mixture of
spirit and water, and to place between the labia  a strip of lint smeared
with simple cerate, and if necessary we should satisfy ourselves by a care-
ful examination as to the state of the parts.  If  much inflammation arise,
a large soft poultice of linseed meal, or " stirabout," may be applied over
the external parts, and black  wash to the  vulva.
  I must beg of the reader to re-peruse the chapter on abnormal conva-
lescence, in connection with this and some of the  subsequent chapters,  as
the deviations therein  described  occur  most frequently after the most
dangerous labours.
  423.  Before concluding*this chapter, I would wish to allude  more dis-
tinctly than I have as yet been  able to do, to  an interesting though not
numerous class of cases, exhibiting the symptoms more or less intense of
powerless labour, with the  exception of  the  inefficiency of the pains.
The pulse is rapid,  the patient very feverish, the head may be affected  or
the abdomen tender, &c.; yet  the labour, though sufficiently  tedious  to
give rise to these  symptoms,  does actually advance and may be completed
by the  natural efforts, but  at a serious expense to the mother, and great
iisk to the child.   I was called  to such a case  some short time ago; the
patient was allowed to deliver herself, and she died of the shock in a few
hours.   The local  injury already described is also  more frequent after
these cases than even after those where assistance has been given.
  I know not any cases in which the physician has more need of all the
tact and judgment which experience only can give, nor any more difficult 
OBSTRUCTED  LABOUR.
255
to describe in a book  so clearly as to  guide the junior practitioner, than
such as these.   The  natural powers  are not inadequate to the delivery,
yet bad symptoms are present, the danger imminent, and greatly increased
by delay.   On  the  one hand, we have to guard against unnecessary in-
terference, and on the other, against the evils of hesitation when assistance
is required.  As it is clear, that the possibility of the labour being finished
by the natural powers alone, is  not in itself a prohibition of all interfe-
rence, I can only repeat that the necessity for our aid, and the time when
it ought to be given, must be deduced from a careful estimate of the pre-
sent symptoms, and the rate at which they have been developed, and if
we find that the probable time required for the completion of  the labour
will be so great as to add to the  patient's risk, then ought we undoubtedly
to put in requisition all our resources for her liberation.
                          CHAPTER VII.

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

   424. Definition. — The progress of the labour is impeded by some
 mechanical obstruction in  the passages, connected with the soft parts,
 which by causing delay in the second stage, leads to the development of
 the symptoms of powerless labour.
   425. Symptoms. —In  the last chapter I stated that delay in the second
 stage of labour gives rise to  a certain series of formidable symptoms, no
 matter what be the cause of delay;  and we there considered such causes
 as act upon the uterus, impeding its action or diminishing its force.  In
 the present chapter we shall investigate certain other causes of delay, such
 as are found in the soft parts of the passages.
   The symptoms in  the two orders will be the same, if the amount of
 delay be equal; but  there is this difference from the commencement, that
 in obstructed labours, the uterine  action is intact, nay,  perhaps  more
 vigorous than usual, but  ineffective in proportion to the magnitude of the
 obstacles.  If they  be not very great, the augmented force brought to
 bear upon them may be successful; if they be considerable, delivery may
 be impossible without assistance ; and lastly, in some  extreme cases,  de-
 livery "per vias naturales" may be impossible.
   Making allowance for  different constitutions, the  symptoms developed
 during the progress of labour will be in proportion to the prolongation of
 the second stage, as laid down in the last chapter.   It will be remarked,
 however,  that some of the causes I am about to enumerate, act upon  the
 first stage.  They certainly do prevent its completion, and by rendering
the progress of the labour mechanically impossible, do really give rise to
the unfavourable symptoms, and  so far may be taken  as an exoeption to
the conclusion that no  evil  arises from a prolongation of the first stage.
However, I believe that in  such  cases, the first stage virtually terminates
before the bad symptoms set in,  for  I have  repeatedly found  that where
       17 
256
OBSTRUCTED  LABOUR.
the physical impediment exists  at the brim, whether it be a tumour or
distortion, the os uteri is fully dilatable, the membranes broken, the cha-
racter and force  of the pains changed as usual, &c.;  in short, a transition
is observed from the local and general condition of the first stage, to that
of the second.
  426.  Causes. 1. Minute or imperforate os uteri.—There are cases on
record in which  before labour, or even for some time after its commence-
ment, no os uteri could be detected.   Mazzoni mentions having observed
such, and Dr. Campbell relates two examples:  "Both were  first preg-
nancies ; in the first, uterine action continued about  twelve hours before
the os uteri could be distinguished, when it  felt like a minute cicatrix.
The second woman had regular pains for two nights and a day before the
os tineas could be perceived, and she suffered so severely as to require
three persons to  keep her in bed.  Both patients were largely bled, gave
birth to  living children,  and had a good recovery." '  1 was myself called
to a case in which the os uteri was not discoverable until after forty hours
of labour, and then it felt about the  size of a small crow-quill;  notwith-
standing the  delay and  obstruction,  however,  the patient was  delivered
naturally, of a living child.
  As the effect of  disease, the os uteri may be contracted, and its oppo-
site  edges become adherent, so as  to close  it  partially or completely.
Again, the os uteri may be diminished and the cervix rendered undilatable,
by cicatrices, the result of former injuries.
  Lastly, a few  cases are on record of total absence of the os uteri, as in
a case which came under the care of my friend Dr.  Ashwell, and which
he has described in Guy's Hospital Reports, it was found necessary to
make an artificial opening with the knife : the labour terminated favour-
ably.
  The amount of delay from this cause varies, but it may be very consi-
derable, and the symptoms will be in proportion.  " We  may suspect,"
says Dr. Rigby, " that the protraction of labour arises from  agglutinated
os uteri, when at an early period of  it, we can discover no vestige of the
opening in the globular mass formed  by the inferior segment of the uterus,
which is forced  down deeply into the pelvis, or at any rate when we can
only detect a small fold  or fossa, or merely a concavity, at the  bottom of
which is a slight indentation, and which is usually a considerable distance
from the medium line of the pelvis.   The pains come on regularly and
powerfully, the lower segment of the uterus is  pushed deeper into the
cavity of the pelvis, even to its outlet, and becomes so tense as to threaten
rupture ; at the same time it becomes so thin, that a practitioner who sees
such a case for the first time,  would be induced to suppose the head was
presenting, merely covered by the membranes.   After a time, by the  in-
creasing severity of the  pains, the os uteri at length opens, or it becomes
necessary that this  should be effected by art;  when once this is attained,
the os uteri goes on to dilate,  and the labour proceeds naturally, unless
the patient is too much exhausted by the severity of her labour."
  427   Treatment. — Our first object is to see what the  natural powers
will be able to effect; for which purpose the patient must be managed as
in natural labour, and allowed to continue her efforts for some time ; there
is no danger  in so doing,  as  it will be a considerable  time before  any
unpleasant symptom will arise. 
OBSTRUCTED LABOUR.
257
  If the continued pressure discover the  os uteri, but the cervix resist
still, then we may try any of the remedies  advised for " undilatable os
uteri" (§ 394), such as venisection, tartar emetic, &c, and in most cases
they will be found  useful.
  In some cases when the os uteri is more or less  closed by agglutination,
although, as Dr. Rigby observes, "die obstacle is capable of resisting the
most powerful efforts of the uterus, a moderate degree of pressure against
it, whilst in a state of strong distension, either by the tip.of the finger or
a female  catheter, is quite sufficient  to overcome it;  little or no  pain is
produced, and the appearance  of  a slight discharge of blood will show
that the stricture has given way."
  If these methods fail, we must have recourse  to the knife, and make
one or more incisions as near the  situation of the os uteri  as possible.
Moscati recommends a number of small incisions around the os uteri, for
the purpose of securing its equable dilatation.*
  428. 2. Carcinoma or scirrhus of the uterus. — Strange as  it may ap-
pear, conception has been known to take  place not only when the cervix
uteri was carcinomatous, but when it was  the seat of open cancer.  Zep-
penfeld, Siebold, Lachapelle, and others, have put such cases upon record.
The latter author records seven cases, of whom four recovered from the
delivery.   Of course such a hardened and undilatable state of the cervix
will offer a very serious obstacle to the descent of the child's head,  and
that in proportion to the extent  of the disease.   In a few instances it has
yielded to the pressure, and the child has been born naturally.
  429. Treatment.—Fortunately such cases are extremely rare ; but from
those who have been most conversant with them, we  find, according to
Bayle, Cayol, and Lachapelle, that some  have terminated without help;
others, according to Siebold, have  been delivered by version; or, accord-
ing to Madame Lachapelle, by the forceps and  by vaginal hysterotomy.
If the cervix resist all the  efforts of the uterus, I suppose we must, as a
" dernier resort," have recourse to the knife ; but it is for the sake of the
child only, as the  mother's end  will only be hastened by it, and therefore
before doing it wre  must be sure that the  child is alive.   If it be not, it
would be better to  open the head.
  430. 3. JYarrow and undilatable vagina. — In  some women the vagina
is naturally small and contracted; but this is rarely a serious obstacle to
the natural powers, unless it be the first child, and the  patient advanced
in life.
  The calibre of the vagina may also be diminished by callosities or cica-
trices, the consequences of former inflammation and sloughing, and which,
consisting of a semi-cartilaginous substance, may form rings or  spirals
around the vagina, and offer great resistance to the descent of the child.
These obstructions will be detected at once, on examination, by their hard
gristly feel and their form.
  Lastly, more or  less perfect  occlusion  of the vagina may be present,
  * The young practitioner cannot be too cautious in resorting to such operations.  la
first labours, the os uteri is not unfrequently found high up, in front of the promontory
of the sacrum, and almost out of reach of the finger. It may remain thus for man)
hours undiscovered by the inexperienced, and although it may cause much delay in the
labour, it will in time be brought into the  axis of the strait by the force of the pain?-
This may be expedited, after labour has continued some time, by drawing it  forward
with the fingers, as advised by Baudelocque (§ 406). — Editor.
                                 \v2 
258                     OBSTRUCTED LABOUR.
owing to  the  adhesion of its sides, sometimes leaving a portion of the
vagina pervious inferiorly, sometimes obliterating nearly its whole length.
  The impediment which a congenital narrowness of the vagina offers is
overcome  by patience, and pains, aided by fomentations or injections, be-
fore unfavourable symptoms arise ; but when it is obstructed by adhesions
or contractions, this may not take place.   The labour is prolonged beyond
a certain time, and then the symptoms of powerless labour (§ 412) set in,
and on examination, the cause of the delay is sufficiently clear.
  431. Treatment. — As in the  cases last described, we must wait until
experience has proved how far the natural powers are capable of overcom-
ing the resistance.  In  some cases we find, contrary to our expectations,
that after the pressure of the child's head has continued for some time, the
stricture yields, and as it were unfolds, so as to permit the passage of the
child.   In other cases laceration takes place (not without danger) and de-
livery follows.
  Should  the parts continue to resist steadily, then we must have  recourse
to bleeding and tartar emetic, which will very often  preclude the necessity
of relief by the knife.   If they fail of producing benefit within a reason-
able time, we  must  interfere to prevent worse results, either the constitu-
tional symptoms already noticed or local injury.  My friend Dr.  Doherty
has very justly observed,  in a paper read before the Obstetrical  Society,
" It is very seldom, even when a single and prominent band encircles the
canal, that this is the only mischief which has been done; for generally
speaking we have more or less puckering of the parietes, and not infre-
quently, as I have already mentioned, communications with the adjoining
viscera.   The consequence of these changes is that the canal is less able
to bear a forcible dilatation; and if the narrowed portion be permitted to
delay the fcetal head too long, a rupture of the vagina above it may occur,
even if no breach of surface already exist.  But if even a small  opening
into an adjacent  cavity be already formed, it is very likely to be converted
into a rent, which throws both chambers into one, constituting one of the
greatest calamities which can befall a woman."
  To avert such a catastrophe, we must have recourse to the knife, if the
previous remedies fail; two, three, or more incisions should be made, just
through the resisting band, if it be circular; but if  the sides of the vagina
be adherent, they must be carefully and gradually divided.   The  pressure
of the descending head will dilate the  passage.  The greatest care  must
be taken not to wound the neighbouring viscera.   The  hemorrhage may
be considerable,  and occasionally the case terminates fatally.
  Should  the uterine action be exhausted by the length of the labour, and
unfavourable symptoms develop  themselves, it may be necessary to termi-
nate the labour promptly by instruments. I  think it may be  a  question
whether, in the more aggravated cases of stricture, premature labour or
abortion ought not to be induced,  if we are cognizant of the fact at an
early period.   I  need not say that in the after treatment the most careful
attention should be paid by the accoucheur himself to the state of the
vagina, and as soon as the inflammation and tenderness subside, a bougie
should  be introduced daily, to guard against the  re-formation of the
stricture.
  432. 3. Tumours in the pelvis. — Tumours of various  pathological
characters  may form in the different  parts of the  pelvis; thus we  may 
OBSTRUCTED  LABOUR.
259
have fibrous, adipose, steatomatous, sarcomatous, and scirrhous growths,
and they may be  situated either behind  the rectum, between the rectum
and vagina, or in connexion with the proper tissues of the vagina.  Again,
the os  uteri may  give origin to a tumour, as polypus.  Dr. Denman met
with a case  of cauliflower excrescence of the os uteri.
   This is not the place for the description of these various diseases, which
I have fully discussed in a former volume.  Our object at present is to
inquire what is their effect upon labour.   The obstruction they offer to the
descent of the child's head will depend  upon their  size,  their mobility,
and their compressibility.  If small, the delay may be immaterial, and the
difficulty overcome by extra force ;  but if beyond a certain size, they may
delay the labour so long as to give rise to the unfavourable symptoms of
a prolonged second stage or absolutely prohibit the passage of the child.
But this  effect of their size is  sometimes obviated by their mobility, i. e.
the tumour  may be pushed to one side, or drawn  up out of the way of
the child, as in a case  published  by my excellent  friend, Dr. Beatty, in
which the tumour was so large, and apparently so  fixed, that Caesarian
section was  anticipated ;  nevertheless at the time of labour it was elevated
sufficiently to allow of the  birth of the child without any assistance.  In
the case  of  polypus, too, we  find that in some cases the pressure of the
child's head has detached the tumour, or  expelled it without  separation,
as related by Dr. F. Ramsbotham.   Lastly, in cases where the tumour is
too large and immoveable, it has been found so far compressible, that after
some delay  and extra compression of the child's head, the labour has ter-
minated  naturally.

                                Fig. 88.
Polypus Uteri.
  The chances in favour of the tumour being elevated or pushed  out of
the way, are increased in proportion as it is high up  in the pelvis; next
to these the most favourable situation is on one side of the promontory of
the sacrum, and the least so, in the antero-posterior diameter.   The diffi-
culty occasioned by the size is augmented by the hindrance they offer to
the  adaptations of the head and to its successive changes of position. 
260                    OBSTRUCTED LABOUR.
  433. When we have reason to believe in the presence  of any of these
tumours, a most particular investigation should be  instituted.  The ex-
amination, as Mr. Ingleby observes, "should be made in the absence of
pain, and (if possible) before the presentation has become engaged in the
pelvis, lest the tension which the mass undergoes  during strong labour
should obscure the diagnosis.  If the presentation be in part only below
the brim, it may be difficult to determine whether the  apparent firmness
of the tumour is not owing to obstructed circulation.  Whilst making the
usual examination "per vaginam," it  will be advantageous  to  pass the
fore-finger of the left hand into the rectum with a view of ascertaining
more correctly the contents of the tumour." *
   434.  Treatment. — If, owing  to the  moderate size  of the tumour, its
mobility or  compressibility,  there is  a probability of the natural powers
being adequate to the delivery, we have nothing to do but to wait patiently;
but if the delay be so excessive as to threaten bad symptoms, or if the
obstruction  be insurmountable, we must  then afford  assistance, and the
mode will depend upon  the  size, mobility, contents, or mode of attach-
ment of  these tumours.
   Thus if the tumour be moveable, and we see the  patient sufficiently
early, we should endeavour to raise  the tumour  above the  brim of the
pelvis, as was done by Dr.  Merriman, during an  interval between the
pains, and maintain it there during the next pains, so as to allow the head
to become engaged in the brim; if we succeed, the  labour will go on
regularly; but if,  as is  most frequent, we fail, we must then  try if the
tumour be  removeable.   If it be a cauliflower excrescence or a polypus,
it will be advisable to pass  a ligature around  it, and remove it.  In the
case of polypus this has  repeatedly been done with  impunity.
   Other tumours have been removed, as in Mr.  Drew's  case of one be-
tween the vagina and  rectum, with  success; but  this is a  much  more
serious operation, and should not be  attempted until we  are  certain that
its bulk cannot be reduced in another way.
   Many of  these tumours are composed of fluid  or semi-fluid matter, and
such may be emptied by passing a trocar and canula, or by a free opening
with  the scalpel; after  which the walls of the cyst  will subside, and
allow of the passage of the  child.  This operation should always be per-
formed before we attempt delivery by operating upon the child.
   If a slight operation  upon the  tumour is likely to be  successful, there
cannot be the slightest doubt that it ought to be preferred, nor do I myself
feel that we should be justified in sacrificing the child, where there existed
any hope of being able to extirpate the tumour.
   435. But suppose the tumour be  solid, immoveable, and incompres-
sible ; then it  is clear that  our only means of delivery is to act upon the
child, and the mode will depend upon the size of  the tumour.   If it be
small, though sufficient  to  obstruct a labour attended with feeble pains,
then perhaps the  addition of extracting force by means of the  forceps may
suffice.   These cases, however, are very rare, and we must take care that
the force employed do not add to the  subsequent risks, by inducing the
evil results  of excessive pressure upon the soft parts of the mother.
   * Facts and Cases in Obstetric Medicine, p. 121.  I beg to refer the reader to this
excellent  essay, and to Dr. Merriman's paper in Med. Chir. Trans, vol. x., for much
valuable detail which I have been obliged to omit. 
OBSTRUCTED  LABOUR.
261
  If the tumour be too large to allow of the use of the forceps, or if they
have been tried unsuccessfully (extirpation being out of the question), we
have  then  no alternative but the reduction of the bulk of the child by
craniotomy, and, if necessary, evisceration.  This, however, is so painful
an  alternative, that it should never be thought of until we are satisfied
that nature is inadequate to the delivery, that the obstacle cannot be pushed
aside, nor removed nor lessened  by puncture, &c, and  that interference
has become a duty to the mother.
   Some few cases  occur in which even craniotomy will not enable us to
effect the delivery ; in which the pelvis is very nearly filled by a firm in-
compressible  tumour, as in the  case related by Dr. Montgomery, and
others.   We have  no remedy for such, except by providing an artificial
exit for the child by performing the Caesarian section ; a formidable and
very fatal operation it  is true, but which is infinitely better than leaving
mother and child to perish.   But before having recourse to it, we must be
perfectly satisfied  that no other means  affords  a  hope of success, and  I
need  hardly add, that none of these serious operations should be under-
taken without a consultation, if that be possible.
   436. 5.  Diseased ovary. — The ovary may be enlarged from disease
originating  previous  to  or during pregnancy, and not suspended by it.
The enlargement is sometimes solid, but more frequently it contains fluid
or  matter of the consistence  of honey.  If the disease  progress slowly,
the uterus with the ovaries by its side, may have emerged from the pelvic
cavity in time to remove  the obstacle, which will then be in the abdomi-
nal cavity.  But in other cases, either from the situation or rapid increase
of the ovarian tumour, or by adhesions between  it and the neighbouring
parts, it is  retained in the pelvis, and may offer serious obstruction to the
second stage of labour.   " There  are two forms  of ovarian tumour,"
says Mr. Ingleby, " which obstruct the  passage of the  child.   In the one
a small cyst in connexion with a very bulky cyst, or else a portion of a
large  cyst,  passes into the recto-vaginal septum, and bulges through the
posterior part of the vagina.   In  the other, and that which occurs by far
the most frequently, the whole  ovary, moderately enlarged, prolapses
within the septum.  The descent is peculiarly liable  to happen  at two
periods : the first, near the end of gestation ; the second during labour;
the prolapsus being promoted by the relaxation  of the soft parts.   The
changes which the ovary undergoes when long detained in the septum,
will depend upon the capacity and  yielding state of the parts.  If the
woman  have not previously borne  children,  it  may remain  small, and
scarcely retard delivery:  but under contrary circumstances, it acquires a
large  size,  and nearly fills the vagina.  In rare cases,  the bulging is said
to have  appeared at the anterior part of the pelvis.  Again, the ovarium
when moderately enlarged and  confined within the abdom&n, may alter
the course of  the gravid uterus in its ascent out of the pelvis, so that the
organ can neither preserve its perpendicular direction, nor freely develope
itself  on the side  on which  the tumour is situated, and thus the lateral
obliquity, as described by writers, is almost necessarily produced.  Al-
though  this mal-position of the  uterus  may fail directly to obstruct the
entrance of the presentation within the brim, the  axis of the organ as re-
spects the pelvis, is no longer maintained, and labour will probably prove
tedious. 
262
OBSTRUCTED  LABOUR.
  The observations made upon other tumours  in the pelvis are in most
respects applicable to enlarged ovaries.  There will be delay in the second
stage, or the head will be  prevented altogether  from entering upon this
stage, in proportion to the size, immobility, and incompressibility of the

                               Fig. 89.
Ovarian tumour.
tumour; modified in some degree by its situation.  But an ovarian tumour
is much  more likely to be moved out of the way of the child at the time
of labour, than any other, and also more apt to give way and burst under
the pressure of the head.
   The diagnosis is  not always  easy.  If the tumour within the recto-
vaginal septum be moveable, elastic, and communicating to the finger a
sense of fluctuation, it is probably ovarian;  but it is not always thus; it
may be hard, not fluctuating, and, in fact, to  the touch apparently solid.
In such cases the only test we can apply practically, is puncture.
   437.  Treatment. — We must first allow time to see whether the tumour
may not be displaced by the efforts  of nature, and also to estimate the
effects of pressure upon it, and we shall have time for this before the bad
symptoms  appear.   If the  obstacle be  insurmountable  by the natural
powers alone,  and cannot be raised above the brim of the pelvis by the
hand, we must then puncture the  cyst through the vagina, nor are we to
be deterred from this on account of the apparent solidity of the tumour,
as many such contain fluid.  A long  trocar should be  used, and plunged
quite through the parietes  of the  tumour.  If fluid be freely evacuated,
we shall have no further trouble with the labour:  if it be viscid, and do
not pass freely through the canula, the opening must be enlarged.
  But suppose the tumour should really prove to be solid,  and cannot be
pushed above the brim ; it is clear that we cannot attempt to  extirpate it
in such a case, and we must then act upon the child.  Version has been
proposed, but it  appears  to me  very  unsuitable,  it adds  much to the 
OBSTRUCTED  LABOUR.
263
mother's nsk without increasing in any degree the probability of saving
the child : the tumour would offer even a greater obstacle to the passage
of the head reversed, than in its natural position.
   If the tumour though solid be small, perhaps a little additional power
might enable the child's head to pass without injury to mother and child,
and in. such a case the forceps might be used, but I do not think suitable
cases for this instrument are frequent.
   If all these plans  fail, or  are unsuitable, we have  no resource but to
evacuate the  brain, and, if necessary, the  contents of the chest  and
abdomen, and then extract the child.
   Dr. Merriman has collected eighteen cases, and it appears " that twice
the  labour  was  effected  by the  pains,  unassisted  by  the  art of the
accoucheur; but one of these lost her life, and one  of the children  was
still-born.  Five  times the perforator  was used after a longer or shorter
duration of labour : three  of these women  died, another recovered very
imperfectly, and one got well.  Five times the  labour was terminated by
turning the child: all the children were lost, and  one only of the mothers
recovered.  Three times the tumours having been opened, the labour was
afterwards trusted to nature: two of these women recovered, but the other
remained for a long time in an ill state of health: two only of the children
were preserved.  In three cases the tumours having  been  opened, it was
still found necessary to have recourse to the perforator: one of these women
died;  one remained in  an ill state of health for eighteen  months, and
then sank under her sufferings; the third recovered.  Thus, in 18 cases, it
appears that of the women,  9 died,
                            3 recovered imperfectly,
                            6 perfectly.
          Of the children,    15 were still-born,
                            3 were alive.
   " Upon the  whole," Dr.  Merriman concludes, " the  evidence we at
present possess, is more in  favour of opening the  tumours, when  they
contain a fluid, than of any other  mode  of procedure; for of the  nine
women who recovered more or less  perfectly, five  appear to owe  their
safety to this operation, and of the children born alive, two were preserved
by the same means."
   In these cases the mortality to the mothers was very great, and though
in all cases there must be risk at the time and subsequently, still there i&
reason to hope that a cautious estimate of the value of the different means
at our command, and  a timely and judicious employment of them, will
insure a more favourable result.  In such cases it must be borne in mind
that whilst the obstacle occasions the  necessity for the operation, the  time
must be decided  by the constitutional symptoms, or, at least that assist-
ance must never be  delayed after the symptoms of powerless labour set in.
   438. With respect to all tumours of the pelvis which have rendered the
use of the perforator necessary, I would wish strongly to recommend the
induction of premature labour  in  the  next  pregnancy, at such  a period
as shall supersede the  necessity of  an  operation, provided that  the size.
situation, and density of the tumour continue the same.
   439. 6. Vaginal cystocele.—I have already spoken of the necessity of
keeping the  bladder empty, as  its  distension very often protracts  the
labour; but the effects may be more serious, if from frequent child-bearing, 
264
OBSTRUCTED  LABOUR.
the posterior and inferior supports of the bladder have been weakened, for
then it may overlap the brim of the pelvis, and be caught by the head of
the child in its descent, and pushed before it into the cavity.  Fortunately
such cases are very rare,  for their consequences may be very serious.
   The patient  will  complain of fulness, tension,  a feeling of pressing
down and dragging, with a desire to  evacuate urine frequently, and of
inability to do so.   On examination we  detect a tumour, in front  of the
pelvis, partially covering the head, and containing  fluid.   The  finger
passes easily posterior to the tumour but not anteriorly,  and the catheter
cannot be passed in the usual direction, indicating clearly  its nature.
With care, there is not much danger of an incorrect diagnosis, but if not
on our guard we may mistake it.  Dr. Merriman relates  a case where the
bladder was  perforated  on the supposition that it was a hydrocephalic
head, and Dr. Hamilton  used to mention one in his lectures, where it was
mistaken for the bag of the waters, and punctured.
   No doubt a bladder sufficiently distended and prolapsed must occasion
difficulty and delay in the second stage, but the danger to the mother from
the rupture of that organ is at least equal to the risk of mischief from the
delay.
                                Fig. 90.
  440.  Treatment. — This double danger renders it necessary that when
we are assured of the nature of the impediment, we should be prompt in
our endeavours to remedy it.  A male elastic catheter must be introduced,
with the  point directed downwards and backwards, and if the head have
not descended too low, we shall probably be successful in emptying the
bladder.   The head  may also  be raised a little with the finger during an
interval to facilitate the introduction.  Even if we succeed, it will be ne-
cessary to watch carefully against the effects of the previous pressure ; but
if we fail, and either  the labour be arrested by the obstacle, or the pressure
threaten a rupture, our only recourse, I believe, is to tap the bladder with
a very fine  trocar, through the vagina.   Let me,  however, impress  upon
my junior readers the necessity of being quite certain of the nature of the 
OBSTRUCTED  LABOUR.
265
case, and of the prolapsed bladder being really an impediment, or in dan-
ger of  rupture, before attempting so serious an operation.
  Should the quantity of urine be moderate, and the pressure not exces-
sive, and especially if the head of the child be small, the case may per-
haps, be left to nature ;  but then, after the labour is over, we must imme-
diately evacuate the bladder, and watch the patient carefully.
  441.  7.  Calculus in the bladder. — It is very rare that urinary calculus
has  been found an obstacle  to  labour;  but  such cases are on  record.
Guillemeau was the first to relate one: the result was contusion, sloughing,
and vesico-vaginal fistula.  La Gonache performed the operation of litho-
tomy under similar circumstances, and  extracted a calculus  eight inches
in circumference.   Smellie relates a case which occurred in the practice
of Mr. Archdeacon, in  which the calculus was expelled by the pressure
of the  head (I suppose through the  urethra), after a long and  tedious
labour:  the patient suffered  from incontinence of urine afterwards.   M.
Dubois detected a calculus in the bladder pressed  down by the head of
the child;  and  M. Philippe  of Rheims extracted one in the fifth month
of pregnancy.
  So long as  the bladder  and  calculus remain above the brim of  the
pelvis, no mischief will  result;  but if  it project backwards, and be caught
by the head, and pushed down before  it, the bladder will be seriously
bruised,  and the labour  impeded in proportion to the size of the calculus.
  A careful examination will show that the tumour is covered by the blad-
der, and its hardness will indicate its  nature.
  442.  Treatment. — If the calculus  be discovered during the first stage
of labour, it may be possible to raise it above the brim, and to maintain
it there until  the head  is engaged, after which there will be no danger;
but if we cannot do this, I fear our only resource is vaginal  lithotomy; as
it is much better to have to deal afterwards with an incised wound than a
laceration.
  443.  8.  Vaginal hernia. — It  is very possible for a loop of intestine to
slip down behind the uterus into the " cul de sac "  between the vagina
and rectum, and if it be empty, it will  be no impediment;  but if it con-
tain a mass of scybala,  that will form an obstacle to the descent of  the
head, but one that is seldom  attended with danger,  except from the pres-
sure to which the intestine is exposed.
  444.  Treatment. — If the  hernia can be  reduced, it must be  done as
early as possible ;  but if not, we  may be able to deliver with the forceps.
It is very rarely, if ever, necessary on this account to lessen the child's head.
  445. 9.  Collection of faces in the rectum. — This is not a very uncom-
mon cause of  delay towards  the  end  of the  labour, nor is such an accu-
mulation inconsistent with frequent and fluid, but small, evacuations daily.
It is easily detected; the tumour  is felt in the situation of the rectum, and
its irregular form and want of elasticity would almost be sufficient to  in-
dicate  its nature.  It  is possible, however, to press it downwards, and
then the  escape of faeces will put the question beyond doubt.
  446.  Treatment. — If proper care  have been taken during pregnancy,
and the first stage of labour, we shall never be troubled by this obstacle;
but if not, we must remedy the neglect by enemata of warm water when-
ever we  detect the state of the intestine ;  and  if,  as in rare cases, this b;
not sufficient, the faeces  must  be removed by a  spatula or scoop.
                                 x 
266
OBSTRUCTED LABOUR.
  447.  10. Swelling of the soft parts. — The late Professor  Hamilton
was, I believe, the first  to  notice this state as an  obstacle to the delivery
of the head.   Dr. Campbell observes, " The  capacity of the pelvis may
be diminished by general  tumefaction of  its  linings, consequent on inter-
rupted circulation, from a long detention  of the child's head, or from fre-
quent examination.   This cause  of  protraction  is one of no ordinary
nature, since, unless the case be promptly and energetically attended to,
the result may be calamitous from  lesion of structure.   Unless a  practi-
tioner have had the management of the  patient from the commencement
of labour,  he is apt to view this variety of diminished capacity, as  arising
from original defect in the  development of the bones themselves."
  448.  Treatment. — Great relief  is afforded by  venaesection;  and  if
necessary,  small  doses of tartar emetic  should  be administered.   Dr.
Campbell advises the application of the forceps, if there be room;  but if
the pains  be adequate, I  would rather leave the labour to  the  natural
efforts,  because of the risk of injuring  the passages.  If the pains be
feeble, we  must, of course, expedite the delivery.
  449.  11. Imperforate hymen. — Impregnation is quite possible without
injury to the  hymen:  cases have been recorded repeatedly of women,  in
whom the hymen was found perfect at the time of labour.  I myself at-
tended one a short time ago.   In most cases the  membrane yields to the
pressure of the head at  once; but it may (as in the  case I attended) offer
a long  resistance; though I  am not aware of its  having ever been the
cause of powerless labour.
  450.  Treatment. — The  remedy is very simple ;  if  the  hymen  do not
yield to the  pressure of the head  after a reasonable time, it must be di-
vided by the scalpel.   A very slight incision will  suffice,  and  great care
must be taken  so  to  support the  perineum, as to prevent fhe  laceration
extending  beyond the fourchette.
  451.  12. Rigidity of the perineum. — I mention this among the  causes
of delay, especially in women of mature age,  although I believe it never
occasions such delay as to give rise  to  unfavourable symptoms, except
when a tough cicatrix has formed after a former laceration.
  In ordinary cases of excessive resistance, much benefit will be derived
from venaesection  and tartar emetic, followed  by fomentations, or gentle
friction  with hog's lard.  If it be clear from any cause (though such cases
must be extremely rare) that the perineum cannot  dilate, an incision must
be made through the obstacle.*
  452.  Other  causes have been enumerated  as  protracting  the  second
stage, as tumours of the labia, prolapse of the uterus, &c.; but though, to
a certain extent, they may have such an effect, yet not so far as  to give
rise to the  symptoms of powerless  labour.  Prolapse of the uterus at the
time of labour can only be partial,  and must arise from excessive  ampli-
tude of the pelvis:  careful pressure around the external orifice will retain
it within the  vagina, and the child will be expelled naturally.   The only
  * In rigidity of the parts, especially the os uteri and perineum, many eminent ob-
stetricians have reported favourably of the inhalation of ether.  "Although greatly
opposed  to the free use of this powerful agent, under all the circumstances indicated
by Dr. Simpson, I should not hesitate," says Dr. Huston in a note to a former edition,
" after the employmont of other suitable means, to resort to that, or, what is  perhaps
better, chloroform, before using the knife, in simple cases of rigidity of the parts men-
tioned."— Editor. 
OBSTRUCTED  LABOUR.
267
labial tumour that is at all likely to call for interference is that  caused by
sanguineous  effusion, which seldom occurs until the head arrives at the
outlet, and does not generally prevent the exit of the child.  If it should
do so, it must be opened; and if, after that, the  delivery do not speedily
take place, the forceps must be used.   Brevity of the umbilical cord, or
its coiling, has also been said to delay the descent of the child; but, I
believe, without any reason.   Those who supposed  this, remedied it by
dividing the  cord, which I believe to be very rarely necessary.
   453. Symptoms. — It is unnecessary that I should do more than allude
to the symptoms which  arise, when, in  consequence of any of these
causes, the labour is delayed  in the second stage; as I have fully de-
scribed them under the head of powerless labour, from which they differ
in nothing, except that we do  not so frequently find the character of the
pains  changed.  It is evident  that the fault is  not in the want or ineffi-
ciency of pains, but in the obstacles  opposed to  them.  The symptoms
then will be  in proportion to the delay, making  due allowance for differ-
ence of constitution and temperament, and the delay will be in proportion
to the extent of the obstruction, assuming that  no interference has been
attempted.
   For some  time (from 12 to 20 hours) after the first stage has been vir-
tually (§ 425) or  really  completed, the   labour  will go  on  apparently
favourably;  but after this, the pains producing no effect, we find  that the
patient becomes  feverish, restless, and thirsty;  the pulse rises, the skin is
hot,  the tongue  dry and furred, and the  gums  and teeth  coated with
 sordes.  In  some cases, but  not always, the  character of the  pain is
 changed;  the outcry and suffering increased, but the force  diminished
 and the voluntary efforts suspended.
   If the patient  be neglected, the unfavourable symptoms increase:  the
 abdomen  becomes tender, and  sometimes tympanitic; vomiting is fre-
 quent ; the urine is retained; the vagina is hot and tender; the discharge
 becomes yellow or brown, and perhaps offensive ; violent rigours occur,
 and the patient is irritable and despondent, and ultimately sinks into  a
 delirious or comatose state.
   454.  Prognosis. — In any case to which we  are  called, our prognosis
 must  depend  upon the actual state of the patient, and the possibility of
 removing the cause, or the facility with which  labour may be terminated
 by instruments.  If called early, before bad symptoms are developed, and
 the cause of delay be  one we can  remove, the prognosis will be favour-
 able,  as far as delivery is concerned, with  a reservation as to the results
 of the operation necessary for the removal of the  cause.   If the  obstacle
 cannot be removed, and we are  obliged to operate  upon the child, there
 will be, in addition to the usual risk of the operation, something addi
 tional in proportion to the difficulty of extraction.   If we be not  called
 until serious symptoms appear, the shock of any operation will add much
 to the patient's danger,  and our prognosis should be very guarded.   In
 these cases it should be distinctly stated that, although there is danger to
 the patient if the operation be attempted, there is much greater danger,
 or perhaps the certainty of death to mother and child, if nothing be done.
   455.  Treatment. — For each  cause of  delay  I  have mentioned the
 special  treatment  necessary.   I shall, therefore, now merely recapitulate
 a few general principles.  1. In  no  case need we interfere, when the
 obstacle can be overcome by the natural powers within a reasonable time 
268
DEFORMED PELVIS.
2. That the less serious the mode  of interference the better ; so that, if
the natural efforts are insufficient, we should endeavour to push the obstacle
out of the way; to remove it;  or to puncture it.   3. That if the uterine
efforts be vigorous, the mere removal of the obstacle will enable them to
complete the labour.  4. That in  some cases, besides removing the cause
of delay, it is  necessary to employ  extracting force; and  in  such cases,
the less violent the  operation  the  better: thus the vectis  (if effectual)
would be preferable to the forceps;  the forceps to the crotchet, and  the
crotchet to  the  Caesarian section.  5.  But in our estimate of the risk of
these operations, we must not omit  the time they occupy, with reference
to the condition of the patient; thus the time gained by the forceps may
render it  more useful than the  vectis.  6. When  the forceps cannot be
used, no false  humanity should make us  hesitate  to  destroy the child (I
assume, of  course, the necessity for an operation)  in time  to save  the
mother; because its life was sacrificed already, and both it and the mother
will be lost, if we do not terminate  the labour.
                         CHAPTER VIII.

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

  456.  Definition. — The progress  of the labour impeded by abnormal
deviations in the form  of the  pelvis, giving rise to  delay in the second
stage, or rendering the descent of the child impossible without assistance,
or altogether impracticable.  The symptoms are those  of powerless labour.
  457.  If the reader will have the kindness to turn back  to the  chapter
on " abnormal deviations of the pelvis," he will find that I there described
the  following variations from  the  ordinary standard: 1, the equably en-
larged pelvis (pelvis aquabiliter justo major) :  2, the equably diminished
pelvis (pelvis aquabiliter justo  minor):  3,  special distortions of the brim:
4, of the cavity: 5, of the lower  outlet:  and 6, oblique distortion.  As
in that chapter these deviations  were described and the means of diagnosis
pointed out, it only remains for us now to  consider their effect upon the
labour,  which I shall do in a few words.
  458.  1. The " pelvis aequabiliter justo major," can  scarcely be included
in the practical consideration of the effect of  distortion:  but as  it does
modify  the labour, a few words may not be amiss.  As  the  adaptations
of the child's head to the pelvis, and the changes observed in it's descent,
depend upon the combined effect of the propelling force  and the resist-
ance, it is clear that if the pelvis be so large as to afford little or no resist-
ance, these changes will not take place ; nor is that of much consequence.
Further, the absence of resistance will render the labour  so rapid as to
preclude due preparation on the part of the mother, as in the cases related
by Drs. Montgomery and Rigby.   In one, a patient  of Dr. Douglass, the
child was born in the night without waking the  mother.   Now are these
rapid labours from deficient resistance, without inconveniences: the uterus
may be depressed to the edge  of the vaginal orifice, and  even somewhat
beyond it, and there is certainly more danger of subsequent hemorrhage. 
DEFORMED PELVIS.
269
The only danger to the child arises from  the chance of its falling on the
ground, when expelled without warning.
  Little can be done in such cases, even if we happen to be in time, except
to support the external parts so as to prevent partial prolapse of the uterus,
and by pressure  over  the uterine  tumour to guard  against flooding.
During convalescence, the patient should be kept a longer time than usual
in the  horizontal position.
  2. The  opposite extreme, the " pelvis sequabiliter justo  minor," may
offer very serious resistance to the progress of  labour.  In general, how-
ever, it renders the labour difficult and tedious, but  not impracticable by
the natural powers.  The moulding and adaptation  of the  foetal head
occupies a longer time, the compression is greater, the pains more violent,
and the second stage more prolonged, but  the amount of delay varies,
and its effects also upon the constitution of the patient.
    459. 3. The special distortions of the brim are very important, and it
 may  be generally remarked, that a small special deformity will prove
 a greater obstacle than the same amount of equable diminution of size.
 When the oval  of the  brim is transposed so that the antero-posterior
 diameter is the longer, the position  of  the child's head will of necessity
 be changed, so as to bring its long  diameter in accordance with  that of
 the pelvis.   The heart-shaped brim  may have no influence upon the head
 unless the promontory of the sacrum  be  much projected;  then we shall
 find a corresponding indentation upon the skull of the child, and perhaps
 a fracture of one of the bones, as  remarked  by Dr. Michaelis  of Kiel.
 And  not  only this, but  the head, if prevented from freely entering  the
 pelvis, and if the pains  be very violent, and the patient have had several
 children, may be driven to one side, and the cervix being unable to resist
 the pressure may give way.   If the  distortion  be excessive, it may pre-
 clude the entrance of the head altogether.
    4.  Distortions in the  cavity may  be  merely a continuance of deviations
 in the brim, or they may be limited to the cavity ;  in the latter case we
 may find the head enter the pelvis with tolerable  facility, and descend in
 the usual manner, until  it arrives at the  impediment.  If the sacrum be
 too straight, there will  be danger of the  head being driven  through the
 perineum for want of the forward direction which is ordinarily communi-
 cated to it by the curve  of the sacrum: on the other hand,  too great cur-
 vature of the sacrum  may be  a serious  difficulty, even insurmountable
 without assistance, or if overcome,  it may exert injurious pressure upos
 the skull of the  child.   Exostosis of the  sacrum will prove an obstacle in
 proportion to its size:  if small, it may be overcome by the uterine efforts
 alone, or with  assistance: if large,  it  may  be incompatible with  the
  delivery of a living child, or even a mutilated  one.
    5.  Distortions of the lower outlet may depend upon those in the upper
 part of the passages, or which  is rare, they may occur alone.  The latter
 consist generally in an approximation  of the tubera ischii, or narrowing
 of the pubic arch, or in anchylosis  of the coccyx.   If the pubic arch be
 narrowed, the antero-posterior diameter of the lower outlet is  virtually
 lessened, because the head cannot fill the arch, but is thrown backwards,
 upon the os coccygis.   If the coccygeal joint be anchylosed, that will also
  diminish  the antero-posterior  diameter  of the outlet;  and if it be  not
 broken by the expulsive force,  it may indent or fracture the bones of the 
270                      DEFORMED  PELVIS.
cranium.  When the pelvis is funnel-shaped, the  resistance will not be
felt until the head is at the lower outlet, and it may then require assistance.
  6. Oblique distortions of the pelvis offer great obstruction to the passage
of the child, and although, if slight, a  modification of the usual adapta-
tions of position may allow its descent, yet in many cases it is  requisite
to interfere and terminate the labour artificially.
  460.  So far, I have  merely sketched the kind of influence which the
various  deformities are calculated to exert upon the labour;  but another
most important consideration remains,  viz., the amount of the  difficulty.
A due appreciation of the limitation caused by the distortion, is absolutely
necessary to the practical management  of such cases, and in forming our
judgment, we must take into account the  relative  as well as  the positive
size of the apertures or cavity; for although they should be much reduced,
yet if the fcetal head be very small, there may be comparatively little diffi-
culty ;  and, on the other hand, if the head be large and the sutures ossi-
fied, a very slight  diminution of the usual capacity of the pelvis will offer
great obstruction.   In  a practical point of view, we may make three de-
grees of distortion:  first,  where the pelvis  is sufficiently reduced in  size
as to offer an amount of difficulty which in some few cases may be over-
come by forcible pains, if time be  allowed, but which generally require
extracting force in addition;  there being space enough to allow the use
of the forceps.  Secondly, where the head is  unable to enter the pelvis,
or having entered, is tightly wedged in the cavity, or impacted, as  it is
called.  In these cases, there is  not space enough to admit the forceps,
nor if they could be introduced, would the head bear the  compression
necessary to enable us to extract it; there is  no resource but to  evacuate
the contents of the cranium.  Thirdly, there are very rare cases of extreme
distortion, where the canal of the pelvis is so reduced that it would be
impossible to extract even a mutilated  child.
   461.  It is not easy to name the actual diameters, answering to each of
these classes, because, as  I have  already observed, the size of the pelvis
must always be considered relatively to the child's head.   But thus much
may be stated, that  a  living child  cannot pass through a pelvis whose
small diameter is less than three inches. M. Le Roi fixes upon 3£ inches,
Drs. Osborn and Aitkin 3 inches, Dr. Jos. Clarke  3£,  Dr. Burns 3^, Dr.
Ritgen  2, Dr. Busch 2\ to 3 inches, as the smallest diameter.   It is clear
then, that unless there be a space of full three  inches, it would be useless,
probably injurious, to use the forceps.   If it  be under this, the  case will
belono-  to the  second class, in which the perforator and crotchet must be
used, provided that there be space enough for the extraction  of the child
after  mutilation.  Dr. Osborn  states that  one inch and a half diameter
will be  space enough for this purpose. M. Baudelocque conceives that
craniotomy is inadmissible when the diameter is only an inch  and two-
thirds ;  Dr. Dewees when it is less than two inches;  Drs. Hull and Burns
think that it may  succeed when  it is  an  inch  and  three-quarters;  Drs.
Gardien and  Hamilton wThen it  is an inch  and a  half; and Dr. Davis
when it is one inch.  If it be much below two inches, the case  will come
under the third class, and our remedy  be the Caesarian section.
   462. If deformity be suspected, an  external as well as  an  internal ex-
amination should be carefully made: if we can reach the promontory of
rh*1 sacrum and the presentation, we can  then  estimate the  relative size
of the head and brim:  if the presentation be  beyond reach, we may still 
DEFORMED PELVIS.
271
De able to ascertain the distance between the sacrum and pubis with tole-
rable accuracy.   In addition there is a peculiarity about the first stage of
labour.   " Besides the general appearance of  the  patient," says  Dr.
Rigby, " we frequently find that the uterine contractions are very irre-
gular ;  that they have but little effect in dilating the os uteri; the head
does not descend against it, but remains high up ; it shows no disposition
to enter the  pelvic cavity, and rests  upon  the symphysis pubis, against
which it presses very forcibly, being pushed forwards by the promontory
of the sacrum."  There is less difficulty in  detecting the disproportion in
the cavity or lower outlet, as it is within reach : and on  examining during
a pain we find that no progress is made, and during an interval we  can
perceive that the head is larger than the passage it has yet to traverse.
   463. Symptoms. — If the labour be  allowed to continue beyond a  cer-
tain time, we  shall have all the constitutional  symptoms of powerless
labour (§ 413), except, perhaps, the change in the pains, because  the
delay is in the  second  stage, really or virtually.  It is true the head may
not be able to clear the os uteri on account of the obstruction at the brim,
but the os uteri becomes  softer and dilatable, the pains forcing, and the
cry suppressed; all marking the  transition from the first to the second
stage, and it is  never until after this change  that bad symptoms set in.'
   But besides  these constitutional symptoms, which I need not recapitu-
late, other effects not unfrequently result, even where  we are successful in
delivering the patient.  The long and forcible pressure  of the head of the
child against the soft parts at the brim  and in the cavity may be followed
by inflammation and sloughing.  Thus the  lower part  of the uterus  and
the vagina may be seriously injured, and if  the slough be deep, the blad-
der or rectum may be perforated.  I have already pointed out the possi-
bility of rupture of the uterus.
   The  child, too, may suffer considerably : if the head  enter the brim  and
be  much compressed,  its life  may be  sacrificed ; or partial pressure on
any part may fracture one of the bones  of the cranium, or give rise to in-
flammation or sloughing of the scalp.
   464. Treatment. — If the  distortion be  slight,  it is possible that the
extra force which will be exerted, may be sufficient after a longer time fc
the expulsion of the child, and a fair  trial should be given.   But  if the
disproportion be so marked  that it is evident that  the  child cannot pass
without assistance, or if unfavourable symptoms are present, we ought to
lose no time in determining by the degree  of  deformity to which of the
classes  (§ 460) the case belongs, and  acting  accordingly.   If it  come
under the first,  and  there be space  enough, we  may try the forceps; if
under the second, craniotomy,  and, if necessary, evisceration  will be  our
only resource ;  if under the third, the Csesarian  section.   I will caution
my junior friends against coming to a conclusion and  acting upon it with-
out a consultation.
  The greatest care will be  necessary after  delivery to guard  against the
consequences I have mentioned. Vaginal injections of warm water should
be used twice a day, and a few leeches  applied to the vulva if necessary.
I  have found great benefit from the exhibition of small doses  of calomel
and opium at moderate intervals, or of  a full dose of opium at bed-time
in these cases.
  I shall now proceed to consider in detail the operations to which  I have
as yet only slightly referred.
        18 
CHAPTER IX.
                     OBSTETRIC OPERATIONS.

              1. INDUCTION OF PREMATURE LABOUR.

 465. Very little  need be  said as to the importance of obstetric opera-
tions  the danger to the mother and child, the circumstances under which
they have been performed, and the little time which is allowed for reflec-
tion, or consulting authorities, all point out the absolute necessity of our
being prepared beforehand for any case which may occur.   If any further
inducement were required, I might add, the influence which a successful
or unsuccessful operation has upon  the reputation of a practitioner, or
refer to the fact which the periodicals attest, that a surgeon maybe indicted
for the results  of his operations.   But I prefer  supposing that a conscien-
tious feeling of our responsibility in undertaking the charge of a case, will
be the strongest inducement to the acquisition  of that knowledge, which
is the safeguard of those who confide in us.   It is, I believe, an axiom,
in which I  fully concur, that no operation should  be attempted without a
consultation, if it be possible to obtain  one.
   Ip. estimating  the dangers of any operation we  must always take  into
consideration the prevalence of any epidemic.   If, for example, puerperal
fever or erisipelas  be epidemic, the danger of any operation is increased
incalculably.
   Obstetric operations may be divided  into three classes: 1, those which
are not intended  to injure the mother or child, as the induction of prema-
ture labour, version, the use of the vectis, and the forceps ; 2, those which
involve the destruction  of the child,  but which are not intended to injure
the mother, as craniotomy, and the  cephalotribe; and 3, those in which
danger is involved to both mother and  child, as the Caesarian section.
   I have said, " not intended to injure," because I would not mislead my
junior readers, by leading them to suppose  that any operation is without
danger to both mother  and child.   They are  all  dangerous, but in dif-
ferent degrees, as we shall see by and by.
   Now let us  examine each in detail.
   466.  1.  The Induction  of Premature  Labour, for the purpose of
saving the  life of the infant, of its mother, or of both, though of compa-
ratively modern origin, is an operation of great value in certain cases, and
it is one of the few instances of an improved science augmenting the
number of operations.
   There would appear to be, in the minds of all  men, a repugnance to
interfere with  the natural progress of those great  phenomena which ordi-
narily run  a definite and uniform course; and in  the  present case this
objection is increased, because the proposed interference is to remedy one
irregularity by another.   Accordingly, the first consideration has always
been, not the  usefulness, but the morality of the operation.   Dr. Denman 
INDUCTION OF  PREMATURE LABOUR.             273
states* that Dr. Kelly informed him "that about the year 1756, there was
a consultation of the  most eminent men at that time in London, to con-
sider the moral rectitude of, and the advantage which might be expected
from, this practice, which met with their  general approbation."   The
conclave  decided in favour  of the morality  of such interference,  and
shortly afterwards the operation was  successfully performed by  Dr. Ma-
caulay.   Subsequently, Dr.  Kelly "practised it, and among other in-
stances, he mentioned  that he  had performed this operation three times
upon the same woman, and that twice the children had been born living."
   So numerous, and, upon the whole, so successful have been the instances
in which it has been tried since Denman's time, that it has taken  its place
among the regular obstetric operations, in the various systems of British
writers and teachers.
   Dr. Denman's remarks upon the propriety  of the  operation, as to
morals, are so conclusive, that I may be excused if I quote them  : " With
regard to the morality of the practice, the principle being commendable—
that of making an effort to preserve the life of a child, which must other-
wise be lost, and nothing being  done in the operation which would be
injurious  or  dangerous to the mother, but  on  the contrary, a probability
of lessening both her danger and  suffering — I apprehend, if there be a
reasonable prospect of success, no argument can be adduced against it,
which will not apply with equal force against any kind of assistance at the
time of parturition ; against inoculation, or medicine in general; and in
fact, against the interposition  of human reason  and faculties in all  the
affairs of life."
   467.  In France,  however, the proposed operation was by no means so
frankly received or so readily adopted.  Certain doctrines of the national
church, or at least the interpretation of them by  the Doctors of  the Sor-
bonne, touching the importance of fcetal life, seem  to have  aggravated
the risk of the operation, and to  have deterred professional  men from
making the attempt.  The great name and extended  influence  of Baude-
locque were  opposed to what he considered (in the case supposed) a
crime ; and a celebrated teacher of the present day, Capuron, has stigma-
tised it as " un attentat commis envers les lois divines et humaines."  Even
so late as  1827, on  the occasion of a memoir presented by M. Coste, de-
manding if it would be allowable to  bring  on labour prematurely in
females labouring under aneurism  of the heart, the Academie Royale de
Medecine pronounced the question "inconvenient et  presque immorale."
It  is said, however, by M. Sue, that M.  Petit ranged  himself on  the side
of the advocates of the operation, and since then it has been recommended
and  practised by Stolz, Ferniot,  Paul Dubois, Dezeimeris, Burckhardt,
Velpeau, Figueira,  Coste, &c.
   The objections of the French authors may be thus  summed up: —
   1. It is immoral.
  2. It is  almost impossible to determine the exact relations between the
head of the child and the pelvis.
  3. The manoeuvres necessary for exciting labour are highly dangerous.
  4. The uncertainty of all women as to the period of their pregnancy.
 * Introduction to Midwifery, p. 318, 7th ed.  For more minute details and references
about these operations I beg to refer the reader to my " Researches on Operatic Mid-
wifery." 
274
INDUCTION OF  PREMATURE LABOUR.
  5. The difficulty of dilatation of the os uteri at the seventh month.
  6. The danger of  subsequent disease.
  Each of these objections will be answered as we proceed.
  It is  quite evident, as M. Marinus observes, that  these writers had in
view the " accouchement force," performed at the seventh or eighth month
—a different operation, and one perfectly unjustifiable at so early a period.
  468. It has been recommended and practised in Germany by Weidmann,
Mai, Siebold (four times), Schilling (once), D'Outrepont (twice), Kiecke
(twice), Haase  (twice), Falco  (three times), Vezin (three times), Mende
(four times), Betschler, Froriep, Wenzel, Spiering, Ritgen (thirty times),
Carus (twice), Kluge (twenty times), Reisinger, Busch, Naegele  (once),
Seulen  (once),  Neumann (once), Spoendli (once), Hayn (once), Mampe
(five times), Rosshirt, Kilian (three times), &c. &c.; but opposed by Stein,
Osiander,  sen.,  Bernstein, Ebermaier, Gumprecht, Piringer, Joerg, &c.
  In Italy it seems to have met with less opposition; or at any rate less
aversion has been expressed.  Successful cases have been published by
MM. Ferrario, Billi,  Lovati, Bongoianni, &c. &c.
  Paul  Scheel,  in Denmark, Solomon de Leyden and Professor Vrolik in
Holland, and M. Marinus, in Belgium, have each advocated the practice.
  469.  So much  for the history of this operation,  and  the  difficulties
attendant upon  its introduction ijnto practice.
  As to the origin of it,  all writers are agreed in attributing it to the fol-
lowing circumstances:  It has not unfrequently happened that the life of a
seven or eight months' child has been preserved by accidental  premature
labour, in cases where the birth of a  child at the full  term  had  been pre-
viously found impossible from pelvic distortion.
  From the complete success of such cases, as regards  both mother and
child, it was inferred that premature  labour, artificially induced, might in
certain cases of pelvic deformity, be employed to supersede an operation
(craniotomy) which involved not only the destruction of the  child, but
considerable risk to the mother.  The  proposal was  not, it  must be re-
membered, to  deliver the fcetus artificially, but merely as was  stated by
Ritgen, "to communicate a slight but  certain impulse," by  virtue of
which the process of parturition may be carried on and completed by the
natural powers.
  470.  The reasoning of Dr. Denman appears to me  conclusive, as to
the " moral rectitude" of the operation; the  next  question, therefore, is
as to its safety to the child and the mother, confining ourselves  for a mo-
ment to the consideration of the cases originally proposed to be benefited
by the operation.
  It is perfectly established that a fcetus is " viable" at the completion of
seven months of utero-gestation, and many instances are on  record of
children born at that period living to a good old age.  M. Chaussier (of
Dijon)  and his  wife were both  seven  months' children ;  his majesty
George  III. was also a seven  months' child;  and M. Fodere relates the
case of  the wife of a judge, whose pregnancies always terminated at the
seventh month.   Examples of " viable "  infants born at an earlier period,
are likewise to be found ; but I beg to refer to the able work of my friend
Dr. Montgomery for further details;  concluding from all the evidence we
possess  of the viability of seven months' children, that premature labour,
accidentally or artificially induced, at the completion of the seventh month, 
INDUCTION OF  PREMATURE LABOUR.
275
does not involve much danger to the child  from the immaturity of its
growth merely.
  As to the actual risk of labour to the fcetus, as ascertained by an esti-
mate of facts, I  may adduce the following testimony:
  Of twelve cases mentioned  by Denman, the  majority of the children
were saved.
  Mr. Barlow reports seventeen cases — six children were still-born, five
died a few hours after birth, and six lived.
  Of Dr. S. Merriman's ten cases, four children were saved.
  Dr. Merriman, jun., mentions  forty-six cases—sixteen children lived,
and all the mothers recovered.
  Dr. Conquest says, that out of nearly one hundred cases, about half
the children were born alive.
  In Mr.  Gregory's case, the child was born alive, but died subse-
quently.
  In Dr. Collins' case, the child lived.
  In Mr. Corry's and Dr. Paterson's cases, the infants were saved.
  Dr. Hamilton states that " previous to the 26th  of January 1836, the
author brought on premature labour in  twenty-one individuals, on account
of defective  apertures, viz., in fourteen, once; in one, twice ; in three,
thrice;  in  two, four times;  and  in  one,  ten times.  Of the  forty-five
infants thus prematurely brought into the world, forty-one were born alive.
The death  of the four still-born can be readily accounted for."   "In the
practice of Mr.  Moir, and Dr. John Moir, premature labour was induced
twelve times on six women.  Nine of the infants were  born  alive, and
the cause of the death of the three still-born infants could not be attributed
to the operation."
  Of Dr. F.  Ramsbotham's sixty-two cases, thirty-three children were
born alive, and  twenty-three lived for a considerable time.
  Dr. Lee  saved twelve children in thirty-one cases  ; in several of which,
the crotchet was necessary after labour had been induced.
  The child lived in Mr. Heane's and M. Spoendli's cases.
  M. Ferrario saved five  children out of six;  M. Kluge  nine  out of
twelve ; M. Solomon thirty-four out of sixty-seven ;  M. Burckhardt thirty-
five out of  fifty-two ; M. Siebold two out of three; M. Mampe four out
of five, the fifth being a shoulder presentation.
  Dr. Shippan,  in his Inaugural Thesis, presented to  the medical faculty
at Wurtzburg in 1831, has given a summary of ninety cases; seventy-
three children were born alive, but eighteen of them died subsequently.
  According to  MM. Velpeau and Kilian, one hundred and fifteen children
were saved out of one hundred and sixty-one cases.
  M. Figueira has collected two hundred and eighty cases from different
sources, in which one hundred and sixty-six children were saved.
  We may conclude from  these  different data, that more than half the
children were saved, notwithstanding  a. cause of failure  to which I have
not yet referred.  I allude to the greater frequency of mal-presentations
in premature labour, than in labour at the full  time.   In Dr. S. Merri-
man's cases, for example, there were  eighteen  mal-presentations  out of
the  forty-six, only one of which was saved.  If  we could subtract all the
cases of mal-presentations, we should  find, I doubt not,  that the propor
tion  of  children lost to  those  saved  by the operation was very much
smaller. 
276             INDUCTION OF PREMATURE LABOUR.
  471.  There is  unquestionably some  risk incurred by the mother, but
not more than by  an accidental premature labour.  After much consider-
ation, Denman concludes that " it is perfectly safe to the person on whom
it is performed."
  We have already seen that Dr. Kelly performed it three times success-
fully on one person.
  Dr. S. Merriman seems to think that  its safety was rather overrated, but
he adds, " at all events, the method  in question, if carefully conducted,
cannot be  more hazardous to the mother, perhaps is much less so, than
the operation for lessening the head of the  fcetus in utero, and it is in-
comparably less perilous than the Caesarian operation, or  the division of
the symphysis pubis."   Out of his forty-six cases, not one proved fatal!
  Dr. Hamilton observes,  " the late Dr. Merriman first called in question
the safety  of the operation; but the cases on which  he formed his doubts
on this point, were evidently cases of accidental coincidence, for the safety
of the practice is  now fully established.
  Dr. Blundell concludes his observations by saying, that "with all its
faults about it, the practice is of great value, and there are now living in
society individuals whose heads have in this manner been preserved from
the perforator."
  In Mr.  Corry's case, the woman recovered rapidly.
  Dr. Gregory and Dr. Collins each operated once,  with safety to the
mothers.
  Dr. F. H. Ramsbotham  has had recourse to  this operation sixty-two
times, and it does not appear that the mother suffered  in any of them.
  Dr. R.  Lee lost three mothers out  of thirty-one cases.
  Mr. Heane  saved the mother.
  The statistical details given by Velpeau and Figueira, would justify, I
think, a much more unqualified  commendation.  Velpeau states that it
has been performed
      In Great Britain.........72 times.
      In Germany  .......    .    79  "
      In Italy...........7  "
      In Holland..........3  "
Making a  total of 161 cases, of which number eight mothers died, five of
them, however, from causes unconnected with parturition.
  M. Figueira has collected two hundred and eighty cases, of which only
six mothers died.
  M. Solomon operated sixty-seven times, M.  Kluge twelve, and M. Fer-
rario six times successfully.
  M. Reisinger lost one patient in  fourteen.
  All M.  Mampe's patients recovered.
  MM. Spoendli's and Seulen's patients recovered wrell.
  Of the  ninety cases  collected by Dr. Shippen, seven mothers died.  In
three of these the operation was performed once ; in  two, twice; and in
one, three times.
   We may therefore conclude, with  M. Marinus, that " if these facts be
true, it is  established that females undergoing this operation incur no im-
mediate danger;  and if we push our researches  still farther, we shall find
that these  same females were not attacked  by pure lesions of the uterus,
as has been advanced ; several of them underwent the operation two or 
INDUCTION OF  PREMATURE LABOUR.
277
Qiree times, with as much safety as if they had been delivered at the full
term of utero-gestation."
  Thus the first, third, fifth, and sixth objections made by the French are
answered satisfactorily.
  472. We have now only to inquire as to the utility of the operation,
before considering the cases to which it is applicable.
  The positive utility of the operation has already appeared in the nume-
rical results taken from different authors, showing that more than one-half
of the children (all of whom  must otherwise have  been  lost) have been
saved, and that but a small proportion of the mothers has been lost.
  473. The comparative utility is equally in favour of the operation.
  It  is peculiar to midwifery operations,  that they form  an  ascending
series, increasing in gravity from  the simplest to the most severe — no two
being equal; and therefore, in considering the suitability or practicability
of any one, we do so with the knowledge that if the one we prefer do not
succeed, we must have recourse to another more severe and more dangerous.
An example will make my meaning clear.  If, in any  given  case, we
attempt  to deliver with the forceps, but  are not able to succeed, we must
subsequently have recourse to the perforator ; there  is no  other method,
of only equal  severity with the forceps, which we can try.   Or again,  if
craniotomy and evisceration will not render the transit of the child possi-
ble, we have no recourse but symphyseotomy or Caesarean section.
  Thus, the alternative of any operation in midwifery is  not one of less,
or even of equal danger, but necessarily one of a more serious nature, and
consequently we cannot estimate the utility of any obstetric operation
fairly, if we consider it by itself;  a just appreciation involves a due esti-
mate of its  alternatives.
   It  is to the alternatives  of the induction of premature  labour, that I
would wish to call attention, as demonstrating very strikingly the compa-
rative utility of the practice.
   In the cases which have been supposed to demand this operation, there
is always a considerable diminution in the calibre of the pelvis from bony
distortion, so that it would  be quite useless, at the full term of utero-ges-
tation, to attempt the delivery by the forceps; the only alternatives, there-
fore,  if we allow pregnancy to be  completed, are, the perforator, symphy-
seotomy, and the Caesarean section.
   Now let us compare the mortality attendant upon each of these opera-
tions with the results of artificial premature labour.
   1.  By the use of the perforator, not only are all the children destroyed,
but extensive statistics have shown, that about one in five of the mothers
perish, either from the direct effects of  the operation, or from the length
of the previous labour.
   2.  Casarean section  is the " dernier resort" of midwifery, involving
the utmost danger to the mother and child, and justifiable  only when no
other chance for either remains.   I have collected 405 cases ; 230 mothers
were saved, and 175 lost, or about 1 in 2^.  Of 221 children, 156 were
saved, and 65 lost, or about 1 in  3^.
   3.  Symphyseotomy is attended with worse results than Caesarean section.
One-third of the mothers  have been  lost,  and many of  those who reco-
vered, suffered severely from the  consequences of  the operation.   One-
half of the  children were lost.
Y 
278              INDUCTION OF PREMATURE  LABOUR.
  If then to the absolute advantages to the operation proposed, be added
the comparative  gain  from avoiding these terrible alternative operations,
we may form a tolerably correct estimate of the utility of the " induction
of premature labour."
  474.  Having, as I trust, established from facts and testimony, the three
leading principles of the morality, safety, and utility of this  operation, I
shall now proceed to inquire as to the cases in which it is available.
   1. The class of cases, for which it was first proposed, and in which it
has been most frequently employed, is that in which the diameters of the
upper outlet of the pelvis are too much  reduced by distortion to  permit
the passage of a foetus at the  full  term,  and yet not so much diminished
as to prohibit the passage of a fcetus at an earlier but still "viable" age.
In the words of Denman,  " It is under circumstances and in  situations
preventing the successful use of the vectis or forceps, and just compelling
us to the fatal measure of lessening the head of the child, that it may be
a duty to propose on a future occasion the bringing on of premature
labour."
   The first step is to endeavour to ascertain  the size of the fcetal head at
different periods of utero-gestation, after the seventh month; in order,
that by adapting the diameters of  the deformed pelvis to the appropriate
diameters of the fcetal cranium, we  may be enabled to fix upon the mo-
ment when  they are  in  correspondence  for  the induction of premature
labour.   It is of course impossible to do this in any individual case, but
an  approximation may be attempted, by taking the  measurements  in  a
considerable  number of cases at the same periods.
   The following table has been thus constructed by M. Figueira.
Age of Foetus.	Bi-parietal Diameter.	Occi pi to-frontal Diameter.	Occipito-bregmatic Diameter.
7th Month. 1\ « 8th " 8£ " 9th "	2 inches 9 lines. 3 " 3 " 1 " 3 " 2 " 3 " 4 "	3 inches 8 lines. 3 " 9 " 3 " 10 " 4 " 4 "	2 inches 10 lines. 3 " 3 " 1 " 3 " 2 " 3 " 4 "
  475.  To this  kind of calculation it has been objected, that we cannot
be quite sure of the exact age of the foetuses measured;  and to the prac-
tical use of it, that the female cannot be quite sure of the exact period
of pregnancy.   That  this  objection has  a  certain weight, must be  ad-
mitted ; but that it is sufficient to prohibit the operation I cannot believe,
for it may always be obviated in practice by assuming the longest possible
period of pregnancy.  If, for example, a patient imagine that she  is six
months pregnant, but that  she may be six and a  half, by calculating for
the six and  a half months, we  shall have assumed the largest size to
which the fcetal  head can have attained ; and if labour be not brought on
till seven months and a half, we shall also have  secured a fcetus of the
"viable" age.
   Ritgen has made another series  of calculations, which have led  to the
following practical adaptations: 
INDUCTION OF PREMATURE LABOUR.
279
   He says that labour may be induced at the
   29th week, when the antero-posterior diameter of the pelvis is 2 inches  7 lines.
   30th      "             "         "          "     2  "    8  "
   31st      "             "         "          "     2  "    9  "
   35th      "             "         «          "     2  "   10  "
   36th      "             "    .     «          "     2  "   11  "
   37th      "             "         "          "     3  "    0  "
   There is a very slight  difference  between the tables  of Figueira and
 Ritgen, which may be allowed for in practice.   The compression of the
 foetal head will also render its diameter less than the subsequent measure-
 ment would lead us to suppose.
   It will be at  once observed that there are  two measurements  of the
 pelvis which limit the operation; if the pelvis exceed  the greater mea-
 surement,  the operation is uncalled for;  and if  less than the least, it will
 not succeed in saving the child.
   The  smallest of these  diameters  appears to  be about two  and a half
 inches, and the  greater three and a quarter.   If the pelvis, in  its sacro-
 pubic diameter, be less than the  former, a "viable" child will  not pass,
 and it is generally admitted that a living child may be propelled through
 a pelvis whose antero-posterior diameter is three and a half inches.
   The opinions of different authors  accord pretty accurately with this cal-
 culation.
   476.  Another difficulty still remains, which has been put forward as a
 very serious objection by the opponents  of this operation ; and this is, the
 uncertainty of ascertaining the exact diameter of the pelvis in  the living
 subject.   Various mechanical contrivances have been proposed by Aitken,
 Coutouly,  Baudelocque, Asdrubali, Chaussier, and others (of which I have
 spoken in a former  part  of this  work); but in this country they could
 rarely if ever be employed.  Nor do I think  them necessary;  a well-
 practised finger  is, after all, the best pelvimeter, and will yield sufficiently
 accurate information.  But giving the utmost force to this objection, to
 what does it amount ?  As Velpeau justly observes: "If the  pelvis be
 wider than we thought, premature delivery (at or after the seventh month)
 is accomplished without risk.  If, on the contrary, the narrowing be more
 considerable, the fcetus will certainly perish; but then,  had no operation
 been attempted until the full term, the fcetus would equally have been lost,
 and the mother would have run greater risk."
   Besides, much information may be derived from the history of the pre-
 vious labours of the patient, for it is rarely if  ever for the first child that
 the induction of premature labour is proposed.
   Dr.  Merriman remarks, " that the use of the  perforator in a former
 labour,  is not alone to be  considered as a justification of this operation."
 This is  undoubtedly true in the present  uncertain state  of opinion, con-
 cerning the use of the forceps and crotchet, inasmuch as the latter instru-
 ment is frequently used where there is no distortion.
   But if we are convinced that the perforator was used, from the impos-
 sibility of otherwise  delivering the patient, it might then be an  adequate
 reason ;  and if it further appeared that her labour had been thus terminated
 more than  once, and for the same reason, the operation would then seem
to be imperatively required.
  I have now answered all the six objections put forward by the French,
as fairly and completely as our facts permit. 
280             INDUCTION OF  PREMATURE LABOUR.
  477.  2.  A narrowing of the transverse diameter of the lower outlet, as
it offers a fixed impediment to parturition, may be an equally valid ground
for the induction of premature labour.
  478.  3.  Exostosis, or fibrous tumours  of the pelvis,  if they  offer an
impediment to the delivery of a child at term, or at the earliest viable age ;
as they are solid and cannot be removed by any operation, will evidently
justify the  induction of premature labour, or abortion, for the purpose of
avoiding the Caesarean section.
  Some of the cases related by Dr. Merriman would appear to confirm
this conclusion, and the authority of Dr. Ashwell and his practice are in
favour of it.
  Mr. Ingleby concludes that " premature labour may with great propri-
ety be proposed on pregnancy recurring, assuming the delivery of a living
child  at term to have already proved impracticable, the tumour td remain
unchanged, and its excision not deemed expedient."
  479.  4.  When the uterus is the seat of fibrous tumoursY and impreg-
nation takes place, certain morbid  changes occur, involving danger to the
mother.  "The tumours soften during the  latter months; the increased
vascular supply leads to inflammation ; unhealthy and imperfect suppura-
tion is established in them,  and death occurs soon after parturition."  This
being the experience of Dr. Ashwell, he has proposed " the induction of
premature  labour before that period when the tumours shall  be subjected to
pressure and  contusion, from the firm,  large,  and unyielding gravid
uterus."
  Before we act upon this  suggestion, however, we must be pretty certain
that such pressure is likely to take  place, and that the case really demands
so serious  a remedy.  Mr. Ingleby has  some valuable  observations on
this subject.
  480.  5.  In the cases I have supposed, the safety of the  child is the
great object of the operation ; and they  are limited, therefore,  to those
patients  in whom the pelvis, though deformed, is still  large enough to
permit the  passage of a " viable " child.   But there are cases where the
distortion is so great as to  render the passage of a seven months'* child im-
possible, and others still worse, where no reduction of the chiWs bulk will
enable it to pass.
  I do  not see why abortion should not be induced at an early period in
such  cases.  The life  of the child must inevitably be sacrificed, and the
safety of the mother alone regarded ;  and surely, after the calculations I
have  adduced, it cannot be pretended that Caesarean section, the alterna-
tive m these cases,  offers such a chance to the mother and child as would
 justify  our preferring it.
   " When the pelvis is known to be distorted," says Dr. Aitken, " so as
to render the  birth of a living child impossible, is it not lawful and pro-
per, to  prevent the dangers of embryotomy, to induce early abortion ?"
  An objection to this extension of the operation has been made by Dr.
Merriman  and others, on the score that it would be " opening a wide door
to the dreadful abuse of the operation." That, in short, by multiplying the
examples  of inducing premature  labour  or  abortion, we  should run the
risk of  its  being performed unnecessarily or for wicked purposes.  But so
may  the fact of its being performed  at all, and so may the practice of
using ergot of rye for the purpose of exciting uterine contractions.   I do 
INDUCTION OF  PREMATURE LABOUR.
281
not, m truth, see much force in this objection, nor do I anticipate any such
prostitution of their power on the part of the members of our profession;
and beyond the profession, the operation is not likely to be much known.
It will of course be necessary that the case be thoroughly investigated by
more  than one person, and the time appropriately chosen.
  Mr. Radford, of Manchester, has suggested that by combining cranio-
tomy  with the induction of premature labour, in those cases where we are
called too late for the fcetus to pass even at an early period, we may avoid
the Caesarean operation.
  481.  6.  In certain cases of rupture of the uterus, the cause is almost
entirely mechanical.  There is some narrowing  of the upper outlet, per-
haps  a projection of the promontory of the sacrum, offering an obstacle
to the ready descent of the foetal head, which is driven forward with great
force  by the  uterine contractions.   Under such circumstances, the head
may be pushed to one side;  and if the tissue be not very firm, it will be
driven through  them into the cavity of the peritoneum.  Recovery from
such  an accident is very rare, but nevertheless it  has  occurred: and if
the woman  become  pregnant subsequently, a  premature  delivery may
save both mother and child.
   As the best argument I can employ in favour of this operation in such
cases, I may mention that it was adopted successfully by Dr. Collins,
when Master of the Great Britain Street Lying-in Hospital.   The patient
had recovered from rupture of the uterus, and  became  again  pregnant.
She was admitted  into the hospital in the seventh month of pregnancy,
and the membranes were ruptured on  the 4th of  March 1832.   Labour
came on on the 7th, and was  completed in ten  hours.  The patient was
delivered of a living  child,  and recovered.   The  child, however, lived
but two days.  The case is  perfectly illustrative of the advantages which
may be derived from  the operation in this class of cases.   The mother
was saved, and the child at  birth appeared likely  to live;  its death does
not seem to have resulted either from its early age or from the labour.*
  482.  7.  Dr. Denman observes,  " There is another situation in which I
have  proposed and tried with success, the method  of bringing on prema-
ture labour.   Some women who readily conceive,  proceed regularly in
their  pregnancy till they approach their full period, when, without any ap-
parently adequate  cause, they have been  repeatedly seized with rigors,
and the child  has instantly  died, though it may not have  been expelled
for some weeks afterwards.  In two cases  of this kind I have proposed to
bring on premature labour when I was certain the  child was living, and
have  succeeded in  preserving the children without  hazard to the mothers.
There is  always something  of doubt in  these  cases,  whether the child
might not have been preserved without  the  operation; but as such cases
often  come under consideration, and as I am disclosing all  that my expe-
rience has taught me, it seemed necessary to mention this circumstance."
Mr. Barlow thinks  the " doubt" expressed in the above extract, a suffi-
cient  ground for negativing the operation.
  483.  8.  The  question has been mooted, whether it would be right to
induce premature labour on  account of the presence of certain diseases
caused by or connected with pregnancy.   Denman  remarks:  " The pro-
  * The patient was afterwards delivered naturally at the  full time.  The details of the
case will be found in Dr. Collins' " Practical Midwifery," p.  255. 
282
INDUCTION OF  PREMATURE LABOUR.
priety of this practice has also been considered when women have, during
pregnancy, suffered more than common degrees of irritation, and espe-
cially when the stomach is in such a state that it cannot bear nourishment
of any kind or in any quantity, and the patients are thereby reduced to a
state of dangerous weakness.   Presuming that these symptoms are purely
in consequence of pregnancy, it may, perhaps, be justifiable to bring on
premature labour."
  Dr. Merriman relates a case occurring in the practice of  a "provincial
surgeon of considerable eminence."   " The patient was  teased with  a
very severe cough,  and her stomach was so irritable as to retain no food
whatsoever, nor even opium in a solid form.  She had taken  absorbents
stomachics,  bitters, aromatics,  and  opiates, without  experiencing any
relief: liniments,  fomentations, and blisters, had been extensively applied
without benefit, and she was thought to be sinking into her grave, when
it was proposed, as a last resource,  to bring on premature  labour, six
weeks before the  full time, and the patient was delivered of a living child,
and ultimately recovered."
   A case of fatal vomiting, during pregnancy, is related by Dr. Johnson
in the Lancet, March 3, 1838, p. 825.  " A lady, thirty years of age,
soon after marriage  ceased to menstruate,  and became  affected with
morning sickness, which symptoms were naturally enough attributed  to
pregnancy.   The sickness, however, gradually became worse, and at last
nothing of any kind could be retained on the stomach.  Pregnancy was
not detected, but the  disorder attributed to some  disease of the pylorus.
The sickness  and extreme emaciation were the only symptoms present.
After death no morbid appearances were observable  in any part of the
body.   The  uterus contained a fcetus about four months old.   This pa-
tient wras literally starved to  death."   " The treatment pursued consisted
in  the  use of various  salines, anti-emetics,  counter-irritation, leeches,
acetate of morphia sprinkled over a blistered surface," &c.
   Surely the induction of premature labour in this case would have been
justifiable, as  affording the mother a chance of recovery.
   Other similar cases are on record,  both of fatal vomiting, and of suc-
cess by means of premature labour; and recently a case occurred to my-
self, in consultation with Dr. Maguire, of Chapelizod.  The patient was
a young woman,  pregnant of her third  child, and at about four months
was attacked with incessant vomiting, until her  life  was rendered into-
lerable, and her strength utterly exhausted.  I never saw such agony in
any case.  We tried all the usual remedies with occasional relief, but the
vomiting  returned, and finding that she could  obtain no nourishment
whatever, that her bodily powers were worn out,  that her  pulse was
steadily 120,  I determined,  at the  sixth  month, to induce  premature
labour, which I effected by puncturing  the membranes and giving ergot
of rye.   She was delivered of a dead  fcetus, recovered rapidly, and has
since borne a child  at the full time.
   It sometimes happens, that  the serous effusion which  is usually con-
fined to  the  lower  extremities  of pregnant females, is extended to the
cavities of the pleura and peritoneum, and as it thus gives rise to a train
of severe and perhaps  dangerous symptoms,  the induction  of premature
labour may be advisable in some cases, and has been practised by Siebold
and Carus. 
INDUCTION OF  PREMATURE LABOUR.
283
  Puzos induced premature labour in  a case of strangulated hernia, to
facilitate the operation, and afford a better chance to the child.  He saved
the child, but the mother died afterwards.
  On this part of the  question, I confess it appears to me almost impos-
sible to  lay down definite, and general rules; the decision must rest with
the judgment of the medical attendants  in each individual case.
  484.  9. The only exception made by Baudelocque to his condemnation
of artificial premature labour, is in those cases of great uterine hemorrhage,
before the completion of the  term of utero-gestation, when the child is
probably destroyed, and the safety of the. mother compromised.
   These  are all the circumstances which have  ever  been  considered to
justify our interference in the manner proposed.
   485.  Mode of operating.—Six methods of exciting uterine contractions
have been adopted and recommended by different practitioners.
   1. Abdominal frictions, and manipulation, with  warm baths, &c, have
been advised,  but they very rarely  succeed, their supposed  advantage
being the absence of unnecessary irritation.
   2. Separating the membranes for two or three inches around the os
uteri, will frequently bring on labour; and as this is the  closest imitation
of  natural  labour,  it  has  been  preferred  by many.   Dr.  Hamilton
remarks, " that he is now convinced, from the experience of the last ten
years, that if there be a sufficient portion of the decidua separated from
the  cervix uteri, there is  no  occasion for  the introduction of the  open
male catheter," i. e. for puncturing the  membranes.   Dr. Conquest con-
siders it as effectual as the other methods, and much  safer for  the infant,
as  saving it from pressure  during the pains.   If it fail, we can still have
recourse to the third plan.
   3. The membranes  may be ruptured, either directly or obliquely.   For
this purpose Wenzel,  Ritgen, Kluge, and others,  have invented appro-
priate instruments; but a female catheter may be used, or a piece of wire,
or a canula having  concealed within  it  a  spring trocar.   Care  must be
taken to wound neither the mother nor child.
   This  plan was adopted in Mampe's and Spoendli's  cases; in 36 of Dr.
F. H. Ramsbotham's—(of these, 24 children were born  alive, and 19
ultimately lived); and from its greater certainty, it has been preferred by
most practitioners.
   4. MM. Briinninghausen and  Kluge have proposed and practised, with
great success, the dilatation of the os uteri, by means of a piece of sponge
placed within it, and maintained there by a plug in the vagina.  Velpeau's
experience of the value of these different plans is thus expressed:  " The
two latter methods  are chiefly practised.  By the third, the effect  is not
always produced ; it required three operations in the  case  related by M.
Riecke.   The separation of the membranes  (the second method) is not
sufficient to bring on uterine  contractions; as the distension of the cervix
is not permanent, the first attempt  is rarely successful.   Distension, by
means of a piece of sponge,  as proposed by M. Kluge, is  much more cer-
tain.  The irritation which results is permanent,  progressive, regular, and
sustained  by the plug, which is maintained in the vagina.   Under the
influence of such an excitement, uterine action  is soon brought on, and
it rarely fails to acquire sufficient energy." 
284
INDUCTION OF PREMATURE LABOUR.
  Hayn, of Konigsberg, to whose case I have referred, adopted this plan
with success ; but other authors do not agree with Velpeau in thinking it
more certain than rupturing the membranes.
  5. Ergot of rye is now generally believed to have the power of ori-
ginating uterine  contraction, and if this be  the  case, it will  probably be
found  to  be the most effectual  and safe mode of inducing premature
labour, because  we can preserve  to the child the safeguard of the liquor
amnii,  which is  of the greatest importance.
  Dr.  F. H. Ramsbotham has mentioned many cases in which it was tried
for this purpose.   Labour was brought on by its use alone, at the  seventh
or eighth month, in twenty-six cases, without interfering with the mem-
branes of the os uteri.  All the mothers recovered, and 12 of the children
were born alive, and 14 still-born.  Of the 12 born alive, 4 only survived
for any length of time.
  Dr.  Paterson, of Glasgow, and Mr. Heane, of Gloucester, succeeded
by this means.
  Mr.  Corry and Dr. Lee tried it, but failed.
  Although  the medicine appears successful as regards the induction of
labour and the consequences to the mother, yet the proportion of children
lost  is  greater than by the other methods; and this must be a serious ob-
jection to its use, when the pelvis will admit the passage of a viable child.
  6. Galvanism, which  Dr.  Radford believes to have the power of ori-
ginating uterine action.  It is certainlv worth a trial, but as yet we have
little evidence of its utility.
  It has been suggested, that  the application of the extract of belladonna
might  aid in the  dilatation of the os uteri; but independent of the fact
being  doubtful,  the practice would be dangerous, in consequence of the
active  absorption  and the development of  the  poisonous effects of the
medicine.
  486. An interval, varying from twenty-four to ninety-six hours, gene-
rally elapses after the operation, before uterine action commences, which
it does sometimes  by shivering and feverishness.  "  Great disturbance in
the nervous system," says Dr. Gooch, "is produced  by it; severe rigors,
rapid  pulse, and delirium,  are the occasional consequences; but these
symptoms,  proceeding from  nervous irritation, do not  continue  long
enough to produce any  serious  consequences."  In many  cases these
symptoms are   altogether absent.  The patient  will require the same
management as after ordinary labour.  It will  be  advisable to  have  a
nurse in'readiness, to supply the infant with its natural nourishment, until
the mother shall have milk for it.

  487. This is  probably the  best place for me to introduce  some notice
of the employment of anaesthetics in midwifery, for even those who object
to their use in   natural labour, admit their great value in  operative mid-
wifery.
  The two sole  agents in use now for the purpose of producing insensi-
bility to pain, are ether and chloroform, but the latter has so far superseded
the former, that  I may confine my remarks to the use of chloroform.
  Tc my friend, Professor Simpson, belongs the credit of having been the
first to  administer ether during labour, and also of having  discovered the 
INDUCTION OF  PREMATURE LABOUR.
285
value of  chloroform as an anaesthetic, and of introducing it into practice.
It  is composed of two atoms of carbon, one of hydrogen, and three of
chlorine, or one of formyle and three of chlorine, sp. gr. 1-480: it rapidly
evaporates,  and  possesses an  aromatic,  pungent  taste,  and a fragrant
smell.
   When inhaled, it gives rise  to exceedingly pleasant sensations, and a
rapid flow of thoughts and images, resembling a pleasing dream, until, as
the dose is increased, these become confused and incoherent, previous to
deep sleep  being induced.   The first stage  is  one  of excitement, then
follows calm sleep, and at length stupor;  but the excitement is said to be
less than when ether is used.
   The beneficial effect is the alleviation of pain, in  consequence of and in
proportion to the amount of insensibility,  so that wTe possess the power of
graduating its effects as we may deem advisable.
   That injurious effects are occasionally produced, is no more than we
should expect from so powerful an agent: that they have occurred in  so
very small a proportion, may well excite our wonder.   Almost all the un-
pleasant  symptoms are referable to the nervous system, such as spasms,
twitchings, hysterics, convulsive movements, convulsions, incoherent talk-
ing, &c.  Several fatal cases of collapse have been recorded, and although
some doubts have been entertained as to whether the death was  caused
by the chloroform, I  fear the evidence is too clear.   It is remarkable that
in most of these cases, I believe, the chloroform was administered, not to
relieve pain, but in anticipation of it, as for tooth-drawing, &c.   It is of
importance  to remember that the pulse is  a very accurate  indicator of the
propriety of continuing the inhalation; we should stop  instantly, if we
find it becoming weak.
   488. So much for the general use of chloroform  ; now let us  see what
has been the result of its  employment in midwifery.  It has been now
used extensively in Great Britain, in America,  and  on the Continent, and
we have  an account of at least 3000 cases in which it has been employed.
From this it appears
   1. That in  midwifery practice, no death has occurred which can  be
fairly and directly attributed to the chloroform.   In the cases brought
forward by Mr. Gream there is no evidence to prove that the deaths did
not result from the circumstances of the labour, and abundant proof of a
disposition to attribute every accident to this new agent.
   2. That some unpleasant  symptoms have occurred in hysterical and
nervous women during the  stage of excitement, but  no instance of the
alarming or even fatal collapse which has taken place in cases unconnected
with pregnancy or parturition.   These  symptoms disappear in a few mo-
ments  if the chloroform be discontinued, or, as is said, if the dose  be
increased.
   3. In  a small proportion of cases, the uterine contractions are weak-
ened, rendered less  frequent, or even  suspended,  so long as  inhala-
tion is continued, but  they return  if the use of chloroform be discon-
tinued.
   4. In the great majority of cases, it does not interfere with the labour
pains, except by suspending all voluntary exertions if the insensibility be
complete.   Where the dose given  is milder,  although  great relief  be 
286              INDUCTION OF  PREMATURE LABOUR.
afforded, the patient will not become insensible, and will be able to exert
considerable force.
  5. That chloroform, in full doses, is  capable  of entirely removino- the
pain of obstetrical operations, and thereby increasing the facility of  their
performance.  Moreover, that the dose can be so graduated as to afford
degrees of relief, so that, in natural labour, a certain amount of suffering
may be spared without producing insensibility or incurring the risk, what-
ever that be, of a full dose.
  6. It neither prevents  nor weakens the subsequent contractions  of the
uterus,  and  consequently does  not render  the  patient more liable to
flooding.
  7. That certain women seem  more obnoxious to its injurious  effects
than others, and in some these effects  are  said  to continue some  time.
Giving full force to these cases, they appear to form a small part of a large
number whose recovery  was not retarded, and whose  subsequent  health
was uninjured.
  These inferences, I think, are fairly deducible from the published cases:
whether, as has been asserted, many fatal or bad cases have  occurred
which have not been recorded I  cannot say, but until  we know the par-
ticulars, it is clear that we can allow no weight to such a supposition.   It
is much to be regretted that so much personal and  party feeling  has
entered into the publications on the subject, instead of a simple desire to
discover in what cases this new agent is admissible, and in what it ought
to he rejected, with the reasons for such decision.
  489.  It is right, however, to notice respectfully some of the objections
which  have been made by most experienced and conscientious practi-
tioners.
  1. The first objection  I shall  notice  is, that as "in sorrow shalt thou
bring forth children " was part of the original curse pronounced upon the
sin of man, therefore any attempt to mitigate the  suffering is a direct and
unwarrantable interference with  an  ordinance of God.  Now it will be
remembered that labour  (" in the sweat of thy brow"), pain, and death
were equally the result of the same sin,  and inflicted by the same Hand,
and yet we never hear of the wickedness of lightening labour, of relieving
pain, or of postponing death, each of  which must be wrong, if relieving
the suffering of childbirth be wrong.   It is monstrous that one sex should
claim the privilege of relief and object to its being extended to the other.
If further argument be  needed,  the reader may refer  to Dr. Simpson's
critical  remarks upon the Hebrew word translated " labour."
  2. It has been stated that in operations, the loss of sensibility deprives
the operator of a valuable indication as to whether he  is inflicting injury
or not.   I do not  see much force  in  this objection,  I confess.  If the
operator be skilful  and habituated to the use  of  instruments, he will  not
do mischief because the patient does not cry out; and  if he be not skilful,
her crying out will  not prevent him.   I am sure that  the patient being
spared the shocking pain of most operations, and the operator the distress
of witnessing it, is a blessing beyond price, and more  than anything cal-
culated to secure a  safe and  skilful performance, and in all probability a
favourable convalescence.
  3. Our ignorance of the bad  consequences of chloroform,  and  oi the 
INDUCTION OF  PREMATURE LABOUR.
287
cases improper for its  exhibition, and the  consequent probability of our
complicating the labour by  some serious  accident voluntarily incurred,
has been, and is yet, I think, an objection  deserving of careful consider-
ation.   No  doubt, the increased and increasing number of facts recorded
affords a ground for sound conclusions, in proportion to their extent; but
it  is still to be desired that there  should be  a careful classification, and
minute  investigation of those cases  in which  any unpleasant symptoms
have occurred, with the object of discovering the circumstances, whatever
they may be, which counter-indicate the employment of anaesthetic agents.
Interruption of uterine action, diminution of uterine force, and affections
of the nervous system, seem to be the chief evil effects to be feared in
parturient women.
   4.  The probability of uterine hemorrhage after labour was formerly
much insisted upon, but I think experience has shown that this fear is
groundless.   It has not occurred more frequently in patients who  have
used chloroform than in others.
   490.  Thus far I have given the inferences which  appear to me to be
fairly deducible from the cases  on record,  irrespective of the opinions of
the various writers who have engaged in the controversy.   The following
practical conclusions may be regarded as  my own opinion, formed  after
much thought and reading, and after  some slight personal experience.   1
would not wish to put them forth dogmatically, for I do believe that we
are not  yet  in a condition to  define  accurately, or to speak positively on
the subject.   I confess that I can  neither agree with those who think that
chloroform can do no evil, and  therefore ought to be used in every  case,
nor yet with those who regard it as in all cases injurious, and therefore to
be reprobated.
   1.  In most obstetric operations, anaesthesia appears to me to be of  great
use, not so  much  because it is supposed to  relax the soft parts,  or to
moderate uterine action, as because it enables the patient to bear the ad-
ditional pain we inflict without outcry or movement.   It surely must be a
great advantage  in  performing a dangerous  operation  that the patient
should lie still, and  not by her  struggles increase our difficulty, and the
risk ofjnjury to herself.  If  the tissues be relaxed, which is doubtful in
many cases, it is  of course an additional advantage;  and if it happened
in a  case of turning that the uterine action  were suspended, of course the
operation would  be all the more  easily completed ;  but these are rather
accidental  advantages  than  essential  consequences.   In operative  mid-
wifery,  therefore, chloroform may be  given until anaesthesia is produced,
before commencing, and its  effects may be kept up during the operation
provided that there  be no counter indication to its use, and that no un-
pleasant symptoms arise; in  either case it  should be given up altogether.
In any operation for terminating labour in a case of convulsions, I should
be unwilling to  use chloroform on account of the nervous excitement it
occasionally produces, notwithstanding that it is said to have been em
ployed  beneficially  in  the treatment  of that  disease: in like  manner  1
should fear to use it in cases  of alarming hemorrhage, lest it should give
rise to severe collapse.  I mention these cases as  illustrative of the  cau-
tion which appear to me necessary in the present state of our knowledge
Further experience may prove this reserve to be unnecessary, or may con
firm its propriety.
        19 
288             INDUCTION OF PREMATURE LABOUR.
   2.  As to its exhibition in natural labour:  as I do not believe  that in
the large majority of cases, convalescence is at all impeded by the suffer-
ing, I cannot see  the necessity, or even the propriety of urging the em-
ployment of anaesthesia in every case; and I do feel  that even  greater
caution ought to be used than in operative midwifery.   We may be justi-
fied in running some risk where an important point is to be gained, such
as perfect quietness during an operation, which we  should not be justified
in incurring merely to relieve pain.   Thus in hysterical or nervous patients,
in those labouring under nervous  affections, or organic disease of the
lungs or heart, &c, I do not think we ought to employ it.
   But on the other hand, as pain is undoubtedly an evil in itself, if there
be no counter indication, and if the suffering be either great or prolonged,
I cannot see that we  are prohibited from the employment of anaesthetics,
more especially as it is not necessary in such cases to produce insensibility.
It is quite possible to afford immense relief, to "render the  pains quite
bearable," as a patient of mine observed, by a dose which does not pro-
duce sleep or impair the mental  condition of the  patient, and which all
our experience.would show is absolutely free from danger.
   In  my own practice I have  never urged a patient to  use chloroform in
natural  labour, and, on the other hand, I have not felt justified in refusing
a moderate dose of it when the patient  urgently desired  it, and none of
the conditions were present which seemed to me to counter-indicate it.
   491.  The  period at which it has been administered varies with different
practitioners; some commence before the os uteri is dilated, others about
the time the  head escapes through it.   There can  seldom be any neces-
sity for  its use, I think, before the os uteri is fully dilatable, and it is more
likely to interfere with the uterine  action at an early than a later period.
At the commencement of the second stage would, I should think, be soon
enough, and this seems to be Dr. Simpson's practice.
   492.  There is  a difference of opinion as to  the extent  to which  the
anaesthesia should by carried.  Prof. Simpson prefers inducing complete
insensibility at first,  and then keeping up just so  much of the effect as
he deems advisable.   Dr. Rigby prefers commencing with smaller doses in
natural labour, and increasing them if necessary;  and the Obstetric Com-
mittee of the American Med. Association, in their Report, agree with this
view.   Of course, if we are to operate, the patient should be placed tho-
roughly under the  influence of chloroform before we  commence, and its
effects kept up by  occasional inhalation.  But in ordinary cases, as I have
said,  I  prefer beginning with a moderate dose and watching its effects,
and if necessary, increasing the anaesthesia.
   The dose should  be administered at  the beginning of each pain, and
increased when the head is passing over the perineum.    The anaesthetic
state may be kept  up for hours without mischief, especially when complete
insensibility is not required.
  I have  tried various modes of administration,  instruments  specially
contrived for the purpose, sponge, lint, &c, and I believe that by far the
best  is  the one  originally proposed by Dr. Simpson, viz. a clean white
pocket handkerchief folded funnel-shape ; into which half a drachm or a
drachm  of chloroform is to be poured, and which may then be first  placed
near the mouth of the patient, and after a few respirations, over both
mouth and nose.   It is a good plan to allow the patient to hold the hand- 
INDUCTION OF PREMATURE  LABOUR.
289
kerchief herself,  unless  we wish  to produce deep  anaesthesia, as  it will
fall from her hand when sleep  commences.*

  * The employment of anaesthesia in all cases of labour, as a matter of routine, merely
for the purpose of securing to the parturient female freedom from pain, has, it is be-
lieved, at present few advocates, but the  number of those who are in favour  of the
practice in certain forms of difficult and instrumental labour  is evidently augmenting.
  It must be admitted, that, in a very large number of  cases of  natural  labour,
anaesthesia has been induced without, apparently, any evil consequences accruing to
either mother or child — whether all the instances in which injury has resulted from the
practice  have been made public we have no  means of judging.  That we  should have
heard  of so few is really a matter of surprise, considering the powerful influence the
several anaesthetic agents must exert upon the nervous system, and the extensive and
careless manner in which they have too often been resorted to.
  It is true that,  in the practice of midwifery, anaesthesia has seldom been carried to the
extent of producing entire unconsciousness, and even when inordinate doses of ether or
chloroform have been administered, the patient has been probably saved from the fatal
consequences of the accoucheur's rashness, by his careless  manner of using the agent,
causing the greater portion of it to escape into the air of the chamber instead of pass-
ing into her lungs.
  The time is rapidly approaching when, from a full and honest comparison of facts,
the question as to the propriety of  employing anaesthesia in obstetric  practice will be
definitely settled, and the cases  and the  period of labour, and the extent in which it
may be safely and beneficially resorted to, become fixed upon certain and well-estab-
lished data.  Already the ultraism  of the early partisans of the practice  is rapidly
abating, while many of those who at first objected to it, as under all circumstances dan-
gerous, if not positively injurious, are willing to avail themselves  of its aid in certain
forms of labour.—: Editor.
Z 
CHAPTER X.
       OBSTETRIC OPERATIONS. 2. VERSION OR TURNING.

  493. The term version, or turning, is applied by midwifery teachers
generally, to that manual operation by which  one presentation is  substi-
tuted for another, less favourable;  and in a more limited sense, to the
rectification of certain malpositions.
  For the furthering of one or other of these purposes, it has been known
to the profession for a considerablf period; but the full benefit of the
operation, and the class of cases in which it  is useful, is of much  later
discovery.   It  is  recommended by Hippocrates, Celsus, P. iEginetus,
Rhodion, &c.; by the early English authors, as Raynalde, Pechey,  &c.;
among the French by Ambrose Pare, Guillemeau, Portal, &c.

  494.  Statistics:—
to	Author.	Hospital, &c.	O 5	O to — a	References.
a			o>		
1781	Dr. Bland,	Westminster Dis-	9	1,897	Merriman's Synopsis.
	Dr. Jos. Clarke,	pensary, Dublin Lying-in-Hospital,	48	10,387	Trans, of Assoc, vol. L
	Dr. Merriman,	London, Private Practice,	14	2,947	Synopsis, 4th edition, p. 335.
1816	Dr. Granville,	Westminster Dis-	8	640	Report of, p. 25.
1826	)	pensary,			
to	I Dr. Collins,	Dublin Lying-in-	33	16,414	Prac. Treat, on Med. p.
1833	j	Hospital,			73.
1828	Dr. Cusack,	Wellesley Dispen-sary,	5	313	Dublin Hospital Report, vol. v. p. 495.
1832	Dr. Maunsell,	Do.	2	442	Edin. Jour. No. 117.
1833		Do.	0	416	Dub. Jour. vol. v. p. 367.
1828	Mr. Gregory,	Coombe Hospital,	3	691	Dublin Hospital Report,
1834	)				vol. v.
to	L Dr. T. Beatty,	Cumberland Street	6	1,182	Dublin Jour. vol. viii. p.
1837	i	Hospital,			66, vol. xii. p. 273.
	Dr. Reid,		20	3,250	Midwifery.
1836 1837	L Dr. Churchill,	Western Lying-in-	11	1,640	See Reports.
1838	J Mr. Mantell,	Hospital,	8	2,510	Amer. Med. Jour. vol. iv. p. 245.
1848	Drs. M'Clintock	Dublin Lying-in-	23	6,634	Prac. Obs. in Midwifery.
Dec.	and Hardy, Mad. Lachapelle,	Hospital, Maison d'Accouch.,	155	15,654	Pratique des Accouch. p. 198.
1799 to July	- Mad. Boivin,	Maternity,	218	20,357	Memorial de l'Art, &c. p. 354.
1811	-				
(290) 
VERSION OR TURNING.                 291
4>	Author.	Hospital, &c.	o> m	O to So £"5	References.
a					
1808	M. Ramboux,	Clin, de Liege,	1	216	Bull, de la Faculte", &c. vol. ii. p. 73.
1825 1826	I Dr. Merrem,	Cologne,	3	157	Do. vol. xvii. p. 283.
1828	M. Papavoine,	St. Louis, Paris,	1	240	Jour, du Progres de M6d vol. xiv.
1829	.....	Hotel Dieu, Paris,	2	280	Velpeau 1'Art d'Ac. p. 50.
1830 1831	i M. Ciniselli,	Clin, de Pavia,	2	94	Gaz.MeUde Paris, 1835.
1833 M. Mazzoni,			18	481	Prospetto Ragionato, &c
1789	-j				
to					
1792					
and	-M. Boer,	Vienna,	61	6,666	Die Naturliche Geburt-
1801					shiilfe, &c. vol. i. pp.
to					72, 148, 237; vol. iii.
1806	_				pp. 62, 130, 245.
	M. Naegele,	Heidelberg,	22	1,411	Velpeau's Tab. View.
1801 to 1807	1 G. M. Richter,	Moscow,	25	2,571	/ Synop. Prac. Med. Ob-\ stetric, p. 416.
	f Do.	Private practice,	27	624	
1812	1				
and	[ E. Von Siebold,	Wurzburg Hospital	6	310	Siebold's Jour, fiir die
1813	J				Geburtshulfe, &c. vol. i. pp. 114, 576.
from	I				
1818 to	V Do.	Berlin Hospital,	60	2,055	Do. vol. iii. to x.
1829	J				
1819 1820	>M. Ritgen,	Giessen,	1	180	Do. vol. vi. pp. 34, 262.
1814	)				
to	}■ M. C. G. Carus,	Dresden,	29	2,133	Do. vol. vi.
1824	i				
	M. Killian,	Clin, de Prague,	63	2,850	Bull, de la Faculte", &c.
1824	)				vol. xxv. p. 352.
to	[ M. Kluge,	La Charite" Berlin,	19	1,254	Siebold's Journal, vols.
1827	J				vi. vii.
1825	Prof. Andre'e,	Breslau,	5	181	Do. vol. vi. p. 154.
1825	)				
to	VDr. Brunatti,	Dantzic,	3	380	Do. vols. vii. ix.
1828	i				
1825 1826	|Dr. Theys,	Trier,	1	49	Do. vols. vii. viii.
1826	Dr. Henne,	Konigsberg,	2	156	Do. vol. viii. p. 121.
1826	Dr. Voigtel,	Magdeburg,	1	29	Do. vol. viii. p. 831.
1827	Dr. Kvistner,	Breslau,	6	176	Do. vol. ix. p. 92.
1829	)				
to	>Dr. Adelmann,	Fulda,	1	166	Do. vols. xi. xiv.
1832	J				
1830	)				
to	[ Dr. Siebold,	Marburg,	8	821	Do. vols. xi. xii. xiii.
1832	J				
1833	i				
1835 and	I Do.	Gottingen,	7	504	Do. vols. xv. xvi.
1836	J				«
 
292
VERSION OR  TURNING.
  Thus we see that the records of English practice yield 49,323 cases,
and 190 cases of version, or about 1 in  259|; French practice, 37,479
cases, and 400 cases of version, or about  1 in 93^; and German practice,
21,516 cases,  and 337 cases of version, or 1 in 63§.   The whole number
of cases is 108,318, and of version, 927, or about 1 in 116£.
  495.  It is not so easy to  make out  a  satisfactory table showing the
danger of the operation to the mother and child, from the want of details.
Many writers do not mention whether any of the  mothers  died, and some
omit the result as regards  the child.
  In the following table, I have taken all the numbers upon which I could
depend, and though the list is  not extensive, I believe that the average
mortality will  be found pretty correct.
Authors.	Number of Version Cases.	Mother Lost.	Children lost.
Dr. Collins....... Dr. Churchill....... Dr. Kluge........ Drs. M'Clintock and Hardy . .	155 218 48 33 5 3 6 11 5 7 6 1 26 18 23	Not stated. Not stated. 6 3 0 0 1 0 0 1 0 0 0 0 1	45 48 35 13 2 0 6 8 3 3 2 0 10 7 5
  Thus, in 192  cases, where the result to the mother is specially men-
tioned, 12 mothers died, or 1 in 16.
  I do not give this result as the exact mortality of the operation, because
it is evident that the deaths  in some cases may have been  owing to the
cause which demanded the operation, as  in  placenta  praevia;  but as we
find that even in several of these cases, the fatal termination was evidently
more owing to the operation than to the  hemorrhage, I  am  inclined to
think the calculation not very far from the truth.  However, any erroneous
inference from these statistics, will be guarded against by the recollection
of the various and serious accidents which require the operation.
  In 565 cases,  where the result to the  child is detailed, 187 children
were lost, or rather less than 1 in 3.
  To a  certain extent the same observations apply to this calculation of
the mortality amongst the infants, and similar allowance must be made.
  496.  The  object of the operation is threefold:
  1. To place the head in a more favourable  relation to  the pelvis, or to
substitute the head for some other presentation.
  2. To substitute the inferior extremities for  some other less  favourable
presentation
  3. To hasten  the termination of labour, in  consequence of complica-
tions, as convulsions, flooding, prolapse of the funis, fyc. 
VERSION OR  TURNING.
293
  It has been proposed to turn and deliver instantly, in case of the sudden
death of the mother, instead of having recourse to the Caesarean section;
but the  mortality amongst children so delivered would preclude this appli-
cation of it.
  There is so much difference in the means by which the first and second
objects  are attained, that it is necessary to say a few  words upon each.
  497.  1.  Version by the head, or cephalic version, as it is termed, con-
sists (a) in clearing the  upper  outlet of any part which may hinder  the
descent of the head ; (b) in seizing the head, and bringing it down to  the
brim of the pelvis;  (c) or in rectifying the  malposition of the head.
  As the majority of children enter the world head foremost, this mode
was decided to be  the  standard  of natural  presentation at a very early
period, and  attempts were made to  correct any  deviations.   Rhodion,
Raynalde, &c,  endeavoured to change footling  into head presentations,
but  not by  internal manoeuvre.  After the  discovery  by Amb. Pare,
Guillemeau, and others, of the  ease with which labour  could  be termi-
nated by bringing down  the feet, cephalic version went very much out of
fashion. By the great bulk of recent writers (especially in our own coun-
try) it is either not mentioned at all, or with reprobation.  Still there  are
cases in which its suitability could not be overlooked, and in consequence
we find an admission here and there of its  utility.   Smellie recommends
it in certain malpositions of the head; Mauriceau  advises  it if the neck
present; and De la Motte, Melli, and Roux speak of success obtained in
this manner.  Le Roi preferred it generally to version by the feet.
   These, however, were only exceptions to the rule:  it remained  for
Flamant, professor at Strasburgh, to recall the attention of the profession
to the operation, in such a way as to procure its re-admission (at least on
the  Continent)  into the  number of valuable obstetric  operations.  His
example has been followed by  several German  and  French writers.
Labbe,  Eckhardt,  and  Wigand,  published  successful  cases  in  1803;
Schnaubert in 1815; D'Outrepont and Regnaud  in 1825.   Busch gave
an account in 1826 of fifteen, cases, in which fourteen infants were born
living.  In 1827 Ritgen  collected forty-five successful cases.  Riecke  has
had sixteen  cases.   It has been  eulogised by MM. Vallee, De  Roche,
Ubersaal, Stolz, and Toussaint.   Joerg and some others advise the head
to be seized and placed in position when nearest the cervix, and Gardien
seems inclined to recommend  it strongly, " if practitioners were  only as
well versed  in the use of the forceps as the Professor of Strasburgh."
  One  of the few British writers who speak well of it, is the distinguished
Professor at Glasgow, Dr. Burns, who says: " For instance, if the patient
be known usually to have a short labour, if the pains be  brisk, the os uteri
dilated, or in a relaxed and easily dilatable state, the liquor amnii retained,
and the head moveable, then  the head may, without  any difficulty or
much irritation,  be  placed in the proper position, with a fair and  reason-
able chance of success."
  I may also cite the testimony of Dr. Dewees, who acknowledges that
" should nothing but the position of the head, with a slightly diminished
capacity in the antero-posterior diameter, affect the labour, we may some-
times enable  the woman  to deliver herself, provided the  waters  have dis-
charged themselves, by the aid of two or three fingers within the vagina,
and applied  to the side of the head, so as to carry the vertex towards one 
294
VERSION OR TURNING.
of the acetabula;"—" when thus placed, we may commit the termination
to the natural efforts, provided  no other circumstance complicates the
labour."
  498.  It is stated  as an objection to the employment of this  kind of
manipulation, that it is more difficult to catch firm hold of the head and
to bring it to the upper outlet; that if we  succeed in bringing it to the
brim we can do no  more, but must  then leave it to nature or use the
forceps.  To these and similar objections, Velpeau has returned the follow-
ing answer:  " 1st, It is  not always very difficult to seize the head, and
to exert considerable force upon it;  2dly, if the waters have not  been
long  discharged, one may often without difficulty seize  the vertex, and
bring it to the  centre of  the  brim, however far it may have been distant;
3dly, that in general it is better to force the head to descend, by pushing
up  the  presenting part,  than by bringing down the head ; 4thly, that
delivering  by the  breech is far from being  a simple  and  safe  operation ;
as regards the child, it is less so than cephalic  version, even if the forceps
should  afterwards be applied."
  No one can for a moment deny that there is considerable weight in the
objections  I have named;  but a more detailed investigation will  show
that they are valid only against an indiscriminate employment of the ope-
ration, and not against its use  in the cases to which it ought to be confined.
These cases may be divided into two  classes:  1, where the pelvis  is of
sufficient size, and nothing but the malposition of the child's head calls
for interference ;  2, in   certain  malpresentations,  such as the  neck or
shoulder, and perhaps  in a few arm  cases, if the uterus be not strongly
contracted, and especially if the waters have not escaped.
   It  is evidently  not calculated  for any case where prompt  delivery is
necessary.
   Its advantages are found to be,—first, a greater facility in reaching the
head, for it  is not proposed to  be used in cases where the feet are near
the os uteri;  and  secondly, a vast saving of infantile life.   This operation
will be no more fatal to  the child than natural  labour, if performed early,
whereas in footling cases and in  version by the feet, one in three is lost.
   499. 2.  Turning by tlie feet,  or podalic version.—This was known  to
the ancients, but  confined by most of them to the case of dead children.
To Ambrose  Pare  we  are  indebted for  demonstrating  its facility and
comparative safety, and for inculcating it in practice.  His distinguished
pupil, Guillemeau, followed in his footsteps, to be himself succeeded by
others of brilliant talent and profound research, who cleared up the diffi-
culties, and settled the limits, and laid down the rules for the operation.
   The peculiar advantages of version by the feet are :
   1. That it  gives to the operator the entire  control over the  whole pro-
cess of the labour, so that he can regulate its duration, either acting with,
or independent of, the pains.
   2. That though inferior in its results to labour with head presentation,
it is about equal to  any  other, and superior to some.
   3. That in some  cases it is the only chance of saving the child's life,
 or of avoiding evisceration.
   4. That in certain cases it affords a probability of saving the  mother's
 life, when other means are hopeless.
   On the other hand, its disadvantages are not to be overlooked; for — 
VERSION OF  TURNING.
295
  1. From the distance the hand has  to traverse, and the  difficulty of
seizing the feet and of turning the  child in utero, there must ever be a
fearful risk of injury to the mother.
  2. The mortality amongst the infants thus brought  into the world  is
very great;  as far as our statistics extend, they yield 187 out of 565 de-
livered, or about 1 in 3.
  500.  From  all that I have said, it will not  be difficult to specify the
cases to which the operation is applicable.
  1. It may be used in all cases of malpresentation, whether of the supe-
rior extremities or trunk.
  2.  If upon the introduction of the  hand it be found impossible to rectify
the malposition of the head, we are  advised to  seek for the feet and bring
them down.
   3.  In all cases of placenta pravia, many cases of ruptured uterus, con-
vulsions, prolapsed funis, &c, the operation is  available, and  has  been
used with great success.
   It is right to mention that Denman and some other writers recommend
turning when the pelvis is slightly too narrow for the child's head ; but I
must confess that this practice appears to me more than questionable.
   501. The next point for our investigation is the period most suitable for
making the attempt; so as not to interfere rashly on the one hand, nor to
delay too long on the other,  "neque temert nee timide-----."  Of the
two errors, it is hardly too much to  say, that excessive delay is the more
serious.
   1. If the case  be one requiring cephalic version for the rectification of a
malposition, it is clear that the operation can only be safely, if at all, per-
formed before the uterine efforts have  wedged the head into the upper
strait; the attempt should be made so soon as it is evident that the natural
powers will not rectify the malposition.  It will  be an additional motive
for prompt assistance, if we find the pains violent, and that the patient
have had  many  children, lest the head, not being able to enter the brim,
should be turned aside, and forced through the uterine or vaginal parietes.
   2. (a) If we are called to an arm presentation, or any demanding podalic
version,  before the escape of the liquor amnii, and we find the os  uteri
hard and undilatable, it will be advisable to wait until some change takes
place, before we introduce the hand; neither is there any risk worth men-
tioning,  provided we remain with the  patient, to operate  instantly when
the waters break.
   (b)  If we see the patient before the rupture of  the membranes, and find
the os uteri soft and dilated or dilatable, there  is no reason  for deferring
the attempt, if the case require this kind of interference, and great advan-
tage in operating while the uterus is distended.   If we take it when the
os  uteri  will admit the finger and knuckles, it is the better time, because
we then turn the child as if in a bucket of water; and this gives us  so
clear an advantage that it needs no  explanation.
   (c) If the os uteri be dilatable, the sooner the attempt is made after the
escape of the waters the  better.   Gardien says that the most favourable
moment is just when the waters break.
   (d) After  the  escape of the waters, we  sometimes find the os uteri
neither rigid nor much dilated, and  the pains  moderate.  In such cases,
no  time should  be  lost; the hand should be introduced into the vagina. 
296
VERSION OF  TURNING.
and gentle yet firm and persevering efforts made to pass the hand into the
uterus.   Dr. Blundell says, " In ordinary cases, if the mouth of the womb
be as broad as a crown-piece, and if the softer parts be relaxed thoroughly,
the introduction of the hand  is not exposed to greater risk than usual;
there  seem to  be no  circumstances preclusive of the operation, and the
sooner you commence the  better."
   (e)  So far, although these cases are  each more serious than  the other,
yet in none of them has any very great difficulty, either of decision or of
execution, been experienced.   We are, however, often called  to  a class
of cases where our utmost judgment, patience, and skill will be needed.
I refer to those cases of arm presentation, where, in the language of Foster,
" the  membranes have been a long time ruptured, the waters totally eva-
cuated, and the womb  closely contracted around the fcetus, which is then
thrust considerably into the pelvis, the parts of the woman being dry, hot,
tender, and  often in a state of inflammation  and tumefaction, especially
when unskilful endeavours have been used to  extract or turn the fcetus,
or to  dilate the parts."
   In such a case, to force  the hand through the os uteri would be to rup-
ture that organ, and cause  the  death of the woman.  It is admitted by all
authors, I believe, that the operation must be postponed for a time, and
means  tried to soften the  uterus and  suspend its contractions.   For this
purpose all are agreed in the propriety  of taking sixteen or eighteen ounces
of blood from the arm, and following up this with a large dose (gtt. Ixxx.
to gtt. c.) of laudanum.  Dr. Collins has proposed another remedy of great
value.   He says, "In such a situation, where the individual is strong and
plethoric, twelve or fourteen ounces of blood should be taken from the
arm, and a table-spoonful  of the following mixture given every half-hour,
which I have found exceedingly useful, both in  quieting uterine  action
and inducing relaxation:
                        R. Aquae Fontis, 3 vi.
                           Antim. Tartar, gr. iv.
                           Aceti opii, gtt. xxx. M.
   By these means, after the lapse of a short time, we shall find the uterus
relax, and the os  uteri soften, so that with a little patience, gentleness, and
time, we may attain our object.
   3.  When the cause  is  one  of placenta pravia, or  even  of accidental
hemorrhage (if it demand  delivery), it is a general rule to operate  as soon
as possible.  The os uteri  seldom offers any resistance, owing to the loss
of blood ; and as this loss is necessarily increased by the natural efforts
in unavoidable flooding, it is evident that the earlier we deliver, the better
for the  patient.
   If we decide upon trying this operation in convulsions, prolapsed funis,
or ruptured uterus, it will  be wise to attempt it as soon as the state of the
os uteri will permit.
   502. Dr. Simpson has renewed the proposal of M. Velpeau* to substi-
tute turning, in certain cases of distortion of the pelvis, for craniotomy,
on the ground  that  the base  of the skull being narrower than the inter-
parietal diameter, and the head more  compressible under tractile than
expulsive efforts, the child might be delivered, and perhaps saved by a
If ss severe operation.   And further,  that as turning might be attempted
                   * De l'Art d'Accouchement, vol i. p. 38. 
VERSION OR  TURNING.
297
at an earlier period than is usual for craniotomy in such cases, we might
thereby afford the mother a greater security of a favourable result to her-
self.  And he has supported his views by statistics taken from Dr. Collins'
work, but without sufficient care and  caution, as it appears to me.
  Now let us examine into the practical application of his proposal.  The
bi-mastoid diameter in the 6 cases  of measurement he gives, varied from
2f in. to 3f in.;  and a living child can pass through a pelvis  of 3^ in.
antero-posterior diameter with or without the forceps.  With a pelvis of
this size the  operation is then unnecessary, and if the  antero-posterior
diameter of the pelvis be less than 2| in. the operation would be imprac-
ticable.  Then these are the limits of the operation : for us to attempt to
drag a child through  a  smaller space would be  unjustifiable.   For the
success of the operation then, we must be able to ascertain that the pelvis
is within these limits, and perhaps  in some few cases, with whose former
labours we are accurately acquainted we may do this, but in an immense
majority of cases it will  be, I think, impossible;  and it  happens, as Dr.
Collins has shown, that the greater number of cases of difficult labour he
met with were first cases, in which, of course, no such precise judgment
could be attained.
   Again, the  life of the child is not  secured and its chance but little in-
creased, even if our estimate of the pelvic diameters be  accurate; for if
in turning with an ordinary-sized pelvis,  one-third  of the children  are
lost, the mortality will be surely more than doubled if its diameter be re-
duced more than one-fourth.
   Moreover,  if we should miscalculate the size of the pelvis, or if the
head should  be a trifle larger than usual, so far  from the safety of the
mother being increased  it would be very seriously diminished;  for we
must then craniotomize the child after incurring the hazard of turning, and
in a most unfavourable position.
   Lastly, even if we succeed, in selecting a suitable case and in extracting
the child, it has yet to be  proved that the mother would not incur con-
siderable danger from contusion  or  laceration  in forcibly dragging  the
child through a narrow pelvis ; for I must remind my readers that we have
no  statistics of the proposed operation to compare with  those of the old
method, the few cases adduced by Dr. Simpson being of  no value for this
purpose.
   I must therefore object to the general adoption of Dr. Simpson's  plan
for the  reasons above stated: the difficulty of ascertaining the exact diame-
ters of the pelvis, the very little benefit to the child, the  great risk to the
mother of doubling the operation, and the uncertainty of benefit even in
suitable cases.
   In these conclusions I am very glad to adduce the concurrence of my
friend Dr. Radford, whose papers  are no doubt familiar to  my readers in
the pages of the Provincial Medical and Surgical Journal.
   503. Method of operating. — This operation is usually divided  into
three stages;  the  introduction,  the turning, and the extraction.  I shall
shortly describe these, in each kind of version.
   1.  Cephalic Version. — The rectum and bladder having been previously
emptied, the patient is to be placed in the posture most convenient to the
operator; some recommend that  she should lie on her back, others  that
she should kneel,  or lie on her left  side, as in ordinary labour.   The latter 
298
VERSION OR  TURNING.
   position is generally adopted in this country.  Whichever hand we choose
   to operate writh is to be well oiled or soaped, and then insinuated through
   the os  externum  edgeways.   Great  gentleness will be necessary, and,
   contrary to the advice of some, it would seem better to do this during an
   interval of pain.  When the greater part of the hand is in the vagina, it
   will be necessary to change its direction from that of the axis of the lower
   outlet, to that of the upper outlet.  This will avoid all injury to the vagina,
   and will bring the points of the fingers to about the situation of the os
   uteri.  Through the os uteri (and membranes  if entire) the hand  is to be
   insinuated very gradually, in a conical form, and during the interval of
   the pains; holding still, but not losing ground, when the pain comes on.
   When  the hand is in the womb, if our object be to rectify the position of
   the head, it  should be seized,  and placed in one of the oblique diameters
   of the  brim, with the  posterior fontanelle corresponding to  one of the
   acetabula — i. e. in the first  or second position.   If our object be to
   change the presentation — for example, to  substitute the  head for a
   shoulder — we must gently push up the shoulder, and then  seizing the
   head, bring it down to the brim, and place it in the most favourable rela-
   tion to the pelvis.
     Having now done all that we can by the hand alone, it may be with-
   drawn, and the further progress of the labour left to the efforts of nature;
   should these be found inadequate, recourse must be had to the forceps.
     This is  the ordinary method of placing  the  head in  position for
   descending; but Wigand has  stated that it is possible, before the waters
   have escaped, to change the position of the head, or even the presentation,
   by external abdominal  manipulations.   Velpeau  confirms  this from his
   own experience,  and something similar is stated by Sennert and Martins.
   Riecke has  also  related several such cases.   Dr. Burns, in a note to his
   ninth edition, states, that " Mr. Buchanan, of Hull,  informs  me  that  he
   succeeded in one instance lately, * where the left side of the breast of the
   fcetus lay diagonally over the pelvis, with the  head forward,' in bringing
f  the head right, by making the patient kneel and raise the  breech, whilst
   the  shoulders were brought as low as possible.  The water had not been
   discharged.   The situation of the head, when it came down, was made
   more favourable by the finger.  The child was alive."
     504. 2.  Podalic Version.—I shall  not repeat what I have  said as to
   the mode of introducing the hand through  the os externum and os uteri.
   The hand  and arm will be our guide ; for it is better not to  attempt to
   put it back, much less to separate it, " after the manner of the ancients."
   Denman remarks, " In no case is it necessary, or in anywise  serviceable,
   to separate the arm of the child previous to the introduction  of the hand
   of the  operator.  In some cases to which I have  been called, in which
   the arm had been separated at the shoulder, I have found greater incon-
   venience, there being much difficulty in distinguishing between the lace-
   rated skin of  the child and the parts appertaining to the mother.  The
   presenting arm is never an impediment of any consequence in the opera-
   tion, and therefore, in  my opinion, ought not to be regarded, or  on any
   account removed."  Arrived at this  point, an examination should  be
   made  as to  the  position of the child's body.   Having ascertained  all
   about  it, the hand  is to be passed  over the front (chest and belly) of
   the child, as it is generally in front that we meet with  the feet.   It  is often 
VERSION OR  TURNING.
299
a matter of difficulty to reach them, as well  from the distance to be tra-
versed as from the contraction of the uterus.
  This part of the operation should be slowly and gently  performed,
resting occasionally, and keeping the hand quite still and flat upon  the
body of the child during a pain, so as to avoid both injury to the mother
and  great pain to ourselves from the violence of the uterine contractions.
  Having found  one or both inferior extremities, " before we  begin to
extract we  must examine the limbs we hold, and be assured that we do
not  mistake a hand for a foot.  The  feet, being held  firmly in the hand,
must then be brought with a waving motion slowly into the pelvis.  While
we  are withdrawing the  hand, the waters of the ovum flow away, and
the uterus being emptied by the evacuation  of these, and the extraction
of the inferior extremities, we must wait till  it has contracted, and on the
accession of a pain the feet must be brought lower, till they are at length
cleared through the os externum."

                               Fig. 91.
   The turning of the  child is accomplished during an  interval of pain,
the feet being brought  over the front of the child, and not over the back,
which would risk dislocation of the  spine; and as the feet are drawn
down, the hand will ascend.
   The extraction  of the child is to be accomplished gradually  during  a
pain, and in drawing  downwards we should be careful  not to place the
fcetus in a wrong position as to the pelvis.  Some advise us to leave the
labour to nature, after turning the child, but to this Dewees objects.   He
says,  " The whole act of turning should be considered as one of necessity
rather than of choice;  therefore, where it is proper to commence with it.
it is, we believe, always proper to finish with it, and not trust the delivery
to the powers of nature, after having  brought the feet into the vagina, as
recommended by some." 
300
VERSION OR TURNING.
  The case is now to be managed precisely as a footling case.
  505.  Throughout  the  operation I have spoken  of bringing down the
feet; it is now right that  I  should  mention some modifications of this
plan.
                               Fig. 92.
  Peu, Burton,  and Wm. Hunter recommend that  the  hips  should be
seized and brought to the brim of the pelvis.   The latter, in his MS. lec-
tures, says, speaking of arm presentations: " In this case you are to in-
troduce the hand into the uterus, and gently put up the arm, and turn the
child  to a breech presentation.   Reduce it if possible to a perfect  breech
case, that it may come more  gradually, on account of the head  and the
navel-string, lest you strangle the child.   If, however, you find  this im-
practicable, let it come footling, but sustain the child at the hips as long
as you can, they being,  next  the  head, the largest and most unyielding
part."  In Germany it has  been advocated by Schweighaeuser, Schmidt,
and  Betschler.  This plan,  however, is  seldom or never tried.   The
breech would be more difficult to seize and bring down by the head, and
we should (as in cephalic version) lose all control over it, after placing it
in position.*                                                      I
  506. Again, it has been strongly advised to hook down the knees in-
stead of seizing the feet, by Burton, Delpech, and  Breen.   In this re-
commendation, Dr. Burns seems to coincide.   I shall quote Dr. Breen's
own statement of its advantages:
  ."•By this proceeding (hooking the finger in the flexure of the knee) the
child  would be made to revolve on the lesser axis of the trunk, and the
foot would be brought into the vagina within the reach of a noose.   By
  * A large blunt hook placed in the groin, affords very effectual control, unless there
be some unusual mechanical difficulty in the case — Editor. 
VERSION OR TURNING.
301
adopting a different procedure, and endeavouring to lay hold of a foot
according to the usual directions, it is obvious that the hand of the opera-
tor must  traverse a  greater space of the uterus — a matter of very con-
siderable difficulty, either when the action of that viscus is strong, or when
it is closely contracted on  the  body of the child.  This difficulty being
surmounted, when the foot  is laid hold of, it is very apt to slip and recede
from  the  grasp, as well from the violence  of uterine action,  as from the
hand being cramped and nearly powerless by reason of the previous exer-
tion.   By adhering to the direction of  hooking the knee, the  hand of the
operator is  in a great measure protected during the pains, and he is ena-
bled  deliberately to proportion the force requisite to change the position,
to the resistance he encounters.  Besides, as the knees  must have  been
nearly in contact with the superior part of  the abdomen, from the earliest
development of the extremities of the  embryo, should what may be called
accidental circumstances have removed them from this natural and usual
position,  but little force will be requisite to restore them to it."*
   Of course, should a foot be nearer the os uteri than a knee, Dr. Breen
would advise its being seized.
   These  reasons certainly appear of sufficient weight to justify the admis-
sion  of Dr. Breen's suggestion, as an improvement  upon  the  previous
mode of  turning.
   507. Lastly.  As it  is  not always easy to  seize both feet, we are told
by many writers not to be  solicitous  about the second, but  to extract by
one alone.   The reason given is simply to avoid pain to the mother, and
to save the difficulty and  trouble of seeking for a second.   A similar re-
commendation has  been  given by my intelligent friend, Dr. Radford of
Manchester; but for very different, and, as far as my experience  goes, for
very valid reasons:
    "  The results of practice," he says,  " prove, what might be inferred by
reasoning,  that the child's life is much  more frequently preserved  in those
cases in which it presents the breech, than where the feet come down first."
 " Is  there,  then, no practice which would enable us to bring  down a part,
approximating in its measurements to  those of the breech  presentation,
which we have already stated  to be so safe to  the child, but which cannot
be effected in turning operations?   There  is, — and this practice consists
 in never bringing down more than one  foot in the manual operation
 of turning a child."
    The following  measurements were  obtained from children born at the
 full period of utero-gestation :
 The circumference of that portion of the head which presents in
                   labour, is from......12 to 13\ inches
        Do.      of the breech, with the  thighs flexed upon the
                   abdomen, as  in breech presentations, from  .  12 to 13J do.
        Do.      of the breech, with one thigh turned upwards to-
                   wards the abdomen the other extended, from   .  11 to 12£ do.
        Do.      of the  hips, the legs extended as in feet pre-   ,
                   sentations, from......10 to 11^ do.

    It is evident from these  measurements, that it will be safer for  the child
 to brino-  down only one foot, for inasmuch as the breech with the thigh
 turned up  is more bulky than the hip with the legs extended, by so much

               * Edinburgh Med. and Surg. Journal, vol. xiv. p. 29
                                  2 A
m 
302
VERSION  OR TURNING.
will the passage be better prepared to admit the quick transit of the child's
head, upon which the safety of the infant depends.*
   Dr. Simpson recommends seizing one  knee, and that the opposite to
the upper extremity which presents, i. e. if the right  arm present, the left
knee  is to be brought down.
   508. From what has  been stated, it will appear that  the difficulties of
the operation are almost entirely owing to  the uterus  being in  action.
When it is quiescent, or nearly so, the  operation is easy; but when the
contractions are violent, it is often tedious, difficult, and very painful, both
for the patient and operator.  These  contractions equally impede the in-
troduction of the hand, the finding  of  the feet, -and the turning of the
child.  Once so much  is accomplished, they become of valuable assist-
ance  in completing the delivery.
   509. The danger to the mother may arise — 1.  From the  operator not
changing the direction of his hand, in accordance with the  pelvic axes,
and consequently pushing his fingers  through the vagina.
   2.  The  hand  may be forced through the walls of the uterus, if too
much force be  used in searching for the  feet.
   3.  The uterus may bruise  itself against the hand, or the limbs of the
fcetus, during the turning.
   4.  Without any evident injury, the irritation of the operation may give
rise to subsequent inflammation.
   5.  The nervous shock may be serious, or even fatal.
   The  simple enumeration of these  dangers ought, one would think, to
go far towards obviating most of them.
   510. The danger to the child consists—1. In compression of the funis,
which commences about the time the  buttocks  appear at the os externum.
After this time, if there  be  much delay,  the child will perish  from the in-
terrupted circulation, unless by chance  the cord should have lodged in
the angle at the junction of the  os  sacrum with the os ilium.   To obviate
this danger, it was proposed by Pugh to introduce a pipe into the child's
mouth, and excite  respiration, whilst the  head was yet in  the vagina.
Bigelow and Baudelocque are said to have employed this in practice.
   2.  If much extracting force be used, the spine may be dislocated; the
hips also;  and the leg has been pulled off.
   3.  Compression of the head is enumerated by Dewees as one of the
dangers to which the fcetus is exposed.
   511. It only remains now for me to say a word as to the after treatment.
The patient will probably need  an anodyne after the operation, and it is
good  practice to join a few grains of calomel with the opium or Dover's
powder.  It will be necessary to exercise great watchfulness to detect the

  * " I have not," says Dr. Huston, in a note to a  former edition,  "for the last twenty
years,  attempted to bring down both  feet, unless I had strong reasons for believing the
child to be dead, or from the existence of some  circumstance requiring rapid delivery,
as convulsions, hemorrhage,  or  laceration of the maternal organs; and under  these
circumstances only when it could be accomplished with facility. For the reasons men-
tioned by the author, it is certainly safer for the child to deliver by bringing down only
one foot, whilst there is no  more difficulty,  and in fact, less for the operator, than in
turning and delivering by grasping both feet.  If any more force be necessary to bring
the hips of the child through the soft parts  of the mother, than can be prudently ex-
erted on one limb of the child, a finger, or  the blunt hook, applied upon the opposite
groin,  will supply the requisite aid."—Editoe. 
THE  VECTIS OR  LEVER.
303
first inroads of inflammatory action, which must be met by antiphlogistics,
according to the strength of the patient, and the violence of the attack.
  Careful inquiry should be made as to the character of the lochial dis-
charge each day, and if necessary the vagina may be syringed with warm
water.
  The most absolute quiet and rest are desirable.   If the infant be alive,
the mother should not be teased with it for some hours.
                           CHAPTER XI.

        OBSTETRIC OPERATIONS.  3. THE VECTIS OR LEVER.

   512. So many claims have been put forth to the invention of this simple
 instrument, that it is not very easy to trace it to its author.  It has been
 ascribed to Celsus, to Mauriceau, to Schitling, and to Palfyn; but the credit,
 so far as  I can judge, belongs  to Henry Roonhuysen, from whom  it is
 extremely probable that  Dr. Chamberlen obtained  a knowledge  of the
 invention.  To others  it was  also communicated, but " for a considera-
 tion ;" and the matter was  kept  secret, until  in 1753 two  Dutch  practi-
 tioners, MM. Jacobus  de Visscher, and  Hugo van de Poll, whose names
 deserve most honourable mention, and more especially as they did not
 practise midwifery, conceived the project of making public a discovery
 which promised such valuable results.   They bought the secret for a large
 sum of money (Baudelocque says 5000 livres de France) of Gertrude de
 Bruyn, daughter of Jean  de Bruyn, and  wife of Herman van der Heiden,
 and immediately published an account of it in the Dutch language,  thus
 terminating the secret history of the vectis.
   I  have  not been able to ascertain that the  Chamberlens  imparted a
 knowledge of the vectis  to  any practitioner  in this  country, although at
 the time of the publication of Visscher and Van  de Poll, the forceps  was
 ordinarily used in London.   Since then it has obtained more or less notice
 in works on midwifery, though it has been to a great extent superseded in
 practice by the forceps.
   513.  In France, Mauriceau invented an instrument something like the
 vectis, for the purpose  of extracting  the head when separated  from the
 body.   In 1715 Isaac de  Bruas, and in 1738 M. Rigaudeaux, constructed
 each a vectis, to meet  the difficulty of certain cases to which they were
 called.  In 1753 Warroquier, of  Lisle, used  one blade of Smellie's  for-
 ceps as a lever.  After the publication of Visscher and Van de Poll, the
 instrument occupied the  attention of the profession, who were much di-
 vided in opinion as to its  merits.   At present it is but slightly esteemed.
   514  As it  was amongst the  Dutch  the vectis originated, so do they
 appear to have estimated  it most highly,  and cultivated it most  success-
fully.
   In addition to the  names of Henry and  Roger Roonhuysen, I may
mention those  of  Ruysch,  Boekelmann,  De Bruyn,  Plattman, Booro,
Rooy, De  Moor, Visscher, and Van de  Poll; of Titsing, Halfyn,  Berk-
mann, Van der Haar,  Stylcke, Jans,  De  Bree,  De Bruas, Van Gems,
        20 
304
THE  VECTIS OR  LEVER.
Rathlauw, &c.  Van Sweiten, in his Commentaries upon the Aphonsms
of Boorhaave, published in 1754, refers to the discovery of this instrument
as a benefit conferred on the human race.   He remarks: " Quamvis autem
egregii viri, quivarios forcipes invenerunt, aut perfecerunt, omnem laudem
mereantur, et  ob  industriam et ob candorem, quo  sua  inventa publico
communicaverunt, tamen  videtur vectis  ille Roohuysianus reliquis esse
praeferendus."
  The celebrated Camper published a paper in 1774, in which he advo-
cated the use of the lever, and spoke highly of its advantages.
  In 1794 Johannes Mulder published a very learned and valuable history
of the forceps and vectis.
  515. The vectis  of Roonhuysen (fig.  93),  is thus described by M.
Preville, from the memoir of Visscher and Van de Poll: " L'instrument
de Roonhuisen est  un  morceau long et quarre de fer bien forge*, de lOf
pouces de long et large d'un pouce: son epaisseur sans  etre garni est de
^ d'un pouce, et etant garni, de § d'un pouce.   Ce fer est droit au milieu
de la longuer de 4 pouces, et se courbe insensiblement vers les extremites.
Ces courbures sont a peu pres semblables, et etant mesur^es  dans leur
concavites, elles ont 3  pouces \ de courbure et environ -| de  pouce de
fond.   Ce levier de fer doit etre soigneusement arrondi  de tous cotes, et
Fig. 93.
Fig. 94.
principaiement aux quatre coins, afin qu'il ne puisse pas faire du mal
lorscj-'on I'appuie.  C'est pourquoi les extremity des courbures, quoique
bien arrondies, doivent £tre garnies d'un  eroplatre de diapalme &endu
Mir du gros linge de la longueur d'un pouce en dedans ;  le morceau droit 
THE  VECTIS OR  LEVER.
305
du milieu situe entre les deux courbures, et par lequel se fait la plus forte
pression contre les os pubis, doit etre tout a fait garni de cet emplatre, et
un peu plus fort au  milieu.  II faut surtout avoir attention que ces empla-
tres soient appliques fort egalement sur le fer, sans le moindre pli.   Apres
avoir garni  le  fer de ces emplatres, on  le garnit tout entier de peau de
chien mince et fort  douce, et il faut observer que  cette peau doit etre ap-
pliquee fort unie, et que les coutures de la peau soient au dehors, c'est a
dire, du cote convexe de l'instrument."   It is added,  "Nous avons
trouve une petite corde entortillee  autour d'un des bouts de l'instrument,
dans l'endroit ou la courbure est  plus  grande, comme on le voit meme
dan  la figure; ce que  nous croyons ne servir a autre chose, si non pour
marquer qu'on doit se servir de ce cote plutot que l'autre, ou pour mesurer
l'approche de l'instrument."
   516. Many changes have been made in the form of the instrument and
in the  materials of which it is  formed.  Titsing padded  it with wool;
Moraud and Herbiniaux  made  it  of ivory;  others  of wood, bone or
silver.
   " When the vectis was  first known in this country," says Dr.  Denman,
"that described by Heister was  preferred to those recommended by the
surgeons of Amsterdam.   The vectis used by Dr. Cole was like one blade
of the forceps, somewhat lengthened and enlarged.   That of Dr.  Griffith
was  of the same kind, with a hinge between  the handle and the blade ;
and  that  of Dr. Wathen  was not  unlike Palfyn's, but with a flat handle
and  a hook at the extremity of the handle,  which prevented its slipping
through the hand,  and might be occasionally used as a crotchet.   Many
other changes have been made in the construction of the instrument, but
the vectis now generally used is  of the following dimensions: The whole
length of the instrument before  it  is curved is 12£ inches. The length
of the blade  before it is curved is 1\ inches.   The length of the blade
when curved is 6£ inches.   The widest part of the blade is If inch.  The
weight of the vectis is 6£  ounces.   The handle is fixed in  wood."
  The one in ordinary use (fig. 94) is that described by Dr. Lowder, and
improved by Mr. Gaitskell, who says, " The  vectis should be thirteen
inches in length, one half  to form  the handle,  the other the curve.  The
handle should be made of hard wood, rendered rough for the purpose of
obtaining a firmer hold, and made to screw on and off.  When the instru-
ment is made with a hinge handle, it is very difficult to introduce ; there-
fore this construction of the instrument should  never be adopted."
  517. The nature  of the  aid afforded by the vectis is threefold :
  1.  To correct malpositions, or aid the natural rotations  of the head at
the brim, or in the cavity of the pelvis; and to this the majority of  French
practitioners limit its employment.
  2.  As a lever of  the first or second kind, i. e. making a fulcrum of the
pelvis, or of the left  hand of the  operator  external to the pelvis.  Its
employment in the first way is extremely hazardous from the certainty of
crushing the  soft structures lining  the  pelvis, and the probability of
injuring the urethra or the child's  head.   Many authorities who employ
and recommend the lever, would  altogether reject it, and I think  justly,
rather than so use it.   This  objection does  not hold against the  second
mode, which is the  proper one, if it be employed  as a lever at all.
  The discoverers and first possessors of the secret,  made the arch of the
                               2a2 
306
THE VECTIS OR LEVER.
pubis the fulcrum.   In order to avoid the urethra, Boom, Boekelmann,
and Titsing rested it upon the ramus of the ischium.
  3. As a tractor.—Dr. Burns says, " It is unfortunately named, for it
ought not  to be employed to  wrench, but  to hook or draw down the
head ; and its proper application would be less apt to  be  mistaken were
it called the tractor."   This can only be done with the  curved vectis;
with the one used  by Roonhuysen no  tractile power could be  exerted.
When the force  thus employed is sufficient, it is by far the safest appli-
cation of the instrument.
  518.  The cases suitable for the employment of the vectis appear to be
the following:
  1.  Before the head has fully entered the upper outlet, when, either from
slight malposition,  or from very slight narrowing, the  uterine efforts are
ineffectual in advancing the labour.
  Froriep  advises it in cases of face presentation, and after version, when
the head is difficult to extract.
  2.  It was  recommended by  its early patrons in cases where the head
had become impacted in the pelvis: in fact, it was considered as  super-
seding  in a great measure the use of the  crotchet.  After the description
I have  given, I need hardly say that  it is not merely powerless in such
cases, but very likely to be injurious.
   Levret,  and some other French writers, have admitted its employment
in  some  cases where  the head was rather tight  in the passage — to use
their own words — on the point of being "enclavee,"  but not when
impacted.
   I have  hitherto  deferred stating  the two principal conditions of its
employment, even  in  these  cases,  viz. the  presence of labour  pains,
without which there could not  be a chance of success; and the dilatation
of the os uteri.
   3. The case  which  appears to me most suitable for the use of this
instrument, and in  which the probability of  success is  greatest, is that in
which the  head having descended into the pelvic cavity, is arrested in its
progress, not by any mechanical impediment, but by the inefficiency (not
absence)  of  labour pains, and when the patient  is beginning  to  show
symptoms of constitutional or local disturbance.  This condition  does not
take place until the second stage of  labour has lasted some time, and as,
after these symptoms  have shown themselves,  there is danger  to the
patient  in  further delay, it  is important to obtain aid.
   " In  this most favourable presentation,"  says Dr. Breen, "the uterine
action is occasionally for hours exerted in vain, from causes which we are
frequently unable to account for.  Much delay may excite fears for the
safety of the child, and lay the foundation of  a tendency to inflammation
in  some of the  soft structures of the mother; indicated by some one, or
several  of the following symptoms ; increased frequency or fulness of the
pulse;  tongue  loaded  in its centre, secretion of urine diminished, and
becoming  higher in colour, sometimes requiring  to be drawn off by the
catheter; countenance  assuming an  anxious aspect;  stomach  irritable;
general increase of restlessness."
 3  Now as there is supposed to  be space enough, and pains, though feeble,
a slight additional force will often succeed in bringing the infant into the
world at once.   As there is nothing in the nature  of the operation to add 
THE VECTIS OR LEVER.
307
to the danger, and especially as the tractile force will probably be  suffi-
cient, it seems peculiarly suitable to this case ; and I may add, that all the
testimony I can collect is in favour of its application.
  4.  In cases of convulsions, or other accidents occurring during labour,
provided only that the pains  continue, the assistance of the lever  may be
sufficient to terminate the labour.
  519. As to the time when the instrument may be most advantageously
used, I may adopt the words of Mr. Dease:  " It requires a certain degree
of cool discernment, which I believe is only acquired by long practice, to
know when a woman is still capable of assisting her labour, or when the
head is sufficiently low in the pelvis to use the extractor."
.   If the object desired, be  to aid the head in passing through the upper
outlet, or to rectify its position there, it will be  well to operate so  soon as
the Os uteri is dilated or dilatable.
   When the head is in  the pelvis, it is desirable to have it as low  down
as may be, as the operation is then much easier.
   " Under these circumstances," says  Mr. Dease, " I think  it  best to
examine the woman as  she lies on her side:  if the surgeon finds  that the
head is sunk deep in the pelvis towards  the sacrum,  at least one-half, he
may apply the extractor:  he should not form his judgment of the descent
of the head from examining towards  the pubis;  for here, from the shal-
lowness of the pelvis, and the  swelling  of the  scalp, he will be very apt
to be deceived, and imagine the head  to be much  lower down than it
really is."
   In coming to a conclusion on this point, however,  regard must be had
to the constitutional symptoms;  if these be urgent, it would be unwise to
lose time after the period at which the vectis may be easily applied.
   The occurrence  of any  of the  accidental  complications, will  in each
case  determine the period for operating,  according to the urgency of the
symptoms.
   520. I regret much not having  any statistical results to submit, but in
this, as in too many other cases,  practitioners  seem to have concluded,
that as the instrument is said to  be quite safe, it was  therefore  useless to
record the facts.
   De  Bruyn is said to have used it successfully 800 times in 42 years.
   MM. Titsing and Berkmann used it 262 times in 24 years, and  saved
80 or 90 children in the 100.
   521. As to the comparative results: the alternative of the vectis  is the
forceps, and their respective  merits have been the subject of controversy
with most writers who have treated  of  them.  Upon reading over the
different sides of the question, it  would  seem that each writer has  taken
up the subject too much as a partisan.  To compare their utility in certain
cases, is little  more than  a waste  of  words; as,  for example, where the
pains have ceased,  or where  compression is required to extricate the head
of the child.   In  such cases, the vectis is of no use, and  it would be
highly reprehensible to  employ it. But  where there  is room,  and when
the pains persist, there the  vectis being sufficiently powerful, has this
signal advantage, that there is but one  blade to be introduced, and but
the thickness of that one blade added to  the child's head.  It is possible
that the single blade may be able to act where the bulk of two would
render extraction  impossible.  These  appear to me to be the peculiar ad 
308
THE VECTIS  OR LEVER.
vantages of the vectis,  and therefore  I shall not  detail the controversy
more fully, but refer  to the works of  Osborn, Bland, Denman, Camper,
Herbiniaux, Levret, Burns, Conquest, &c, &c.
   One point, however,  I must notice,  which has been urged in favour of
the vectis, viz., the secrecy with which it may be used.  Now  this I con-
sider a decided disadvantage.   I  most fully agree with the opinion of Dr.
Osborn, and shall  make  no apology  for transcribing it at length,  as  it
applies forcibly to all midwifery operations :
   " In  the  first place I am persuaded, that if concealment in the use of
the means intended for relief in laborious  or difficult labours  be not per-
mitted, but  that the absolute necessity of such means be first established,
and that every practitioner be obliged openly and  avowedly to use them,
we should never again hear or read of one person  having used the vectis
in 800 and  another in 1200 cases (Van Swieten, Camper, and Herbiniaux).
Nor shall we again hear of the great number of women which some  prac-
titioners are constantly boasting of having delivered; for no man can
attend a great  number  of women in labour, in  the manner he ought, in
the way nature demands, or a conscientious discharge of his duty requires.
Nor do real difficulties occur  so often, as  to render it possible  to believe,
that any man's life could afford  such numbers of difficult cases as are
stated in the printed  accounts from abroad.   As  I feel thoroughly con-
vinced of the  propriety and necessity of a fair and candid avowal of the
use of instruments, in every case of midwifery where they are to be em-
ployed, so  I must  insist that their concealment cannot be justified by any
proper motive.  Such  an open  avowal implies a conviction in the practi-
tioner's mind  of that  irresistible necessity for their use, that  supersedes
 every other consideration; it implies  a consciousness of the rectitude of
his conduct, and it implies a voluntary acceptance of the  consequences
 of the operation, which ought to make part of his professional  duty: and
 it clearly demonstrates to the  satisfaction  of the patient and her friends,
that no motive of  convenience to himself  could urge him to an operation
which may prove ruinous to his own reputation and  interest.  Besides,
not to insist upon that responsibility from  the operator,  is to deprive the
 patient of the  best and surest  security against a precipitate performance
 of the  operation.  If once the  practitioner can rest assured, that, let the
 event of the  case be  ever so  unsuccessful, the injurious  effects of his
 operation will  be  buried  in eternal oblivion, by  blending the mischief
 arising from the indiscreet use  of instruments with  the natural conse-
 quences of labour,  he will certainly have nothing to weigh  against the
 tempting advantages of convenience or emolument to himself; but while
 he is shortening the duration of the most irksome  part  of his professional
 duty, the waiting upon a slow and lingering labour, he will flatter him-
 self, that, by delivering, he is  doing an acceptable service to his  patient,
 in shortening the duration of her sufferings."*
    522   Method of operating. — Premising then that the case is one
 adapted for the vectis, that there is space enough, that the os uteri is fully
 dilatable, if not dilated, that there are pains, and that the patient and her
 friends have been made acquainted with our intention, it next remains for
 us to consider  the  method of using the instrument:
* Essays on Midwifery, p. 144. 
THE  VECTIS OR LEVER.
309
  1st.  As a lever, and,
  2dly. As a tractor.
  1. As a lever. — The first point to be decided is, over what part the
instrument is to be applied ; and here we have latitude enough.
  " Some," says Dr. Gooch, " apply it over the occiput; others  behind
the ear, by which it has a bearing against the prominence of the  mastoid
process; and others  against the chin.   The two first are perhaps the best
when the head is high, as considerable force is required to move it, which
may be employed with more safety against either the occiput or  mastoid
process than against the chin.  But when the head is low down, resting
on the perineum, less force will be necessary, and the vectis  may then be
applied against  the  chin; but  the instrument requires  to be used  with
great caution, lest the jaw should be injured."
  De Bruyn applied it over the mastoid process;  Camper over the lower
jaw ; Lowder on the forehead* &c, &c.
  I have already pointed out the temptation to make the soft parts of the
mother the fulcrum,  and the mischiefs  which result.  As far as my judg-
ment extends, it would seem that the vectis  ought never to  be used as a
lever of the  first class; even as one of the second class, much  caution
will be necessary.
  " When an instrument of this  sort  is used, it is proper to make the
hand the fulcrum on which it acts: now if the force  required is but small,
this  may certainly do well enough, but where  great  force is required,
this  is a very bad support; besides the bony parts  of the  pelvis lie so
convenient, that we may rest our instrument  on any part of it.   Yet we
should recollect, that whatever part we  convert into a fulcrum, we injure
more or less, according to circumstances.  If we apply it over the sym-
physis pubis, we press upon the urethra ; or if in other situations, we shall
injure  the clitoris or vagina."*
   " The injuries inflicted indeed must have  been frequent and great—
and this led Pean, in 1772, to suggest  the possibility of delivering by the
vectis, without making a fulcrum of the mother's structures.  He proposed
a practice, which is now sometimes adopted, of grasping the shank of the
instrument with the left hand — the outer edge of the  little finger being
applied towards  the vulva—making that hand the fulcrum, and pressing
the extremity of the blade on the child's head, by raising the handle
firmly  on the right."f
   Having determined on what part of the infant the lever is to be applied ;
the instrument is to be well warmed, greased or soaped, and the patient
placed in the usual position for delivery, on  her  left side;  the  operator
is to introduce  one or  two fingers of his left hand to serve  as a director
for the vectis, which is to be carefully and gently passed over the  con-
vexity of the child's  head, until it has reached the point to which the force
is to be applied.
   " This attained, the handle should  now be held firmly with the  right
hand, while the index and middle finger of the left, fixed about two inches
from the screw part, within the vagina, become a fulcrum.  On this ful-
  * London Practice of Midwifery, p. 208.
  •j- Ramsbotham's  Lectures in Medical Gazette, May 31, 1834, p. 307.   See also Bau
delocque, vol. ii. p. 47. 
310
THE  VECTIS OR LEVER.
crum or point of support, the instrument is made to move from the sacro-
iliac symphysis towards the hollow of the ilium, by the action of the  right
hand on the handle.   In this way it describes the section of a circle, and
glides on to the occiput.  Should the occiput point  to the right ilium,
                               Fig. 95.
the left hand must be employed ;  if to the left ilium, the right hand must
be used.  When a pain takes place, the accoucheur should gently aid it
by drawing  down in the axis of the pelvis.  In this way the occiput is
depressed, while the  chin  approaches the child's breast,  and the head is
reduced to the smallest compass, and is thus  enabled to pass through the
cavity of the pelvis.  As soon as the occiput is brought so low as to press
on the perineum, the instrument should be withdrawn, and re-introduced
with the usual precautions.   The object now in view is to place the instru-
ment over the face of the child.  To effect this, the hand  must be  passed
up, as at first directed, to the right or left sacro-iliac symphysis, according
to the situation of the face.   When the instrument  gets above  the brim
of the  pelvis, a finger or two must be inserted by the side of the  instru-
ment, and pressed on till it passes over the forehead on to the face, so as
to embrace the chin.   The  practitioner has now nothing to do but to draw
down during  the time of  pain, increasing the power according to  the
degree of resistance."*
   Or if we  prefer it, the right hand, grasping the handle, may be made
the fulcrum, and the force applied by the left hand  at the junction of the
blade and handle, directing it downwards and backwards until the descent
of the head  is accomplished.
   " If the instrument should slip, a fresh purchase must be obtained.  As
the head passes  over the perineum, the efforts may be relaxed; and if the
pains appear sufficient, it may be withdrawn  altogether, and the termina-
tion  left to nature."
* Gaitskell, London Medical Repository, November, 1823, p. 380. 
THE  VECTIS OR LEVER.
311
    523. 2. As a tractor.—The preliminary steps, introduction, &c, are
  the same  as when it is used as a lever;  but instead of making use of one
  hand as a fulcrum, both  hands are employed  in the one office of main-
  taining a firm purchase, and  drawing downwards and a little backwards
  during the pains.   The effort is to be relaxed during an interval; and
  this alteration of traction and  rest  is to be continued until the head  has
  descended to the  inferior outlet   As  before,  it may be allowed to pass
  over the perineum  without assistance, if the pains be adequate to its  ex-
  pulsion.
    524. There is, I believe, no danger to  the  mother or child when  the
  vectis is  in skilful hands, but in those of the ignorant or inexperienced
  great mischief may be done.
    1. It may be introduced before the os uteri  is dilatable ; of this error,
  contusion, laceration,  and death may be the consequences.
    2. By  an incautious mode of passing the instrument, the parietes of the
  uterus may be ruptured.
    3. By  employing the extracting  power, without  bearing  in mind the
  different axes of the pelvis, and the position of the fcetal head in relation
  to those axes, the lever will be inefficient,  and  the mother injured.
    4. By  passing the instrument outside of the  uterus instead of within its
  cavity, a  fatal wound maybe  inflicted.
    5. By  exerting the power  without regard to the pains, the operation
  will be in vain.
    6. By  making a fulcrum of the soft  parts of the  mother,  much injury
  may result.
    7. By  exerting too much force as the head  passes over the perineum,
  or neglecting to  support  it, you may tear  the perineum, so as to lay the
  genital fissure open into the anus.
    8. By  making too much pressure with the point of the instrument upon
{  the part of the child to which it is applied, a wound may be  inflicted.
'   525. The subsequent treatment varies very little from that required aftei
  ordinary labour; there is  very little shock,  and no injury, if the operation
  be skilfully performed.   The  parts should, however, be carefully exam-
 • ined, and, if necessary, a spirit lotion applied.    The same treatment should
  be applied to the head of the child, if the instrument have  bruised the
  integuments. 
CHAPTER XII.
            OBSTETRIC  OPERATIONS.  4. THE FORCEPS.

  526.  It will be at once admitted, I believe, that the greatest triumph
of surgery is to diminish  the  frequency of operations, and to  substitute
those of minor severity and danger, for others involving more serious risk.
If this be true, then it must be granted  that the invention  of the forceps,
and their employment  in  practice, is  the greatest improvement recorded
in the annals of operative  midwifery.  Before the introduction of this in-
strument,  the only extracting force at command was  obtained  by the  in-
sertion of a  hook into the  head of the child — such as is now used in the
operation  of craniotomy.
  This  proceeding must of course have been fatal to the child in an im-
mense majority of cases,  and  the very''few who were born  alive, must
have been subsequently endangered by the mutilating process employed
in the delivery.  But  this was not all; every man  possessing common
feelings of humanity must have shrunk from the painful necessity  of such
a proceeding, and have deferred  the  operation  as  long as possible, by
which the danger to the mother was greatly increased.
  Now, from this double risk and fearful mortality we have been relieved
by the invention of the forceps; for although we  are still obliged to de-
stroy the child  occasionally, to secure the safety of the mother, yet  this
class of cases is incomparably smaller  than that in which, by the timely
application of  the forceps, both the child and mother escape injury,
  For these  reasons, I conceive that I am justified in stating that the in-
vention  and employment  of this instrument is the greatest improvement
that has ever occurred in midwifery, even though I may not go the length
of certain of its advocates, in asserting  that it is  entirely without danger
to the mother or her infant.
  527.  It cannot be said that the ancients were altogether ignorant of this
method  of extracting the infant, although it does not appear to have been
generally known.  Mulder, in his valuable work, gives the following ex-
tract from a  translation of  the works  of  Avicenna: " Oportet ut inveniat
obstetrix possibilitatem hujusmodi fcetus, quare subtilietur  in extractione
ejus paulatim;  tunc si valet illud in  eo,  bene est;  et si non liget eum
cum margine panni et trahat cum subtilitur valde cum quibusdam attrac-
tionibus.  Quod si illud non confert administrentur forcipes, et attrahatur
cum eis;  si  vero non  confert  illud extrahatur cum incisione, secundum
quod facile fit, et regatur regimine fcetus mortui."
  This very distinct allusion to the forceps seems to have made no  im-
pression, for we find no similar attempt  to extract the child until the mid-
dle of the sixteenth century;  at which  time (1554)  Rueff recommended
in instrument  resembling a pair of lithotomy forceps, for the purpose of
extracting dead children, or of supplying a deficiency of manual force.
It does  not  appear, however, that he appreciated  the value of the forceps
as subsequently employed, nor did his  contemporaries carry out his sug- 
THE  FORCEPS.
313
gestion, for it was not until a century later that the instrument was brought
into practice.
  Before the time of the Chamberlens, it was  unknown in England, and
even at the time that Dr. Hugh Chamberlen published his  translation of
Mauriceau, in  1672, it was still a secret.  No allusion to such an instru-
ment is to be found in Raynald's work (1634), nor in the translations of
Portal  (1705), Deventer (1716), or La Motte  (1745).
  528. In his preface to  the  translation  of Mauriceau, to which I have
referred, Dr. Hugh Chamberlen, after mentioning the method of extract-
ing the child  by hooks, observed,  "But I can neither approve  of that
practice,  nor  of  those  delays, beyond twenty-four hours,  because  my
father, brother, and myself (though none else in Europe, as I know) have,
by God's blessing, and our industry, attained to and long practiced a way
to deliver women in this case without  any prejudice to  them or their in-
fants ;  though all others (being obliged, for want of such an expedient,
to use the common way)  do and must endanger, if not destroy, one or
both, with hooks.  By this manual operation, a labour may be despatched
(in the least difficulty) with fewer pains and sooner, to the great advantage
and without danger, both  of woman and  child; if, therefore, the use of
hooks  by physicians and chirurgeons be condemned (without thereto ne-
cessitated through some monstrous birth), we can much  less approve of a
midwife using them, as  some here in England boast they do, which rash
presumption in France,  would call them in question for their lives."
   This extract, however,  does not  fix the date of the  invention  by Dr.
Chamberlen, nor have we  any  accurate data for doing so.   Through the
kindness of a  friend, I possess a pamphlet (" A voice in Rhama") by Dr.
Peter Chamberlen, published  in 1647, in which he speaks of his father's
(Dr. Paul  Chamberlen) discovery for  the  saving of infantile life.  This
would fix the  date of  the discovery some time  before 1647.   Of the sons,
Drs. Peter and Hugh Chamberlen  are the only ones whose names  are
familiar to us.
  From some  inaccuracy of expression in the extract I have quoted from
Dr. Hugh Charaberlen's preface, it was even doubted whether the instru-
ment alluded  to was  the  forceps, but  that doubt has been set at rest by
Mr. Cansardine, who  has published an account of the discovery of Cham-
berlen's own instruments.
   " The estate of Woodham Mortimer Hall, near Maldon, in Essex, was
purchased by Dr. Peter Chamberlen, some time previous  to 1683, and
continued in his family till about 1715, when it was sold by Hope Cham-
berlen to William Alexander, wine merchant, &c."
   In an old chest,  found  in one of the chambers of this house, certain
obstetric  instruments  were discovered, along with  " old coins, trinkets
gloves, fans, spectacles, &c," and were presented to Mr. Cansardine, who
thus describes them :  " First, we have a simple vectis, with an open fenes-
trum;  then we have  the  idea of uniting two of these  instruments by a
joint, which makes each blade seem as  a fulcrum to the  other, instead of
making a fulcrum of the soft parts of the mother; and which also unites
a power of drawing the head  forward.  This idea is at first by a pivot,
which being riveted, makes the instrument totally incapable of application.
Then he goes  to work again, and having made a notch in each vectis for
the joint, he fixes a pivot  in one only, which projecting, is to be received 
314
THE FORCErS.
mto a corresponding hole in the other blade, after they have been applied
separately.  It may be observed, that although there is a worm to the pro-
jecting part of the pivot, yet there is no corresponding female screw in the
hole which is to receive it.   Every practical accoucheur will know, that
it is  not easy, or always possible, to lock the joints  of the forceps with
such accuracy as to bring this pivot and hole into opposite contact.  This
Chamberlen soon discovered, and next produced a more light and manage-
able instrument, which, instead of uniting  by a pivot, he  passes  a tape
through the two holes, and winds it round the joint, which  method com-
bines sufficient accuracy of contact, security, and mobility."*
  There can now be no doubt  of the credit of the invention being due to
Dr. Paul Chamberlen, and I have proved that it took place before the
year 1647.   The secret was, however, carefully preserved, nor had  it
been communicated in the year 1716, for in Dr. Hugh Chamberlen's third
edition of Mauriceau, published in that year, the passage I have quoted is
continued in the preface.f
  About this time, or soon after, the secret appears to have been commu-
nicated to one or two, for Dr. R. W. Johnson, when  speaking of the
forceps, says:  " Besides these, I have a pair of forceps, which did belong
to the late Mr. Drinkwater (late Surgeon and Man-midwife at Brentford),
who began  practice in 1668, and died in 1728.  The size  and form  of
this  pair  agree with those of Chapman and Giffard, save  only that the
hooks of the handle are turned outwards."
  * Mr. Cansardine's paper in Med.  Chir. Trans, vol. ix. p. 183.
  f " The accompanying cut is taken from a drawing of the most perfect of Chamber-
len's instruments.  No. 1 is the forceps locked: a, the blades;  b, the handles; c, the
hole in the joint, through which is passed the  string to connect the blades.
  "No. 2, the front view of a single blade:  a, the fenestra; b, the groove in  the
phanks forming the lock, by which the two blades, perfectly similar in form,  are adapted
to each other; c, the  handle.
                                 Fig. 96.
                                              I
  " The following are the dimensions : extreme length, eleven inches and a half; length
of blades, seven inches and a quarter; of handle, four inches and a quarter; greatest
width between the blades, three inches and three-eighths; width between the blades at
the points, three-fourths of an inch;  greatest breadth of the blade, one inch and a
half."—Appendix to Dr. Ramsbotham's Principles and Practice of Obstet. Med. and Surg.—
Ewtob.
 
THE FORCEPS.
315
  And Mr. Chapman, in 1733, published a description and a plate of the
instrument, which he had  used  from the year 1726, stating it to* be  the
instrument used by the Chamberlens ; but without stating whence he pro-
cured it.  I have not succeeded in discovering from whom he received it,
though from his not claiming the merit of the invention, it is evident that
it was communicated to him.  He has, however, the great credit of being
the first in these countries who published an account of it for the benefit
of the profession.
  After this period, the forceps is described and recommended for various
cases by almost all British writers.
  529.  The credit of first introducing this instrument into French practice
is due to Palfyn or Gilles le Doux of Ypres.  One of the first persons who
used it was M.  Duse, whose example was followed by Mesnard, Gregoire,
Levret, Coutouly, &c.
   The earliest German practitioner who  made use of the forceps appears
to have been Cornelius van Solingen,  in 1673;  he was followed by
Slevogt, Velsen, Schlichting, &c.

                               Fig. 97.
                             Short Forceps.

  530.  The  original instrument has  been variously modified according
to the fancy of different practitioners.
  The chief peculiarities may be pointed out in a few words.
  1. The most striking variation observable, is in the length of the instru-
ment— some  being sixteen or eighteen  inches long, and others  only
eleven.   The object of the greater length is evidently to enable us to act
before the head has  descended into the pelvis.  The shorter forceps can 
316
THE FORCEPS.
only be used when the head is in the cavity.   The  longer instrument
possesses  greater lever power,  and requires greater skill and care in its
management.
  2. There is a considerable difference in the distance between the blades
of different forceps when closed—some  being nearly wide enough to
admit  an  ordinary sized  head, whilst others approximate  very closely.

                               Fig. 98.
Long Forceps.
These instruments must necessarily possess  a very different  degree of
force; with the latter the head maybe powerfully grasped and compressed,
and a great extracting force exerted, whereas the former can do little more
than extract with moderate force, when the resistance  is not great.   The
latter are the more useful in  skilful hands, but the former are, perhaps,
%afer for ordinary use.
  3.  To some of the instruments a second curve is added, the convexity
of which is intended to correspond to the hollow  of the sacrum, and the
concavity to the symphysis  pubis, in order that  the  instrument  may be
applied in the  axis of  the cavity and upper outlet.  The second curve
(" curvatura nova," as Mulder calls it) has been added both to the long
and short forceps.  I do not believe that it is advantageous in either kind;
in the latter it  is often  very inconvenient.  " It is far better to  have both 
THE  FORCEPS.
317
these instruments perfectly straight, the diversity of curves recommended
by different writers answering no useful purpose."
  4. The fenestrum varies in length and breadth in different  forceps —
in some it is altogether absent, and in others it is very wide.   The object
of the  latter modification  is to avoid as much as possible  adding to the
bulk of the child's head,  and  to diminish the risk of injury to mother and
child.   I doubt whether the object be attained by this arrangement, and
when the forceps are introduced antero-posteriorly, the additional breadth
of the blade which is underneath the arch of the pubis, may prove very
mischievous to the sides of the outlet.
  5. In other forceps the breadth of the blade is continued to the handle,
for the purpose of containing  an  opening, through which the other blade
(which is slightly narrower) is passed, so as to insure their apposition.
  6.  Certain contrivances have been added to the handles of  the instru-
ment, to prevent their being pressed too closely together; and in some
forceps the  blades do not  cross, in order to avoid compressing  the child's
head.
  7.  The  blades  have been wrapped with leather, to prevent injury to
the scalp of the child.  This plan is now very properly abandoned, as it
could not be of any use,  and  rather added to the difficulty of introduc-
tion.
                                Fig. 99
Radford's Forceps.
  8. Mr. Radford has  altered the long forceps, and, as he states, with
great advantage.   The  blade, which is to be applied over the occiput, is
                                 2b2 
318
THE FORCEPS.
much shorter than the other, so that when it touches the neck, the  other
(owing to the oblique position in which the head descends) will embrace
a great extent of the anterior part of the head.   He has also lessened the
compressing power of the instrument, by placing the joint nearer the outer
end of the forceps.
  9. Dr. Davis, of University College, London, has shown much ingenuity
in varying the forceps, so as to meet the different circumstances in which
they are required.
  In London, a modification  of Levret's forceps is used  for the higher
operation, and Smellie's for the cavity of the pelvis.  In Edinburgh, both
the  long and short forceps are  employed, with the single or double curve.
In Dublin, the long forceps is rarely used; and the short one resembles
Smellie's, without the second curvature.   In France, Levret's forceps, or
a modification of it,  is in general use.  In Germany, the forceps of Boer,
Levret,  Schmidt, Stark, Siebold, Briinninghausen, Naegele, Osiander,
&c.;  and in Italy the forceps of Levret or Assilini are employed.
  Since the first edition of this work I have taken some  pains to modify
the  shape and proportions of the short forceps, and from the testimony of
many practitioners, I think I may say that I have succeeded in improving
the  instrument, although the alterations are but slight.   I  still prefer the
single curved forceps.  The  length should be 12  inches, of which the
handles occupy 4.   The interval between the points of the blades when
closed should be  1 inch, and  at the widest part of the  curve  3 inches.
The breadth of each blade  at the widest part should  be 1 inch, the fenes-
trum 2^ or 3 inches  long, having the lower part of the blade solid  steel,
to give greater firmness.   The curve of the instrument  should not com-
mence for fully 3^  inches  above the  handle,  and will  consequently be
much increased towards the point.   Lastly, the edges of the blades and
fenestra must be nicely bevelled off.  The advantages I have found  from
these changes are an increase of tractile power, without the necessity of
grasping the  handles  so tightly, and  compressing the head;  the  exact
fitting of the  head into the hollow formed by the curves, so as  to avoid
distending the  perineum  by a part of  the instrument not actually out of
use, and the prevention of springing and slipping by the solidity of the
lower part of the blades.
  The hand that is to  use the  instrument is, however, of more importance
than the instrument  itself, of  which it may be observed with truth, that
" that which is best administered, is best."
  531.  The object of  the operation  with the forceps is,
  1.  To facilitate delivery, when its progress is arrested by certain  mal-
positions of the head,  at the brim, or in the cavity of the pebyis.
  2.  To supply the  want of uterine action, or  to render it effective for
the expulsion of the child.
  3.  To save  the mother from the evil consequences of  a labour too
prolonged, and from the necessity of a severe operation.
  4.  To save the life of the child, or at least afford it a chance of escape
from certain destruction.
  532.  That these objects are  attainable, will, I trust, appear from the
nature of the  aid afforded by the forceps, and that they have been in many
instances attained, the statistics of the operation will prove.
  It was not  for some time after the invention of the instrument that its 
THE FORCEPS.                         319
powers, and the limitations of those powers,  were  understood.  The
story of Chamberlen's Paris adventure is a good illustration.  He visited
Paris, and offered to deliver any patient the faculty chose with his instru-
ment ;  they gave him a case of distorted pelvis; he tried, and of course
failed,  and left the  city in disgrace.   Had he carefully studied the cases
to which  the instrument was applicable, he would have been spared the
annoyance.

   533. It is evident that the forceps possesses a twofold power.
   1. That of grasping and compressing the head  of the child.
   2. That of acting as a lever of the first kind,  and as an extractor.
   The compression exercised by it must be limited within the degree the
head  can bear without injury, and may  be limited by the form of the
instrument.   The extracting force will be in  proportion  to the firmness
of the grasp, and limited by the resistance, and the danger of injury to
the mother.
   Now it is ascertained, that if there be space sufficient,  such  a grasp
may be obtained of the child's  head, without injury to it, as  will enable
us to extract it, and that the extracting force thus exercised is not suffi-
cient  to injure  the mother; thus the forceps may supply the want  of
uterine pains.
   Many cases occur in which the transverse  diameter of the child's head
is slightly greater than the antero-posterior diameter of the brim, or the
transverse diameter of the lower outlet;  but where  a slight additional
compression would enable it to pass: now, if this do  not  exceed the
amount of compression which the head will safely bear, and if the force
required for extraction  be  not  sufficient to injure the  mother, such com-
pression and extracting power may  be afforded  by the forceps, which
will thus render the uterine action effective.   No doubt it requires great
tact and long experience to decide upon the probability of success, but
we have  high  authority for the propriety of  the attempt in such cases.
To those  who lack  experience, the failure of a very cautious effort will be
an  adequate evidence of its impracticability, and with ordinary care,  no
mischief will be done.
   Lastly, in most cases where the head is not impacted, a sufficient grasp
may almost always  be  obtained, either at the upper outlet or in the cavity,
to enable  us to change the position of the child.

   534. Statistics. — I trust I have made it appear,  from  the nature of
the aid afforded, that  the first  and second objects of the  operation are
attainable;  how far this is the case with  the third and  fourth must  be
shown by statistics.  But before I give the results of the operation to the
mother and child it may be well to ascertain  the average  frequency of its
occurrence.  For these purposes, I have searched all the records within
my reach, and the result is the  following tables :—
21 
320                         THE FORCEPS.
FREQUENCY OF THE OPERATION.
 a.  Among British Practitioners.
Date.	Authors.	Total No. of Cases.	No. of Forceps Cases.	References.
1781 1787 to 1793 1818 1825 to 1833 1828 1829 1826 to 1837 1834 to 1837 1838 1840 1836 to 1840 1849 -	Dr. Jos. Clarke . . . Dr. Merriman. . . . Dr. Granville .... Ed. Lying-in Hospital . Dr. S. Cusack. . . . Do...... Dr. Collins..... Dr. Beatty..... Mr. Warrington . . . Do...... Mr. Mantell .... Dr. Churchill .... Drs. M'Clintock and "1 Hardy /	1,897 10,387 2,947 640 2,452 398 303 16,414 1,182 4,666 88 110 2,510 1,640 6,634	12 14 21 5 15 1 3 24 9 9 1 3 6 3 18	Merriman. Trans, of Assoc, vol. 1. Synopsis. Report of West. Disp. Reports. Dub. Hosp. Rep. vol. 5. Do. Prac. Treat, on Midwf. Dub. Jour. vols. 8, 12. Guy's Hosp. Reports. Amer. Med. Journal. Do. Do. Researches, &c. Pract. Obs. p. 95.
b.  Among French Practitioners.
Date.	Authors.		Total No. of Cases.	No. of Forceps Cases.	References.
1797 to 1809 1803 to 1811 1808 1815 to 1828 1829 1829 1830, 1831	Madame Boivin . . Madame Lachapelle. M. Ramboux . . . M. Pigeotte de Troyes M. Papavoine. . . Hotel Dieu, Paris Sig. Cinicelli . . .		20,517 22,243 216 1,362 24 280 94	96 174 2 2 1 1 1	Memorial, p. 337. Prat, des Accouch. Velpeau. Do. Do. Do. Do.
c.  Among German Practitioners.
Date.	Authors.	Total No. of Cases.	No. of Forceps Cases.	References.
1801 to 1807	M. Richter, Moscow .	3,195	49	Velpeau.
1811 to 1827	Moschner and Kursak,			
		12,329	120	Siebold's Jour. vol. 9.
1812 to 1813	C. v. Siebold, Wurtzburg	318	26	Do. vol. 1 to 3.
1817 to 1826	Do. Berlin . .	1,634	212	Do. vol. 3 to 8.
1827 to 1829	E. v. Siebold, Berlin .	491	77	Do. vol. 9 to 11.
1829 to 1833	Do. Marburg	344	34	Do. vol. 10 to 13.
1834 to 1837	Do. Gottingen	507	37	Do. vol. 15 and 16.
1825 to 1827	Dr. Kilian, Prague . .	2,350	120	Velpeau.
1808 to 1814	Dr. Henne, Copenhagen	655	1	Siebold's Jour. vol. 2
1826	Do.....	130	4	Do. vol. 8.
1821 to 1825	Dr. Riecke ....	219,303	344	Velpeau.
1819, 1820	Dr. Ritgen, Giessen	180	20	Siebold's Jour. vol. 6.
1825	Dr. Merrem, Cologne .	142	5	Do. vol. 7.
1814 to 1827	Dr. Carus, Dresden . .	2,908	184	Do. vol. 9.
	Dr. Naegele, Heidelberg	1,411	22	Velpeau.
1825, 26 27	Dr. Kluge, Berlin . .	809	65	Siebold's Jl. vols. 7, 8, 9.
1825, 1826	Prof. Andre" e, Breslau .	351	8	Do. vols. 7, 8.
1825, 26, 27	Dr. Brunatti, Dantzic .	284	22	Do. vols. 7, 9.
1825, 1826	Dr. Theys, Trier. . .	49	3	Do. vols. 7, 8.
1826	Dr. Voigtel, Magdeburg	29	3	Do. vol. 8.
1827, 1828	Dr. Kiistner, Breslau .	370	8	Do. vols. 9, 10.
1830, 31, 32	Dr. Adelmann, Fulda .	170	7	Do. vol. 14.
1797 to 1837	Dr. Jansen, Ghent . .	13,365	341	Med. Gaz., March 6,1840.
				Schmidt's Jahrbiicher.
 
THE  FORCEPS.
321
  Thus among British practitioners we find 144 forceps cases in 52,268
cases of labour, or about 1 in 362f.
  Among the French, we have 277 forceps cases in 44,736 labour cases,
or about 1 in 162.
  And among the Germans, 1702 forceps  cases in 261,224 labour cases,
or about 1 in 153^.
  If we add the whole together, we find 2,123 forceps  cases in 358,228
cases of labour, or about 1 in 168^.

      RESULTS OF THE OPERATION TO MOTHER AND CHILD.
Authors.	Number of Forceps Cases.	Mother Lost.	Children lost.
	52	2	9
	18	2	4
	14	2	Not stated.
	21	0	6
	5	1	Not stated.
	104	4	a
Edinburgh Lying-in Hospital	15 4	Not stated. 0	5 1
	111 6	0 1	0 0
	6	Not stated.	3
	1 42	0 3	0 31
Dr. Churchill.......	8 9	0 0	6 0
Drs. Hardy and M'Clintock . ,	18 96	5 Not stated.	8 20
	79 19	14 2	23 5
Dr. Siebold.......	312	11	47
	20 8	3 1	4 4
	23	1	6
	3 8	0 2	0 1
	7	1	1
   Now if we add together the number of forceps cases where the result to
the mothers is stated, we shall find, that of those detailed by British prac-
titioners, of 414 forceps cases, 20 mothers were lost, or 1  in 20^.
   Amongst the French and Germans, in 479 cases, 35 mothers were lost,
or about 1 in 13|.
   Whilst of the children, the British statistics give 64 lost in 296 cases,
or about 1 in 4£; and foreign statistics 111 in 575  cases, or about 1
in 5.
   The total result is, that in 799 forceps cases, 54 mothers were lost, or
about 1 in 15;  and in  889 cases, 184 children were born dead, or about
1 in 5.
   It will be admitted, I think, that these tables exhibit British practice in
a very favourable light.
   I am unable to explain the  greater proportional frequency of operations
in some of the German reports, except  by supposing that  their hospitals, 
322
THE  FORCEPS.
being on a  small scale,  are  reserved  for the worst cases met with in
extern practice among the poor.   Were I quite sure of this  being the
case, however, I should have omitted them from Table I, as  they would
then manifestly be an unfair record  of  the proportional  frequency of the
operation.
  It would be unjust to compare the frequency of  forceps cases among
the Germans and British, without recollecting the  minor degree of mor-
tality amongst the children in the practice of  the  former, and  the very
much smaller number  of crotchet cases.  It would seem, that although
the Germans use the forceps much more frequently than we do, they often
thereby avoid a much more fatal operation.
  The rate  of mortality exhibited by  the last table, is  undoubtedly an
over-estimate,  as many of the deaths  included in  it were unconnected
with the operation ;  but as this is not stated, except by a few authorities,
though probably equally true  of all, I have preferred quoting the numbers
given, and appending this note.
  It is greatly to be regretted, that the statistics of  the result of the ope-
ration to the mother and child are so limited.  Many writers  who have
carefully recorded the  number of operations, have very carefully omitted
to state whether the mother recovered,  or the child was saved, leaving us
to make the inference that both were saved.   But we know that such an
inference would  be incorrect.  Can any one  believe, that whilst British
practitioners lose one woman in twenty-one, Mad. Boivin and M. Baude-
locque lost none at  all ?
  I have, therefore, omitted or marked in the latter table, all those who
have neglected to state the results.
  535.  If we fail in our endeavours to extract the infant with the forceps,
we have no  resource but to employ the perforator and crotchet, and, there-
fore, in estimating the utility  of the forceps, we must also compare it with
its alternative operation, inasmuch as every successful case of the former
may be considered  as so much gained  from the latter.
  Now, in craniotomy all the children are destroyed, and one  in five of
the mothers is lost; whereas  we have  seen, that by the forceps we save
four out of five of the children, and  nineteen out of twenty of the mothers.
If we had  more minute reports, the success would undoubtedly appear
much  greater.
   536. The special advantages of the  forceps are said to be:
   1.  That they are easily applied.
   2.  That their powers are calculated to attain the  object for which they
are used.
   3.  That they do  this by imitating the natural powers.
   4.  That they aid the expulsive  efforts of the uterus better than any
other instrument, and supply their place, which no  other instrument can.
   5.  That they are less liable to slip than the vectis.
   6.  That they are attended  with less  fatal consequences than  the perfo-
rator and crotchet.
   On the other hand, those writers who have defended  the use  of  the
vectis, as compared with the forceps, have enumerated  several disadvan*
tages of the latter—such as,
   537. 1. The difficulty of their application  in all cases, and in some,
the impossibility of using them, owing to the position of the head or want
of space. 
THE FORCEPS.
323
  That the introduction of two blades may be more difficult  than  that
of one, in certain cases, is very evident, but that there  is  much greater
difficulty in introducing the forceps  than  the  vectis,  in  the  majority of
cases proper for its use, I  do not believe.  The latter part of the objec-
tion is  of no force, because those cases where the introduction  of the
instrument is impracticable, are not cases in which its employment is  con-
templated, and,  undoubtedly, when the impaction was so  great as to
prevent the application of the  forceps, it would more surely render the
vectis useless.
  2.  The risk of bruising the os uteri in the application of the forceps.
  I do not think that there is much  risk, if  the operator be a competent
person.   Dilatation or  dilatability of the os  uteri being  an essential  con-
dition of  the operation, the supposition would  involve great want of  skill
and care in the operator.
  3.  That when  the forceps are applied, they are apt to slip and lose  their
hold.
  This may sometimes happen, but it is  much more likely to occur  with
the vectis.
  4.  That the pressure upon the child's head may destroy life.
  No doubt;  but as the pressure is regulated by the resistance, this ought
never to happen, except in cases in which the  crotchet must otherwise be
used, and in which the vectis would be powerless.
  5.  That by adding to the volume of the head, they are apt to lacerate
the perineum.
  That the compression exercised upon the head of the child  is amply
sufficient  to compensate for the additional bulk of the blades,  there can
be  no doubt, even in those cases where the extraction is most easy; but
we have an additional safeguard in the removal of one of the blades just
before the head passes over the perineum.
  6.  That as they can  never  be used secretly, they have a tendency to
alarm and intimidate the  patient, and  in this respect are inferior to the
vectis.
  When speaking of the vectis, I mentioned its secret employment, among
its disadvantages; and I now quote this objection,  for the purpose of en-
tering once more my earnest protest against the  employment of any in-
strument  secretly.*
  538. Having now given the history of the operation, stated its objects,
and shown that  they are  attainable, from the  nature of  the aid  afforded,
and from  numerical calculations; and having enumerated the positive and
comparative advantages of the operation, with the  objections  that have at
different times been made to the use of the instrument,  I shall next  pro-
ceed  to mention  the cases  to which the forceps has been  considered appli-
cable.   I  would wish, however, that  it should be  remembered, that  as  I
am  not writing the  history of my own experience only, but  that of others,
so I am not to be considered as necessarily the advocate of the forceps in
all these cases.   I have selected them from authors of the highest author-
ity, and their evidence is altogether independent of support from me.
  *  The forceps and  vectis are calculated for different  cases.   Under some circumstances
one  and under some the other is to be preferred.   When the object is merely to change
the position of the head, to facilitate its rotation, or to apply a very moderate degree of
extractive force,  the vectis answers very well; but whenever much traction is neces-
sary, it is nearly useless.—Editor. 
324
THE FORCEPS.
   I must also premise,  that in no case is the forceps (or  indeed any in-
strument) to be applied,  until we  are perfectly satisfied that the 'obstacle
cannot be overcome by the  natural powers, with safety to  the mother and
child.
   1. When the the head  is unable to enter the brim of the pelvis from
malposition (suppose with its long diameter corresponding to the antero-
posterior diameter of the upper oudet), which is not rectified by the pains,
the long forceps may be applied to  change the position, provided the os
uteri be fully  dilatable, and that the change cannot be made by the hand
alone.
   2. When the head is in the upper outlet, fitting closely, but not im-
pacted, and the pains are inadequate to  overcome  the resistance,  a little
help with the forceps, applied laterally  (in relation to the  pelvis), will
often overcome the difficulty.
   3. When the head, presenting  at the  brim, is somewhat too large for
the antero-posterior diameter of the pelvis, if the excess be not  more than
may be remedied  by the allowable degree of compression, the  operation
may be successful.
   It will require some experience to ascertain this, before a trial,  but  as
the alternative is the crotchet, it is  surely worth while to make a cautious
attempt with  the forceps,, from which no harm need result in case of
failure.
   In all these cases it  will be necessary to  use  the long forceps;  in
the following, the shorter  are sufficient, but of course either may be em-
ployed.
   4.  When the head is  in the cavity of the pelvis, and is there detained
by want of space, if the compression  required for its extraction be not
greater than the head of  the child will bear with safety, the forceps may
be safely used, either laterally, obliquely, or antero-posteriorly.
   Siebold is said to have been able to reduce  the transverse diameter of
the head of the child six lines with Levret's forceps; Osiander, nearly an
inch ; Baudelocque, four and a half lines;  Thouret and Velpeau,  five or
six lines; and Flamant,  five and a half lines.   Of  course the amount will
be in inverse proportion  to the degree  of  ossification.
   5.  In face  presentations, the longest diameters of the child's  head are
brought to bear upon the  pelvis, adding greatly to the difficulty of its transit
through the lower outlet, even when the pelvis is large, and still more, if
it  be under the average dimensions.   In such cases, aid may often be
given by the forceps, so as to save the  child's life, and to mitigate the suf-
fering and its  consequences to  the mother.  It is not, however, to be as-
sumed,  that because the child descends faceling, that assistance will be
necessary ; the majority  are delivered by the natural efforts.
   6.  The same observations  apply to certain, though more rare  cases,
when the forehead is turned towards the symphysis pubis.
   7.  But the  utility of the forceps is seen more clearly in those cases in
which the pains, at first very strong, have gradually declined  so as to be
nearly or altogether powerless, but not from the resistance occasioned by
a narrow pelvis.  There  may be sufficient space, the os uteri and external
parts well dilated, and yet the labour does not advance.  In such a case,
the second  stage cannot be very  much prolonged  without certain  symp-
toms arising,  indicative of danger to  the mother; and here we are able 
THE  FORCEPS.
325
to relieve her without difficulty or risk, and to save the child (if it be alive
at the time) by the timely use of the forceps.
  In such cases (and every one must have met with them) I think I may
say, that the operation adds absolutely nothing to the danger either  to
mother or child.
  8. When the head or arm descends .with the head, the additional bulk
will require more expulsive force, and occasionally, aid must be afforded
by the forceps.
  9. In some cases of convulsions, hemorrhage, and rupture of the uterus,
where  the head is within reach, the forceps are found extremely useful in
expediting the delivery.
   10.  In certain cases of breech presentation, it is very difficult to ex-
tract the head after the body is expelled, either from malposition,  or from
the incompressibility of the base of the skull; in these cases the difficulty
may be removed or  overcome by the forceps.
   11.  The forceps may be used after the vaginal hysterotomy or symphy-
seotomy.
   12.  In prolapse of the funis, when it is  an object to hasten the labour,
in order to save the  child.  The pulsation  of the cord will show whether
the operation affords a chance.
   539. These  are, I believe, all the  cases in which the forceps have been
used or recommended by high authority;  to complete the subject, I may
mention certain cases in which they  ought  not to be employed.
   1. In distortion of the pelvis, or  when  its calibre is diminished from
any cause, such as tumours,  exostosis, &c, if the narrowing of the pelvis
be  too great to admit of the passage  of the  child's head, when moderately
compressed; such cases can only be terminated by the perforator.
   2.  When the os  uteri is  rigid and undilatable, or when the passages
are much inflamed and swollen, the  forceps ought  not to be used.
   3. In some cases, where the patient has been mismanaged, and allowed
to remain too  long, the  system  is in such  a state that we  are obliged  to
have recourse to the most expeditious mode of delivery.  In these cases
(especially if there be a doubt of success with the forceps) it may be wiser
to have recourse to the perforator.   But such cases could scarcely happen
under  the care of a well-educated practitioner, nor are they at all frequent.
  4. If the child be dead, we are advised  to prefer craniotomy.   If we
are quite  certain that  the child  is dead, the principal  objection  against
craniotomy is removed ;  but this it is not always easy to determine. The
stethoscope is a most valuable source of information; but it must be
remembered, that while its positive evidence is unquestionable, the nega-
tive evidence (i. e. no  sign being audible) is not equally conclusive.
  Dr.  Collins, whose  experience has been very extensive, remarks: " I
know of no case where the advantage derived from the use of the steth-
oscope is  more fully demonstrated, than in the  information it enables us
to arrive at, with regard to the life or death of the  fcetus, in the progress
of tedious and difficult labours."
  540. We next,come to consider the period for  operating.  " It is one
of the  nicest points in practice, correctly  to decide, whether any given
case of protracted labour may be trusted with safety to the further exer-
tions of the natural agents,  or  whether the means of art ought to  bf
promptly brought to  their  assistance.   In  determining  this important 
326
THE FORCEPS.
question, the whole of the symptoms are to be collectively and severally
considered, and their different  tendencies  accurately examined, that we
may equally escape the imputation of haste and indiscretion  on the one
hand, and of delay and indecision on the other; yet, let us ever bear in
mind, that  more injury may possibly  accrue  from too long delay, than
arise from premature assistance."*
  The decision of this point must, in a  great measure, be left to the
judgment and experience of the  practitioner.   No very definite rule can
be laid down: we find both individuals and nations differing  upon the
subject;  the Germans operate more  frequently, and  at an  earlier period
than the British, but on the other hand, they have fewer crotchet cases.
  In forming our decision, there are several points for consideration:
  1. The local circumstances of the  case, such as the position of the head,
space in the pelvis,  complications,  &c.;  these constitute the principal
grounds of necessity for the operation, and have been enumerated.
  2. The general  condition of  the patient, and the presence or absence
of the  symptoms of a prolonged second stage; if  present,  their amount,
urgency, rapidity of development, &c.
  Our great object in the  use of the  forceps, is to  anticipate these formi-
dable symptoms, and to rescue  the patient from the danger.  I think then,
that as regards the mother, we may conclude:
  1. That as these formidable symptoms are not consequent upon a pro-
longed first stage ;  therefore, before the completion of the first stage of a
labour, that is, before the os uteri is perfectly dilated, and the membranes
broken, the use of the forceps  cannot  properly come into contemplation.
But I would remark, that when the  obstacle is at the  upper outlet, the
second stage virtually commences when the  os uteri is fully  dilatable, as
the head cannot pass through it, and the usual symptoms may arise if the
labour be sufficiently prolonged.
  2. That when the second stage  has lasted so  long,  as to prove the
inadequacy of the natural powers, or at all events, as soon as the symp-
toms of a prolonged second stage make their  appearance (quick pulse,
dry tongue, fever, &c), then we  ought promptly to interfere.   " A  prac-
tical rule has been formed, that the head of the child shall have rested for
six  hours as low  as the  perineum, that is, in a  situation which would
allow of their application, before the  forceps are applied, though the  pains
should have altogether ceased during that time."
  The symptoms, however, are  a surer guide  than  the duration of the
labour merely; some patients will show more signs of suffering after  six
hours, than others after twelve  or sixteen.   Dr. Collins  observes:  " Let
it be carefully recollected, at the same time, that so long  as the head
advances ever so slowly, the patient's pulse continues good, the abdomen
free from pain on pressure, and  no obstruction  to the  removal of the urine,
interference should not be attempted, unless the child be dead."
  At the same time, as  we know  that after  a certain duration of the
second stage,  these  unpleasant  symptoms do  arise, the  length of the
labour cannot be  altogether omitted in our estimate  of the case, and is a
reason for great vigilance.
   3. We must not omit the consideration of  the  life of the  child; after
* Ramsbotham's Practical Observations on Midwifery, vol. i. p. 256. 
THE FORCEPS.
327
the child, and it may even die  before the symptoms on the part of the
mother become very formidable, though this is not always the case.   This
condition may sometimes be detected by the stethoscope, the  action of
the heart becoming feeble and irregular.  In such a case, if no counter-
indication existed, we should be justified in interfering for the purpose
of saving the child's life, provided the operation were practicable.
   541.  Method of operating.—When once we have determined upon
the propriety of operating, the  operation itself is not very difficult;  it re-
quires a thorough tactile knowledge of the pelvis, some manual dexterity
and steadiness.   I shall first describe the application of the long forceps
at the brim, and  then (the  long or  short forceps) in the cavity of the
pelvis.
   I.  The long forceps. — These  may be applied  either in the transverse
or antero-posterior diameter of  the pelvis.   If our object be compression,
or a change of the position, the antero-posterior diameter will be the best;
but if additional force be required, they may be applied transversely (%. e.
over the occiput and forehead of the child).   In this position, as there is
more space, their application is more easy;  but it must  be remembered,
that in  proportion  to  the grasp  we take of the head in its longitudinal
diameter, we diminish that diameter, but increase the transverse, and so
may add  to  the difficulty of  the  descent  of the head.   Therefore,  only
sufficient force should be used to  enable us to extract.

                               Fig. 100.
*u  T}ei\ ab0U-t t0 app y &e.lonS forcePs> « is to be  remembered that
the difficulty exists at the brim  of the pelvis, that the antero-posterior
diameter, or that from the symphysis pubis to the promontory of the sacrum
is diminished; m the application of the instruments, therefore, care should
7�54 
328
THE  FORCEPS.
the second stage has lasted a certain  time, there is  considerable risk to
be taken that they be  placed over the head,  in  such a situation that they
may occupy the most roomy part of  the pelvis, which will be its lateral
diameter.  In a natural presentation and  situation, one blade of the in-
strument will consequently be placed over the forehead, the other over the
occiput."*
   The patient is to be placed  on her left side (or on her back), close to
the edge of the bed; the forceps, warmed  and  oiled, are to be within
reach, and the operator should introduce two or three fingers of his left
hand, or his whole  hand, during an interval  of pain, along the  head of
the child within the os uteri, for the purpose of protecting it, and guiding
the blade of  the forceps.
   The upper or anterior blade is then to be passed along the inside of the
fingers  or hand, in the axis of the upper outlet, until it glides  over the
part of the head to which we wish to apply it.  It is then to be retained
"in situ" by an assistant, and the hand or fingers withdrawn;  the right
hand (or two fingers) is next to be introduced  on the opposite side, and
the second blade passed carefully up, and applied  to the head.   If the
blades have  been properly placed, they will lock;  but if not,  one must
be withdrawn and re-introduced.   When locked, the handles may be tied
together or grasped firmly, and the extracting force applied, of which I
shall speak presently.
   The most  important points to remember in the application of the long
forceps are:
   1.  To guard the os uteri with one hand.
   2.  To introduce  the upper or anterior blade  first.
   3.  To pass the blades in the axis of the upper outlet.
   4.  To regulate the force of the grasp, according to  the circumstances
of the case.
   542. II.  The short forceps.—These maybe passed in accordance with
the transverse, oblique, or  antero-posterior diameters of the pelvis.  In
many cases where it would be  impossible to  pass  them laterally, we may
succeed in passing them  antero-posteriorly, and  in  extracting the  child;
but we must bear  in mind the observation made when  speaking  of the
long  forceps, that the pressure in the long diameter of the child's head
(i. e. when the forceps are introduced obliquely or antero-posteriorly) in-
creases its lateral or transverse diameter, and  so far augments the difficulty
of its extraction.
   The  bladder and rectum should be evacuated before  the attempt  is
made, and the forceps warmed  and  oiled, as already mentioned.  The
patient is then to be placed near the  edge of the bed, and after a careful
examination, our decision formed  as  to the  part to  which the instrument
is to be applied.   One or two  fingers are then to be introduced into the
vagina, during an  interval of pain, to guide the forceps and  protect the
soft parts.
   " The forceps  must be  introduced, one blade after another, first intro-
ducing the fingers  of each hand to carefully guard  the bows  past  the os
uteri, and fairly over the side of the head, for  should the os uteri get be

                 * Waller's edition of Denman, p. 279, note. 
THE FORCEPS.
329
tween the head and forceps, it would at once prevent any firm hold of the
head, and you consequently fail in the attempt, and also bruise the part
that intervenes, so as to endanger  an excoriation  and great  inflamma-
tion."*
   We must always be careful that " the point of the instrument be con-
stantly kept in contact with the  head ; to  effect which, it will be necessary
to remember, that the child's  head is in every part convex, and, therefore,
as the instrument advances, the handle must be raised,  or otherwise in its
progress it may pass on, instead of going under, the os uteri, if  any part
should remain in contact with the child's head."f

                                Fig. 101.
  The forceps must be introduced at first in the axis of the lower outlet,
but this  direction must be almost immediately changed into that of the
upper outlet, or  there will  be danger of wounding the posterior wall of
the vagina.   The upper or anterior blade should be introduced first, and
then the  lower or  posterior one.   When both are applied, they ought to
be opposite, and if so, will easily lock, but " if, on endeavouring to lock
the forceps, it should be found that  they  do not readily come together,
they have not been properly introduced ; no  force or violence should be
used to bring them together, but the second blade  should be withdrawn,
and introduced afresh."|
  Great care must also be taken, that the soft parts, or hair, are not included
in the lock, as this will give  great pain.  The lower part of the handles
may be tied  together by a ligature, so as to determine the force of the
grasp, which has this advantage, that it fixes the  degree of compression,
and leaves the operator at liberty to occupy himself  with  the extraction
only.   If, however, the head fit tightly, and more compression than merely

                  * Pugh, Treatise on Midwifery, 1754, p. 83.
                  | Osborn, Essays on Parturition, p. 99.
                  J Merriman, Synopsis of Difficult Parturition, p. 197.
                                 2c2 
330
THE FORCEPS.
that which is sufficient for extraction be  necessary, it will be useless ; the
operator must then regulate the compression with his hand, and extract at
the same time.
   " When the forceps are first locked, they are placed far backward, with
the lock close to, or just within the internal surface of the perineum ; and
they can have no support backwards except the very little which is afforded
by the soft parts.  The first action with them  should therefore be made,
by bringing the. handles, grasped firmly in one or both hands  to  prevent
the instrument from playing upon the head of the child, slowly towards the
pubes, till they come to  a full rest.  Having waited a short interval with
them  in this situation, the handles  must be carried back in the same slow
but steady manner to the  perineum, exerting, as they are carried in the
different directions, a certain degree of  extracting force ;  and after  wait-
ing another interval,  they are again to be  raised towards  the  pubes, ac-
cording to the situation of the handlesV'*
   We must  remember,  " that the force employed in extracting the head
be always and steadily from blade  to blade, but with intervals resembling
the labour pains, and constantly in the direction of the axis of the pelvis,
till the  occiput begins to emerge from under the arch of the pubis,  when
the handles are to be raised over the symphysis pubis with the right hand,
while the  left is  applied  to strengthen and preserve the perineum."f
   " The  whole  power or force which the instrument enables us to use,
ought not to be exerted in the first  instance, but such a degree as any
individual case  may  require,  which can only be known by first trying a
moderate degree of force, increasing it slowly and deliberately, according
to the exigence  of each case."|
   When  we thus employ the  power we possess gradually,  steadily, at
intervals, and in the direction of the axes of the pelvis, we  must not forget
the danger (in  some cases at  least)  from pressure or contusion.   Our
guide in this matter is the pulse, which rapidly rises if injury be inflicted.
   " If the pulse  be  120 or 130 before you  commence operations, it is
clear that you cannot, from counting the beats, take an intimation whether
the soft parts have  or  have not  sustained  injury;  but  if,  before  the
forceps be applied, the pulse is under 100  in the minute, then should
contusion be produced by your efforts with the instrument, the rise  of the
pulse will indicate it. After every effort with the forceps, therefore, count,
waiting two  or three minutes, so as to allow the beats  to subside after
muscular exertion, and  count completely round the circle.  If you find
it below  100, no serious  injury has  been inflicted; if the frequency is
increasing, although  it  do  not  necessarily follow  that serious  injury has
been inflicted, yet the existence of contusion becomes probable,  and fur-
ther efforts must not  be  made without much further consideration."^
   When  our efforts have been so far successful, that the occiput  emerges
from the  lower outlet, if there be  pains, it is  better to remove one blade
 (the posterior one, when they are applied antero-posteriorly) of the forceps,
to lessen  the risk of laceration, and the  perineum should  be carefully

            * Denman's Introduction, p. 281.
            f Osborn, Essays on  Parturition, p. 100.
            X Denman's Introduction, p. 280.
            g Blundell's Principles and Practice of Obstetricy, p. 505. 
THE FORCEPS.
331
supported by an assistant, whilst the operator  uses  the  other blade  as  a
tractor if necessary.
  If the head  be high up in the pelvis, we must take care that the usual
half-turn be made as it descends, so as to bring the face into the hollow
of the sacrum.
  In breech cases, when  the head is detained, the  operation is not very
different; the blades are to be  passed up antero-posteriorly, or laterally,
and locked across the  chin, or  back of the head,  and the extracting force
applied, gently, firmly, and at  intervals, not forgetting  the natural turns,
so as to bring the face into the  hollow of the sacrum, if possible.
  543. Difficulties.—■" The difficulty of applying the forceps," says Dr.
Denman, " is most frequently  occasioned by  attempting to apply them
too soon; or passing  them in a wrong direction; or by entangling the
soft parts of the mother between the instrument and the head of the child,
against all which accidents we  are^o be on our guard."
   1.  The first difficulty we meet with is in the introduction of the blades.
There may not be space enough,  and if we find  this to be the case, after
a fair and careful trial, we are not to persist at the risk of injury to the
mother, but craniotomy must be performed.
   When the head is pressed down against  the tuberosities of the ischia,
there may be some difficulty in passing the blades between  them, and if
the head  cannot be raised up during an interval of pain, the forceps had
better be applied antero-posteriorly, or both blades  being introduced pos-
teriorly, we may gradually slip them to either side.
   I do not speak of  the difficulty of applying the forceps when the  os
uteri is rigid, because  it  should never be attempted.
   2. As I have already mentioned, there may be some difficulty in lock-
ing the blades, and then  one of them  must be withdrawn  and re-intro-
duced.  It is  quite possible to  deliver  the  child without locking the
blades, but there  is more chance of injury, and  the instrument  is more
apt to slip.
   3.  The extraction  may be  difficult or even  impossible.  The great
value of experience in such cases  is, that it teaches  us how far we may
carry our efforts without  injury.   Perhaps  a  little  more compression  or
a little more force may crown our  efforts with success, provided that  it
do  not exceed safe limits.   But great care and caution will be necessary,
and if we find our efforts fruitless  after a fair trial, we shall then be justi-
fied in having recourse to the perforator, nor will  the patient be the worse
for the  failure with the  forceps,  if the attempt have been judiciously
made.
   544. The principal  dangers  to the mother are:
   1.  In the introduction of the blades, if it be not  effected in the axis of
the upper outlet, the vaginal parietes may be lacerated, and if the cervix
uteri be not guarded by the hand, the blade  may be pushed through it,
or it may be included  between the end  of the  blade and the child's head.
Cases of inal-practice  illustrative of these dangers might easily be quoted,
but it is sufficient for my purpose  to allude to  them as a caution.
  2.  The soft parts  in  the pelvis  may be bruised  or lacerated in the
extraction.
  3.  The perineum may  be lacerated.
  The dangers to the  child arise: 
332
THE FORCEPS.
    1.  From want of care  in  introducing the  blades, by which the  scalj
 may be bruised or torn, or an ear cut off.
    2.  From excessive compression, by which the skull  may be indented
 the bones fractured, or death from pressure induced.
    Dr. Blundell  has given a  distressing picture of the  accidents  which
 may result from  an incautious or  maladroit  use of the forceps.
    " The grand error you are apt to commit in using the long forceps, is
 force.   In violent hands, the  long forceps is a  tremendous instrument;
 force  kills the child, force  bruises the softer parts, force occasions mortifi-
 cation, force breaks open the neck of the bladder, force crushes the nerves •
 beware of force, therefore,  arte  non  vi.   Other errors, too,  there are
 against which I beseech you to guard.   You may use the forceps without
 heed; you  may try to use it when  the parts are rigid,  and  the os uteri
 not fully expanded ; you may attempt  to apply it, without  knowing the
 position of the  head;  you may oscillate the instrument too  extensively
 from side to  side; you may draw without intermission, instead of imitating
 the pains ;  you may close the handles too forcibly by the hand or ligature;
 you may hurry the head through the outlet; you may neglect to throw the
 face towards the sacrum ; you may forget the perineum ; you may fail to
 conduct the head, when it emerges, towards the abdomen and  the mons,
 by drawing it too much upon the  perineum."
   545.  After-treatment.—The first  symptom which will require  our at-
 tention, is the shock caused by the operation.   If it be great, a combina-
 tion of opium with  ammonia will be found the best remedy,  with  wine
 and water in moderate quantity.  If it be not severe, perfect quiet will be
 sufficient, and the subsequent  management  is the same  as  after ordinary
 delivery, with increased caution, however, and daily attention to the state
 of the vagina.  If there be any  soreness or inflammation, warm  water
 injections should be used twice a  day.*

   * Although Dr. Churchill avows his preference for " the long or short forceps with
 the single curve," &c, he appears in reality not to  be at all tenacious on the subject
 of its construction.   " The hand," he remarks,  "that is to use the instrument is, how-
 ever, of more importance than the instrument itself, of which it may be observed with
 truth, that ' that which is best administered is best.' "  In this expression, I conceive,
 he inculcates a great error.
  A prudent and well-qualified operator, it is  true, will not do harm with a bad instru-
 ment, but he may be unable to accomplish any good purpose with it, in cases where
 one better adapted would render him successful.
  " I have repeatedly," says  Dr. Huston, in a note  to a former edition, " seen gentle-
 men of large experience in the art, completely foiled in  attempting to grasp the head
 at the upper strait, with a forceps having only the single curve, although when  an in-
 strument differently constructed was placed in  their hands they accomplished it very
 readily; and I have myself delivered, successfully for both mother and  child, under the
 same circumstances, with a long double-curved forceps, after  others  had failed with
 those without the second curve,  or of insufficient length."
 _ If the use of the forceps is to be confined to cases in which the head has descended
 into the cavity of the pelvis, resting on the perineum or protruding at the os externum
 vaginae, then, indeed, " the hand that is to use the instrument is of more importance
 than the instrument itself;" nor is it of  much importance what hand it is, if guided by
 the common feelings of humanity, so simple and easy is the operation.   But when it is
 important to hasten the delivery while the head remains  above the upper strait, or is
 still engaged in it, as in convulsions, hemorrhage, some cases of prolapse of the  funis,
aneurism, inability of the woman, in consequence of feebleness, to sustain longer the
natural parturient efforts, or from  contraction of the brim in a degree not so great as
to demand the perforator — in such cases the  kind of instrument we employ is of the
greatest importance.  The blades must be  adapted to the head of the child, the  shape 
THE  FORCEPS.
333
must correspond with the axes of the pelvis, and the handles must be long  enough to
allow of  the operator obtaining a secure hold outside and free of the vulva, or success
is  not to be expected at the hands of the most dexterous obstetrician.  British practi-
tioners, I am aware, seldom employ the forceps  under the circumstances I have men-
tioned.   In this I think they are wrong, — they  differ, certainly, from the practitioners
of this country and of Continental Europe.
   " In England," says Dr. Robert Lee, " there  are few practitioners of judgment and
experience, who have frequent recourse  to the forceps, or who employ it before  the
orifice of the uterus is fully dilated, and the head of the child has descended so low into the
pelvis,  that an ear can be felt," &c*   According to this  rule, every case in which  the
unaided  powers of the woman fail to make the head " descend so low into  the pelvis
that an ear can be  felt," calls for the perforator!   The  fruits of this practice may be
learned from the following table, furnished by the  same  author.  No one can fail to be
struck with the disparity in the practice  of British, compared with  that of the Conti-
nental practitioners.
A Comparative  View of the Frequency of Forceps and Craniotomy Cases in eleven Lying-in
                                    Hospitals.
Hospitals.	No. of Labours.	Forceps Cases.	Proportions.	Cranioto-my Cases.	Proportions.
Dublin, Clarke . . .	10,199	14	1 in 728	49	1 in 248
Do. Collins . . .	16,654	27	1 in 617	118	1 in 141
Paris, Baudelocque . .	17,388	31	1 in 561	6	1 in 2898
Do. Lachapelle . . .	22,243	76	1 in 293	12	1 in 1854
Do. Boivin ....	20,517	96	1 in 214	16	1 in 1282
Vienna, Boer ....	9,589	35	1 in 274	13	1 in 737
Heidelberg, Naegele . .	1,711	55	lin 31	1	1 in 1711
Berlin, Kluge ....	1,111	68	lin 16	6 •	1 in 185
Dresden, Carus . . .	2,549	184	lin 14	9	1 in 283
Berlin, Siebold . . .	2,093	300	lin 7	1	1 in 2093
   From this table it will be seen that those who  relied most on the forceps, had the
fewest occasions to resort to craniotomy, and vice versa.  Of the extreme cases on each
side, it will be observed that Dr. Collins, whilst he employed the forceps but once in
617 cases, resorted to craniotomy once in 141 cases;  or nearly four and a half times as
often as the forceps.   Dr. Siebold, of Berlin, had recourse to the forceps once in every
seven cases, and craniotomy but once in 2093 cases!   It is not difficult to imagine on
which  side  was the greatest  mortality.   Whence arises this prodigious difference ?
Unquestionably from the different principles by which  the practitioners of these coun-
tries are guided.  As properly observed by Dr. Lee, ' if we compare  the reports of the
principal Lying-in Hospitals of Great Britain, France, and Germany, and examine the
doctrines inculcated by the best  systematic writers of these countries, it is impossible
to avoid being struck with the want of  uniformity which prevails in all that relates to
the operations of midwifery.  Although the cases of difficult parturition must be nearly
the same in every part of Europe, cases of instrumental delivery are far more numer-
ous in some countries and institutions  than in others, and the method of operating  is
widely different.'
   To the practitioners of this country, -the reports  of the English Lying-in Hospitals
are surprising, especially when it is considered that they are under the supervision of
men of the  most exalted standing in the profession.   The frequency with which many
of the Germans employ the forceps  is in strong contrast with British  practice, and per-
haps scarcely more rational.
   In the United States, so much looseness and neglect prevails in regard to obstetrical
statistics,  that it is  not  easy to arrive  at exact results; but there can be no question
that while the forceps is far more frequently employed than by the English, it is much
more rarely resorted to than by the practitioners of Northern Europe.
   The frequent occasion which English practitioners find for the performance of crani-
otomy appears to proceed from the  rules by which they are  governed in regard to the
use of  the forceps, and which limit its application  to a comparatively small number of
* Clinical Midwifery, by Robert Lee, M. D., &c, page 1. 
334
THE  FORCEPS.
cases.   Whether these rules  are deduced from a consideration of the mechanical pro-
perties of the instruments they employ, or whether the instruments are constructed in
reference to the objects contemplated by the rules, they certainly concur in restricting
the use of this  means of relief within much narrower limits than either Continental or
American practitioners deem necessary or proper.  That the  forceps commonly em-
ployed by our English brethren, whether long or short, are capable of accomplishing
the objects which their rules  contemplate, is hardly to be denied ; almost any form of
instrument of  the kind  ever invented, however rude, in  competent hands, will prove
sufficient.  But have we  not instruments  of better construction, of greater mechanical
powers, and capable of being successfully employed under a wider range of circum-
stances than  are embraced in the canons  of English obstetricy ?
  The sufficiency of the English  or any other forceps for  the management of cases
where the head of the child has passed through the upper strait  is admitted; but are
they equally  capable of useful application before matters have advanced thus far ?  It
is believed that they are  not.  The application of  the various short forceps, when  the
head of the child has not passed through the upper strait, seems to be out of the question.
The distance which it is necessary to pass them within the pelvis, and the almost impossi-
bility of obtaining a secure hold of the head with so short an instrument,  render them
valueless.  The only exception, if  there be any at  all,  is  the forceps of Dr. Davis.  A
very serious  objection, however, to this instrument is that which is common to  all of
its class,—the blades are so short that, when introduced sufficiently far to embrace the
head in the upper strait,  the lock is brought within the vulva.   This, beside the danger
of injury to the parts, leaves to the operator a very insufficient hold of the handles for
efficient action.   The great width of the blades, too, is  objectionable, as Dr. Davis him-
self has found and endeavoured to obviate by the occasional use of one blade made very
narrow.
  These objections are made, however, with much deference, not only from the high
character sustained by the eminent inventor, but because it is the instrument preferred
by the able Professor of  Midwifery in Jefferson College, Dr. Charles D. Meigs.
  Our author prefers " the long  or short  forceps, with the single curve."  There is
certainly no advantage in the second curve to the short forceps: these being only adapted to
cases in which the head has descended  into the cavity of the pelvis, when  there is but
one strait to pass, an instrument which corresponds in form with the axis  of that one
strait, is of course all that is required.   But it is widely different when the head  is to
be delivered from the upper strait.   It must be borne in mind that the axes of the two
straits run in very different directions — that of the upper strait being downward and
backward, and of the lower, downward and forward.  Now in order to embrace the head
in tne upper strait, the instrument must pass through the  outlet in the axis of the
lower strait, or  nearly so; and consequently, it must have a form corresponding, in a
considerable degree, with the  curved line running through the axes of both  straits
otherwise there will be excessive pressure made upon the perineum by the instrument
and eatreme difficulty in  adjusting it properly on the head of the  child.

                                     Fig. 102.
  A glance at the accompanying cut will exhibit this better than any verbal description.
A. The sacrum.  B. The coccyx.  C. The pubis.  D.  The perineum.  Dotted line a, plane 
THE  FORCEPS.
335
of the upper strait;  dotted line b, plane of the lower strait; c, imaginary line passing
from the umbilicus to the upper part of the coccyx, and through the centre of the upper
Btrait or its axis; d,  a similar line, extending from the middle of the sacrum through
the os externum vaginae, and marking the axis of the lower strait.  The curved dotted
line between these straight  lines, shows the course the head of the child must take in
passing through the pelvis, and which must necessarily be traversed  by the forceps
when applied at the superior strait.
  The extreme difficulty, not to say failures, which Dr. Huston, of Philadelphia, expe-
rienced in operating  with the short forceps and those of single curve, under the circum-
stances we are considering, induced him many years ago to attempt to supply what
Beemed to him a great deficiency in the various forceps in common use.   While engaged
in this task, the late Dr. Eberle placed in his hands  the forceps of Professor Siebold.
"I saw at once," he remarks in a note to a former edition,  "that it possessed many
advantages over any others that I  had seen, and that with some little alterations it
would accomplish the objects I had in view.  The instrument of Siebold, thus modified
according to my own views, I now present to the public, after nearly twenty years of
trial, and sanctioned too by the experience of a number of my friends.   An account of
it has never before been published, but it was exhibited several years ago to the College
of Physicians  and the Philadelphia  Medical Society, and subsequently it has been re-
ferred to by Professor Meigs in his Philadelphia Practice of Midwifery.   The annexed
engravings (Fig. 103) represent the instrument and its several parts, as made for me fcv
Weigand and Snowden of this city, pretty accurately.

                                      Fig. 103.
     "Kith of the blade at a, one inch and five-ejgbths;  of the fenestra, one inch;  sepa-
ration of  the  blades at  the widest part when properly locked, two inches and a hatf
(but this  is increased  nearly a quarter of  an inch by the manner in which the blades
are ground, being concave on their inner face, and convex externally: by this arrange-
ment the  liability of the instrument to slip  off the  head is  lessened);  length of the
blades to  the lock  at  ft  nine  inches;  length  of the handles from the joint  at ft, five
nches  The lock, which is  exactly like that of the German instrument, is formed by
a thumb-screw c, which  is fastened into the male branch at d, and  is received into a
mortise m the female branch at e.  This mortise is countersunk, so that when the screw
or pivot is screwed down  completely, the blades cannot be separated 
336
THE  FORCEPS.
  *• By the kindness of Dr. Mochring, a former pupil of Siebold, I have before me the in-
strument  of  that  distinguished professor, made by ' Windier, of  Berlin,'  and which
may therefore be regarded as accurate.   On comparing mine with it I find them to dif-
fer as follows:
  " Although the instruments are of the same length, the blades  of mine are an inch
longer than those of Siebold, and the handles, from the pivot, correspondingly shorter.
This brings the lock more completely free from the vulva when operating at or above
the upper strait; at the same time, the shaft, or narrow part of the blade beyond the
pivot, constitutes in fact part of the handle equally effective with the  handle proper.
The fenestra of the blade is nearly double the width of that of the German instrument,
and the sweep of the second curve an inch and a quarter greater.
  " The instrument is also four ounces lighter than the Berlin-made forceps.
  " The objects gained by these modifications are:
  "1.  The blades  being longer, as stated, the soft  parts of the woman cannot be en-
tangled with the lock.
  "2. The increased width of the fenestra? avoids adding the thickness of the instrument
to that of the head, renders it less liable to slip off,  and lessens its weight.
  " 3. But the most important  modification is in the increase of the second or pelvic
curve, by which the blades correspond better with the form of the pelvis, so  that when
their extremities are in the axis of the upper strait, their shafts pass directly through
the axis of the outlet.  By this  arrangement, the instrument  is more readily applied
when the head is high up, and all  undue  pressure on the perineum is avoided.   This
form of the instrument also enables the operator to apply it when the patient is on her
back on a mattrass, without bringing her down so low as  to have her limbs off the  bed,
which adds much to the comfort of the patient and the decency of the operation.
  " From this description of the instrument it will be understood that it is calculated,
in every case, to be passed along the sides of the pelvis."
  The following figures represent the forceps invented by  Dr. Hodge, of the University
of Pennsylvania.   It is calculated, in a considerable degree, to accomplish  the same
objects  as the one employed  by Dr. Huston.   The eclectic forceps, as Dr. Hodge calls
his  instrument, weighs one pound and one ounce;  being nine ounces lighter than the
French forceps, as usually manufactured by Mr. Rorer of this city, and eleven ounces
lighter than a specimen of Dubois' forceps, made in  Paris.

                                    Fig. 104.
 
THE  FORCEPS.
337
  " The whole length of the instrument in a direct line from ft to c is 16 inches.  From
the joint a to extremity ft, the length of the handles is 6-8.  From a to c c, extremities
of the blades is 9-5, in a direct  line.   From a to d, length of  parallel  shanks is  3-5.
From d to c,  the proper blades, in a direct line, is 6 inches.  From c c, the extremities,
to ef, the greatest breadth,  3-7 inches.
  " The separation between the points c c,  when the handles are in contact, is -5 of an
inch.   From e to/, the  greatest breadth  when the handles touch, is 2-5; when the
separation at ef is 3-5, the points c c are separated to 2 inches.
  " The breadth of the blade is  1-8, slightly tapering to 1-7 near c c, the extremities.
The breadth of the fenestra is 1-1; the thickness of the blade is -2 of an inch.
   " The perpendicular elevation of the points c c, when the instrument is  on a horizontal
Burface,  is 3-4 inches, which indicates the degree of curvature of the blades.
  " The elevation of  the handles near the joint,  above the same horizontal line, is 1-3
(including the thickness of the blades), which indicates the extent of the angular bend
in the handles."
  An important modification of the forceps has been  recently announced by Dr. Bond,
of Philadelphia (American Journ. of the Med. Sciences; Oct., 1850).
   At  an early period of his professional life it occurred to him that obstetrical cases are
Bometimes, although  not very frequently,  met with  where, owing to the position or the
form  of  the foetal head, and its relation to  the pelvis, it is found impracticable to adapt
the clams to the head so as  to lock the branches, or  to do so without violent injury to
the mother or child.
   Dr. Blundell very justly observes, "Unless the blades be elastic, absolute adaptation
can (I conceive)  never be  obtained; for while the  form of the instrument remains
unchanged,  that of the head itself varies."  " The  lock should be loose, so as to admit
of a junction of the blades, although they may not be brought into exact apposition  with
each  other; for, in  applying  them to the head,  this  adaptation  cannot  always be
obtained."    For this reason, he says that Smellie's lock  (made loose) is decidedly the
best.
   Dr. Meigs says, " If we fail to adjust the branches accurately in apposition, we either
cannot make them lock, or we lock them in such a way that the edge of the instrument
contuses, or even cuts the part of the scalp or cheek on which it rests, leaving a scar,
or actually breaking  the tender bones of the cranium, while the  other edge  cuts the
womb or vagina by its free projecting edge.  In fact, the forceps is designed for the
sides of the head;  and if, under the stress of circumstances,  we are compelled to fix
them in any other  position, (an incident  not very unfrequent), we shall  always feel
reluctant to do so, and look forward with painful anxiety to the birth, in order to learn
whether we have done the mischief we feared, but which we could not avoid."*
   " The difficulty and the danger in  such cases," remarks Dr. Bond, " evidently arise,
to a great extent, from the want of an accommodating, rocking motion of the branches
of the forceps  upon  each  other, such as will allow the  depressed  (' cutting  and  con-
tusing') edge to rise,  and the elevated edge to sink  and come in contact and apposition
with  the head ; that is, so that the blades may be adapted to the head by varying from
their  usual relation to each other.
   "None of the French forceps, or their numerous  modifications, so far as I know, are
intended to  admit  of such  a motion.   When locked,  they are truly locked; and what-
ever be the form of the head, or whatever the parts of the head to which the instrument
is applied, the head  must conform to the  forceps and not the forceps to the head.
Smellie's joint (which can hardly be called a lock) will admit of some motion, if made
loose, as recommended by Dr. Blundell; but this motion is very limited  and unregu-
lated.  Dr.  Davis, of London, has adopted Smellie's  joint, but without observing Dr.
Blundell's precaution as to its looseness.   The lock of Dr. Siebold's  forceps, when the
pivot is partly unscrewed, will admit  of the  lateral  motion of one branch  upon the
other, to a very considerable extent.   The branches of forceps  are  two levers of the
first kind, the pivot  being the common fulcrum of each.   It is to be observed in  Sie-
bold's forceps, that the branches  are so much curved—make so wide a sweep—that the
fulcrum  is far removed from the direct line between the  power (the  hand)  and the
weight (the head); and it will be seen on examination that this circumstance will render
their lateral or rocking motion nearly useless, if not dangerous.   Indeed, I should infer,
from  the structure of the joint and the form of the blades, that the use of this motion
was never contemplated by the inventor."
  • See " Obstetrics;  the Science  and the Art," chap, xv., for much information and
excellent lessons on the use of the forceps.  I commend attention to the author's em-
phatic inculcation of the idea, that " the forceps is the child's instrument,"
                                      2d 
338
TnE  FORCEPS.
  "In the instrument,* which is illustrated in figs. 105, 106, 107, I  have attempted
to supply what has  seemed to me an obvious desideratum, viz. to give the branches of tht
forceps an  accommodating rocking motion upon each other, the extent of which can be regu-
lated at will, and which  shall in no respect lessen the power of the instrument.  The mecha-
nism devised to obtain this motion is very simple, not liable to derangement, and it may
Fig. 105.                  Fig. 106.                      Fig. 107.
be adopted in the construction of forceps of other forms than that here presented; pro-
vided that the pelvic curvature of the branches does not take such a wide sweep, as to
throw the pivot far out of the direct line between the handle and the centre of the
fenestra.
  " The instrument will be seen  to differ, as a whole, from any now in use; although no
one of its modifications, except  the. lock, has any claim  to novelty.   The handles are
Dr. Siebold's, with unimportant modifications.   The  blades  are Dr.  Davis's, a little
modified.   Its whole length is about fifteen inches, and its weight about fifteen ounces.
The length of the handle is six inches, and that of the blade nine inches.  It might be
made somewhat shorter and lighter without impairing  its power.
  " In fig. 105 (the pivot of full size), the screw  is of about double the diameter and
nearly double the length of those in other instruments.   This additional  strength ia
necessary, because the bearing point of the pivot is not immediately above the blade in
which it is  inserted (as in other instruments), especially when this bearing point is
elevated  so as to give the blades  a  free  rocking motion.  The additional length ia
  * " The instrument, from the manufactory of Messrs. John Rorer & Sons, of Phihv
delphia, is made of German steel, and spring-tempered." 
THE  FORCEPS.
339
required to give the screw a firm lodgment, when it is partly withdrawn from the blade.
The thumb-piece is made to fit so close upon the female blade, but without resting upon
it, and is  so thick and rounded, that there may be no risk of injury should  it ever
happen to be brought into contact with the patient.   The screw,  when well made,  will
turn so easily that  the thumb-piece may be  made  much less  prominent than it is
here represented.  When the forceps is used, the thumb-piece should be placed parallel
with the blades;  otherwise it may interfere with the rocking  motion.   Between the
thumb-piece and the screw, the pivot is of the form of two frusta of cones of equal
dimensions, united together at their smaller diameters, forming an  obtuse angle or
groove at their junction.  The base of that cone joined to the  screw projects a little,
forming a shoulder, intended to limit the motion of the screw into the blade.
   " The notch in the female blade, made to receive the pivot, is so deep that the pivot,
in relation to the edges of the branch, is nearly in the middle; yet the  width  of  this
branch, opposite to it, is swelled out, so as  to  give it adequate firmness.   The width
and the form of the sides of the  notch are accurately adapted to those of the pivot,  and
the  bottom of the notch terminates in an edge,  like the knife-edge of a balance, which
is intended to rest in, and bear upon, the angle or groove in the pivot.   On the under
side of the male  blade is seen a protuberance, finished so as to present no  salient points.
It is a shield  for the extra length of the screw.  When the pivot is  screwed entirely
down, the branches have no more lateral or rocking motion than those of any other
forceps, and, in  this condition,  they will very generally be used.  But by turning the
screw, so as to elevate  the bearing point, more  or less freedom  is given to  the rocking
motion, according to its elevation; and this  motion is effectually restricted within  any
desired limits.  When, by means of this free motion, the operator has been enabled to
grasp the head, he may sometimes change its position, so  that  the clams may be then
adapted to the head, without the obliquity at first necessarily allowed to them by the
elevation of the pivot;  and then, if desirable, the pivot may be screwed down, and the
blades will become as fixed as those of other forceps."
   " It will be seen that the blades of those here presented (figs. 106 and 107) resemble
nearly those of Dr. Davis.   The shanks are considerably longer; the clams are  not
quite  so long;  the radius of their pelvic curvature is a little less, especially that of the
outer limbs, so that it will be less  liable to be obstructed by  the promontory of the
sacrum, in passing the instrument above the superior strait.   The fenestra are wider
in their middle and posterior part than those in most other forceps now in use.  When
the  pivot is elevated, so as to allow the blades their rocking motion, this width becomes
especially requisite in order to secure a firm hold on the head, and to avoid the risk of
their slipping  sideways.  The space between the blades is such, that, when applied to
the  head,  the handles shall not be at a distance from  each other, awkward and incon-
venient to the operator.  From the pivot, the upper line of the shank continues forward,
without any elevation or depression, to the beginning of the pelvic curvature;  and the
form and the relation of the shank to the clam  are intended to  be such as  to interfere
the least with the perineum.
   " While a form has been selected, which, it is  believed, will admit of application easy
and safe for the mother and child, and grasp the head above the superior strait, it will
be seen (fig. 106)  that the pivot is in a direct line between the handles and the centre of
the fenestra.   This is a point of importance in those cases where the rocking motion of
the blade may  be required,  as it will cause each limb of  the clams to press with nearly
equal  force, thus avoiding  undue pressure upon any one  part  of the head, and  the
liability to slipping or displacement.
   " The handles are made partly of ebony, and they resemble those of Siebold, although
considerably lighter.  The precise model, of those represented in the illustration, is not
important; for it may be varied  to suit the grip  or the taate of different operators."
   "  I am aware that  the first impression of some persons, upon  looking at the illustra-
tions,  will be, that the instrument is too straight, that the pelvic curvature ought to be
continued into  the shanks.   If the whole operation, or the most difficult and important
part of it, consisted in passing the blades above  the superior strait, narrow blades, with
a curve of a wider sweep, like  those  of Professor Siebold, slipping in probably with
rather more facility, would be preferable.   But as those here represented can be  passed
above  the  superior strait with facility, it seems to  me  that what I have already said
upon the importance, in many cases, of having the pivot in nearly a direct line between
the handles and the fenestra, furnishes a valid reason for adopting a model not differing
essentially from that  here presented.
  " Others may object, that unskilful and incautious  persons will be tempted to care
lessness in applying  such  a forceps, and to avail themselves of the free motion of its
lock  unnecessarily.   Professors  of obstetrics, if they deign to notice it, ought to give 
340
THE  FORCEPS.
their pupils the proper directions and precautions in the use of this instrument, n* they
do in that of others.   Some persons are, indeed, so unhandy in the use of any instru-
ment or tool,  that all  the professors  in the land cannot give them  such tact  and
dexterity, that they ought to be allowed to approach the puerperal bed.  Should  this
instrument happen to fall into  such hands, the danger to either mother or child would
probably be much less than from the use of powerful,  unaccommodating forceps, mis-
applied by such hands."
  The remarks of Dr. Churchill on the "period of operating," are highly judicious,  and
deserving of the especial attention of the junior practitioner.   They are the more sa-
tisfactory because they inculcate  sounder doctrines, according to our view of the sub-
ject, than are  to be found in the writings of some of our late as well as older British
authors, at least.
  Dr. Merriman says, "it is a  rule of practice, that the forceps  shall never be  npplied,
till the ear of the child has been within reach of the operator's finger for at least six
hours."
  Dr. Denman  pronounced it " improper to attempt to  apply the forceps before an ear
can be felt."
  Dr. Burns says: "In almost every case where the forceps are beneficial, the head
has so far entered the pelvis as.to  have  the ear corresponding to the  inner surface of
the pubes, and the cranial bones touching the perineum."   Again, " When the finger,
without the introduction of the hand into the vagina, can easily touch the ear, and when
the cranium is  in contact with, although not  protruding the perineum, the  forceps is
applicable."
  " The delivery of a female with forceps," says Dr. Collins, " when the os uteri is fully
dilated, the soft  parts relaxed, the head resting on the  perineum,  or nearly so,  and  the
pelvis of sufficient size to permit the attendant to reach the ear with the finger, is so simple
that any individual, with moderate experience, may readily effect it.   I have no hesi-
tation in asserting, that to use  it under  other circumstances, is not only an abuse of the
instrument, but most hazardous to the patient."
  If we are never to apply the forceps but when  an ear can be felt, and " the head rest-
ing on the perineum," there is indeed little occasion for a long instrument; but what ia
to become of patients labouring under organic affections of the heart, hemorrhage, con-
vulsions, some  tumours  of the pelvis, slight  contractions of the brim, great tfebility,
aneurism, hernia, arrest of the  head from want of proper rotation,  &c. ?  German,
French, and American practitioners, will not  feel themselves at liberty to stand by in
such cases and  see their  patients  sink into the grave without  attempting delivery until
the head rests upon the perineum, or an ear can  be felt; nor will  they dare to plunge the
perforator into  the fcetal head,  without first endeavouring to save its life by the use of
the forceps.
  As to the ear as a guide, Dr. Rigby is perfectly right in  saying that the position of
the head should always " be determined by the direction of the fontanelles and  sutures,
not by feeling for the ear."  " The ear can seldom be reached without a good deal of
pain, even under the most favourable circumstances." — (Rigby's System of Mid-
wifery.)
  The average  of the results of British practice, as  shown by their statistics, is cer-
tainly creditable: this is owing, no doubt, in a great measure, to the prudent avoidance
of all unnecessary interference.  But in shunning one  error, we not unfrequently  fall
into  the opposite extreme ; and this would appear to be the case with our brethren of
England and Ireland.  If we confine our examination  to instrumental cases, the compa-
rison between them and their neighbours is less flattering to them.
  When the difficulty exists " at the brim of the  pelvis, it will be better in all cases to
apply the forceps in  the transverse diameter."  If there  be want of space, it will be
almost always in the antero-posterior diameter, and on that account there will be diffi-
culty in passing the blades of the forceps between the head  of the child and the pelvis;
not only so,  but it is nearly impossible to pass the posterior blade far enough, in con-
sequence of the projection of the sacrum—if  the instrument be straight, that is, with-
out the second  curve, the extremity will be arrested by the upper portion of the sacrum,
or the shank of the blade will press very seriously against the perineum;  in fact, it
cannot pass  thus without pushing this part back with great violence, as  any one may
see by looking at the vertical view of the pelvis represented in figure 102, page 334.
  In attempting to apply the instrument antero-posteriorly, there is always  danger of
injuring the bladder and  rectum, which  alone is  a  sufficient reason for rejecting this
mode of operating, if any other will answer.
  The only valid reason that can be discovered for applying the forceps antero-poste-
riorlv is, that the pressure made by the instrument in that case is upon the part of  the 
CRANIOTOMY.
341
head corresponding with the least diameter of the brim.   But if the blades be made
without pretty wide fenestra, their thickness will be added to that of the head, and will
be quite equal to all that will be gained by the compression, if this be confined within
the limits prescribed by a regard for the safety of the child; and if the head must be
reduced more than this, the perforator should be employed.  It  must  be admitted by
all who have had any experience in these matters, that the soft parts of the mother will
bear as much compression as the brain of the child: if this be so, where the life of the
latter is to be preserved, there  is, certainly, no reason why the necessary compression
or moulding of its head may not be left to the influence of the resisting parts.   When
this moulding operation is left to the maternal parts, the compression is made exactly
at the points where it is needed, which can hardly be expected from the arbitrary in-
fluence of the instrument.   Entertaining these views, Dr. Huston has long rejected the
forceps  as a means of compressing the head, unless when the perforator is  required,
and employs it only as a lever to alter the position of the  head, or as  a tractor to aid
in its expulsion.  That the forceps should never be used as a compressor, but solely as
a tractor, is also strongly insisted upon by Professor Meigs. — Editor.
                           CHAPTER XIII.

             OBSTETRIC OPERATIONS.  5. CRANIOTOMY.

   546.  The next obstetric operation we have to consider, belongs to the
 second class, that is, where one life is  sacrificed to  secure the other; the
 mother's safety being purchased by the destruction of her child, in cases
 where both would be lost if no interference were attempted.
   The instruments (or part of them) employed  in this operation, are  of
 great antiquity;  and although they were originally proposed for the ex-
 traction of dead children only, yet this scruple had not the effect of saving
 the life of the  child, but merely postponed  the interference until after its
 death.   This  conscientious   quibble  (refusing  to  destroy  a  child, but
 allowing it to die) was soon detected, and then the hook was  used with
 living children, provided that delivery were  otherwise impossible.
   The class of cases to which it was applied, doubtless  included  a vast
 number which were subsequently relieved by the forceps;  but there was
 still left a great many in which it was indispensable.
   Several of the ancients recommend this operation.   Hippocrates advises
 the breaking up of the cranium and extraction by the hook.
   Moschion advises embryulcia in those cases where the fcetus  cannot be
 extracted by the  hands, and  if embryulcia  be insufficient, the  exsection
 of the limbs and  body of the child.
   Albucasis, the Arabian physician, describes instruments for compressing
 and breaking up the child's head, and  others for extracting it.
   Of certain cases of difficult labour,  when the child is presumed to  be
 dead, Celsus remarks, " Si caput proximum est, demitti debet uncus, qui
 vel occulo vel auri, vel  ori interdum etiam fronti recte injicitur."
  In the l Birth  of Mankinde,' written by  Eucharius Roslin,  translated
into  Latin  about  the year  1535, and into English by Thomas Raynalde,
in 1634, I find  the hook recommended to bring away dead  children.
" If so be," he says, " that  it lie the  head  forward, then fasten a hook-
either upon one of the eyes of it, or the roof of the mouth, or  under the
                                 2d2 
842
CRANIOTOMY.
chin, or on one of the shoulders — which of those parts shall seem most
commodious and handsome to take it out by, and the hook fastened to
draw it out very tenderly, for hurting of the woman."  If the head be too
large, it is to be opened with a sharp penknife, or broken in pieces.
  He also recommends excision of the extremities, if they present, (the
child being dead,) or evisceration, to facilitate the delivery.
  Ambrose Pare's work is  dated 1579, and it was translated into English
in 1634.   In it are  given  plates of different hooks  for drawing out the
child, and a knife for the excision  of the limbs.
  From  this time we find  the  operation recommended by every author,
but the instruments  underwent considerable  modification,  and  the class
of cases  in  which they were used considerably decreased.  Of course
this latter change was one of the  consequences of the invention  of the
vectis and forceps.
   547. The following  are the principal modifications of the instruments
for craniotomy:
   1. Albucasis describes a species of forceps with teeth, which he terms
a " misdach, or almisdach," for the purpose of crushing the head, and
enabling it to pass.          y
   2. He also gives  a plate of a single  and double  hook,  for extracting
the child, and of a knife for cutting off the head.
   3. Ambrose Pare  contrived two kinds of blunt hooks, and a double
one  with sharp points, for the extraction  of the fcetus, and a knife for
excision.
   4. Mauriceau  invented  an instrument which he called  a " tire tete,"
consisting of a  circular  plate  of  steel, fixed  upon a rod.   The circular
plate was to be  introduced  into  the head, (previously opened by a scal-
pel,) and being  placed  across the opening,  traction  was  to be  made.
This instrument was never much used, owing to the difficulty of intro-
duction, and its feeble power when introduced.
   5. Sir F. Ould's  " terebra occulta" consisted  of a  sharp-pointed rod
inclosed in a canula  or sheath, and retained by a spiral spring at the lower
end.   "When the handle  was pressed upwards, and the resistance  of the
spring overcome, the point of the instrument protruded a certain distance,
but was retracted when the pressure upon the handle was removed.  Its
application to  the head was easy and safe; but it  must have been nearly
useless, from the small opening it  made.
   6. Dr. Simpson,  of St. Andrews, invented  an instrument which  he
called  a "ring scalpel," for opening the skull.  It consists of a loop of
steel, through  which the finger is to be passed, and from which pro-
trudes a sharp-pointed blade  about an inch long, by which the  cranium
was pierced.
   7. M. Mesnard described a crotchet which could be used either double
or single, and which was the original of the one in present use.  He also
gives a plate of a " perce-crane,"  and a pair of " tenettes a conducteur,"
that is, craniotomy forceps.
   8. Dr. Burton copied Mesnard's double crotchet and "perce-crane"
with some slight modification.
   9.  M. Levret  gives a plate of a single  crotchet which was arranged
to fit into a socket on the top of another blade for the purpose of protect-
ing the mother, and  rendering the purchase more secure. 
CRANIOTOMY.
343
  10. Dr. Smellie recommended Mesnard's crotchet (single or double);
but instead of the " perce-crane," he used a pair of strong scissors, with
stops  at  the  shoulders to prevent the blades entering too far.  Denman
abolished the cutting edge altogether, and added strength to the blades.
A spoon was also used to evacuate the brain, but it is now very properly
discarded.
  11.  Dr. Wallace Johnson  published an account of his instruments for
opening  the head and extracting the child.  I do not know that they have
ever been used by any other person.
  12.  Dr. Aitken proposed a flexible or living crotchet, which could be
adapted  to the convexity of the child's head.
  13.  M. Baudelocque recommended a very simple extractor, consisting
of a small piece of wood, to the centre of which a ribbon wTas  attached.
An incision having been made with a bistoury or " perce-crane," the bar
of wood was to be introduced and placed crosswise, and then extraction
made by the ribbon.
   14. M. Osiander has  given a plate of an  instrument for piercing the
skull, and another  for extracting.   The latter is the same as  Smellie's
double crotchet.
   15. M. Joerg advises an  instrument like  a trephine for opening the
head, and a simple hooked rod for extraction.
   16. Dr. Davis has invented several species of crotchet, both single and

                   Fig. 108.                         Fig. 109.
 
344
CRANIOTOMY".
double, as .well as a pair of forceps for breaking up the skull.   These are
well exhibited in the fourth edition of his work.
  These are a few of the principal instruments which have been employed
in the operation of craniotomy.  I have not given a detailed description,
because most of them are discarded ; the instruments in general use being
a pair  of scissors with shoulder-stops, as recommended  by Smellie, but
having a sharp edge on the outside (fig. 108), and a modification of Mes-
nard's  simple crotchet (fig. 109).  I have found it an advantage to shorten
the  points of the scissors above the stops, and also the hook of the crotchet;
the  latter of which should  be slightly cleft.  Mr. Holmes has modified the
latter, so that by closing the handles we open the blades (fig. 110). Fur-
ther, I  have added plates of a knife for cutting off the head or limbs if
necessary (fig. Ill), a blunt hook (fig. 112), and Dr. Davis's bone forceps
for  breaking up the skull (fig. 113).

                   Fig. 110.                       Fig. ill.
  From tne inconveniences sometimes experienced with the crotchet, and
to avoid  the risk of injuring  the  mother, craniotomy forceps have  been
employed by different individuals.
  Among the moderns, M. Mesnard has the credit of first inventing and
using this instrument,  and since his time it has undergone various modifi-
cations. 
CRANIOTOMY.
345
  Dr. Haighton used a pair resembling the lithotomy forceps ; and since
his time Drs. Conquest and Davis, Mr. Holmes, and others, have invented
and described varieties of the instrument (fig. 114).  The object of each
is the same, viz. to avoid the risk of tearing the soft parts of the mother;
and the principle of seizing the skull between two blades, furnished with
teeth, is also alike.

     Fig. 112.            Fig. 113.                    Fig. 114.
  I am free to confess that I do not like the craniotomy forceps, although
I have tried them repeatedly.  They are by no means so manageable as
the crotchet; and the interposition of the hand of the operator will always
protect the mother from injury by the latter.
  There is  one case, however, in which the forceps  may be more useful,
and that is, when the bones  of the head are extremely hard, so  that it is
almost impossible to fix the point of the crotchet.*
  17.  M. Baudelocque, jr. has  invented an instrument, which he calls a
" cephalotribe," for the purpose  of crushing the head (fig. 115.)   It con
sists of a very strong pair of forceps, about two feet in length, the handles

  * Professor Meigs uses the forceps and perforator represented in figures 116 and 117.
Tliese forceps possess advantages over the ordinary instruments for extraction after 
346
CRANIOTOMY.
of which  are connected  by a screw which pierces them,  and which is
turned by a handle until the blades are so closed as to effect their object

                                Fig. 115.
Velpeau states that instruments somewhat similar have been formerly used
by Assalina, Osiander, Delpech, Colombo, &c.  M. Baudelocque is said
to have used it three times successfully (and safely as regards the mother)
in the year 1832, and  once again in 1834.   It is also said that M. Cham-
pion has tried it with success.
  Its appearance is so formidable, that I doubt if it could be used in this
country.  I am not aware that the attempt has been made.
  548.  The object of the operation of craniotomy is to terminate the labour
with safety to the mother, in cases where from the disproportion between
the  size.of the fcetal head and the pelvis, a living child can neither be ex-
pelled by the natural powers, nor extracted by the forceps.  Such a case,
if left to nature  (as it is  called)  will terminate fatally for both  mother and
child;  consequently, although the child is destroyed  to  facilitate the de-
livery, and to save the mother, it can hardly be said to be sacrificed, inas-
much as no  efforts of ours could have ensured its safety.
  The case presupposes on  the one hand, actual disproportion, sufficient
to prohibit the passage of the fcetal  head, even when compressed; and on
the  other, that the distortion is not so great as to prevent the extraction of
the  child when mutilated.

perforation of the head, and  are  certainly safer in unpractised  hands than the
crotchet.
  They are eleven inches in length; the gripe is serrated and the sides of the man 
CRANIOTOMY.
347
  Dr. Osborn states that when " the bones approach much nearer to each
other than three inches, it is  utterly impossible  for a living  child at full
maturity by any means to pass."*   He fixes upon 2f inches as the diam-
eter rendering craniotomy necessary.  M. Alphonse Le Roi says that 3£,
Dr. Atkin 3, Dr. Jos. Clarke  3£, Dr. Burns 3£, Dr. Ritgen 2, and Dr.
Busch 2£ to 3 inches, is the  smallest antero-posterior  diameter through
which a living child can pass.
  As to the other limit of the operation, that  is, the  smallest diameter
through which  a child can be extracted after  craniotomy, Dr. Osbornf
remarks:
  " Whenever there is a space from pubis to sacrum, or from the fore to
the hind part of the upper  aperture  of the pelvis, equal to an inch and a
half, I am convinced it will be  always practicable to extract a child by
the crotchet, after the head has been some time opened, and the texture
dibles are rounded, in order that they may not pinch any tissues except those intended
to be included  in the bite, which, on account of the serra, is very sure and strong.—
(See Obstetrics — The Science and the Art, 2d edition.)

               DE.  MEIGS'S EMBRYULCIA INSTRUMENTS OB. PLIERS.
Fig. 116.                    Fig. 117.
* Essays on Midwifery, p. 194.      ■}■ Ibid, p. 200. 
348
CRANIOTOMY.
of the child's body is softened by putrefaction (as recommended above)
and the whole of the parietal and frontal bones are picked away."
  Baudelocque says that the crotchet is  inadmissible when the diameter
is only 1| of an inch; Dr. Dewees, when it is less than 2 ;  Dr. Hull and
Dr. Burns believe that it may succeed when the diameter is  If; MM.
Gardien and Hamilton when it is  l£;  and Dr. Davis when it is 1 inch.
  549.  The nature  of the operation is simple, but the aid afforded may
vary in degree.
  1. In the case of  dead children, the older practitioners used the crotchet
alone as an extracting force, without opening the head.
  2. In some cases where  the  sutures are very loose, the  evacuation of
the brain will be sufficient,  as the  bones of the cranium collapse so much
under the influence of the pressure downwards, that the  child may be
expelled by the natural powers.   But in this  case, it is assumed that the
pains are sufficiently strong and frequent.
  3. When  (as is frequently the  case)  the pains are  inefficient, or when
the state of the  patient  demands prompt relief, then we must not only
evacuate the brain, but add extracting force by means of the crotchet or
craniotomy forceps.
  4. In  some cases,  the distortion of the pelvis  is  too considerable to
admit the passage of the  head, even when emptied  of its contents; or
the obstruction may result from the ossification of the  bones of the skull;
in either case, an extension of the operation is necessary to complete the
delivery.  This may be  effected by breaking up the cranium with a small
pair  of  forceps, resembling  Dr.  Davis's;  or, according to  M. Baude-
locque,  jun., by the use of the cephalotribe.   It would require unusual
hardihood to venture upon the latter instrument in private practice in this
country.
  5. In these cases of distortion,  after the head has been extracted piece-
meal, we may find  it  impossible  to bring away the body  of the infant.
We must then use the perforator,  for the purpose of evacuating the con-
tents of the chest and abdomen,  and  afterwards  apply  the  crotchet to
extract the child.
  One or more of these modifications of the operation will be  successful
in  all cases which come  within the limits already described.
  550.  Statistics.—The positive advantage we obtain from embryotomy
is the safety  of a large proportion  of the mothers, who, in addition to the
children, tnust have perished had no aid  been afforded.   The  children
of course are all lost.
  What the proportion of success is, I  shall now endeavour to show; but
previous to this I shall adduce whatever evidence we  possess to ascertain
the comparative frequency of the operation. 
CRANIOTOMY.
349
FREQUENCY OF THE OPERATION,
a. Among British Practitioners.
Date.	Authors.		Total No. of Cases.	No. of 1 Crotchet Cases.	References.
1781	Dr. Bland.....		1,897	8	Merriman's Synop.p. 333.
1787 to 1793	Dr. Jos. Clarke .		10,387	49	Trans, of Assoc, vol. 1.
	Dr. Merriman. .		2,946	9	Synopsis.
1818	Dr. Granville . .		640	3	Report, p. 25.
1828, 1829	Dr. S. Cusack. .		701	5	Dublin Hosp. Reports.
1832, 1833	Dr. Maunsell . .		839	6	Ed. and Dub. Jour.
1829	Mr. Gregory . .		691	2	Dub. Hosp. Rep. vol. 5.
1826 to 1833	Dr. Collins. . .		16,414	79	Practical Treatise.
1834	Dr. Thos. Beatty		1,182	3	Dub. Jour. vols. 8, 12.
	Mr. Lever . . .		4,666	25	Guy's Hosp. Reports.
	Dr. Read . . .		3,250	15	
1836, 37, 38, 39	Dr. Churchill . .		1,640	11	Reports to June, 1840.
1838	Mr. Warrington .		88	1	American Journal.
1829	Mr. Mantell . .		2,510	3	Do.
1848	Drs. M'Clintock and "> Hardy . . . /		6,634	52	Pract. Obs. p. 95.
b.  Among French Practitioners.
Date.	Authors.	Total No. of Cases.	No. of Crotchet Cases.	References.
1797 to 1809 1803 to 1811	Madame Boivin . . . Madame Lachapelle. .	20,517 15,652	16 14	Memorial, p. 337. Prat, d'Accouch. p. 500.
c. Among German Practitioners.
Date.	Authors.	Total No. of Cases.	No. of Crotchet Cases.	References.
1801 to 1807	M. Richter, Moscow .	2,571	3	Velpeau.
1811 to 1827	Moschner and Kursak,			
	Prague .....	12,329	4	Siebold's Jour. vol. 9.
1812	Dr. Siebold, Wurtzburg.	170	1	Do. vol. 1.
1818 to 1829	Do. Berlin . .	97	1	Do. vol. 10.
1832	Do. Marburg .	155	1	Do. vol. 13.
1814 to 1827	Dr. Carus, Dresden . .	2,908	9	Do. vol. 9.
1819	Dr. Ritgen, Giessen	103	1	Do. vol. 6.
1825 to 1827	Dr. Kilian, Copenhagen	2,350	4	Velpeau.
1794 to 1804	Dr. Henne, Prague . .	500	1	Siebold's Jour. vol. 2
	Dr. Naegele, Heidelberg	1,411	5	Velpeau.
1821 to 1825	Dr. Riecke ....	219,303	84	Do.
1825, 26, 27	Dr. Kluge, Berlin . .	809	8	Siebold's Jl. vols. 7, 9.
1825	Prof. Andr($e, Breslau .	351	2	Do. vols. 7, 8.
1827	Dr. Kustner, Breslau .	176	2	Do. vol. 9.
1829	Dr. Adelmann, Fulda .	57	1	Do. vol. 11.
1797 to 1837	Dr. Jansen, Ghent . .	13,365	5	Med. Gaz., March 6,1840.
  Thus, among British practitioners, we have 270 crotchet cases in 54,485
cases of labour — or about 1 in £01f.
  Among the French, 30 crotchet cases in 36,169 — or 1 in 1205|.
  And among the Germans, 132 crotchet cases in 256,655 labours — or
1 in  1944£.
                                2e 
350                         CRANIOTOMY.
  Added together, we have 347,309 cases, and 432 in which the crotchet
was used — or 1 in 803f.

         RESULTS OF THE OPERATION TO THE MOTHERS.
Authors.	No. of Crotchet	Mothers	Authors.			No. of Crotchet	■ Mothers
	Cases.	died.				Cases.	died.
Dr. Smellie ....	44	4	Dr. Beatty ....			3	0
Mr. Perfect ....	3	0	Dr. Churchill .			11	1
Dr. Jos. Clarke . . .	49	16	Mr. Warrington			1	0
Dr. Granville. . . .	3	3	Dr. Siebold . .			3	1
Dr. Ramsbotham . .	34	6	Dr. Ritgen . .			1	0
Dr. Maunsell . . .	5	2	Dr. Kluge . .			8	3
Mr. Gregory. . . .	2	1	Dr. Andr^e . .			2	1
Dr. Collins ....	79	15	Dr. Kustner. .			2	0
Drs. M'Clintock and 1 Hardy . . . . J	52	8	Dr. Adelmann .			1	0
  This table gives a mortality of 60 in 303 — or about 1 in 5.
  At first sight one would expect the mortality among the mothers to be
less, after the use of the crotchet than the forceps;  but the result of these
investigations  shows the reverse to be the case.  The only explanation I
can  give, is founded  upon  the  natural unwillingness of every humane
practitioner to destroy life — the consequence of which  feeling is, the
delay of the operation  so long as there is  a hope of evading it.   This
delay, however, is unfavourable to the mother, and  when at  length the
operation is performed, although it may have been less severe than deli-
very by the forceps, yet her condition rendered her much more  susceptible
of injury from it.
  551.  The comparative advantages of the operation are very decided.
In the cases we have  supposed, the forceps is useless, and the natural
powers inefficient; if, therefore, embryotomy were rejected as inadequate,
the only alternative would be the Csesarean section, the mortality of which
is much greater, for 1 in 2^ of the mothers are lost; and 1 in 3| of the
children.
  It would, however, be a serious omission if I did not notice another
alternative operation, which, although not available after labour has com-
menced, may  supersede the  necessity for embryotomy in subsequent preg-
nancies.   I allude to  the induction of premature labour.  In all cases
where  pelvic distortion renders  craniotomy necessary at the full time, it
becomes  our duty to recommend the induction of  premature labour in
subsequent pregnancies, at such a period  as shall, if possible, afford a
chance of life to the child, or at least save the mother from a severer ope-
ration.   The mortality among the mothers is about 1  in 50, and more than
half the  children are saved.
   552.  So much for the positive and comparative  advantages  of the ope-
ration.   I am not aware that there can be any just objections against it, in
suitable cases: but undoubtedly there are most weighty objections against
employing it,  without  careful consideration  and consultation.   In  fact, it
ought  to be deeply impressed upon  every practitioner, that he who de-
stroys the child, without due evidence that this is  his only resource for
saving  the mother, is guilty of murder.
   But it may be asked, when the responsibility is so serious, what evidence 
CRANIOTOMY.
351
will be sufficient to satisfy a conscientious practitioner that he may not be
committing a crime in his anxious endeavour to afford relief?   To this it
may be answered:
   1.  That the continuance of strong labour pains for a certain time, with-
out  any advance of the  head of the child* is  so far evidence of  a fixed
obstacle to the passage of the child.
   2. The failure of a cautious attempt to introduce the forceps, will, to a
certain extent, demonstrate the amount of the  disproportion between the
head and the pelvis; and  the failure of a careful  yet firm attempt at ex-
traction by the forceps (when the application has been effected), will prove
that the disproportion cannot  be remedied by compression.
   3. A well-educated finger  will enable  us in most cases  to  ascertain
whether the diameters of the  pelvis are such as will allow of the passage
of a living child.   And even though this mode be uncertain, we have  a
means of correcting our estimate, by comparison with the child's head, in
apposition with the pelvis.  If the natural efforts after several  hours, or
the forceps  with  a proper and  safe amount of compression and force,
 cannot  bring the widest part  of the head of the child through the narrow
part of the pelvis,  we may fairly conclude  that the only resource  is
 craniotomy.
   4. The general condition of the mother will also aid our decision.   If
 she be much exhausted, if fever be present, the uterus powerless, the life
 of the child doubtful, and the  success  of the forceps dubious, we may
 shrink from inflicting the double shock of an unsuccessful application of
 the forceps, and subsequent delivery by the crotchet.  But these cases are
 very rare ; they only happen when the patient has been mismanaged, and
 it requires experience and judgment to decide upon the propriety of termi-
 nating them by embryotomy.
    A careful consideration of  these circumstances  will, I think, enable us
 to arrive at a correct conclusion in an individual case; and as the respon-
 sibility incurred  in  the destruction  of the infant  may lead to timidity, it
 should also be remembered, that hesitation to  act when the case is clear,
 involves a  more  fearful responsibility, by compromising the life of the
 mother.
    553. The cases in which the operation is demanded are:
    1.  When the child is dead and  the labour tedious.  But we must be
 quite sure that the child be dead, before this is made the ground of inter-
 ference. If the head be  putrid, and there is space  in  the pelvis, it  is
 much better to use  the forceps, as the bones and integuments of the skull
 give way so easily under  the crotchet, that it is  sometimes very difficult
 to extract the child. I have  seen the operation prolonged two hours from
 this cause alone.
    2.  In distortion of the pelvis, when the antero-posterior diameter of the
 brim  is less than three inches, we have no  chance of delivery by the
 natural efforts or by the forceps; so  that to  save the mother, we must
 destroy the child.
   3.  When the transverse diameter of the lower outlet is diminished  to
 the same extent by the approximation of the tubera ischii, if the forceps
 applied antero-posteriorly are insufficient to move  the head, we must have
 recourse to craniotomy.
         23 
352
CRANIOTOMY.
  4. When the calibre of the pelvis is diminished to a certain degree by
a fixed obstacle — as, for  example, a  fibrous tumour,  or an exostosis
growing  from the bone  or periosteum, it may not be  possible  for the
natural efforts alone,  or aided by the forceps, to expel the child.  In such
cases it will be necessary to lessen the head and apply the crotchet.
  In these three  latter classes of cases, the  passage through the pelvis
may be so much diminished  as  to render it necessary  to break up the
skull, or  to eviscerate the child.
  5. In  some cases of  ovarian disease,  where the tumour has  formed
adhesions within the pelvis, so as to prevent  its being pushed above the
brim, it has  been found necessary to lessen the head, before the child
could be extracted.  We are  not, however, to decide upon this measure
until the  natural  powers have had a fair trial, as it sometimes happens,
that in the progress of labour the tumour is so much displaced as to allow
of the passage of the child (§ 437).   Further, it  will be  worth  while,
before sacrificing the  infant, to ascertain whether the  contents  of the
tumour may not be drawn off, by passing a long trocar into it.  If a small
quantity  of fluid  escape  it  may allow of  the application  of the forceps,
and so enable us  to save the child.  If, however, the tumour prove to be
solid and immoveable, we  must,  as a " dernier ressort"  have recourse to
the perforator and crotchet.
  6.  When the child is hydrocephalic to such an extent  as  to prevent its
entering  or passing through the pelvis, whether distorted  or of the natural
size, there can be no question of the propriety of opening the head.
  7.  In  some  cases of  convulsions,  rupture  of the uterus, &c, where
immediate delivery is necessary, and where the forceps cannot be applied,
craniotomy must  be performed.
  8.  In  flooding cases, before the head has passed through  the os uteri,
if the  cervix be  dilatable the child  may  be thus delivered;  and  this  is
peculiarly desirable when the flooding is  large  and the  child premature.
Of course it cannot be attempted when the placenta covers the os uteri,
nor need we have recourse  to it unless  the woman is endangered by the
hemorrhage.
  9.  If  an  arm  descend along with the  head, the diameters of which
correspond  closely to those of the  pelvis (whether the  latter be  of the
usual size or not), it may be necessary to terminate  the labour by opening
the head.
   10.  I  have already alluded  to a class of cases, where, from mismanage-
ment, the patient  has been  allowed to continue too long without help, and
m  consequence is greatly  exhausted, with fever, quick  pulse, delirium,
&c.  In  such cases  the  patient will die if she be not assisted; and  from
the unfavourable state in which she  is, she  cannot bear a prolonged oi
very painful operation.   Now if there be  sufficient  space for the forceps,
they ought to be preferred, and it would  be very wrong to use the per-
forator ;  but if this  be  doubtful, and the probabilities  against our suc-
ceeding  with that instrument, then  the  consideration  of the  patient's
inability  to bear a severe operation may in some cases decide us in favour
of  embryotomy.   These cases, however, are  but  few, and they must be
well marked, to justify our  adopting at  once such extreme measures.
   11  In footling or breech cases, when the head (separated or not  from
!he oody^ cannot be extracted, we must evacuate its contents. 
CRANIOTOMY.
353
  554.  The next question to be decided is the period of labour at which
the operation should be performed.
  1. In all cases where the diminution of the pelvic diameters is so great
as to render it impossible that a living  child can be  born  naturally or
extracted, there can  be no  hesitation in recommending that the head
should be opened at an early period of the labour, say as soon as the os
uteri is dilated or fully dilatable.  By this means we shall afford a chance
of the completion of the labour by the natural powers, as there can be no
objection to waiting a few hours before extracting the child.
  2. When the distortion is less, we cannot be sure  as to the result of
the natural efforts, and we must wait until it is evident that they are inade-
quate ; then an endeavour should be made to use the forceps, and if this
fail, there should be no delay in the performance of embryotomy.
   3. These observations will apply equally to the case of morbid growths,
ovarian disease, &c,  obstructing the passages.
   4. In cases of convulsions, ruptured  uterus, &c, the time for the ope-
ration  is determined  by circumstances connected with those accidents,
and which will be found laid down in the chapters on the subject.
   5. In the mismanaged cases to which I have alluded, the condition
of the woman, which determines the necessity for the operation, will also
point out the importance of promptitude.  If the case be so bad that we
dare not risk a failure with the forceps, it is clear that we  cannot afford
to delay embryotomy.

                               Fig. 118.
2e2 
354
CRANIOTOMY.
  555.  Mode  of operating.— It is not  absolutely necessary for  the
operation  that the os uteri should be fully dilated, though it is a great
advantage, and greater care will be required when this dilatation has not
taken place.
  The rectum and bladder are first to be evacuated;  the patient is  then
to be placed on her left side, with the hips over the edge of the bed, and
an assistant beside her, to fix and steady the abdomen.
  One or two fingers of the left hand are then to be introduced  into the
vagina, and their extremities fixed upon that part of the head of the child
which is to be perforated.  Contrary to ancient practice, this should never
be the sutures, because after the incision is made in that situation, the
bones collapse and close it.   Having determined upon the situation, the
perforator is  to  be passed along  close to the palm of the hand and the
inside of the fingers, so  as to  avoid injury to  the soft parts of the
mother.
  Having  arrived at the point  of insertion into the  skull, guided  and
guarded by the fingers of the operator, it is to  be pressed firmly forwards
with a semi-rotatory motion, until it pierce the bone (fig.  118); it is then

                               Fig. 119.
to be passed in up to the shoulders, ana the handles are to be separated
by an assistant as widely as possible (fig. 119).  The cutting edges of 
CRANIOTOMY.
355
the scissors are then to  be placed at right  angles with the first incision,
and again separated, so as to make a crucial incision.
  This being effected, the perforator is to  be passed into the skull, the
brain thoroughly broken up, and the medulla oblongata cut across.   The
scissors are then to be withdrawn, and the first part  of the operation is
completed.
  The left hand is again to be introduced, as a guide and guard to the
crotchet, which should be  passed into the cranium for the purpose of com-
pletely breaking up the  brain.  I dwell upon this point, because instances
are on record of the child being born alive after the operation of cranio-
tomy, to the  disgrace of the  operator,  and the  distress of  the patient and
her friends.   When this object is  attained, if  we wish to terminate  the
operation at once, the crotchet  may be fixed on the outside or inside of
the head; the former was adopted by the older practitioners, but the latter
is recommended generally at present (fig. 120).   In some cases it is useful
to employ two  crotchets—one internally and the other externally.
Fig. 120.
   The  scalp should  be carefully folded over the edges of the bones, in
order to prevent injury to the passages, and then extracting force  must be
gradually and steadily applied during  the pains, or at intervals, in imita
tion of  them.
   The  left  hand should  be passed into  the vagina, and placed on the
head, opposite  to  the insertion  of the crotchet, both for the purpose  of
steadying it and of preventing mischief jf the instrument should slip.   If
the part of the skull  in which the crotchet is fixed give way, we must
obtain another purchase. 
356
CRANIOTOMY.
   The amount of force, and its continuance, will depend of course upon
the resistance to the passage of the child; but if after a certain time no
progress be made, in  order to avoid contusion of the soft  parts  of the
mother, it will be well to break up the skull with the forceps adapted for
that purpose (fig. 113).
   The perineum  must be carefully  guarded, and care must be taken  that
no injury be inflicted by the speculse of bone.
  After the head is extracted, the  body generally follows without much
difficulty; but should this not be the case, we must have recourse to evis-
ceration.  The scissors must be plunged into the chest, and  the contents
broken up : the crotchet hooked upon the ribs, and traction exerted.  The
contents of the abdominal cavity may be evacuated in a similar way, and
after this we shall generally be able  to extricate the child.
Fig. 121.
   If the craniotomy forceps be used, one blade must be passed into  the
 skull, and the other on the outside, and sufficiently far to  secure  a firm
 hold (fig. 121);  the blades then  being closed, the  operator must draw
 down firmly, yet gently, and at intervals.

   556. The principal difficulties of the operation are as follows:
   1. If the bones of the skull be very firm, it is not easy to perforate, and
 the point of the scissors is very apt to  slip.   This can only be avoided by
 great care  and steadiness.
   2. A similar state of the bones will offer  a  serious obstacle to the  in-
 sertion of the point of the  crotchet; but a little perseverance will in most
•cases overcome it.  The fingers of the left hand placed on the outside of
 the skull, will render it still more easy.
   3. The extraction may be difficult.   If the narrowing be not too great, 
CRANIOTOMY.
357
the difficulty may be overcome by steady force;  but if such a degree as
may  be exerted with impunity do not move the head, we must then break
up the skull, as already stated.

   557. The dangers to which the patient may be exposed in this opera-
tion, are  more serious than when the forceps is used.
   1.  The perforator may slip, and the vagina  or uterus be wounded.
   2.  The hook may slip, or the bone in which it is fixed may suddenly
give way; and if the  hand of  the operator be liot interposed, a severe or
even fatal rent may be inflicted.
   3.  The perineum may be lacerated by the injudicious exertion of ex-
tracting force.
   4.  From the condition  of the patient, she generally suffers  more from
the  shock to the nervous  system,  than  in  the  operations  previously
described.
   5.  There is also greater danger of subsequent inflammation of the womb
or vagina, with perforation of the bladder, especially if much  force have
been necessary.

   558. After-treatment.—The nervous shock will be best remedied by
quiet, small doses of opium, and moderate stimulation.
   The state of the vagina and uterus should be carefully watched, and
vaginal injections of warm water used occasionally.
   If any symptoms of inflammation  arise, they must  be met promptly
by the  appropriate remedies, — venaesection,  leeching,  calomel,  and
opium, &c.
   In other respects, if the patient go on well,  she must be treated as after
natural labour. 
CHAPTER XIV.
    OBSTETRIC OPERATIONS. 6. THE CESAREAN SECTION, OR
                          HYSTEROTOMY.

  559.  So far, I think, our investigations have fully borne out an obser-
vation made in a former chapter (§ 473), viz.: that  obstetric  operations
formed an ascending series—each one exceeding the other in importance
and  danger;  and that whilst  no two  could be compared  in terms  of
equality, the value of each was shown by its alternative, which is always
one of greater danger.   Thus the mortality of premature labour is less
than its alternative, the crotchet; that of the forceps less than the crotchet;
and we -shall now  see that  inasmuch as when it is employed early, the
safety of the  mother is nearly secured, the danger of embryotomy is  far
less  than that of the Caesarean section.  This  operation is  indeed the
" dernier ressort"  of midwifery.   Preferable as  it is to the certain death
of both parties, it  is far more  serious in its consequences than  any  other
operation.  It comes under the class of operations already noticed, in which
the life of mother and child are necessarily more or less compromised.
   It is of very ancient  date, being known to the  Greeks,  and called
vdregoropoToxiri, or  su^ioAx*]; but I believe  by them only employed after
the death of the mother.
   From the  circumstances of  several  remarkable  personages having
entered the world  in this way, it was  deemed fortunate to be so born—a
royal road, in short, to distinction.
   Pliny has  recorded that Scipio Africanus was thus extracted.   He
says, "Auspicatius enecta matre nascuntur, sicut Scipio Africanus  prior
natus."   He  is not correct, however, in stating that Scipio was the first
thus brought into the world; Claudius Caesar, who distinguished himself
in the war with the Samnites,  having preceded him.
   From being thus " cut out" of their mother's womb, these  individuals
were first  termed  " Caesones," afterwards  " Csesares," on the  authority
of Pliny, Festus,  Pompeius, Solinus, &c.   " Quia caeso matris utero  in
lucem  prodiscunt."
   Caeso Fabius, who was three times consul, was thus extracted.
   Julius  Caesar is also stated to  have been  brought into  the world by
means  of this operation, although it  is an error to  state that the  name
Caesar was given to him on this account, inasmuch as he inherited it from
his father.
   Among the ancients,  persons thus born were considered  sacred  to
Apollo, to which Virgil alludes in  the lines—
               " TJnde Lycham ferit exsectum jam matre peremta
                Et tibi, Phoebe, sacrum."—^3neid, x. 315.

   Thus ^Esculapius was called the son of Apollo, because (it is said) he
was brought into the world by hysterotomy.
   For  this reason also, those  things  in  Rome which were  sacred  to
 Apollo, were preserved by the family of the Caesars.
                                                          (358) 
             THE  C2ESAREAN  SECTION, OR  HYSTEROTOMY.         bi)d

   Some modern historians have included Edward VI. King of England,
among  those who benefited  by this  operation, and this statement is
repeated in some  works on midwifery.  I have taken  some trouble in
tracing  this story, and I find no reason  to believe it to be true.   Sir John-
Hay ward, in  his " Life and Reign of Edward VI.," was  the first to put it
upon record.  He says, "All reports do constantly run  that he was  not
by natural  passage delivered into the world, but that his mother's body
was opened for his birth, and  that she died of the incision the fourth day
following."
   That the latter statement is inaccurate, is proved by an examination of
a MS. of the  ceremonies of her funeral.  Queen Jane Seymour died Oct.
24, 1537, twelve days after King Edward's birth.  With regard to  the
mode of the  king's entrance  into  life, I shall quote the words of  the
compiler of these memoirs.  In the  notes he observes, that Sir John Hay-
ward was  the first to record the fact,  " for none of our historians  that
wrote before Hay ward, give any countenance to this, but  only mention
her departure soon  after,  except  it be Sanders,  (whose  pen  was  not
directed so much by truth as malice,)  who frames a story, that when  the
Queen was in extreme labour, they asked the King whom he would have
spared—the Queen or his son ?  He answered his son, because he could
easily find  out other wives.  But yet even he has not a word of cutting
the young  infant out of his mother's  belly."  This story is manifestly
fabulous, inasmuch as  the  fact of the  infant being a son could not  be
known  before its birth, and otherwise  the point intended by it would be
without force, because he had already a daughter.  The commentator adds,
" that Dr. Burnet (now bishop of Salisbury) mentions original letters in
the  Cotton Library, that  show how  the  Queen was  well delivered.
These letters  are  exemplified  in Fuller's Church History, the one from
the Queen  herself  and the other from her physicians, both written to  the
Privy Council."
   This  evidence, I conclude,  sets the question  at rest, and I ought per-
haps to  apologise to my readers for occupying so much time with it; but
it appeared to me to be as well to ascertain the truth about it.
   There is also a tradition that Robert II. King  of Scotland, was born by
the Caesarean section, an accident having happened to his mother.
   To return to the regular history of the operation.
   Rousset, about 1581, published a treatise on  the Caesarean section, in
which  he  quotes  ten  successful cases.   On  one  of  the patients  the
operation was performed six times ;  she became pregnant a seventh time,
and  no one being  willing  to operate, she died  undelivered.  His essay
was  translated into Latin by Bauhin, 1661, and may be found in Stach's
Collection.
   To this work of Rousset's,  Bauhin  added an appendix  of cases;  he
states that he saw the operation performed seven times.
   There is no doubt that  in many of  these cases the operation was  un-
necessary ;  but I do not see ground for Mauriceau's  assertion that " that
which Rousset reports of the Caesarean section, is nothing but the ravings.
capriciousness, and imposture of their authors."
  There is no mention of the operation  in Raynalde's work  on thf
" Byrth  of Mankynde" (1634),  nor in the " Childbearer's Cabinet," so that 
360                   THE CESAREAN  SECTION,
we are indebted to the French and Germans for our earliest  information
on the subject.
   Ambrose Pare, whose  work  was translated  in 1634, (having  been
written in 1570,) was opposed to the performance of the operation on the
living woman, on account of the danger of hemorrhage, but recommends
it. for the purpose of saving the child when the mother has died suddenly.
   In the translation of Guillemeau's work, 1635, there is a chapter on the
Caesarean section, which is  recommended immediately after the death of
the woman, "that thereby the child maybe saved, and receive baptism."
" In some women," the author observes, " I have made this practice very
fortunately, and among the rest, in Mad. le Mabre, M.  Phillippes my
uncle being joined with  me;  and likewise  in Mad. Pasquier, presently
after she was dead, Mons. Paraeus  and the Curate of  St.  Andrew being
present."  As  to  performing  it on living women in difficult  labours, he
says, " Which for my owne part I will  not counsell any one to do, having
twice made tryall  of it myselfe, in the presence  of Mons. Paraeus, and
likewise seene it done by MM. Viart, Brunett, and Charbonnet, all excel-
lent chirurgions, and men of great experience and practice, who omitted
nothing,  to do  it artificially and  methodically.   Nevertheless,  of five
women in whom this hath been practised, not one hath escaped.  I know
that it may be alledged that there be some that have been saved thereby;
but though it should happen  so, yet  ought we rather to admire it, than
either practice or imitate it."....." After Mons. Paraeus had
caused us to make trial of it, and seene that the success was very lament-
able and unfortunate, he left and disallowed this kind of practice, together
with the whole  college of chirurgions of Paris."
  In Chamberlen's translation of Mauriceau (1672),  we find a strong
protest against  performing  the  operation on  living women, and great
doubts expressed as  to its  having  ever been successful.   He admits  its
utility when the mother is dead.
  Dionis, whose work was translated in 1719, has a chapter on the Caesa-
rean section wThich he recommends when the woman is dead, but depre-
cates it during her life.  He describes the operation minutely.
   Sir F.  Ould,  1742, is the first British author I possess who  notices the
operation, which he says may  be performed " either while the mother is
living, or after her death, according to  the nature  of the circumstances."
Nevertheless, he observes that the " Caesarean operation is most certainly
mortal, as we shall endeavour to prove presently from reason and the na-
ture of the thing;  and I hope it  will never be in the power of any one to
prove it by experience."
  La Motte's work was  translated in  1746.  He neither discredits the
oases related by previous authors, nor  doubts the possibility of success;
but he observes, " the os sacrum, ischium,  and  pubis, being  from their
first conformation so close to one another, that the surgeon can hardly in-
troduce a few fingers between them, it  being consequently impossible for
the child to come through, is the only  case where this operation is to be
put in practice."
  Burton,  in 1751, entered into a  more minute  detail than any of hia
predecessors, and gives references to cases.   He concludes that " seeing,
therefore, both reason and repeated experience confirm the possibility  of 
OR HYSTEROTOMY.
361
success in this operation, nothing should deter a skilful operator from per-
forming it when it is absolutely necessary."*
   Smellie, 1751, takes,  as. usual, a sound common sense view of this
matter: " When a woman," he observes, " cannot be delivered by any
of the methods  hitherto  prescribed and recommended  in laborious and
preternatural labours, on account of the narrowness or distortion of the
pelvis, into which it is sometimes impossible to  introduce the hand; or
from  large excrescences and glandular swellings, that fill  up the vagina
and cannot  be removed ; or from large cicatrices in that, part and at the
os uteri, which cannot be separated ;  in such emergencies, if the woman
is strong and of a good habit of body, the Caesarean operation is certainly
advisable, and ought to be performed; because the mother and child have
no other chance to be saved, and it is better to have recourse to an opera-
tion which hath sometimes succeeded, than leave them both to  inevitable
death."f
   The  operation  is described by almost all authors, both English and
Continental, but with  considerable  difference of opinion both  as to its
usefulness, and the cases to which it is applicable.  I shall not, however,
occupy the reader with further detail, but  again  refer him to my Re-
searches on  Operative Midwifery for those minute particulars which would
be misplaced here.
   560. After this short sketch, we may proceed to consider the operation
itself, its object, and the means for attaining it.
   The objects of this very formidable operation are of extreme importance.
   1.  To afford a chance of escape  to the mother, and of life  to her off-
spring, in cases where the child cannot be extracted through the natural
passages by any means at our command.
   2.  To extract the  child so  promptly, as to afford it a chance of life,
when the death of the mother has taken place suddenly.
   3.  To relieve the mother from the risk of fatal inflammation, owing to
the presence of the fcetus  in  the abdominal cavity, acting as a foreign
body.
   561.  The nature of the operation by which these objects are to be ef-
fected, is  simple, viz., that of cutting through the abdominal and uterine
parietes, so as to come at the child, and then removing the entire contents
of the uterus, and closing  the  external incision by sutures  and sticking
plaster.
   But though so simple, it is  most dangerous.  Wounds of the perito-
neum of the simplest kind, though not necessarily and  invariably fatal,
are very frequently so.  In most cases, inflammation of the serous mem-
brane has followed, and  in very many it has terminated in death.  There
is another source of danger.   If the  wound in the uterus  should not be
completely closed by its  contraction, hemorrhage to a fatal amount, from
the uterine sinuses, may occur, though it  is not so frequent as was sup-
posed by the earlier writers.
  This appears to have been the cause of death in the  cases  related by
Dr. Cooper  and Mr. Thompson.
  The formidable nature of the operation, however, only makes  it tho
more  necessary to ascertain clearly the grounds upon which it is justifiable
                   * A new System of Midwifery, p. 272.
                   f Midwifery, vol. i. p. 239, 6th Ed.
                                 2F 
362
ME CESAREAN SECTION,
It is sufficiently evident, from what has been already stated, that the older
practitioners performed it unnecessarily; this is proved, I say, by the fact
that the same woman bore children afterwards without assistance.  Now
it is an established axiom in midwifery, that the mother's life is not to be
compromised in order to save the child.  A certain amount of risk may
be fairly incurred, but beyond this, the safety of the mother is  to be pre-
ferred, and if  necessary, the child sacrificed.   In no  cases where the
mother's security can be so purchased, can we be justified in having re-
course to the Caesarean section; but there are cases on record, where the
pelvic outlets are so narrowed by distortion, that a mutilated child could
not be dragged through.
  In  Mr. Thompson's case, the  antero-posterior  diameter  of the upper
outlet, was only £fhs of an  inch.   In Dr. Cooper's second case, it was
1|-, and the transverse diameter of the lower outlet, only £ an inch.   In
Dr. Young's case, the antero-posterior diameter of the upper outlet, was
If inches.   In a skeleton in Dr. Hamilton's possession,  it was only fths
of an inch.
  In  one of Dr. Hull's  cases (Ann Lee), the conjugate  diameter, taken
from the symphysis pubis to the projection of the sacrum, was If inches,
and from the acetabula to the projection  of the sacrum,  1 9-l6ths inches
on each side.   In the other case (Isabel Redman), the passage was  nar-
rower, though the deformity was different.
  " Out of 80 cases, the operation was  necessitated by narrowness of the
antero-posterior diameter of the pelvis in 62.
                  Thus it was      1  inch in  1 case.
                                 1£  "  in  8 cases.
                            1} to 2   "  in 23  "
                            2 to 2£  "  in 25  "
                            2£to2§  "  in  5  "*

  It is quite plain that a fcetus ever so  much  mutilated, could not pass
through some of these pelves, nor through any without great efforts.
  Dr. Osborn, who was extremely cautious, and  had a  great horror of
this operation, has fixed l£ inch antero-posterior diameter, by 3 transverse,
as the smallest space through which a child, after evacuation of the con-
tents of the cavities, and the breaking up of the  cranium, could be ex-
tracted by the crotchet; but others have deemed  this impossible.  Cer-
tainly great risk of injury to the soft parts of the mother, would be incurred
by the force necessary to drag  the fcetus through so small a space,  not
quite, perhaps, but nearly equal to that resulting from the Caesarean ope-
ration.
  We may,  therefore,  safely conclude  that when  from any  cause  the
antero-posterior diameter of the upper outlet, or the transverse  diameter
of the lower, is not more than 1^ inches, there is no possibility of delivery
" per vias naturales," but that we must have  recourse to the  Caesarean
section.
  562.  Statistics. — But it may fairly be  asked, what  chance does  so
serious an  operation afford to either  mother or child ?   The  only mode
of answering this question, is by adducing the evidence on record.   The
following tables contain a list of  British and American  operations,  suc-
cessful and unsuccessful.
* Velpeau, Traite" des Accouch. p. 457. 
I. SUCCESSFUL CASES.
No.	Date.
1	1739
2	1793
3	1822
4	1827
5	
6	1833
7	1835
8	1838
9	
10	
11	,
12	1845
13	1847
14	1849
Operator, or Authority.
Mary Dunally, Midwife,  .   .  .
Mr. Barlow.......
Mr. Cellen, New York .  .   .  .
Dr. Richmond, Ohio, Amer.  .  .
Mr. Knowles, Manchester,   .  .
Mr. Greaves, Rockingham   .  .
Mr. Gibson,  Philadelphia, Amer.
  Ditto.....
Dr. Fox   ....
  Ditto......
Dr. Wright   .   .   .
Mr. Goodman.   .   .
Dr. Henderson, U. S.
Dr. Radford  .   .   .
Patient's name.
Alice O'Neal
Jane Foster
Mrs. Sankey

Mrs. Haigh
 Hours
  in
Labour.
12 days
 5 days
5 days

3 days
Cause.
distortion
distortion
distortion
Results
  to
Mother.
rec.
rec.
rec.
rec.
rec.
rec.
rec.

rec.
rec.
rec.
rec.
rec.
rec.
rec.
Child.
dead
dead
saved
saved

saved
saved

saved

saved
saved
saved
putrid
saved
References.
Ed. Med. Essays, vol. v. pt. 1, p. 439.
Med. Rec. and Res. p.  154.
New York Journal, Mar. 1823.
Western Medical Journal, Nov. 1827.
Transactions of Prov. Assoc, vol. iv.
Lancet, 1833-4, p. 148.
American Jour, of Med. Science, May,
  1835.
Lancet, March 28, 1840.
Lancet, 1833-34, p. 148.
Ranking, vol. vii. p. 239.
Ranking, vol. v. p. 293.
Prov. Med. and Surg. Journ. Aug. 22,
   1849.
II. UNSUCCESSFUL CASES.
				Hours		Results	Results	
No.	Date.	Operator, or Authority.	Patient's name.	in Labour.	Cause.	to Mother.	to Child.	References.
1	1737		.Paterson .	7 days	#	died	dead	Smellie's Midwifery, vol. iii. p. 423.
2 3 4	1740			•	• •	died died died	alive alive dead	MSS. Lectures. Ditto. Hull's first letter.
								
								
5					. .	died	dead	Ditto.
6	1769		Mar. Rhodes	24 hours	. .	died .	alive	Medical Obs. and Enq. vol. iv. p. 261.
7	1774		Eliz. Foster	2 days	moll, ossium	died	alive	Ibid. vol. v. p. 218.
8	1774		Eliz. Clarke	12 days	. .	died	alive	Hamilton's Outlines, p. 339.
9	1775			•	•	died	dead	Hull. [Table continued on next page.]
 
II. UNSUCCESSFUL CASES—CONTINUED.
No.	Date.
10	1777
11	
12	1794
13	1798
14	1795
15	1798
16	1799
17	1800
18	.
19	, .
20	, .
21	
22	1817
23	1821
24	
25	1820
26	1821
27	
28	1826
29	1829
30	
31	1834
32	1843
33	
34	
35	
36	1845
37	1847
38	1849
Operator, or Authority.
Mr. Atkinson, Leicester  .
Mr. Clarke, Wellingborough
Dr. Hull, Manchester  .  .
  Ditto.......
Dr. Hamilton, jun., Edinburgh
Mr. Kay, Forfar ....
Mr. Wood, Manchester.  .
Mr. John Bell, Edinburgh
Mr. Dunlop, Rochdale .  .
Mr. Wood......
Dr. Kellie, Leith ....
Mr. Kinder Wood  .  .  .
Barlow and Cort....
Barlow and Dugdale   .  .
Dr. Henderson, Perth .  .
Dr. Radford,  Manchester .
  Ditto......
Drs. Douglass and Vanvalsah
Mr. Crichton.....
Dr. M'Kibbin, Belfast ..  .
Mr. Ward......
Dr. Montgomery, Dublin .
Dr. Elliott, Waterford .  .
Mr. Whitehead, Manchester
Mr. Braid......
Messrs. Bailey and Hardy
Mr. Lyon, Glasgow .  .  .
Mr. Skey, London .  .  .
Mr. Campbell, Lisburn.  .
Patient's name.
El. Hutchinson

Isabel Redman
Ann Lee
Jean Douglass
El. Thompson

Susan Holt .
H. Rheubotham
Ann Hacking
Mrs. Ridged ale
Mrs. Lowe  .
Mary Ashwell
Mary Nixon
 8 days
 3 days
12 hours
10 days
2 days
3 days
24 hours
18 hours
34 hours
19 hours

 6 days
Cause.
moll, ossium

moll, ossium

malacosteon
malacosteon
 distortion
distortion
distortion
distortion
distortion
distortion
exostosis
fibrous tum'r
 distortion
 tumour
distortion
distortion
DO
Oi
4~
Results
  to
 Child.

 alive
 dead
 saved
 dead
 alive
 alive
 saved
 saved
 alive
 dead
 dead
 dead
 alive
 alive
 alive
 dead
 dead
 dead
 saved
 dead
 dead
 dead
 dead
 alive
 dead
 dead
 saved
 dead
 saved
References.
Hull, p. 67.
Mem. Med. Soc. vol. v
First Letter, p. 162.
   Ditto.     p. 172.
Outlines.
Hull's letter.
Mem. Med. Soc. vol. v.
Med. Chir. Trans, vol. iv. p. 347.
Hull's Baudeloc. p.  134.
Med. and Phys. Jour. vol. vi. p. 346.
Ed. Jour. vol.  viii. p. 11.
Med. Chir. Trans, vol. vii. p. 264.
Barlow's Essays.
Merriman, p. 317.
Ibid.
Ed. Journal, No. 146.
   Ditto.
Amer. Med. Jour.
Ed. Jour. July, 1828, p. 53.
Ed. Jour. Nov. 1831, p. 352.
Lancet, March 28,1840.
Dub. Jour. vol. vi. p. 418.
Letter to the Author.
Ranking, vol. vii. p. 330.
 Ditto.
 Ditto.
Ed. Mon. Jour. Dec. 1845.
Ranking, vol. v. p. 293.
   "    vol. x. p. 330. 
OR  HYSTEROTOMY.
365
  Thus in British and American practice, out  of 52 cases, 14  mothers
were saved and 38 lost, or nearly three-fourths.
  Out of 49 cases where the result to the child is mentioned,  28 were
saved and 21 lost, or 1 in 2^.
  In addition,  I have collected from foreign authorities 371 cases, out of
which 217 mothers recovered and 154 died, or about 1 in 2£.*
  Out of 189 of these cases where the result to the child is given, 139
were saved and 50 lost, or nearly one-fourth.  Taking the entire  number,
which  amounts to 423, we  find that  231 mothers  were saved  and 192
lost, or about 1 in 2£;  and that out of 238 children, 167 were  saved and
71 lost, or about  1 in 3^.
  The  reader  will probably be  as much surprised as I was myself at
the number  of operations  here  recorded.   They  exceed any  hitherto
collected, except those  published by M. Figueira (i.  e. 790 cases, of
which 424 were  fatal).   To  guard  against mistake,  I have  carefully
quoted my authorities in the work  referred to, and where these are but
secondary, I have consulted the originals, as far as I could obtain  access
to them.
  As to the value of each case, that must depend upon the reporter.  I
have not  felt it my duty to exclude any which  are  related upon definite
authority—my  endeavour throughout has been to ascertain that authority
as far as  possible, and to avoid repetitions.   For so much I am respon-
sible, and I trust I shall be found correct.
   It  may, however, be objected to  this catalogue  of operations, that
many of the cases occurred in the " dark ages" of midwifery, and may,
perhaps, have  been exaggerated, or invented.   I do not know that we
can fairly deny their authenticity; but suppose  that we admit  this, and
only take those which have  occurred  since 1750, the result will still be
more favourable  than we should have anticipated — for this calculation
gives 321 operations, from which 149 mothers  recovered, and by which
130 children were saved, and 57 lost, in 182 cases where  the  result is
mentioned.
   563. Further: on a good number of these patients  the operation has
been performed more than once; on some, three and four times.  And
if we credit the  older writers (and I do  not know why we should not),
we find five, six, and seven times with success.
   This is shown in the following table:
  * I do not mean that so many mothers were saved from death by the operation, but
that they were saved from the effects of the operation.  No doubt, many were really
saved from death, which could not have been otherwise avoided ; but we have proof that
many could have been  delivered by other means, inasmuch as they afterwards bore
children naturally.
  In 11 cases recorded in Foreign Journals since my tables were constructed, I find that
6 mothers were saved and 5 lost; 8 children were saved and 3 lost.
2f2 
866
THE CESAREAN SECTION,
No.
 1775-9
 1797 I
 1801 [
 1805 J

 1796 '
 1810
 1802
 1805
 1805
 7-11
 1817 (
 1819 S
 1821 I
 1826 i
 1823
I 1823 I
) 1825 \
Operator, or
 Authority.
— Guillet  .
LeNoirandLe-
  brun  .  .
M. Jobert  .
M. Peyronnie
M. Sommius
A Surgeon at
  Paris  .  .
Count Nessan
M. Lambron

Mangold  and
  Burckhardt

M. Bacqua .
Rhode   and
  Somner

Lorinzer .  .

M. le Maistre,
  d'Aix  .  .

M. Locher .
M. Merrem .

M. Bosch

M. Schenck .

M. Dariste .

M. Michaelis
M. Gardey .

Dr. Schmidt.
Dr. Engeltrum
Patient, or
  Place.
his own wife

his own wife
at Aucois
L. Mautz

— Gabery.



— Groger .

— Fauve  .
— Viandes
Martinique

— Adawetz
Amsterdam
Number
of Ope-
rations.
6 times

3 times

twice
twice
7 times

5 times

3 times
6 times
7 times
twice

3 times

twice

twice

twice

3 times

twice

twice

twice

twice

twice

4 times

twice

twice

twice <
 No. of
Children
 saved.
Result to
Mothers.
saved.

recovered.

   do.
   do.
   do.

   do.

   do.
   do.
   do.
   do.
recovered twice—
died after third.

recovered.

   do.

   do.

   do.

recovered once—
died second time.

recovered.

   do.

   do.

   do.

   do.

   do.
recovered once—
died second time.
recovered once—
died second time.
   564. After a careful examination of the cases  on record, I think we
may fairly conclude, that  as  so many women  have recovered from the
operation, it does afford a chance to both mother and child, and that there-
fore we may be justified in having recourse to it; but that, as  the  danger
is much greater than from  any other operation, we should not be warranted
in performing it,  if there were a prospect of success by other means.
   This, then, constitutes the sole advantage of the operation, that in cases
where  we cannot deliver the patient by any other means, and when, conse-
quently, both mother  and  child would inevitably die, if left unaided, we
may afford each a chance by performing the Casarean section.
   It has no comparative advantages, being itself the ultimate standard by
which the other operations  are  to be estimated, and which are valuable,
inasmuch as they afford a means of escape  from this more formidable one.
In this point of view I must not  omit noticing  one, which although not
available  in any case  to which we are  called  at the time of labour, may 
OR  HYSTEROTOMY.                      367
prevent the necessity of a second  operation.  I allude to the artificial
induction of premature labour, or of abortion.   Whenever the diameters
of the pelvis are so reduced  as  to  render the extraction of a mutilated
fcetus impossible, or even hazardous, I conceive that it would be grievous
neglect of duty (if we have a voice in  the  matter) not to propose this
alternative.   It is true that  by tfiis operation the child will be lost, but
the mother will in all probability be saved ; and the bare chance of saving
the child by Caesarean section, can never compensate for the additional
risk to the mother.
   565. The disadvantages of the operation will be easily gathered from
what has been said; they are mainly, the great risk of hemorrhage or of
fatal peritonitis to the mother, and the small chance afforded to the child;
these constitute the objections to the operation.
   That these  are very serious objections cannot be denied, nor that they
would be insurmountable, had we any other mode of delivery.  But when
we consider that  the  only choice is between this operation, which does
afford some chance, and certain death to both mother and  child,  we
cannot, I think, hesitate about running the risk.
   Doubtless,  however,  the  dangers of the operation  should make us
pause, and  carefully examine the facts  of the case,.with the aid of the
experience  of others,  before we decide upon this proceeding.   In the
present day it would be an indelible disgrace to an  accoucheur, that his
patient, after recovering from the Caesarean operation, should bear children
without assistance.
   566. The cases suitable for the operation are not very numerous.
   1.  When the pelvis is so  distorted  from  any cause, that the diameter
of the  upper or lower outlet  is  reduced to an inch and  a  half or
two  inches, it  may  be considered impossible  to extract a mutilated
fcetus ; or, if  possible,  it must  be  with so much force  as to entail the
death of the mother.
   The operation is equally necessary under these circumstances, whether
the child be alive or dead,  and  it may also  be required (in consequence
of mollities ossium) after several children have been born naturally.
   2.  Morbid growths from the periosteum, which offer a  fixed and per-
manent obstacle, may so much  reduce  the  calibre of the passage as to
render this  operation necessary. This was the case with the patient of
my friend Dr. Montgomery.
   But before  we  decide upon  the necessity for this mode  of delivery,
we must be quite sure  that the obstacle can  neither be  displaced nor
reduced in volume; and  this  can  seldom be  determined until  labour
commences.
   3.  In  some cases of ruptured uterus, when delivery is imperative, but
impossible "per vias naturales," Caesarean section has been recommended.
It appears  to  me that the additional risk from the operation, renders its
propriety very questionable.
   4.  The operation  has been performed successfully in cases of extra-
uterine fcetation, where the continued presence of the fcetus  in  the abdo-
minal cavity threatened the mother's life.
   5.  In  case  of the sudden death of the mother, Caesarean section may
be performed for the purpose of saving the infant   Many successful cases
are on record.
         24 
368
THE  CESAREAN  SECTION,
  6. If, towards the end of pregnancy,  the  uterus be wounded  exten-
sively, Dr. Hull conceives the Caesarean section necessary.
  Of course the operation will be useless, unless the woman have arrived
at that period of pregnancy when the child is " viable."
  It will also be in vain if much time have elapsed after the death of the
mother.'   Dr. Jackson, however, recovered an  infant  half an hour  after
the  death  of the mother.
  7. Authors  have mentioned  other cases to which  the  operation was
applicable, as in occlusion of the vagina, scirrhus  uteri, &c.
  But these do not appear to  me  adequate  grounds for so serious an
operation.
  567. The best period for the performance of the operation appears to
be at the  commencement of labour, provided there be no doubt of its
necessity.   The strength  of the woman is then unimpaired, and she can
not only support the operation better, but has greater prospect of escaping
subsequent inflammation.
  It is supposed, and I thinlc not without  foundation,  that the ill success
which  has attended  the  operation in this country, is owing  to  the late
period at which it has been undertaken.
  In Mr.  Thompson's case,  it  was performed  24 hours after the com-
mencement of  labour;  in Dr.  Cooper's,  12 hours;  in Mr.  Chambers'
case the  labour had lasted  12  days; in  Dr.  Hamilton's, more than 2
days; in Mr.  King's,  more  than 3  days; in Mr. Atkinson's,  nearly 3
days; in  one  of  Dr. Hull's (Isabel Redman), 12 hours; in the  other
(Ann Lee), 10 days;  in the case  of Mary  Dunally, 12 days; in Mr.
Barlow's case, 5 days.
  Dr. Hull proposes to operate as  soon  as the os uteri is dilated, and
before the membranes burst.
  De Graafe advises the  operation to be performed just  after the rupture
of the membranes, and the commencement of the expulsive pains.
  568. Method of Operating.—Having determined  upon the necessity,
and the proper period for the operation, the next subject for consideration
is the best mode of performing  it.   Very little alteration has taken place
in this respect since the earlier writers.
  The bowels and bladder are to be evacuated, and the patient placed on
her back, upon  a table covered by a mattress.   Her fortitude must decide
upon the necessity for restraint,  and its amount.
  Before  commencing the operation it  will be proper  to ascertain  (by
the  stethoscope) the situation of the placenta, or, at least, that it is not in
front.
  The incision through the integuments  must then be  made, either verti-
cally, through the linea  alba-—obliquely, on the outside of the rectus
muscle—between  that muscle  and the  spine—or horizontally, beneath
the  umbilicus.  The latter is the best, if the patient be  deformed. It
should be about eight or ten inches in length, and when vertical, it may
be commenced a little above  the umbilicus and  terminate near the pubes.
  This incision should divide the parietes of the abdomen down to the
peritoneum, which is then to be cautiously punctured, and a director, or
the  finger, inserted into the wound, so as to avoid injuring the intestines,
sjnd the peritoneum divided.
  The uterus will  now be exposed, and an  incision must be made into, 
OR HYSTEROTOMY.
369
but not through its parietes, of the same length as that through the abdo-
minal parietes.  This  incision  must be  cautiously deepened,  until the
membranes  are exposed.  A slight opening must then be made in them,
and some of the  liquor amnii removed, by small pieces of sponge.  It
has occurred to me that this might most readily be effected by a syringe.
The object in view is to prevent effusion  into the  abdominal cavity.   By
Lauverjat and others we are recommended to rupture the membranes pre-
viously.   The opening is then  to be enlarged, and the infant withdrawn,
the funis tied, and the  placenta and membranes removed.
   The remaining liquor amnii,  with  any blood which may have escaped,
must be removed from the cavity of the uterus, and the operator should
make sure that the os uteri is pervious for the escape of  the lochia.
   No sutures are required in the uterus ; as it contracts, the wound will
be reduced  to about l£ to 2 inches in length, and the lips will come into
apposition, if it be healthy.   It is only in cases where they do not do so,
that there is anything to fear from hemorrhage.   When  the uterus is dis-
eased, the wound does not close perfectly, and of course, union  cannot
take place.
   The  abdominal cavity is next to be  lightly sponged, to remove any
blood which may have escaped, and then, the intestines being retained
" in situ" by an assistant, the lips of the external wound are to be closed
by so many sutures as  may be necessary.
   Dr. Munro, of Edinburgh, advised " that in performing the Caesarean
operation, we should be careful that the viscera be exposed as little as
possible; and that the sides of the wound should be kept contiguous by
a greater number of stitches than are commonly employed in wounds, in
order to exclude the air from the cavity of the abdomen.
   In addition to the sutures, straps of  adhesive  plaster may be applied.
and over all I would suggest Dr. Macartney's water-dressing.
   The patient must then be placed in bed, and the utmost quiet observed.
Cordials will probably be necessary during and  after the operation ;. and
when the patient is settled in  bed, an opiate may be given.
   As a variation from this mode of operating, I may mention Dr. Aitken's
suggestions  of performing it " while the parts are immersed in tepid water,
so as to exclude the air," and so, perhaps diminish its fatal effects.   I  do
not know that this plan has ever been tried.
   569.  The difficulties of the operation are not great.  With a little  care,
we may avoid  that part of the  uterus to which the placenta is  attached,
and which is the most vascular,  as  the  stethoscope, previously applied^
will indicate whether it is  situated anteriorly or  not.    Caution will also
avoid wounding the  child when dividing the uterus.
   In  approximating the lips of the external wound, the  intestines are
sometimes troublesome, and it is of importance not to include any, as that
would add the dangers of strangulated  hernia to the unavoidable risk of
the operation.
   The principal dangers of the operation are —
   1. Hemorrhage, from the  incomplete  closure of the wound  in the
uterus.
   2. Strangulation of a loop of the intestines, either in the wound of the
uterus, or in the external wound ; although due  attention will  avoid this
danger  altogether. 
370
SYMPHYSEOTOMY.
  3. Subsequent inflammation of the uterus and peritoneum.
  The patient may die of the shock within a few hours, or her strength
may be exhausted  by hemorrhage into the abdominal  cavity; but if she
survive for a day or two, her death will then probably be owing to inflam-
mation.
  570. Subsequent Treatment. — The most incessant  care and attention
will be required.  The water-dressing should be continued, and it may
be as well to administer small doses of calomel and opium.
  On the first  appearance of inflammation at  the  edges of the wound,
leeches should be applied along it, and if there be tenderness, a consider
able number should be applied over the abdomen, and repeated if neces
sary, and the doses of calomel and opium increased.
                         CHAPTER  XV.

          OBSTETRIC OPERATIONS. 7. SYMPHYSEOTOMY.

  571. But one more operation remains for consideration, and I should
have omitted it altogether, had I not felt  it as as much a duty to point out
its inapplicability, as the suitability of the others to the cases for which
they were intended.   I do not for a moment wish to undervalue the hu-
manity which desired to substitute a minor operation for one so formidable
as the Caesarean section.   But when the  results of experience support the
opinion of the wisest  and best midwifery authors, it would  be  criminal
neglect did I not adduce the objections to this operation in their strongest
form.
  First, however, it may be interesting to give a sketch of its history.
  M. Sigault, while yet a student, being impressed with the fatal  results
of the Caesarean section, conceived that it might be altogether avoided
by an artificial separation of the ossa pubis.  This notion was based upon
the assumed  fact,  that  this joint spontaneously  separates in difficult
labours.   This has been asserted over and over again by the older writers,
and upon this assumption Sigault based his experiments upon the dead
body.
  In the year 1768, he presented a memoir to  the Faculty de Me'decine
on the subject, proposing that the operation should be tried at first upon
animals, and then upon condemned criminals.   The memoir was referred
to M. Ruffel, who reported unfavourably, and the subject was dropped.
  However, M. Sigault was not discouraged: he again proposed it in his
Thesis, on taking his  degree at Angers, and in Paris, on seeking  for his
license:  and as the proposal was communicated to others, and favourably
received, it excited a  good deal of interest.
  In M.  Alphonse Le Roi, Sigault met with  an able second,  and  they
determined  to  give the operation a fair trial the first opportunity.   This
occurred on the 1st of October,  1777, in the case of-----Souchel, who
bad previously been delivered by craniotomy.   She was  safely delivered 
SYMPHYSEOTOMY.
371
by the new operation, and a report was immediately made to the Faculty
de Medecine, who were requested to appoint.a commission to superintend
the patient's recovery.
  MM. Grandclas and Descemet were appointed to this office, and not-
withstanding that the bladder was injured, and the mother barely escaped
with life, such was the enthusiasm excited in the Faculte de Medecine by
their report,  that they lost  sight of the  calm investigation becoming a
learned body, and on the strength of one  case — and that not a very satis-
factory one — voted medals to MM.  Sigault and Le Roi, and procured a
pension for the former and for his patient.
   The inscription upon the  medal was:
                     1768. Sectionem Symphyseos Ossium
                        Pubis. Invenit. Proposuit.
                               A. 1777.
                             Fecit feliciter
                           M. Sigault, D.M.P.
                     Juvat M. Alphonsus Le Roi, D.M.P.

   Persons were not  wanting to applaud the inventor  and his operation,
which was characterised as  " the result of inspiration," and several prac-
titioners in France and Germany followed his example.
   M. Sigault himself operated on four other women, one of whom died,
and several  of the  children.   He seems, indeed, to  have become less
oonfident in  its safety and  efficacy;  for  he  refused to perform it unless
there was a  space  of 2^ inches in  the  short diameter;  and before  his
 death, in such a case, he recommended the  Caesarean section.
   " It was soon found, however, not to merit the high encomiums  be-
 stowed upon it.  Every operation was found to have its victim, although
 it was several times performed upon women, whose pelves were  either
not at all, or very slightly deformed,  and who,  either  before or  after  the
operation, were delivered without any extraordinary assistance — a con-
vincing proof  that the operation had been, in these cases at least, unne-
cessarily resorted to." *
   In 1778, he published a  " Discours sur les advantages de la  Section
du Symphyse du Pubis," in which he examines the usual means of as-
sisting difficult labours, and  concludes by stating his reasons for preferring
Symphyseotomy to the Caesarean section.
   The first persons, I believe, who investigated the propriety and efficacy
of the new operation  in this  country, were Dr. W. Hunter, Mr. Hunter
 and Dr. Denman.   The former published the result of his inquiries in the
 London Med. Obs. and Enquiries.
   " The women of Great Britain," says Dr. Osborn, l< are therefore under
considerable obligations to the late Dr. Wm. Hunter, who, from an accu-
rate mensuration  of those  pelves where  the  Caesarean operation had
actually been performed  in this  country,  and of others still  smaller, pre-
served in  his museum, has demonstrated the futility of the section of  the
symphysis as  a succedaneum for that operation, or as a certain means of
preserving both the mother and child."
   He suggested a  combination of the Sigaultian operation with cram
otomy, as affording the mother a better chance than the Caesarean section.
But, as Dr. Osborn  remarks, " Prof. Guerard's  case is exactly in pohu
* Hull's Second Letter, p. 94. 
372
SYMPHYSEOTOMY.
and confirms by experiment what was to be  expected H priori.   The
child's head in that case was opened, after the division of the symphysis
had been performed; but the professor was, notwithstanding, foiled  in
every attempt to deliver, both by the forceps  and the crotchet;  and the
event in the end proved fatal to the mother."*
  The next writer who notices  the  operation, is Dr. Leake, who, in his
work  on the Diseases of Women, 1781, has a few pages upon this ope-
ration, of which he  is inclined to judge favourably, though with  caution.
He answers some of the objections urged against it, but admits that more
experience was required.
  The operation was performed in the year 1782,  for the first  and last
time in this kingdom, by Mr. Welchman, of Kington, in Warwickshire.
The child was putrid, and the mother  died;  but Mr. Welchman thinks
that her death was not caused by the operation.f
  Dr. Osborn, in his " Essays on Midwifery,"  1783, gives a good histo-
rical sketch of the operation, and after a very careful examination into the
merits of  it, he arrives at the conclusion that " no circumstance whatever,
real or imaginary, can ever render it a warrantable operation."
  Mr. Dease, in his " Observations in Midwifery,"  1783, disapproves of
the operation.  He  says, it was " of worse consequence than the Caesa-
rean ;  as  it subjected the woman to all the dangers of the latter, without
the same  advantages of saving the child."
  Dr. Hamilton,  sen., in  his " Outlines of the Theory and Practice  of
Midwifery," 1784,  doubts the  efficacy of the operation, and points out
its hazard.
   Dr. Aitken, " Elements of Midwifery,"  1784, says that the operation
may be useful " when about half an inch of addition to the short diameter
(of the pelvis) is sufficient to allow delivery."
   Dr. Hull, in his  First Letter, 1790, points  out the inadequacy of the
operation ; and in his Second Letter, enters more fully into the history of
it, and shows that  the combination of symphyseotomy with craniotomy
(first  proposed by Dr. Hunter, and repeated by Mr. Simmons)  is  worse
than the Caesarean section.
   Dr. Denman, in his " Introduction  to Midwifery," objects to  the ope
ration, except, perhaps, in a case where the  life of the child (it being
alive) was of such immense importance to the nation, that the mother
might fairly run the risk.
   By every modern British writer the operation is  denounced, and is not
likely ever to be again attempted in this country.
   The contagion of enthusiasm spread rapidly among the French, though
some more cautious and philosophical writers held aloof, and others de-
cidedly disapproved of the new operation.
  . It  has  not, however, even in more  modern times, been  so completely
discouraged as we  might have expected from  the results of the  cases in
which it has been employed.
   The operation has  been performed in Italy.  It has also been  modified
by Prof.  Catolica,  after the suggestion of Desgranges and Champion.
Instead of dividing the symphysis, the ossa pubis were cut through, nearer
their junction with  the ossa ilia, and by this means a positive increase in
            * Essays in Midwifery, pp. 282, 323.
            f Lond. Med. Journal, 1790.  Hull's First Letter, p. 138. 
SYMPHYSEOTOMY.                       373
the antero-posterior  diameter  was gained.   M. Galbiati  performed this
operation in 1819, and it proved fatal.
   In  Germany, it was at first highly extolled;  but the general opinion
uterwards was unfavourable to its utility.  Indeed, it would be astonishing
>o find any candid  man who could  resist the evidence  afforded by the
cases in which it has been tried.
   572. Statistics.— 49  cases have been recorded ; of these 16 mothers
died, or about 1 in 3 out of 40 cases; the child was born  alive in 11, and
dead in 19, or 1 in 2.
   I shall not give these cases in detail, but a slight analysis may show more
fully the slight ground the advocates of the operation had for exultation.
   1.  It was performed unnecessarily in four cases, as was  proved by a
subsequent natural delivery.
   2.  Without any cause in one case,  the patient having borne children
naturally, and there  being no'deformity; and in another, where there was
sufficient space.
   3.  Without the possibility of benefit from it in one  case, where the
antero-posterior diameter was only If inch.                 *
   4.  Although 33 mothers recovered, 10 children were  lost, 14  saved,
and 1 much injured.  Of 7 nothing is stated.   Of the 16  mothers who
were lost, 5  of their children only  were saved;  9 were dead, 1 much
injured, and of 1  nothing is stated.   So that,
   5.  In the latter case, 16  mothers were sacrificed to save 5 children.
   6.  Again,  although 33 mothers recovered, yet to save 14  children they
paid very dearly — for  1 had the bladder and urethra  injured;  2 had
incontinence of urine; 3 had prolapsus uteri.    In 1, the  bones  of the
pelvis exfoliated, the^cervix uteri and  posterior part of the  bladder were
gangrenous; and several were endangered by the operation, whilst of  a
great number no details are given.
   We shall  now examine the  merits  of  the operation  a little more
minutely.
   573.  The object of the operation is to increase the short diameter of the
pelvis, by the enlargement  of the arch formed by the ossa ilia and pubis,
so as  to allow of the passage of the child in  cases where it must other-
wise have been extracted through an artificial opening; and by this means
afford a greater chance of life, both to  the mother and child.
   574. The  nature of the aid afforded is easily comprehended, though
the amount is altogether overrated by the early advocates  of the operation.
 The cartilage of the symphysis pubis  being divided, the pressure of the
head, or the  assistance of  the operator, may separate  the ossa pubis, at
 the expense of some of the sacro-iliac ligaments;  for the separation of
the ossa pubis will be exactly in proportion to the yielding of the sacro-iliac
synchondroses ; so that, if the latter were anchylosed, the operation would
 fail altogether.
   Again,  it must be remembered, that owing  to the  posterior situation
of the sacro-iliac synchondroses, the space gained will be  mainly in the
oblique diameter of the pelvis; next  to this in the transverse, and least of
all in the antero-posterior diameter.
   But it is from the last mentioned diameter being too short  that the diffi-
culty exists, and therefore upon the amount gained in it, depends the sue
 cessful issue of the  operation.
                               2g 
374                       SYMPHYSEOTOMY.
  The entire question turns upon  this point.   If by the separation of the
ossa pubis so much space be gained as will make up the difference between
the  sacro-pubic diameter in a deformed pelvis, and the same diameter in an
ordinary one, then t/ie  operation is, at least mechanically, adapted to the
object in view.
  Hence it is very important to ascertain as nearly as we can, how much
may thus be added to the antero-posterior diameter.   We know  from
Sigault's and Le Roi's case, that  the  ossa pubis may be separated four
inches:  how much will this increase the short diameter ?
  Dr. Bentley, in his dissertation, quotes  the experiments of Ripping of
Paris, and Lobstein of Strasburgh, in  support  of the conclusion that the
utmost gain by the operation is four lines  in the short diameter, and Dr.
Aitken says half an inch.  •
  I feel satisfied myself that half an inch  is the very utmost that can be
gained, except by such violence as would  be utterly unjustifiable.
  But then  Dr. Leake observes that the head will press into the opening,
and " it will therefore follow that as much of the occiput, or hind head,
as  is  intruded into an  aperture at the  pubis of two inches  and a half, so
much precisely will be the space  gained  by this operation, and super-
added to the short  axis of  the pelvis from  sacrum to pubis,  which will be
equal to the enlargement from side to side — the circumstance here con-
tended for."
  This is undoubtedly ingenious, but  not  quite correct, inasmuch as the
long  diameter of the head  at the upper outlet corresponds with one of the
oblique and  not with the sacro-pubic diameter;  so that the occiput would
correspond  pretty  nearly with the  acetabulum,  and the tuber  parietale
with  the interval between the ossa pubis.   In this situation, no  part of the
head  could  pass through  the  opening, unless the operator changed  its
position.  Further, Dr. Osborn  has justly remarked, that this pressing
into the opening would be  at the expense of so  much injury  to the bladder
and soft parts, as would render the operation unjustifiable.
  575.  The advantages of the  operation,  as  enumerated by its sup-
porters, are:
  1.  That it substitutes an operation of  less  danger for  the  Caesarean
section; but, this,  we have seen, is not true, for although 1 in 3 of the
mothers only are lost by it (rather less than by  the Caesarean section), yet
those who recover are liable to accidents which fully counterbalance this
slight advantage.
  2.  That it affords a better chance of saving  the child; but we have
seen  that only one-half of the children were saved, whilst by the Caesarean
section, more than two-thirds were preserved.
  3.  That it is  a  less painful  operation.  This  is true as regards the
period of operating;  but  if  the  period  of convalescence be included,
with  the sequelae which occasionally occur with each,  I should doubt the
fact.
  4.  " The  section of the pubes which  allows  the child to  be born by
the natural passage, carries not with it those ideas  of cruelty which the
Caesarean operation does,  where  the  patient is, as  it were, embowelled
alive." (Leake.)
  This is very plausible but very false humanity.
  576.  The objections against the  operation are to my mind  unanswer- 
SYMPHYSEOTOMY.
375
able, although some that have been put forward as such have been refuted
by experience.   It must be remembered that the operation is contemplated
for those cases in which the Caesarean section would otherwise be neces-
sary.
  1. For these cases the operation is inadequate.   In  a former chapter,
we have seen that the Caesarean operation  ought  not to be performed in
any case where the antero-posterior diameter is more than 2 inches, inas-
much as the delivery can  be accomplished by a less hazardous  method.
Now as  the  Sigaultian  operation adds but half an inch (at the  utmost),
this would increase the antero-posterior  diameter to 2^ inches.   But it
has been ascertained that a living child cannot pass through a pelvis whose
short diameter is less than 3 inches ; consequently, the Sigaultian section
cannot avail in these cases, unless craniotomy be  superadded.  But  the
mortality of the two would be greater than that of the Caesarean section,
for 1 in 3 of the mothers  would be lost, and all the children, by the com-
bined operations;  wThereas by the latter,  although 1 in 2\ of the mothers
are lost, more than two-thirds of the children are  saved.
  2. Even if the space gained would secure the  delivery, the mortality
of mothers and children would not justify its preference  to the Caesarean
section — especially if we take into account the sequelae.
  These objections appear to me quite conclusive against the operation;
but as others have been adduced, it may be as well to  enumerate them.
  3. The cartilage of the symphysis  may be ossified ; which  will render
the operation impracticable, even after it  has been commenced.
  4. Great injury  may be inflicted by the  knife on the  bladder or soft
parts within the pelvis.
   5. Equal injury may happen from the  violence used in separating  the
ossa pubis.
  6. The soft parts may be injured by pressure against the edges of  the
divided ossa pubis.
  7. The sacro-iliac synchondroses may be ruptured past remedy.
  8. The divided  cartilages may not unite.   Experience, however, has
shown the groundlessness of this objection.
  9. The admission of external air may excite inflammation.
  These latter objections have of course a certain weight, but hardly suf-
ficient to prohibit the operation, if it were adapted for the cases for which
it has been proposed.
  But there is another class of cases  for which it would seem at first sight
more  suitable, and which indeed appear to have  been contemplated, by
those who recommend its performance, where the antero-posterior  diametei
of the upper outlet is three inches.   I mean those cases, where  the diffi-
culty is too great for the forceps, and in which (as we have seen) crani-
otomy is necessary.  Here the gain of half an inch might enable a livino
child to pass.   But the operation is objectionable in these cases, because
of the results;  for, independent of the ill consequences to those who re
cover, we find that 1 in 3  of the mothers die, and only half of the  children
are saved ; whilst, although all the children are sacrificed by craniotomy,
only 1 in 5 of the  mothers die.
  And it must also be  borne in mind, that these  results of craniotomy
have occurred under more unfavourable circumstances  than  those of  the
Sigaultian operation. 
376
SYMPHYSEOTOMY.
  577. From these considerations, I trust that my readers will agree with
me in the following conclusions:
  1. That  the  Sigaultian operation  is undeserving of the encomiums
passed upon it, inasmuch as it offers no increased chance of safety to the
mother or child — the statistics of the cases in which it has been tried
having shown that 1 in 3 of the former, and one-half of the latter are lost;
besides that in those  of the mothers who recover, much inconvenience is
experienced from the sequelae of  the operation.
  2. That  it is perfectly inadmissible as a  substitute  for the Caesarean
section, because the utmost space gained by it would not permit the child
to be born  alive in any case in which  the Caesarean operation ought to be
contemplated; and if the child must  in addition be destroyed, the com-
bined mortality of the mothers and children would then be  far greater
than from the Caesarean operation.
  3. That  it is equally inadmissible as a substitute for  craniotomy alone,
in cases where the forceps  are inadequate, because the consequences to
the mother  are more serious from it than from craniotomy.
  578. If,  as I believe, these conclusions are correct, I need only add an
account of  the mode of performing the operation, not as  a model, but to
complete its history.   Perhaps the best mode of doing this,  is to give the
account of  one of M. Sigault's cases, abridged by Dr. Osborn.
  " Mons.  Sigault, with a common bistoury, cut through the integuments
and linea alba, beginning the operation at the upper and central part of
the symphysis pubis ; then introducing his fore-finger as a director, he cut
through the ligaments and cartilage; immediately on  the completion of
which, the  two ossa pubis, with a peculiar noise,  spontaneously separated
two inches  and a half:  this was demonstrable, for M. Le Roi laid his four
fingers into the opening.   M. Sigault immediately introduced his  hand
into the uterus, broke the membranes, and brought down the feet.  M.
Le Roi accomplished the delivery.  The whole operation, both section
and delivery, was finished in five minutes. The child was born alive.  A
ligature was passed round the body of the mother, to keep the  pelvis firm.
The patient having no bad  symptoms, was  left  till the next day, when
every circiynstance continued favourable ;  she had  passed  her urine vo-
luntarily  twice, there had been no hemorrhage, and she had suffered little
pain."
  Having entered  thus fully upon the operations proposed  for the relief
of the previous classes of unnatural labour, we may now resume the con-
sideration of the remaining deviations from natural  labour. 
CHAPTER XVI.
             PARTURITION.  CLASS II. UNNATURAL LABOUR.
    ORDER 5. MAL-POSITION AND MAL-PRESENTATION OF THE CHILD.

      579. We have already  investigated  those cases of unnatural labour
   which arise from defective uterine power, and  from an abnormal condi-
   tion of the passages.   The only class of deviations which remains, is that
   which is caused  by some  peculiarity on the  part of the child.  In these
   cases we assume that the uterine power  is intact, and that there is no im-
   pediment in the passages.   The difficulty is a purely mechanical  one;
   but if it be not removed after a certain time, the constitution is  involved,
   and the characteristics which we noticed in powerless labour, present
   themselves.  Thus, as in the case of defective passages, that which  at
   first was purely local and mechanical, involves  at length the vital powers
   and the constitution of the patient.
      We shall first notice certain mal-positions.   1.  Face presentations,  as
4  they are called ;  and, 2, those cases in which the forehead emerges under
   the arch of the pubis.
      580. Mal-position.   1.  Face  Presentations.   At first sight it may
   seem strange to call a " face presentation" a mal-position; but a moment's
   thought will show that when the face is  placed across  the upper outlet, it
   is merely because, from  some cause, the head which presented has devi-
    ated from its usual mode of descent.  Dr. F. Ramsbotham remarks, " I
    am inclined to think that most of the face presentations we meet with  in
    practice, were  originally brow presentations, and have been changed by
    the action of the uterus in the way I have already specified."  In face
    presentations the head  is bent backwards, so as to place the face nearly
    flat across the brim of the pelvis in its oblique diameter.
                                    Fig. 122.
2 g 2                     (877) 
878                      MAL-POSITION AND
  581.  Mechanism. — The face may present in two positions, according
as the forehead is towards one or other os ilium.   In  the first position,
the  forehead is  towards the left ilium, or rather the left acetabulum, and
the  chin  towards the right ilium, or right sacro-iliac synchondrosis, the
bridge of the nose representing the line described by the sagittal suture in
the  first cranial  position (fig. 122).   The  right side of the face is anterior,
and being  anterior  is  more depressed than the other  upon entering the
brim, so that, on making an examination, the finger touches the right eye
or the zygoma,  and upon this part the primary tumour forms.  M. Naegele
remarks  that there  forms " a swelling,  first  upon  the upper part of the
right half of the face, which  in this species of face  presentation (first
position) is always situated lowest."   If  the progress of the head through
the  external passages be unusually rapid, this is the only tumefaction ob-
served ; but if  it advance slowly, and the head  remain  a long time in the
cavity of the pelvis  before it actually enters the vagina, the inferior  half
of the right side of the face, viz. part of the right cheek, will he remarked
after birth as being the  principal seat of the swelling."
  The head, as we have said,  enters the brim obliquely as to its diameter
and plane, and thus descends into  the cavity;  when there, the  chin
makes a turn from right to left, and so emerges obliquely under the  arch
of the pubis (fig. 123), whilst the vault of the  cranium sweeps over the
perineum.
  This first position is by far the most frequent.
                              Fig. 123.
  The second position is the reverse of the first:  the forehead is turned
towards the right  acetabulum, and the chin to the left sacro-iliac syn-
chondrosis (fig. 124).  The primary tumour forms on the  upper part of
the  left cheek, and the secondary (if there be two) on its lower part; the
face enters the cavity obliquely, and so emerges from the outlet; but the
chin makes a quarter turn from left to right anteriorly, and when expelled
is under the irch of the pubis, whilst the head sweeps over the pelvis. 
MAL-PRESENTATION OF THE  CHILD.             379
  The older writers describe the head as emerging from the lower outlet
in face presentations,  with  the chin towards  the  perineum;  and Dr.
Smellie has given a plate in illustration of this.  A moment's examination

                                Fig. 124.
will show that this is mechanically impossible, and the careful observation
of Naegele and others has been unable to detect any such case.
  582.  Statistics.  1. Frequency.
a. British Practice.				c. German Practice.		
		Total	Face	'	Total	Face
Author.		Number of	presen-	Author.	Number of	presen-
		Cases.	tations.		Cases.	tations.
Dr. Jos. Clarke		10,387	44	MM. Moschner anc		
Dr. Merriman		2,947	10	Kursak	12,329	122
Dr. Granville .		640	1	Dr. Carus	2,557	24
Dr. S. Cusack		701	3	Dr. A. E. v. Siebol	d 1,003	10
Dr. Maunsell.		839	7	Dr. E. C. v. Siebol	d 494	4
Mr. Gregory .		691	2	Dr. Kilian	9,392	122
Dr. Thos. Beatty		1,184	4	Dr. Merrem .	157	1
Dr. Collins .		16,414	33	Dr. Naegele .	115	4
Mr. Lever		4,666	24	Dr. Kluge .	. 799	6
Dr. Reid		3,250	15	Dr. Brunatti	100	2
Drs. M'Clintock and				Dr. Adelmann	57	1
Hardy		6,634	14	Dr. Jansen .	13,365	15
b. French Practice.						
Mad. Boivin .		20,517	74			
Mad. Lachapelle .		15,652	65			
M. Ramboux .		491	3			
M. Dubois		10,742	30		l [	1 ! 1. J
 
380
MAL-POSITION AND
  Thus, in British practice, out  of 48,353 cases,  there were 157 face
presentations,  or 1 in 308;  among the French, 47,402 cases, and 172
face presentations, or about 1 in 275£;  and among the Germans,  40,368
cases, and 311 face presentations, or about 1 in 129f; the whole giving
640 face presentations in 136,123 cases, or about 1 in 212£ cases.
  As to the mode  of delivery, and results to mothers and children, I
cannot make out a regular table, but must content myself with such scat-
tered notices as I have been able to obtain.  Mr. Giffard relates 4 cases:
1 was delivered naturally,  and 3 with the forceps;  neither mothers nor
children were  lost.  Dr. Smellie gives  19 cases: 3 delivered naturally;
5 by version;  4 by the forceps,  and 5 by craniotomy: 3 mothers  and 11
children were  lost.
  Mr. Perfect  relates 8  cases:  1 delivered naturally, 2 by version, 4 by
forceps, and 1 by craniotomy : none of the mothers, but 2 of the children
were lost.
  Dr. Jos. Clark performed craniotomy twice in his 44 cases; all  the rest
were delivered naturally.
  Dr. Ramsbotham has  recorded 3  cases:  2 delivered by the  forceps,
and 1 by craniotomy ; all the children were lost, but none of the mothers.
  Dr. Granville's single case was delivered by version.
  Dr.  Cusack's 3 cases were  delivered  naturally;  neither  mother nor
child was lost.
  Dr. Collins' 33 cases were all  delivered naturally ;  the  mothers were
saved, and  but 4 of the children lost, 1  of which was an  acephalous
fcetus.
  Of Madame Boivin's 74 cases, we are informed that 41 were delivered
naturally, 14 by version, and 2 by craniotomy, but nothing is said of the
mortality.
  Of Madame Lachapelle's 65  cases, 41 were delivered naturally, 20 by
version, and 4 by the crotchet;  7 children are stated to have been lost.
  Of Dr. A. E. v. Siebold's 10  cases, 6 were delivered by the forceps.
  Of 80 cases under the care of Dr. Boer  of Vienna, all but  one were
delivered without assistance; in  that one case  the forceps  were  used.
None of the mothers suffered, and 3 or 4- of the children only were  lost.*
  Thus, so far as our data go,  out  of 344  cases, 248 were  delivered
naturally, and 77 required artificial assistance (i. e. 42 version, 20 forceps,
and 15 craniotomy).  In 150  cases where  the  result to the mother  is
given, 3 died, or 1  in 50; and of 216 children, 14 were lost,  and  15
destroyed, or  about 1 in  7.
  It is worthy of remark, that  the mortality  among both mothers and
children is greatest  when assistance was given; for of Dr. Collins' 33
and M. Boer's 80 cases, delivered naturally, none of the mothers, and
but 7 of the children, were  lost.  These notices show also  the  change
of opinion as to the necessity for assistance.
   583.  Causes.—It  is very difficult to assign correct causes for this mal-
position.   It  may  be Owing  to some  shock, coughing for instance, or
sudden uterine action, just before the head takes up its permanent posi-
tion at the brim
  ."I have treated," says Dr. Huston, in a note to a former edition,  "seven cases of
face presentation; four were delivered with the forceps, one with the vectis, and the
others without assistance, the children being small.  The mothers all recovered, but
two of the children were still-born."—Editor. 
MAL-REPRESENTATION OF  THE  CHILD.            381
  Dr. Simpson attributes mal-position and mal-presentations generally to
the following causes:—
  1. Prematurity of the  labour;  parturition occurring before the natural
position of the fcetus is established.
  2. Death of the child in utero;  or,  in other words, the loss  of the
adaptive vital reflex actions of the fcetus.
  3. Causes altering the normal  shape of the fcetus or contained body,
or causes altering the  normal shape of the uterus or containing body, and
thus forcing the fcetus to assume, in its reflex movements, an unusual po-
sition in order to  adapt  itself to  the unusual  circumstances in which it
happens to be placed.
  4.  Praeternatural presentations  are occasionally the  result of  causes
physically displacing  either the whole fcetus or its presenting part,  during
the latter periods of gestation or at the commencement of labour.
   584. Diagnosis. — " The presentation of the face," says  Dr. Denman,
" is discovered by the general  inequalities of the  presenting part, or by
the distinction of the particular parts, as  the eyes, nose, mouth, or chin."
There is no very great difficulty in  making  out this presentation before
tumefaction takes  place ; but afterwards it may be mistaken for the breech,
unless we  are very careful.  The bridge of the nose will be the best
guide, as being prominent, firm, and unlike any part of the  breech.  The
eyes or mouth may be confounded with the anus, and the malar bone with
the tuber-ischii.
   585. Symptoms. — The only effect which  a face presentation has upon
labour is to retard the second  stage, but not to such an extent, or very
rarely, as to give rise to  unfavourable symptoms.   The resistance to  be
overcome is greater, because the bones of the face and base of the cranium
which pass  the first through the brim, cavity, and outlet are incompressi-
ble, and because there is not the same power of adaptation  ; but the im-
pediment only calls forth more energetic action on the part of the  uterus,
and we perceive that  the progress of the labour, if slow, is  still evident.
The suffering, of course, is more severe, as well as more prolonged.
   The child when born  is a frightful  object in most cases; one eye closed,
and the half or the entire  of one  cheek  swollen, red, and contused; but
these injuries speedily pass away, and in a day or two  the  face assumes
its  ordinary aspect.  I  should  mention, that if  a  rough  and  careless
examination of the presenting part be made in these cases, the eye may
be  seriously damaged,  or  even destroyed.  The mortality amongst the
children is rather more than in  head presentations, but  less than  in any
other mal-presentation.
   If, as is very  rarely the case, the   delay  should be excessive, the
symptoms  of powerless  labour (§ 413) will  be developed, and will calf
for prompt relief.
   586. Treatment.—Formerly, when this mal-position was  regarded
as an unnatural presentation, it was held necessary or advisable to deliver
the patient  by art without loss  of  time, as  appears from the statistical
results of the operation.   M. Portal  appears to have been the first to sus-
pect that nature might be adequate to the delivery, and Deleurye concurred
in this opinion.   M. Boer, in 1793,  objected to any interference ;  and of
late years it has been  established as a rule, that assistance is unnecessary
merely on account of the  mal-position.  If there  should  be any dispro- 
382
MAL-POSITION AND
portion between the size of the head and the pelvis, or the pains should
become insufficient, or accidental complications occur, then of course, we
must have recourse to the mildest form  of assistance.  If within reach, the
forceps will probably be the best instrument.
  In  ordinary cases  we must keep up the courage of the patient, and
exercise all our own patience and kindness until the delivery be effected.
  If there  be a difficulty in establishing respiration, after the birth of
the  child, as from the cerebral congestion there may be, the cord must be
divided, and an ounce or two  of blood allowed to  escape,  previously
to applying the ligature.
  The child's  face may be  fomented  with  a decoction of chamomile
flowers or  poppy heads, and afterwards bathed frequently with a spirit
lotion.
  587. 2. The forehead towards the arch  of the pubis.—When
describing the mechanism  of parturition, it was stated, that when the head
presents in the third or fourth  position, it ordinarily changes into the

                               Fig. 125.
second  or first in its passage through the pelvis, but  that occasionally,
this change of position does not take place, and that the head then passes
down through the lower outlet, with the forehead turned  obliquely under
the arch of the pubis.   When  there, the head  may be forced equally
down, if there be room, presenting the  longitudinal  diameter (a little
modified)  to the antero-posterior diameter of the lower outlet, or the
forehead may remain stationary at the pubis, whilst the posterior part of
the head sweeps over the perineum. 
               MAL-PRESENTATION OF THE CHILD.             383

588. Statistics. — Frequency.
Authors.	Total No. of Cases.	Forehead to Pubis.
	1,897 2,947 640 303 849 16,414 6,634	5 44 2 2 7 12 15
		
		
		
		
Dr. Collins...........		
		
  Thus, in 29,684  cases, the face was turned to the pubis  87 times, or
about 1 in 342£.
  As to the result to the child; of 22 cases where the result is specified,
9 were lost.
  589.  Causes.—It is not easy to explain why the ordinary change does
not take place.   I have observed that it may. be prevented if the pelvis be
somewhat narrower than  usual, and especially if it be funnel-shaped :
also, if the pelvis be disproportionately large, as due resistance will then
be wanting;  and lastly, if very violent pains come on suddenly just after
the head has entered the brim.  It is probable that other causes may pro-
duce similar effects, but they are not so easily detected.
  590.  Diagnosis.—The mal-position will be detected by  the  flatter
shape of the forehead, which does not fill up the arch of the pubis so well
as the posterior part of the head; and especially by the situation of the
fontanelles, the large one being anterior, and the smaller one posterior.
   591.  Symptoms.—The effects  of this  mal-position upon  labour in its
second  stage are by no means serious; in ordinary cases it causes some
delay at the latter part  of it, and calls for more expulsive force;  but the
effort is successful,  and the child  is expelled.  If,  however,  the pelvis be
narrower than usual, it may offer a considerable impediment, as a larger
diameter is presented to the lower outlet than in the usual position.  '
  The effect upon the child is generally of no moment, unless the pelvis
be so deficient as to require an operation.
  592.  Treatment.—If the pelvis be  not smaller than usual, there is no
assistance necessary; and, if we suspect a narrowing, still sufficient time
must be allowed to  prove whether the relative disposition be such  as the
natural  agents  can  overcome.   If it be not, then, after a due and careful
estimate of the  obstacle, we must  determine whether there is room  for the
application of the  forceps, or whether  the only alternative is craniotomy.
In  some few cases  the forceps may be  necessary from a failure  of the
uterine power.  The time for operating must be determined by the amount
of the obstacle, and the symptoms present.
   593.  Mal-presentations.—Having taken the presentation of the head
as a type of natural labour, we must include the presentation of any other
part of the  body under the class of mal-presentations.  If we were to
follow implicitly Baudelocque, and other foreign authorities, there  is
scarcely any part of the body which may not present; but Denman, La-
chapelle, and Naegele consider that such regions as the back, loins, belly,
neck. &c, never  constitute the presenting part.
  Taking the presentations in the order of their frequency, we shall now
inquire into
         25
« 
384
MAL-POSITION AND
    1. Breech presentations, 1 in 52.
    2. Presentations of the inferior extremities, 1 in 92f.
    3.       "       of the superior extremities, 1 in 261£.
    4. Compound presentations, where two  or more parts present at  the
 brim.
    594.  Presentation of the Breech.—The breech may present itself
 at the brim in different positions; but  as  it enters  it will be found to
 arrange itself so that, 1, the back of the child is  turned anteriorly towards
 the belly of the mother; or, 2, the back of the child shall look posteriorly
 to the back of the  mother.   Not that the back of the  child is  directly
 anterior or posterior, but oblique; the transverse diameter of the child's
 hips corresponding to one or other of the oblique diameters of the brim.
    "In every  case," observed M. Naegele, "whether the  nates have at
 first a  completely transverse  or  oblique  direction, they will always be
 found,  on pressing lower into the superior aperture of the pelvis,  to have
' taken an oblique position, and that ischium which is directed anteriorly to
 stand the lowest.  They pass  through the entrance, cavity, and outlet of
 the pelvis in  this position,  which is oblique both as  to  its transverse
 diameter as well as to its axis."
    Thus, in the first and most frequent  position, the left ischium cor-
 iesponds to the left acetabulum, and, being  anterior,  it is depressed, and
 presents at the os uteri,  so that the finger impinges  upon it if it be passed
 into the centre of the os uteri.   In this  oblique position  the  breech
 descends into the cavity, and this part first passes through  the  vaginal
 orifice, and appears between the  labia; whilst the  other ischium  sweeps
 over the perineum, and  the belly  of the child is  towards the inner surface

                                Fig. 126.
ol the right thigh of the mother.   " The rest of the trunk," according to
the admirable description of the author just quoted, " follows in this posi-
tion ;  and as the breech approaches the inferior aperture of the pelvis, the
shoulders pass through  its  superior aperture in the left oblique diameter; 
MAL-PRESENTATION  OF THE CHILD.
385
and during its passage (viz. the breast) through the pelvic outlet, the arms
and elbows, which were pressed against it, are born at the same moment."
It is not always the case that the arms are pressed close to the side of the
child, one  or  both maybe  stretched  out above the head, and then, as
labour advances, first one will be pressed through  the  orifice (generally
the right), and then the  other, or it may be necessary to draw them down.
  " But whilst the  shoulders'are .descending in the above-mentioned ob-
lique  position, the  head, which during the whole progress of the  labour
rests with its chin upon its breast, presses into the superior aperture in the
direction of the right oblique diameter (viz. with the forehead correspond-
ing to the right sacro-iliac synchondrosis), and then into the cavity of the
pelvis in the same direction, or one more approaching  the conjugate dia-
meter.  After this, it presses through the external passage and  the labia
in such a manner, that while  the occiput rests against  the os  pubis, the
point of the chin, followed  by the rest of the face,  sweeps over the peri-
neum as the head turns on  its lateral axis from below  upwards."  This
brings the occipito-frontal diameter  of the head in correspondence with
the long diameter of the outlet.
  In the second  position, the  right  ischium, corresponding to  the right
acetabulum, is turned forward  and depressed, passing obliquely through
the cavity and outlet in the former case, but with the direction of its  sur-
face reversed ; its anterior surface being  directed towards  the left side  of
the pelvis  and left thigh of  the mother, whilst the head enters in the left
oblique diameter.
  The tumour (marked by a red or  livid spot) will be  found  on the left
or right ischium, according as it was  the first or second position.

                               Fig.  127.
   595. M. Naegele has noticed two deviations from the ordinary mechan-
ism of breech cases which I shall  give  in his  own words.   First: " It
sometimes happens that the body, which, directed with its anterior surface
forwards and to the right, or forwards and  to the left, is born as far as the
shoulders, turns itself then (and frequently during the course of  a single
pain, by which it is fully expelled) from the side  completely forwards, and 
386
MAL-POSITION AND
then to the opposite side, so that the anterior surface of the child, which,
for instance in the first case, was, before the pain came on, still directed
forwards and to the right, will be afterwards instantly, in the twinkling of
an eye, situated backwards and to the left."  Dr. Collins has noticed this
change as rendering the interference recommended by  some authors un-
necessary.
   596. The second deviation is thus described by Naegele.  " It some-
times happens  in presentations of the  nates, that the head does not rest
with the chin upon the breast;  but the occiput, as in  those of the face, is
pressed  against the  nape of the neck; in this case the  passage  of the
breech through the pelvis, according to which  species of nates  presenta-
tion  it may be, follows  in the  manner already described, as far as the
head; this, with  the occiput depressed  on  the nape  of the neck,  enters
the superior aperture with the vertex corresponding to one or other ilium
of the  mother, and in passing  through it, and pressing lower into the
cavity of the pelvis, the vertex gradually  turns more  and  more  back-

                               Fig. 128.
wards, so that when the trunk is born, the arch of the cranium is directed
to the hollow of the sacrum, and the inferior surface of the under jaw to
the internal one of the symphysis pubis.   The passage through the infe-
rior aperture takes place in the following way, viz. whilst  the under jaw
presses with its inferior surface against the os pubis, the point of the oc-
ciput, with the vertex, followed  by the  forehead, sweeps first  over the
perineum."  Thus bringing the occipito-mental diameter of the head into
apposition with the antero-posterior diameter of the outlet.
   597.  Thus,  as I observed in speaking  of the passage of the  head,
whether we consider the ordinary or extraordinary adaptation of the dia-
meters in breech presentations, we see at once the admirable way in which
the arrangements are  calculated  to provide  for the passage of the  child
with the least possible waste of space; and it may convince us that in far
more cases than we should d. priori suppose, nature is adequate to the ful-
filment of the functions of parturition ; and interference, when injudicious,
Is  more likely to impede than to further her efforts. 
              MAL-PRESENTATION OF  THE  CHILD.

598. Statistics.  1. Frequency.
387
a. British Practice.			b. French Practice.				
Authors.	Total No. of Cases.	Breech presenta-tions.	Authors.			Total No. of Cases.	Breech presenta-tions.
Dr. Bland. . .	1,897	36	Mad. Boivin . .			20,517	373
Dr. Jos. Clarke .	10,387	61	Mad. Lachapelle			15,652	349
Dr. Merriman .	2,947	78	M. Ramboux			491	4
Dr. Granville	640	2	M. Dubois . .			10,742	391
Edin. Lying-in 1 Hospital . /	2,452	17	Hotel Dieu, Paris,			280	3
			M. Mazzoni . .			452	5
Dr. Cusack . . Dr. Maunsell	701 416	14? 6					
							
Mr. Gregory. . Dr. Collins . .	691 16,414	14 242	c. German Practice.				
Dr. Beatty . . Mr. Lever . . Dr. Reid . . .	1,182 4,666 3,250	28 69 79	M. Richter . . Moschner and i			2,571 12,329	48 125
Mr. Warrington. Mr. French . . Dr. Churchill . Drs. M'Clintock 1 and Hardy . \	110 89 1,525 6,634	4 2 35 101	A. E. v. Sieb< E. C. v. Sieb< M. Kilian M. Naegele Dr. Merrem Dr. Henne Dr. Kluge Dr. Carus Dr. Brunatti Dr. Theys	rid )ld		1,944 1,165 2,350 1,411 299 655 1,074 2,908 295 28	44 18 125 76 14 6 27 43 6 1
			Dr. Adelmann .			63	2
  Thus in British practice, breech presentation occurred 768 times in
54,001 cases, or about 1 in 70 ; in French practice 1125 times in 48,134
cases, or about 1 in 42^ ; and in German practice 535 times in  26,982
cases, or about 1 in 50^; the entire number of breech presentations being
2438 in 129,117 cases, or about 1 in 52.
  The following table exhibits the result to the child in as many cases as
I could collect:
Authors.				No. of Breech Presentations.	Children lost.
Mr. Giffard.....				13	4
Dr. Smellie .				27	16
Mr. Perfect .				9	2
Dr. Jos. Clarke				61	21
Dr. Ramsbotham .				14	7
Dr. Merriman				79	9
Edinburgh Hospital Mr. Gregory ,. . Dr. Collins .				17 14 242	6 4 73
Dr. Beatty Mr. Lever				28 69	12 30
Dr. Churchill .				35	14
Drs. M'Clintock and Hardy .				80	18
 
388
MAL-POSITION AND
   Thus  in 678 cases of breech presentation 195 children were lost, or
about 1 in 3*.
   599.  Diagnosis. — The breech  of the child  is  distinguished by  its
roundness and softness, by the cleft between the buttocks, by the anus,
and by the organs of generation ; and it would seem unlikely that it should
be mistaken  for anything  else.   Yet  it may be  confounded with a face
presentation which has advanced slowly, and where there is much swell-
ing ; to the touch there is really a great similarity, but in the latter we have
the bridge of the nose obliquely across  the os uteri, and in the  latter the
more or less  moveable coccyx may be felt close to the anus, and joining
the broader and firm sacrum.  This will also distinguish  it from shoulder
presentations, which might be mistaken for the tubera ischii.
   The discharge of meconium is of very little value, as it occurs in head
presentations, although in the  latter case Dr. Collins remarks,  " it comes
away in a more fluid state, and has not its natural appearance, being mixed
with the discharges from the uterus and vagina."
   600.  Symptoms. — The duration of the labour varies  a good deal;  in
some cases it is concluded as  quickly as if the head  descended,  in others
it  is more tedious; there is more delay when the arms are stretched up-
wards than when they are  down by the side.  There is also delay in the
expulsion of the head, owing  to the incompressibility of the base of the
skull, which is  the first to enter, and its being less able to  adapt itself to
the brim.
   It is very seldom that any bad symptoms arise on the part of the mother,
as assistance is generally afforded;  but there is danger that mischief may
be done, if the interference be not judiciously timed, and  gently executed.
If there be any narrowing of the brim, there will  be  proportionate delay;
and if the patient be not delivered, the symptoms of powerless labour may
be developed.
   That  there is danger to the child, the statistics I have given prove ; more
than one in four being lost, and this is owing to the delay in die transmis-
sion of the head.   The  body does  not dilate the passages so well as the
head, as the head is wider than any part of the  body.  This of course
occasions the head to pass slowly;  but besides, a  little  time is required to
allow of the adaptation of the head to  the brim, cavity, and outlet, and
for such compression as  can be made; and as during  this time the cord
is  exposed to  pressure,  it is  not  surprising that asphyxia or pulmonary
apoplexy should result, of which the child generally  dies.
   Even where  the life of the child is saved, the  pressure  to which. the
organs of generation have been exposed may be followed by inflammation
and sloughing,  according to Denman.
   601.  Treatment. — A very minute and thorough examination is neces-
sary in these cases, to assure ourselves of the accuracy of our diagnosis;
but this  once done, the  less  frequent the examinations are  renewed the
better, lest the parts should be irritated.  As to the actual management, I
must repeat what I have  said  before,  that the less interference the better
for the patient.  Dr. Collins remarks  most soundly,  " the most common
and dangerous error committed by the medical attendant  arises from offi-
cious and injudicious attempts  to hasten or assist during the early stages of
labour, than which he could not well adopt a more  hazardous course.  No
interference whatever is required, until the breech shall have been expelled 
MAL-PRESENTATION OF THE  CniLD.
389
through the external parts, unless the uterine action be inadequate to effect
this; otherwise the child must often be forfeited, owing to difficulty expe-
rienced in consequence of the soft parts being badly prepared to admit
the passage of the head.  This being the most critical part of the delivery,
should much delay take place, the continued pressure on the funis speed-
ily deprives the child of life.   To guard against this, therefore, the breech
should be permitted to pass  slowly and unassisted, so as  gradually  and
perfectly to dilate the soft parts, thereby greatly facilitating the completion
of the labour."
   At the same  time as the breech passes,  the perineum must be carefully
guarded (§ 348) with the left hand, whilst the right is employed in sup-
porting the child as it is expelled, and carrying it forwards and downwards
towards the  legs of the mother, allowing it  perfect liberty to change its
position or make  such turns  as the mechanism may impress upon  it.   It
will rarely if ever be necessary for us  to attempt to adapt the child to the
passages, as we have seen (§  595) that even when the head is in an appa-
rently unfavourable position  at the brim,  it rectifies  itself in  the cavity.
What we must do,  is to offer no impediment to their changes.
   When the umbilicus appears at the external orifice, the  danger from
pressure on the funis commences;  the cord should be drawn down a little,
and removed as much as possible out of the way of pressure.   The
strength of  the pulsations is an important guide  as to the necessity for
assistance ; if they be strong, we can allow time for the natural powers to

                               Fig. 129.
act; if, on the contrary, they be very weak, we must expedite the delivery
as much as possible, consistent with the safety of the mother, by drawing
down the  body of the child during a pain.
  When the chest is through the external parts, the arms may  offer a dif-
ficulty; if they be close to the side of the child, we shall have no trouble,
                                2h2 
390
MAL-POSITION AND
 but if above the side of the head, they must be brought down by passing
 one or two fingers over the shoulder as near as possible to the elbow, and
 then drawing it across the  face and chest until the elbow arrives at the
 external orifice:  having extracted one, the other  is easily liberated, and
 it is generally easier to begin with the one nearest the  perineum.   Great
 care must be taken not to draw directly downwards, or we may break the
 arm, but across the front of the child, and neither violently nor suddenly,
 or much mischief may be done to the soft passages.
   When the arms are free, the shoulders will  pass out, and the head of
 the child will take up its position at the brim  in  the manner described,
 but  here there is a considerable delay.  If there be no demand for prompt
 delivery, and the cord  pulsate strongly,  it is  better not to interfere, and
 when the head is in  the cavity, two fingers of the  left hand may be intro-
 duced and placed in the mouth or, what is better, on the upper jaw, which,
 for many reasons, is more suitable than the lower, as usually recommended,
 and pressure made  so as to depress the  chin upon the breast; thus pre-
 senting a shorter diameter of the  head to  the lower outlet, and facilitating
 the expulsion of the head.  The body of the child should be carried for-
 ward to the thighs of the mother, and extracting force, varying in amount
 according  the exigency  of the case,  applied  to the  shoulders,  in the
 diameter of the  axis of the lower outlet.   " In  some few cases," Dr.
 Collins  says, " advantage is derived from pushing up the head a little, so
 as to alter  its position."   This  manoeuvre, when dexterously executed,
 will generally extricate the head with ease and  promptitude  if the patient
 have had children.   In these cases it is peculiarly  necessary that pressure
 should be applied over the uterus  from  the time that the chest is expelled,
 in order to secure the regular expulsion of the  after-birth.
   602.  But if the uterine power  should fail  (as in powerless labour), or
 any  circumstances demand speedy delivery before  the breech is expelled,
 one  or two fingers should be passed into the groin, and assistance gently
 and steadily afforded during a pain.   The blunt hook  is frequently  used
 for this purpose, but it has serious disadvantages, and if used incautiously,
 the thigh of the child may be  fractured.   After the breech is born, we
 may extract by grasping the body of  the  child, covered with a napkin;
 and  let me impress upon  my junior readers, that extracting force to be
 successful (not to say safe) must always be made in the axis of the  brim
 or outlet at whichever part the resistance may be.
   In some cases, however, the head is not so easily extracted, and I per-
 fectly agree with Dr. Collins that " should there be any considerable ob-
 struction to the getting away of the head, we  are by no means justified
 in using violence; the soft parts of the mother  will be sure to suffer  from
 such a  mode of proceeding,  and on  the child's  part, nothing is  to be
 gained;  as it is  destroyed by pressure on the funis, continued during the
 time the ordinary efforts have been diligently but unsuccessfully employed
 for its delivery." If the pulsation in the cord have ceased, " the only safe
 plan under these circumstances, will be to lessen  the head  by means of
 an opening made behind one or both ears."  If the pulsation be good, it
 will be worth while trying the forceps, provided they can be introduced
 without  difficulty ; but we must remember that  we cannot in these cases
gain much  space by compression, because we grasp the  base of the skull.
  603.  2. Presentation  of the inferior  fxtrfmitifs. — Under this
he .d I include presentations of one or both of the knees or feet, as the 
MAL-PRESENTATION OF THE  CHILD.
391
former are always converted into footling cases  as  the labour advances.
In point of frequency they stand next to breech presentations.
  604. Mechanism.—Adopting Naegele's arrangement, we shall make
but two divisions of this mal-presentation.  1. When, the toes are directed
                               Fig. 130.
backwards, and 2, when the toes are directed forwards.   The former is
the more frequent, and both correspond to the two classes of breech pre-
sentations.
   As we should expect, the feet, meeting with no resistance to fix them,
are liable to change their position during their descent until the hips enter
                               Fig. 131.
 
392
MAL-POSITION AND
the brim, which they do precisely as was described in breech cases (§ 594).
In fact, in its further progress, the  case is identical with breech cases, and
the description already given will serve as well for footling cases, on
which  account I need not repeat it.
   The expulsion of the body of the child may be more rapid, owing to
the absence of the additional bulk of the  thigh when  doubled up on the
abdomen, but it is just so much the less safe for the child.
   605. Statistics.   1.  Frequency.
a. British Practice.			b. French Practice.		
	Total	Pres. of		Total	Pres. of
Author.	Number of	Inferior	Author.	Number of	Inferior
	Cases.	Extr.		Cases.	Eitr.
Dr. Bland	1,897	18	Mad. Boivin .	20,517	242
Dr. Jos. Clarke	10,387	184	Mad. Lachapelle .	15,652	247
Dr. Granville .	640	3	M. Ramboux .	601	3
Dr. Merriman Ed. Lying-in Hosp.	2,947 2,452	40 8			
					
Mr. Gregory .	691	7			
Dr. Maunsell .	839	21	c. German Practice.		
Dr. Thos. Beatty .	1,182	15			
Dr. Collins .	16,414	187	MM. Moschner and		
Mr. Lever	4,666	29	Kursak	12,329	82
Mr. French .	89	1	M. Richter .	2,571	30
Dr. Churchill.	1,525	22	Dr. A. E. v. Siebold	2,059	25
Drs. M'Clintock and			Dr. E. C. v. Siebold	947	11
Hardy	6,634	38	Dr. Kilian	2,350	8
			Dr. Carus	2,908	23
			Dr. Kluge .	1,074	17
			Dr. Brunatti	295	3
			Dr. Theys .	21	2
			Dr. Adelmann	53	2
  Thus in British practice we have 54,363 cases, and 572 presentations
of the inferior extremities, or about 1  in 95.
  In French practice, 36,670 cases, and 492 presentations of the inferior
extremities, or about 1 in 74?.
  In German practice, 24,607 cases, and 203 presentations of the inferior
extremities, or about 1 in 131.
  Altogether, 117,640 cases, and 1268 foot or knee presentations, or about
1 in 92f.
  The following table shows the mortality among the children:—
Authors.	Footling Cases.	Chil-dren lost.	Authors.	Footling Cases.	Chil-dren lost.
Mr. Giffard . . .	23	13	Mr. Gregory . . .	7	3
Dr. Smellie . . .	9	3	Dr. Beatty . . .	15	10
Mr. Perfect . . .	11	6	Dr. Collins . . .	187	73
Dr. Jos. Clarke . .	184	62	Mr. Lever ....	29	16
Dr. Ramsbotham	2	1	Dr. Churchill . . .	22	10
Dr. Merriman . .	40	6	Drs. M'Clintock and		
Edinburg Hospital .	8	2	Hardy . . .	25	6
 
MAL-PRESENTATION  OF THE CHILD.              393
  This gives a very large mortality, 210 children  being lost out of 562,
or about 1  in 2\.
  606.  Symptoms.—The first circumstance in the labour which excites
our suspicion of its being unnatural, is very often the early rupture of the
membranes, and the large quantity of liquor  amnii which escapes, and
on making an examination we discover the absence of  the head blocking
up the brim, although we may not be  able to  make out the  presentation.
As the labour advances, one or both of the feet descend through the os
uteri, sometimes with the toes pointing downwards, but  more frequently
bent up towards the labia.  An examination at this period will enable us
to form a diagnosis.  The labour proceeds gradually, and  the hips de-
scend into the pelvis;  then  the  chest, shoulders  and  head, precisely as
described  in breech presentations, and with the same evolutions and
adaptations.
   Danger to the mother can only arise from a prolongation of the second
stage, or injury to the passages, and there is little risk of either so long as
violent efforts be not made to extricate the  child, and if the pelvis be well
formed.
   The danger to the child is greater than in breech presentations, one in
two and a half being lost, and from precisely the same  cause which made
the latter more  dangerous than  head presentation, viz., the  inadequate
dilatation of the passages.  The  child passes through, as a wedge, and
each succeeding part being wider than the  preceding, has to effect dilata-
tion  sufficient for itself, and that  at a  stage when time is of great value
from the pressure to which the child is exposed.  The breech, with the
legs turned up,  is certainly less bulky than the  head,  and therefore pre-
pares badly for the quick transit of the latter;  but if the size  of the breech
be diminished by the thighs being extended, it is clear that much greater
resistance  and delay of the  head will result: and in this greater delay,
and consequent  prolongation of the pressure upon  the funis  is the expla-
nation of the increased mortality.
  607.  Diagnosis. — Footling cases may  be  confounded with presenta-
tions of the head; and if one foot only be down, the  heel  may be mis-
taken for an elbow.   However, a little care will enable us to distinguish
them.   For instance, the foot is longer and the sole flatter than the hand;
the toes are shorter,  and more of  a length than the fingers, and the great
toe does not separate from the others,  as the thumb does from the fingers.
The presence of the heel with the ankle-bone on each side, is quite dif-
ferent from the hand and wrist.   Tracing from the heel along the sole of
the foot to the toes will, of course, distinguish the heel from the elbow.
" In an examination the knee may be distinguished from the elbow, for
which it may in some degree be  mistaken,"  Naegele remarks; " in that
it is thicker, that it has two prominences, and a depression between them ;
while, on the other hand, the elbow, which is thinner, presents to the feel
between the two prominences a projection in which it seems to end."
  608.  Treatment. — In every particular, the treatment of breech presen-
tations applies  to footling cases, except that I think  there is rather more
temptation to pull down the child  at an early period, because of the greater
facility for  so doing; but, from what I have said, it must be evident that
it is more necessary that the labour should be let alone.   There can be no
occasion to interfere until the pressure upon the funis is felt, and  then the 
394
MAL-PRESENTATION  OF THE CHILD.
risk to the child must decide upon whether assistance is to be given or not
The same method must be adopted for extricating the arms, and for facil-
itating the expulsion of the head;  and in the more difficult cases we have
the same remedies at command.
  609. 3.  Presentation of the superior extremities. — In almost all
cases  of this kind it  is the shoulder which primarily presents, and after-
wards the arm prolapses; occasionally, however, we find the hand at the
beginning of the labour at the os uteri, and more rarely the elbow.
  In all cases the back of the child either looks forward towards the abdo-
men of the mother  (fig. 132), or backward towards her spine (fig. 133):
the former being twice as frequent as the latter.

                               Fig. 132.
  In the majority of cases, with such a position of the child, labour may
be considered as impracticable, unless assisted by art;  and yet, even with
such an untoward position, the natural powers have occasionally succeeded
in expelling the child.  Dr. Denman, in 1772, first noticed the fact, though
he appears to have mistaken the process: he supposed that, during an in-
terval of uterine relaxation, the shoulder and arm receded, and the breech
came down into the pelvis; hence the name he gave to it, " spontaneous
evolution of the fcetus."  We are indebted to the accurate observation and
ingenuity of my friend, Dr. Douglass, a distinguished practitioner of Dub-
lin, for the true explanation of the process in an essay published in 1811,
from which the following short description is extracted.   Before its expul-
sion the situation of the foetus " resembles the larger segment of a circle;
the head rests on the pubis internally, the clavicle presses against the pubis
externally, with the acromion stretching towards the mons veneris: the
arm and shoulder are entirely protruded, with one  side of the thorax not
only appearing at  the os externum, but partly without it: the lower part
of the same  side of the trunk presses on  the  perineum, with the breech
cither in the hollow of the sacrum, or at the brim of  the pelvis,  ready  to
descend into it; and by a few further uterine efforts, the remainder of the
trunk, with the  lower extremities, is expelled.  And, to be more minutely
explanatory of this ultimate stage of the process, I have to  state that the 
SUPERIOR EXTREMITIES.
395
breech is not expelled exactly  sideways, as the upper part of the trunk
had previously been ; for, during the progress of that pain by which the
evolution is completed there is a twist made, about the centre of the curve,
at the lumbar vertebrae, when both buttocks, instead of the side of one
of them, are thrown against the perineum, distending it very much;  and
immediately after the breech, with the lower extremities, issues forth ; the
upper and  back part of it appearing first, as if the .back of the child had
originally  formed the convex, and its  front the concave  side of the
curve."

                               Fig. 133.
  Thus the head, and the shoulder depressed in the pelvis, are fixed, and
the remainder of the body doubled up, is inch by inch  forced into the
pelvis, and through the external parts, until all below the arm is expelled,
leaving the case to be terminated as a breech or foot presentation.   At no
part of  the process is the arm at all retracted; but if moved at all, it is
still further protruded: the name of " spontaneous expulsion," given by
Dr. Douglass, is therefore more suitable than that of "  spontaneous evolu-
tion."  An essential condition  of this extraordinary effort  of nature, is
the relative disproportion of the  fcetus  and pelvis; either the fcetus  must
be smaller or the pelvis larger than usual, to permit it.
  The accuracy of Dr. Douglass's explanation has been proved by the
observation  of  Dr. Gooch  and others.  I  can also add my  testimony,
having some years ago had an opportunity of witnessing the process. 
396              MAL-PRESENTATION OF  THE  CHILD.
610. Statistics.—Frequency.
a. British Practice.			a. British Practice.		
Authors.	Total No. . of Cases.	Pres. of Sup. Ex.	Authors.	Total No. of Cases.	Pres. of Sup. Ex.
Dr. Bland . . . Dr. Jos. Clarke . Dr. Merriman. Dr. Granville . . Ed. Lying-in Hosp. Dr. Collins. . . Mr. Gregory . . Dr. Cusack . . Dr. Maunsell . . Dr. Beatty . . . Mr. Lever . . .	1,897 10,387 2,947 640 2,452 16,414 694 701 839 1,182 4,666	8 48 19 1 4 40 4 5 4 4 12	Mr. Mantell . . Dr. Reid . . . Dr. Churchill . . Drs. M'Clintock ) and Hardy $	2,510 3,250 1,525 6,634	4 18 9 26
			b. French Practice. Mad. Boivin . . 20,517 Mad. Lachapelle . 15,652 M. Ramboux . . 491		80 68 4
  Thus in British practice it occurred 206 times in 56,738 cases, or about
1 in 275^; and  in French practice, 152 times  in 36,660 cases, or about
I in 241.   Altogether, 358 times in 93,398 cases, or about 1 in 260|.
Authors.	Presentation of Superior Extremities.	Mothers lost.	Children lost.	Delive Version.	red by Crotchet.
Mr. Giffard	24	0	15	21	
Dr. Smellie	34	3	19	28	
Mr. Perfect	6	1	2	6	
Dr. Jos. Clarke .	48	6	21		
Dr. Ramsbotham	27	6	18	12	11
Dr. Merriman	19	. .	2		
Edin. Hospital .	4	• . •	2		
Dr. Collins .	40	4	20		
Mr. Gregory . .	4	. . .	3		
Dr. Cusack.	5	0	2	4	
Dr. MaunseU . .	4	• • •	4	2	
Dr. Beatty .	4	1	4	4	
Mr. Lever .	12	3	8		
Dr. Churchill	9	0	6	9	
Drs. M'Clintock and ) Hardy . . $	26	2		19	4
  The second of the preceding tables is intended to show the mortality
to both mother and child, so far as it is mentioned by the author:  where
it has not been recorded, I have left the space blank; but if either died,
[ have so specified.   I have thought it worth while, also, to add  some
columns showing the different modes of delivery practised.
  From this record we find, that out of 240 cases of presentation of the
superior extremities 125 children were  lost, or rather more than one-half.
Out of 235 cases 26 mothers were lost, or nearly 1 in 9.
  611.  Symptoms. — Labour with this mal-presentation is, as the statis-
tics show, extremely dangerous to the mother and  child, and  especially 
SUPERIOR EXTREMITIES.
397
as the remedy involves a very serious operation.  Dr. Rigby has given a
graphic picture of a case of this kind when unassisted:  " after the mem-
branes have burst, and discharged more liquor amnii than in general when
the  head  of the nates presents, the  uterus contracts tighter around  the
child, and the shoulder is gradually  pressed deeper into the pelvis, while
the  pains increase considerably in violence from the child being unable,
from its faulty position, to yield to the expulsive efforts of nature.  Drained
of its liquor amnii, the uterus remains in its state of contraction even dur-
ing the intervals  of the pains; the consequence of this  general and con-
tinued pressure is, that the child is  destroyed from the circulation in  the
placenta being interrupted, the mother becomes exhausted, and inflamma-
tion or rupture of the uterus and vagina are the  almost unavoidable re-
sults."
  On the part of the  mother, so long as the labour  is virtually (§ 386) in
the first stage, the symptoms  are perfectly natural  and favourable;  but
after the second stage (marked by voluntary effort and change of cry)  has
lasted  for some time, then we have in detail  the  symptoms of powerless
labour, exactly as I have described  them (§ 413);  but with a difference
in the results, owing to the mechanical obstruction offered by the mal-posi-
tion of the child; and I regard these cases as the most striking illustration
of the fact I  have repeatedly pressed upon the reader's attention, viz. that the
development of unfavourable symptoms is owing to  the stage at which the
delay occurs-, and not the kind of  impediment; for here we find that the
same  symptoms  arise from a purely mechanical  impediment on the part
of the child, the uterine  system being in perfect integrity, as we found to
result  from  inefficient pains, from tumours in the soft passages, or from
deformity of the pelvis.
  612. Diagnosis. — Our first suspicion will probably arise from finding,
on  examination, that  we are not able to reach the  presentation ; this, of
course, proves  nothing;  but it ought to induce a very careful investiga-
tion, and  we may find the os uteri very little dilated, and suffering com-
paratively little pressure during each  pain, or the hand may be felt pro-
truding through the undilated os uteri.  The high situation of the presenta-
tion (if it be the shoulder) renders  it difficult to ascertain the part which is
descending.  We may derive confirmation of our suspicions from finding
the bag of the  membranes protruding, of a conical or elongated form,  and
evidently not covering the head.
  When  the shoulder has descended a little, we may be able to reach the
axilla, and we shall find that it is rounder than the elbow, and has not the
condyles  of the humerus, so that this will decide  the point for us.
  The hand may be  mistaken for the foot;  but its shortness, the length
of the fingers,  and the devarication  of the thumb, will  enable us to  dis-
tinguish it.   The situation of the thumb and the aspect of the palm of the
hand will mark whether it is the right hand or the left.
  613. Causes. — This mal-presentation has  been attributed to irregular
early contractions of the uterus, to irregular distention, to obliquity,  &c.
&c.   They may possibly have some such effect; but I think all the  ex-
planations as yet offered are insufficient.  Dr.  Rigby concludes, "we
may,  therefore, state that the causes  of  arm  or  shoulder presentations are
of two kinds,  viz. when the uterus  has  been distended by  an unusual
quantity of  liquor amnii, or when, from a faulty condition  of the early 
898
MAL-PRESENTATION OF  THE  CHILD.
pains of labour, its form has been altered, and with it the position of the
child."
  614. Treatment. — As (with very few exceptions) the  labour is im-
practicable, we have nothing to expect from the natural efforts, except an
increase of  difficulty, it becomes our duty to interfere  promptly in every
case.  Should the mal-presentation have been detected before the rupture
of the membranes, and before the os uteri is fully dilated, we may wait
for a time to allow of as  complete dilatation as possible, nor is  there any
risk  so long as the membranes are entire.  But if they have given way we
ought not, and if the os uteri be fully dilated (whether the membranes be en-
tire or not), we must not wait a moment, but proceed to deliver by turning.
When the liquor amnii  has not escaped there is seldom any difficulty, but
after that event we  generally find the uterus  more or  less strongly con-
tracted upon the child,  and in proportion to this contraction  is  the diffi-
culty.   If the uterine action be  very  intense, the  operation may be im-
possible without risk of rupturing the uterus ; and in  such cases, instead
of proceeding at once to  turn, a dose of tartar emetic or opium, or a com-
bination of  both, may be given, so as  to moderate or suspend uterine
action, and  admit of the introduction of the hand.   If  the pulse be quick
and  strong, vensesection  may be beneficial.  I have already given  the
details of this operation (§ 493).*
  Should these measures  fail, and version be impracticable, we must open
the chest of the child, and eviscerate ; after which it may be extracted by
the crotchet.
  " Several writers," says Dr. Collins, " recommend in difficult cases of
this  nature, the  separation of the child's  head, so as  to  bring  the body
away by the  presenting  arm, and afterwards deliver the head by  the
crotchet: this we would condemn, unless we failed  in our efforts, by break-
ing down the thorax, which is very unlikely, if the operation  be properly
performed,  and  the  pelvis not extremely under size.   We  once saw  a
delivery effected as  above described, and the greatest difficulty was expe-
rienced in the extraction  of the head ; it was necessary to  introduce the
hand to bring it into the vagina,  and then it had to be lessened before it
could be removed."
  615. But it will at once be asked, what practical application can be
made of our knowledge of the occurrence of spontaneous expulsion.   I
am afraid  not much.  I am  satisfied that we ought not to wrait for it in
any  case in which turning can easily be accomplished, because if it do
not occur (and according to Dr. Douglass it does  not occur  above once
in 10,000 labours),  the operation will  be rendered tenfold more difficult
from the greater  depression of  the child, and  more  energetic action of

  * Dr. Churchill is not sufficiently decided in his recommendation of bleeding in these
cases.  When the waters are evacuated, and the uterine contractions so strong as to
render turning difficult and dangerous, there is no remedy equal to bleeding — largely,
even ad deliquium — giving, at the same time, a full dose of laudanum, to prevent any
undue reaction. If the practitioner is prompt and  skilful, he may effect  the turning
before the relaxation consequent upon the bleeding shall have passed off.  It is unne-
cessary in these cases to lose time by searching for both feet, as delivery can be accom-
plished equally  well by bringing down only one, while the risk to the child is less. If,
however, the child  be dead, or there is much hemorrhage, it will be  proper to seize and
bring down both feet,  with the view of accomplishing the  delivery more rapidly, pro-
vided both can be gained without much delay or difficulty. —Editob. 
COMPOUND PRESENTATION.
399
 the  uterus;  it would, in fact, be exchanging a  comparatively  easy and
 not  very dangerous operation for a very difficult one, in which the risk to
 the  mother would be great, and the death of the child certain,  provided
 this rare phenomenon did not occur.  I  think, however, that in  such  a
 case as Dr.  Douglass has described, we  may venture upon a little delay
 to afford a chance of spontaneous expulsion.  "If the arm of the fcetus,"
 says Dr. Douglass,  "should be almost  entirely  protruded,  with  the
 shoulder pressing on the perineum ; if a considerable portion of its thorax
 be in the hollow of the sacrum, with the axilla low in the pelvis: if, with
 ihis disposition, the uterine efforts be still powerful,  and if the thorax be
 forced  sensibly lower  during the pressure of each successive  pain, the
 evolution may with great confidence be expected."
   As the  minute details  of management  are the  same in natural and
 unnatural  labours, I  have not thought it necessary to repeat them,  but
 refer the reader to the chapter on that subject (§  357).
   616. 4. Compound Presentations. — From  an  untoward position of
 the  body or  extremities of the child, one or more  parts may come together
 to the os uteri; in some cases merely adding to the bulk to be transmitted
 through the  passages without altogether preventing it, in others rendering
 interference  necessary for the delivery.  For instance :
   1. The hand or arm may present with the head, of course adding to its
%ze, and perhaps, if the pelvis be small,  prohibiting its entrance into the
 passage.   Nor is this  without danger  if the uterine action be violent.
 However,  as Dr. Merriman  has observed,  it  rarely occurs except when
 the  pelvis is large.  For which reason, if it be discovered early, a cautious
 attempt should be made to replace the arm  above the head so as to allow
 it to descend alone, but, above all things, we must be cautious neither to
 draw down  the hand nor to displace the head,  as either  may convert  a
 simple manageable case into an arm presentation.

                                Fig. 134.
26 
400              MAL-PRESEXTATION OF  THE  CniLD.
  If the  arm cannot be replaced, the case must then be treated as one
of relative  disproportion; perhaps a little time and extra uterine action
(which is generally exerted, as we have said, in proportion to the demand
for  it) may suffice:  if  not, and the delay should  excite unfavourable
symptoms,  we must first see if the forceps are applicable, or version, and,
as a last resource, if all others fail,  we must lessen  the head.   I prefer
the forceps to version, because  of  its  inferior mortality as regards  both
mother and child; and version (when possible) to the crotchet, for the
same  reason.
  2.  The feet and hands may present,  or one of each,  and in these cases
it not unfrequently happens that the cord prolapses (fig. 134).
  In such cases, it is evident that  one or  other extremity must descend
and give the character to the labour, making it an arm  or footling case.
  'Now it is exactly for  the determination of this question that we ought
to interfere.  There can be no  doubt  of the propriety of drawing down
the foot or  feet into the  pelvis so as to preclude the possibility of the arm
descending, and when this is done, the case is one of footling  presenta-
tion, and to be managed accordingly.
  But I must repeat my caution that the greatest care  is necessary, first,
not to mistake a hand for a foot, and  secondly, not to favour the descent
of the hand and arm by the mode of examining.
   Prolapse of the cord  increases the danger to the child, and may (ac£f
cording to  the rules laid down) require us to hasten the labour if thefiul-  •"
sations be weak and the woman have previously had children.
                         CHAPTER XVII.

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

  617.  1. Plural Births.—I have already stated (§  228) the signs by
which twin pregnancy is to be recognised, and also that in the majority
of cases they are very dubious. Each child possesses its special envelopes
and a separate placenta, though they are sometimes so pressed together as
to appear but one, and occasionally a vascular communication passes from
the one  to the other.   The labour is often premature, and the children are
generally smaller than usual.
  The mode  of transmission of each child may be perfectly natural, or
either or both may come under some of the orders of unnatural labour
already  described, requiring the management suitable for such cases:  so
far, a separate notice  of plural births is unnecessary:  but  on - the other
hand, there are some important points of practice, and  some details as*to
the presentation and mortality in such cases, which require to be investi-
gated.   In this chapter, therefore, I shall chiefly remark upon %e circum-
stances  peculiar to plural births, and, to avoid repetitions, refer to the
previous section?  for the ordinary treatment. 
PLURAL  BIRTHS.—MONSTERS.
401
  A woman may conceive of two, three, four, or five children, but I am
not aware of more than four children having been born alive at one birth.
  The  statistics I have been able  to collect are not very extensive, but
there are some interesting points which I have endeavoured to investigate
as fully as the means permit.

   618.  Statistics.—1. Frequency.
a. British Practice.
Authors.
^Mft-
Total No.
of Cases.
Twins.   Triplets.
Quadru-
 plets.
Dr. Jos. Clarke  -
Dr. Merriman
Dr. Granville
Edinburgh Hospital
Dublin Hospital -
Dr. Maunsell
Mr. Gregory
Dr. Beatty -
Mr. Lever -
   Reid   ---
  F. Warrington -
   Churchill
Drs. M'Clintock and Hardy
 10,307
  2,947
   640
  2,452
129,172
   839
   691
  1,182
  4,666
   580
   110
  1,640
  6,634
 184
  39
   9
  31
2,062
  13
  12
  18
  33
   9
   3
  25
  95
 3
 1

 2
29
b. French Practice.
Mad. Boivin
Mad. Lachapelle -
Hotel Dieu, Paris
M. Mazzoni -
20,357	154	3
15,481	165	3
280	4	
452	9	
c. German Practice.
Dr. Henne  -
Dr. Richter
Moschner and Kursak -
A. E. v. Siebold -
Dr. Riecke -
Dr. Kluge  - •  -
Prof. Andre"e
Dr. Theys  -
Dr. Brunatti
Dr. Adelmann
Dr. Jansen -
1,214	1	
2,571	52	
12,329	165	
1,409	20	
219,303	2,545	34
809	15	
176	5	
55	4	
99	2	
56 ,	1	
13,365	157	1
   So far as these numbers go, we  find among British  practitioners, in
 167,676 cases, 2,572 cases of twins, or about 1 in 65j, and 37 cases of
 triplets, or 1 in 4,531^.  Among French practitioners, in 36,570  cases,
 3jS2  cases  of  twins,  or about 1 in 110;  and 6 of triplets, or 1 in 6,095.
 Atnong German practitioners, in 251,386 cases, 2,967 cases of twins, or
.about 1 ig 84; and  35 of triplets, or  about 1 in 7,185.  Taking the
 whole, we have'455,632 cases, and 5,871 of twins, or 1  in 77|; and 78
 cases of triplets, or 1 in 5,840.
                                   2i2 
402
PLURAL BIRTHS.—MONSTERS.
  I have formerly quoted the comparative frequency in different countries
stated by M. Quetelet.

  2. Mortality.
Authors.	Twin Cases.	Children lost.	Triplet Cases.	Children lost.
	14	9	1	
	8	2	2	
	7	7		
	184	282	3	
	15 '	9	2	4
	9	4		
	240	58	4	4
	12 18 33	16 8 6		
	157	16		
Drs. M'Clintock and Hardy . . .	95	19		
  Thus out of 792 cases of twins (i. e. 1,584 children) 436 were lost, or
about 1 in 3^;  and out of  12 cases of triplets (i. e. 36 children)  11 were
lost, or 1 in 3.
  This mortality, however, which  is very large, must be qualified by'jdr'
lowing for the great number  of children whose death could not  be attri-
buted to the labour.   Dr. Jos. Clarke had 43 still-born; Dr. Collins had
54 premature labours  among the twin cases, and 12 cases of the  birth of
a putrid fcetus.
  The mortality to the mother in twin cases has been computed as 1 in
20:  in Dr. Collins' cases it was 1 in 34.   I regret that, from the imper-
fection of the records, I cannot give ample statistics on this point.
  As to the sexes in twin cases, the following cases are recorded:—
Authors.	No. of Twin Cases.	Both Males.	Both Females.	One Male and one Female.
Dr. Jos. Clarke.....	184 240 33	47 73 11	68 67 11	71 97 11
	457	131	146	179
   Thus we find that twin children are most frequently of opposite sexes,
and  that twin females are  more  common than  twin males.  From Dr.
Collins' most excellent record I may state, that of his twin male cases 23
were dead (one putrid), and that of these 23, 13 were the first-born chil-
dren ;  of the female twins, 11 were dead (4 putrid);  and  of the twins
of opposite sexes, 22 were  lost (7 putrid), of which  15 were boys and 7
girls.  This is important, since from it we learn that there is  more danger
to the boys than the girls, and particularly when they are twin cases of
opposite  sexes.                                             ^
   From the reports of the same authors, the presentations, placed in order
of birth,  were as follows:— 
PLURAL BIRTHS.—MONSTERS.
403
Authors.	Both Head.	Head and Breech.	Head and Foot.	Both Breech.	Breech and Head.	Breech and Foot.	Both Foot-ling.
Dr. J. Clarke Dr. Collins .... Mr. Lever ....	16 103 15	30 7	25 25 5	2 8 2	6 25	1 9 1	3 6
	Foot	Breech	Headfc	Face	Head	Foot	Foot
Authors.	and	and	Arm or	and	and	and	and
	Head.	Elbow.	Sho'ld'r.	Head.	Face.	Hand.	Breech.
Dr. J. Clarke	10						
Dr. Collins ....	19	1	5	1	1	1	1
Mr. Lever ....			2				
   Dr. Collins thus states the mortality of his different presentations:  when
 both were head presentations, he lost 24 (4 putrid), when the head and
 breech (i. e. the first child with the head, and the second with the breech)
 presented, 2 of the former and 5 of the latter were lost; when the head
 and feet, 2 of the former and 3 of the latter;  when the feet and head, 4
 of the former and 2 of the  latter;  when the  breech and the head, 1  of
 the former and 6 of the latter; when both were footling cases, 2 were
 lost;  when the breech and feet, 3 of the former and 2  of the latter were
 lost.
   This confirms what I have elsewhere stated, that the less  the passages
 are dilated by the presenting part, the greater  the mortality amongst the
 children, because of the delay in the transit of the remaining parts of the
 body of the child.
  619. Symptoms. — The first, second,  or  third child may present natu-
 rally  or unnaturally, and in that respect the  course of the labour will
 resemble that of similar cases with  single children.   But it  is generally
 remarkable that the progress of the first  child  is slower than we should
 have expected; for, on examination, there appears no want of space, and
 the pains may be strong.  This I suppose arises from the pressure of the
 entire  uterus not bearing directly upon the child which is to pass first, but
 at least as much and primarily upon the second child.  The pressure upon
 the second child causes it to press down the first child ; but in this  trans-
 mission of force much power is necessarily lost, and thus it is that we find
 very gradual progress in these cases, notwithstanding that the pains  are
 good and the space ample.   When the first child is born, whatever sus-
 picions may have been previously entertained  are changed into certainty,
 unless in the case of a small blighted fcetus;  for, upon placing the hand
 upon  the  abdomen, the uterus is felt  nearly as large as at first, and  the
 child may be detected through its parietes.
  After the birth of the first child, there is an interval of rest, varying
from ten  minutes  to some  hours;  nay,  instances are on record  of days
and weeks intervening before  the  birth of the  second child.   Of 212
cases related  by Dr. Collins, in which the interval is accurately marked,
in 38  it was 5 minutes; in 29, 10 minutes; in 45,  15 minutes; in 23, 
404
PLURAL BIRTHS.—MONSTERS.
20 minutes; in 30, half an hour;  in 5, three quarters of an hour; in 16,
1 hour; in 8, 2 hours; in 3, 3 hours; in 5, 4 hours;  in 1, A\ hours; in
3, 5 hours ;  in 2, 6 hours ; in 1, 7 hours ; in 1, 8 hours ; in 1, 10 hours;
and in 1, 20 hours.  Thus in by far the larger number the uterine action
was resumed within half an hour.  Dr.  Merriman refers to three remark-
able cases;  in one the second child was retained fourteen  days after the
first;  in the second, it  was retained  six weeks; in the third case, the
woman was  delivered of twins, and two days afterwards of two more boys.
  After this interval, whatever it may be, the pains return;  and if there
be nothing unusual on the part of the child, the  labour  is completed in
less time than with the first child, because of the previous dilatation of the
passages.   For the same reason, when the second child presents with the
breech or foot, the mortality is  less than usual.   Dr. Denman remarks,
" the  most fortunate presentation of the second child in a twin  case  is
certainly with the inferior extremities, because it may in this position  be
extracted without injury or difficulty,  and if assistance be required, this
may be given with safety and convenience."
  620. Treatment. — Whether  the  first child present with the head or
any other part, it is to be treated exactly according to the rules heretofore
laid down, just as  if it were a single birth; and so, as far as  the labour
is concerned, must the second child;  thus if the first be a natural labour
and the second  a  mal-presentation, we need not interfere with the first,
but assistance may be necessary with the last child; or the first may be a
mal-presentation requiring assistance, and  the second a  natural labour
needing none.   So far we must act according to the nature of the case.
But suppose that the uterus do  not resume its action after the ordinary
interval, are we  still to leave all to nature ?  It is  clear that, if the pas-
sages be allowed to recover from the former distension, there will be more
trouble with the  second child, especially if  it be a mal-presentation; and
that there must  be a risk of hemorrhage so long as the uterus remains
uncontracted ; and it would seem that delay involves danger to the second
child.  For these  among other reasons, opinions have varied  as to the
necessity of interference, and as  usual  the practice has ranged from one
extreme to  the other; some  having  advised instant  delivery to  obviate
these  dangers, and others, finding that  in  many cases left to nature  no
evil has followed, recommending that we  should abstain from all inter-
ference.
  Dr. Denman advises us to wait for four hours, " if there be no cause
for delivery  sooner."  Dr. Ramsbotham two or three  hours.   Dr. Burns
about an hour.   Dr. F. Ramsbotham  agrees with  Denman.
  Dr. Campbell suggests that ergot should be  given before  we attempt
to extract  the child.   The rules laid  down by Dr. Collins appear to me
extremely judicious ; he advises a middle course: " As soon as the first
child  is born, a binder should be applied so as to make gentle pressure
upon  the abdomen; we should  not leave the house until the second child
is delivered.  If we find after  the lapse of half an hour that the mem-
branes of  the  second child still remain unbroken, they may be punctured
with advantage,  with the view of  exciting uterine  action, as the soft parts
having been so well dilated by the passage of the first, no bad result can
ensue.  This expedient in some  instances  will be found not to succeed ;
and in such cases, when we do not  observe any progress made in the 
PLURAL BIRTHS.—MONSTERS.
405
course of two  hours after rupturing the  membranes, the best mode  of
proceeding will be to pass the hand cautiously into the uterus, and bring
down the feet.  There will be but little difficulty experienced in this ope-
ration, the parts being in so relaxed a state.   When the  head  has made
any  considerable descent  into the pelvis, the  forceps will be the best
means of affording  assistance.  It is very rarely, however, that we are
called upon to  effect delivery by either of  the latter methods:  yet  expe-
rience has shown that the  second child is very likely to be still-born if
left longer than two  or three hours unassisted."
   There are circumstances, as Dr. Merriman has justly  observed, which
would negative any  delay in the delivery of the second child;  as, for ex-
ample, 1, when artificial aid has been required with the first child; 2, when
the second child presents preternaturally ;  and 3, when the labour is com-
plicated with convulsions, hemorrhage, &c.
   Any deviation from  normal  labour with  the second child is  to  be
treated according to the rules  laid down, without regard to  its  being a
twin case.
   621. With regard to the  placenta of  the first child; unless  it come
away quite easily, I  believe that in all cases  it is  better to leave it until
after  the birth of the second child, as its removal might excite uncon-
trollable flooding.   After  the birth of the second (or  third) child, the
binder is to be tightened,  and some degree of  pressure  or friction made
upon the uterus, and when we find it disposed  to contract, then  we may
draw down (in the axis of  the upper outlet) first one cord, and if that do
not yield, the other,  or both together, so as to aid in the  expulsion.   But
it must be remembered that after the delivery of plural children the uterus
is less disposed to renew its exertions, and therefore a longer interval must
be allowed: and  that  by  the detachment of the placenta a much  larger
surface of bleeding vessels will be exposed, and, therefore, that we should
avoid  their forcible  separation  by traction,  and should be  particularly
careful to  secure the due and permanent contraction of  the uterus after-
wards.
   "In twin cases,"  Dr. Collins  observes,  "when it becomes necessary to
remove the placenta, we should  be careful not to withdraw our hand from
the uterus, until both be separated, at the same time waiting for uterine
action, so as to induce  as  perfect a contraction of this organ as practica-
ble :  a point of most vital importance."
   The shock to the  nervous system is generally greater than after natural
labour, and in  some  cases it is very severe :  this may justify the exhibition
of stimulants and opium, and it demands extreme quiet  and care.
   The management  of twin cases applies  equally to triplet and quadruple
cases; especially the care recommended as to the placentas.
   Dr. Denman states that " it is a constant rule to keep patients, who have
borne one child, ignorant of there being another, as long  as it can possibly
be done."   There  is certainly no occasion to frighten the patient by an
abrupt communication; but,  on  the other  hand, I do believe that conceal-
ments are bad, and that in midwifery as everywhere else, " honesty is the
best policy;" besides, the patient is almost certain to suspect  the state of
the case, and to inquire concerning it.  I  think with Dr.  F. Ramsbotham,
that in all cases " it is better neither to inform  her abruptly of the nature
of the case, nor to make any mystery about it; but certainly to tell her, 
406
PLURAL BIRTHS.—MONSTERS.
that she will soon give birth to a second ;  and this may be coupled with a
congratulation on the fortunate progress of the labour so far;  and an assu-
rance that she will have but little more pain to bear, and that the case pre-
sents  no feature calling for anxiety."
  622. I have hitherto spoken only of twin cases in which  one of the
children only presented; but it has occasionally happened, that both bags
of membranes have ruptured, and  an extremity of different children de-
scended at the same time.   Thus, the late Dr. Fergusson of  this city, has
published  a case in wrhich the  head of one child and  the  foot of^ another
presented  together.   The midwife  drew down the leg, and so jammed
the  head and breech in the  pelvis together.   However, the pains being
powerful,  expelled the natural presentation first and the other  afterwards.
A similar case is recorded  in  the Edin. Med. and Surg. Journal, 1822,
by Mr. Alexander, and Mr. Allen relates one in  the Med. Chir. Trans.
vol. xii., in which the two heads  occupied the pelvis together, and both
were  naturally expelled.   Dr. F.  Ramsbotham mentions  having been
called to a case when a right and  a left foot belonging to different children
presented; he pushed  up one  and  extracted by the  other,  and both
children were born living.
  Such cases are no doubt  very puzzling at first,  and may excite some
anxiety as  to the result;  but it may be remarked, that the  descent of a
foot with the  head proves that the pelvis is unusually large, and in all the
cases  it appears  that the pains were very powerful.  It would, therefore,
be right, if we could not push up one of the presenting parts,  to give  fair
play to the natural powers, and only upon conviction  of their inefficiency
to lessen the bulk of one child.  If the head  of the footling  case were
within reach, it would be better to operate upon it, as the  child's  life will
have already  been compromised by the pressure upon the cord, whilst the
other  child has incurred little or no  danger.
  In  such a case as Dr. F. Ramsbotham's,  we must of  course  adopt a
similar line of practice, pushing up one leg and drawing down the other,
until the breech be engaged in the upper outlet.
  623.  II. Monsters. —All that  is obstetrically important  relating to
this subject may be comprised in a few words.  As far  as  we are con-
cerned, we may divide all these  deviations from  normal formation  into
monstrosities by  defect and excess,  those  from  disease, and the  cases
where two children are conjoined.  The only practical point involved, is
their relation in size to the pelvis ;  consequently with those by defect we
have nothing to do, as there is no difficulty in their transit through the
pelvis.  Monsters from excessive development of  different parts likewise
come under the class of which we are treating, just so far as their bulk is
rendered disproportionate to the pelvis.
  624. The principal diseases which  render  the child disproportionate to
the passages, are hydrocephalus and ascites.   Neither are very uncommon,
and most practitioners must have met with cases of them.  When a child,
affected with hydrocephalus, presents  at the  brim, the  entrance may be
effected with difficulty, or it may  be quite impossible: the head is nearly
incompressible.   On examination, therefore, we find that, notwithstanding
good pains, in well-marked cases, the head does not dip  into the pelvis;
that no advance whatever is made by the uterine pressure (fig. 135).  The
head  feels full and tense.   If the  labour were  left  to nature we should, 
MONSTERS.
407
after due time, have all the bad symptoms of a prolonged second  stage.
The diagnosis is obscure: if we ascertain  the pelvis to be of the usual
size, and  still find that the great bulk of the head is above the brim and
cannot descend, the case is clearly one of  great disproportion, and it  is

                               Fig. 135.
equally plain that the excess is on the part of the child; in such circum-
stances it will be fair to suppose the case one of hydrocephalus, especially
if we find the pulsations of the fcetal heart have ceased.
  I need  not  say that the diagnosis will be  much more difficult if the
feet present, although the same  principles  of treatment  apply  equally,
first having established the impracticability of delivery, from relative dis-
proportion.
  625. In ascites, there is much less  obscurity; the head  having been
expelled, it is easy to  see  that the difficulty arises from the distension of
the abdomen of the child, and a careful examination will, in most cases,
distinguish between ascites and tympanites.   In the latter  case, the air is
seldom limited to the  abdomen, but the face and chest will be found more
or less puffed.
  626.  Double monsters  are  very rare, and may create great difficulty
in the delivery, although there are cases on record of the children having
been born alive.  Dr. Burns quotes several such:  "In the seventh volume
of the Nouv. Journ. p. 164," he says, " is a case where two children were
born at  the  full time, united by the  inferior  part of the belly, from the
centre of which came the  cord.   The vertebral columns almost  touched
at the lower part.  The two children, who were of different sexes, lived,
we are told, twelve days,  but nothing is said of the labour.  In the Bul-
letins for 1818, p. 2, two  children, who were joined by the back  at the
sacrum, are  stated to have been  born,  and lived till the ninth day.  The
first child presented the head, but the midwife could not well tell how the
second got  out.  There  is another  case, at page  32, of a woman who,
after many days of labour, bore a monster double in its upper parts. The
6pinal column was united from the sacrum to the top of the dorsal vprte- 
408
MONSTERS.
brae, then the cervical vertebrae divided to form two necks.  The midwife
finding the head to present along with the cord and a hand, tried to turn,
but could discover nothing but superior extremities.   She, therefore, let
her alone.   The head was  afterwards expelled, but neither nature nor
art could  deliver the body.   M. Ratel finding the head  and two arms
already almost separated from the  body, cut these parts  off, then intro-
ducing his hand, he found  another head,  turned the child, and brought
away the whole mass."
   There is a skeleton in the Royal College of Surgeons of Ireland of a
double monster, the children being joined by the lower part of the sacrum,
and I believe they were also born alive.  The Siamese twins  is another
instance of the kind.
   627. Treatment. — I  have already stated the  general principle  by
which we  are to be governed in  all these  cases.   Whenever the  mon-
strosity adds so much to the bulk of the child as to render the delivery
impracticable by the natural powers, we must lessen the bulk.
   In  cases of hydrocephalus there  need be no hesitation ; in most cases
the child is dead, and, as in well-marked examples there is no chance of
such an adaptation  as will enable the head to pass, the sooner it is per-
forated the better. The ground of the operation is the mechanical impedi-
ment to delivery, and the death of the child  will justify  an early inter-
ference.   The operation is very easy;  but, should the  operator not have
suspected hydrocephalus, but disproportion from another cause, the sudden
rush of water may alarm him lest he should have perforated the bladder.
In footling cases the head must be perforated behind the ears.
   When the body cannot be extracted, owing to the distension by air or
water, relief  may be afforded by plunging the perforator into the body.
   As to  the double monstrosity, Dr. Burns  remarks very truly,  "the
general principle of conduct must be, that, when the impediment is very
great, and does not yield to  such force as can be safely exerted by pulling
that part which is protruded, a separation must be made, generally of that
part which is protruded, and the child afterwards turned, if  necessary.
Unless the pelvis be greatly deformed it will be practicable to deliver even
a double child by means of  perforation of the cavities,  or such separation
as  may be expedient,  and  the use  of the hand,  forceps, or crotchet,
according to circumstances.  A great degree of deformity may render the
Caesarean operation necessary.
   I may add, as a caution to my junior readers, that the  destruction of
a monster after birth (no matter how great the deformity) is punishable w
infanticide. 
CHAPTER XVin.
           PARTURITION-CLASS III. COMPLEX LABOUR.

     •   ORDER 1. PROLAPSE  OF THE FUNIS UMBILICALIS.

  628. Having fully considered natural labour, where the agents or ele-
ments of parturition are equally balanced; and  unnatural labour, where
the abnormal deviation is dependent upon some deficiency or irregularity
in the power, the passages, or the child, we shall now pass on to the third
class, or complex labour, in which, as I observed before, the characteristic
is not any thing in the mechanism of labour, but arises from some acci-
dental  complication.   The labour itself may be natural or unnatural, but
more frequently the former than the latter: however, with the  considera-
tion of the labour (except as connected with the complication) we  have
nothing to  do.                                                  .
   The first complication I shall describe is prolapse of the funis, either
alone,  or along with the presenting part; and occurring either at the
commencement or during the course of the labour.

                              Fig. 136.
  This  accident has  no influence whatever upon the progress of the
labour;  but a very serious one upon the life of the child, and any inter-
ference which may be advised is for the purpose of rescuing it from peril.
  629.  Statistics. — We may form some  idea  of the frequency of its
occurrence and of the result to the child, from  the following table: —
                                2K                     (409) 
410                      PROLAPSE  OF THE
1. Frequency.
British Practice.				French Practice.		
		Total No.	Prolapse		Total No.	Prolapse
		of Cases.	of Twins.	Authors.	of Cases.	of Twins.
Dr. Bland. . .		1,897	1	Mad. Boivin . .	20,517 '	38
Dr. Jos. Clarke .		10,387	66	Mad. Lachapelle	15,652	26
Dr. Merriman .		2,947	8	M. Mazzoni . .	452	18
Dr. Granville Edin. Lying-in 1 Hospital . J		640	1			
		2,452	3			
Dr. Collins . .		16,414	97	German Practice.		
Dr. Cusack .		398	6			
Dr. Maunsell		839	2	M. Richter . .	624	4
Mr. Gregory.		691	7	A. E. v. Siebold	492	2
Dr. Beatty .		1,182	6	Dr. Voigtel . .	29	1
Mr. Lever		4,666	6	Dr. Jansen . .	13,369	86
Dr. Reid . .		3,250	16			
Mr. French .		89	1			
Dr. Churchill		1,525	7			
Drs. M'Clintock ) and Hardy £						
		6,634	37			
  Thus; in British practice it occurred 263 times in 54,011 cases, or about
1 in 207^; in French practice, 82 times in 36,621 cases, or about 1 in
446^;  and, in German practice, 93 times in 14,514 cases, or about 1 in
156.  Taking the whole together, we have 105,146 cases, and 437 exam-
ples of prolapsed funis, or about 1 in 240.
  The risk to the child may be estimated from the following table:—
2. Mortality.
			Cases	Chil-	Cord	Delivered Naturally.	Delivered	Delivered
Authors.			of Prolapse.	dren lost.	re-placed.		by Version.	by Forceps.
Mr. Giffard			21	17	2		15	5
Dr. Smellie			6	2	,		5	
Mr. Perfect			4	8			4	
Dr. Jos. Clarke .			66	49				
Dr. Merriman .			8	4				
Dr. Ramsbotham			1	1	. ,		1	
Dr. Collins.			97	70				
Dr. Cusack			5	5				
Mr. Gregory			7	4				
Dr. Beatty.			6	4				
Mr. Lever .			6	2				
Dr. Churchill .			7	5				
Drs. M'Clintock and I	[ardy		87	25	5	6		
Mad. Boivin			38	9			25	13
Mad. Lachapelle			26	7	2	1	10	13
Dr. Voigtel			1				1	
Dr. Jansen .			86	38			46	6
  Here we find that out of 392 cases of prolapse, 245 children were lost,
or more than one-half; a larger mortality than we find in any other order
of practicable labour. 
FUNIS  UMBILICALIS.
411
  It must always be  remembered, when speaking of the results of this
accident to the child,  that in lying-in hospitals many of the cases do not
seek admission till some time after the occurrence, when the chance of a
safe delivery is diminished; and some not until  the cord has  ceased to
pulsate.   Twenty-two such cases occurred out of the 73 unfavourable
ones Dr. Collins has recorded.
  630.  Causes. — Many circumstances have been assigned  as likely to
cause, or to favour the occurrence of this complication.
  1. Mal-position of the child.—Smellie, in his plate of this accident, has
represented the child  lying across the uterus, with the  umbilicus  at the
upper outlet, and the cord hanging down in the cavity of the pelvis; and
Froriep regards this as an exact explanation.  After a careful examination
of the cases I  have seen, and a tolerably extensive investigation  into those
recorded  by authors, I can find few, if any, facts in support of  this view,
and must, therefore, attribute the explanation rather to Smellie's ingenuity
than to his observation.
  2. It would appear that a small child, with  a large quantity  of the
liquor amnii, by allowing the head of the fcetus to move away from the
brim of the pelvis during the latter months, will favour the  escape of a
loop of the funis.
  3. The sudden rupture of the  membranes, and the forcible rush of a
large quantity of the liquor amnii, may have a similar  effect, and especially
when aided by an untoward position in the  mother,  as occurred to a
patient  of mine who was standing  up when  the membranes suddenly
ruptured.
  4. It will be favoured by a presentation of the feet or knees, as they do
not fill up the upper outlet; and even where the cord does not descend
at the  commencement of labour, it may before the breech enters  the
pelvis.   M. Naegele is not correct, however, in stating that it  occurs most
frequently with footling cases.
  5. M. Naegele adds, irregular shape, or irregular action of  the  uterus
as an occasional cause.
  6. Excessive length of cord forms undoubtedly an important element;
but it requires other conditions also, since in the  cases  of cords of from
thirty-six to fifty-four inches long which I have noticed, no prolapse oc-
curred.
   7.  I  may state, from my own observation, that  I have found, in several
cases of prolapse, that the placenta was situated low down near the cervix
uteri, and, in  some few others, that the funis was inserted into the lower
edge of the placenta.
   There  are cases, however, which  are  not attributable to any of these
causes.
  I have already mentioned a case  in which prolapse was prevented by
the coiling of the cord round the neck of the child.
  631. In all cases of prolapsed funis, the child  is in the utmost danger
from the moment the upper strait of the pelvis  is  filled by the part of the
child descending, in  consequence of the pressure upon the cord, just as
in footling cases.  The effects  of this pressure are in proportion  to  the
time it  is continued, if the cord be  not  partially shielded  from it  by its
situation.
  There  are but few cases in which the child escaoes safely when the 
412                       PR0LAP.SE OF THE
labour is left to the natural powers.  In  those in which I have seen this
happy result, the pelvis was very large, the child of a moderate size, and
the pains very violent, so that the second stage of labour occupied but a
very short  space  of time.   The  same  result will obtain in those cases
where the cord is shielded from pressure, by being lodged in the angle at
the junction of the sacrum  and ilium.  The chances will be  still greater,
if the patient have previously borne five or six children.
  632. Treatment.—The means to be  adopted will  depend entirely
upon the state of  the prolapsed cord.   Should it exhibit marks of putre-
faction, or be without pulsation, it will  be useless to interfere, because
hopeless as regards the life of the infant, and the labour may be allowed
to terminate naturally.   Capuron advises us not to interfere at once, even
though the  cord  should pulsate, but rather  to wait until the pulsations
become feeble.  It will certainly be desirable that the os uteri should  be
as  much dilated  as possible;  and  if we discover the prolapsed cord
before the  rupture  of the  membranes, it will be well to postpone their
rupture until that  object be effected.
  Various modes of management have been proposed.
  1.  We are advised to push  the  cord upwards, beyond the brim of the
pelvis, and there to retain it with one or two fingers, until the upper outlet
be filled by the descending head.
  This would seem easy and certain, but in practice it is not so;  for the
pains which force down the head, force down the cord also,  and besides,
there is some risk of displacing the head.  This re-position  is still more
difficult, if any other part than the head present.  On the whole, I believe
I may say that it rarely succeeds.
  2.  It has been  proposed to return  the cord, and to  hook it over the
limbs of the child.   This may also succeed, but it is a very difficult and
a somewhat dangerous  operation, and I am  inclined to agree with Dr.
Burns, that " if the hand is to be introduced so far, it is better at once to
turn the child."*  It  is but right to add, that Sir R. Croft succeeded
twice in this way.f
  3. Various mechanical expedients have been  contrived for retaining the
cord  when  replaced.  Thus enclosing  the cord  in  a leather bag, and
pushing it beyond the  head of the child, was recommended  by Mac-
kenzie ;| attaching the  cord to  the extremity of a canula, by Ducamp;
or of a catheter, by Dudan ;§  the reductor, by Aitken ; a thin elastic flat
rod of steel, by  Dr. D. Davis ;|| and a modification of some of these
contrivances was  suggested by Champion, Favereau, and Guillon.H
  Dr. Harris, of  Philadelphia, returned  the cord  above the knees in a
Dreech presentation, and the child was saved.
  4.  Osiander, Busch, Hogben, and Hopkins,  propose to retain the cord
by  introducing a  piece of sponge after its replacement.
  5.  Dr. S. Merriman has twice  succeeded in saving the infant, not by
leturning the  cord, but by placing it in  the angle formed by the junction
            * Principles of Midwifery, p. 433.
            ■j- Merriman's Synopsis, p. 99.
            J  Merriman, p. 99.
            § Revue Med. 1828, vol. iii. p. 502.
            |] Elements of Operative Midwifery, 1825, p. 170.
            J Velpeau, Trait6 des Accouchemens, p. 342.  Ed. Brux. 
FUNIS UMBILICALIS.
413
of the sacrum and ilium, where it is in a great measure shielded from
pressure.
  6.  If we determine to try the  preceding plans, or if the advance of the
head  preclude  any attempt at re-position, or, lastly, if the cord  come
down during labour, we  may increase the chances  of safety by applying
the forceps and hastening delivery, as soon as the head is within reach.
  7.  If the patient have had children before, and if the pelvis be roomy,
and the soft parts well dilated, perhaps  the best chance for the child is in
turning, particularly if there should be a mal-presentation.
  But as  this operation  is  not  without hazard to the mother, we should
accurately estimate the favourable or unfavourable probabilities as regards
the child,  before we attempt it.
  Madame Boivin  turned the child  in  25 cases, and used the  forceps in
13  out of the 38 cases she has recorded, and saved 29 children.  Madame
Lachapelle in 23 cases used the forceps 13  times, and version 10; 17
children were saved.
   In one  case, Dr. Collins saved the  child by returning the  cord, and
retaining it by the hand  in the vagina; in another, by enclosing it in  a
linen bag, returning  it, and retaining it there by introducing a piece of
sponge.*
   Should  the delivery have been completed within  a short time after the
cord  has ceased to pulsate, it will be  our duty to employ for some time
the usual  means for resuscitating the child:  so long as the heart beats
ever  so faintly, there  is hope.

  * " Many various methods of repositing the cord, or putting it back into the womb,
above the fcetal head," remarks Dr. Meigs (Obstetrics; the Science and the Art, 2d ed.),
" have been proposed; they have mostly been found ineffectual, the cord being apt  to
fall down again, even  after it had been put into the proper place. I have never yet
had an opportunity to try a method which I beg leave to propose to  my readers, and
which is as follows: Take a piece of riband or tape, a quarter of an inch wide and four
or five inches long.  Half an inch from the end, fold the tape back, and sew the edges
so as to make a small pocket.   Then fold the  other end in the opposite direction, and
sew that also, to make a pocket of it.  Now if the cord be taken in the tape, and held
as in  a sling, a catheter may be pushed into  one of the pockets,  and  that one thrust
into the other, so that we shall have the cord  held as in a sling, which is itself sup-
ported on the end of the catheter or womb-sound.  Let the catheter be now pushed up
into the womb, beyond the fcetal head; it will carry the secured portion of cord with
it, and the  catheter being withdrawn, the tape is left  in the uterine cavity,  where no
harm  can be occasioned by its presence.   If required,  several such  tapes could be
secured round the cord, and  all of them fixed on the end of  the  Bame catheter, and
pushed at the same moment far up within the cavity of the womb." — Editor
2k2  . 
CHAPTER XIX.
           PARTURITION. —CLASS III.  COMPLEX LABOUR.

             ORDER 2. RETENTION OF THE PLACENTA.

  633. In the definition of natural labour I included the expulsion of the
placenta " in due time;"  and when speaking of the third stage (§ 339) I
mentioned that Dr. Clarke found the  average interval  between  the birth
of the child  and expulsion of the after-birth was 20 minutes, and that out
of 277 cases observed by myself, in 250 it was expelled within a quarter
of an  hour;  from these data I remarked "we may conclude  with the
highest authorities, that in natural labour the placenta ought to be expelled
within an hour or an hour and a half,  and that when  the interval  exceeds
this, the case fairly comes under  the order of " retained placenta."
  There is, however, an exception to the stringent  application of this rule,
and that is when,'from the length of the labour or  its abnormal character,
the uterus has  been over-fatigued, so that it does  not so soon resume  its
contractions.   There is no reason to suppose the  uterus exempted from
fatigue in proportion to its exertions,  any more  than any muscle of the
body; and when it has been so fatigued,  we do find that it requires and
takes a longer interval of rest than usual, and that after this has elapsed,
it contracts again, and expels the remaining contents.  In estimating the
interval which ought  to elapse  before we interfere, we must,  therefore,
take into  consideration  the peculiar kind of labour and probable  amount
of fatigue, and allow a  certain variation accordingly.
  Some writers  have recommended that the placenta should  never  be
extracted except in case of hemorrhage;  but it was found that if left to
nature, it was occasionally retained until it putrefied  and excited uterine
inflammation ;  for this reason, others recommended its  immediate extrac-
tion ; but the truth appears to lie between  the two  extremes.  We do not
interfere when the uterus is adequate  to the expulsion, but when we are
convinced that its efforts are suspended  or inadequate, we extract it, to
avoid the risk of hemorrhage or inflammation of the  uterus.*

  * No patient can be safely left until the placenta is delivered and the uterus has bo
far contracted as to secure her from the danger of hemorrhage.  Dr. Robert Lee is of
opinion that, "in all cases, whatever the cause of the retention may be, if the placenta,
at the end of an hour, is not detached from the uterus and  expelled, it should be with-
drawn artificially by passing the hand along the  cord to its insertion, expanding the
fingers, and grasping the whole mass, or as much as can be seized and brought away.
The difficulty of removing portions of  placenta, adhering with more than  the natural
firmness to the uterus, is only increased by delay."—Clinical Midwifery, p. 191.  But,
with Dr. Meigs (op. cit), we believe " there can be, nor ought to be, no fixed rule on the
subject, except this one rule, namely, the placenta must be got  away, as there is no
security while it is left."  Dr. Meigs thinks that he has never waited for its spontaneous
extrusion more than an hour and a half, for  he has always supposed that if it would
not take place  in one hour, there was little prospect of its  taking place in twenty-four
hours.  He admits, however, that cases may and do occur, in which  a longer delay
might be advisable;  though he has not met with such cases. These remarks, of course,
refer to the placenta retained in utero, and not to  cases where  it is partly expelled into
the vagina; for, when in the vagina, there can certainly be no necessity for waiting at
all; it ought to be removed at once. — Editoe.
                                                            (414) 
RETENTION OF THE  PLACENTA.               415
  634. Definition.—I would therefore define cases of retained placenta"
to be those in which the uterus does not, after a  due interval of rest,
detach or expel the placenta, and which, consequently, require extraction.
This interval  may  be fixed at  an  hour and  a  half, or  thereabouts, for
ordinary  cases; but, on the one hand, more time may  be required if the
fatigue have been excessive, and on the other, prompt interference will be
necessary,  if hemorrhage supervene.
   635. Statistics. —The following table will enable us  to estimate its
frequency,  causes, and, in some measure, its consequences.
	Total	Retained		Irregular	Morbid	Mothers
Authors.	Number of Cases.	Placenta.	Inertia.	Contrac-tion.	Adhesion.	lost.
Mr. Giffard . .		24	3	7	11	3
Mr. Perfect . .		19	2 •	14	3	4
Dr. Jos. Clarke .	10,387	21		5		5
Dr. Ramsbotham		27	' 2	1	24'	10
Dr. Granville. .	' 640	7				
Edin. Hospital .	2,452	6				6
Dr. Cusack . .	701	22	. .	5		1
Dr. Maunsell. .	416	2				
Dr. Collins . .	16,414	66	37	19	10	6
Dr. Reid . . .	3,250	32				
Dr. Beatty . .	783	1	1	.	.	1
Mr. Lever. . .	4,666	37	22	. .	15	
M. Riecke. . .	219,303	188				
A. E. v. Siebold .	238	8	1			
   From this it appears that in 259,250  cases, it occurred 392 times, or
about 1 in 661 ^.  In 186 cases, when the result to the mother is given, 36
died, or about 1 in  5:  but much allowance must be made for this exces-
sive mortality, owing to mismanagement on the part of midwives before
an  accoucheur  is called in.   The immediate cause of death is generally
hemorrhage.
   636.  Causes and Treatment. — The principal causes of retention of
the placenta are: 1. Inertia  of the uterus.   2.  Irregular contraction of
the uterus:  and 3. Morbid adhesion between the  uterus and placenta.
These we shall consider separately with their treatment.
   1.  Inertia of the uterus. — I have already stated that the contractions
which expel the child  may detach partially or wholly the  placenta, or it
may be unaffected by them:  in this state it will of course remain until the
recurrence of uterine  action.  But cases not unfrequently occur in which
the uterus remains quiescent  after expelling the  child, owing  sometimes
to the length and severity of the labour, and sometimes apparently to a
peculiarity of uterine constitution ; in other words, to  a cause  unknown.
Now if  in such  cases  the  placenta be  entirely adherent, no evil conse-
quences will result for some time ; there is, of course, the risk of a partial
separation occurring, and a secondary risk from decomposition if it remain
long enough :  but there is no immediate danger.   On the other hand, if
it be partially or wholly detached, and lying in the uterus, the  separation
will have exposed many large vessels, and the absence of uterine  con-
traction permits the  uncontrolled escape of blood, so that in these cases
        27 
416
RETENTION OF THE  TLACEXTA.
         there is generally more or less flooding—it may be even to a fatal extent:
         therefore, in addition to the more distant danger, which these cases  share
         in  common with the former, there is immediate danger from  hemorrhage
         of  the most urgent kind.
           If the hand be placed upon the abdomen, the uterus is  felt large and
         flabby, without any of the firmness which  is its characteristic in a state
         of  active contraction.
*          637. Treatment. — The promptitude of our interference depends  en-
         tirely upon the presence or absence of flooding.  If there be great hemor-
         rhage, the placenta must  be instantly removed either  by traction by the
         cord, or by the introduction of the hand.   There is one exception to this
         rule, however,  and that is when  hemorrhage has occurred to such an
         extent that the patient has fainted, and is almost moribund : in this case
         a very little additional loss may be fatal, even so little as may occur on
         removing the placenta ;  but as for the present it is arrested by the syncope,
         we may postpone the operation until the patient rallies  a little, taking care
         not to  wait until the hemorrhage returns.
           " If there have already been hemorrhage so  profuse  as  to  occasion
         danger," says Denman, "and the common consequences of loss of blood,
         as  fainting  and the  like, have already followed, the placenta ought  not
         then to be extracted,  nor the patient disturbed, nor any change made, till
         she is somewhat  recovered from her extreme debility;  as the danger
         would be thereby increased, and the patient die,  during, or immediately
         after the operation, as I have seen and known in several instances."
           There may, however, be no flooding:  and in some cases  it might be
         possible to remove the placenta by a  steady pull at the cord, but, to  say
         nothing of the risk of breaking it, we should only be exposing the patient
         to  a risk of hemorrhage by withdrawing  the  placenta whilst the uterus
         was relaxed.  The best plan is first to try and excite the uterus to con-
         tract by friction and pressure  upon  the abdomen, and  to draw by  the
         cord steadily and firmly.   If the uterus still remain inert, we are recom-
         mended by M. Mojon, and some continental  practitioners, to  inject  the
         umbilical vein with cold water, so as to stimulate the uterus by the im-
         pression of  cold.  1  have mentioned this, but I  should fear that there
         would be risk of exciting  inflammation by it.  I  have, however, repeat-
         edly given the ergot of rye in such cases,  and with the best effects; when
         successful, it brings  on uterine contractions, and causes  the spontaneous
         expulsion of the after-birth, at the same  time that it effectually guards
         against hemorrhage.   If it fail, we have no resource  but to extract  the
         placenta by the hand, an operation never to be lightly undertaken, as it is
         one by no  means  free from danger.   It should be performed very gently
         and deliberately.  The fingers, formed  into a cone, are to be  introduced
         into the vagina and os uteri, in the axis of the outlet and brim, guided by
         the funis, and so gradually up to  the placenta, which  may be grasped by
         its  inner surface, as Hamilton and Burns recommend, or the finger may be
         gently insinuated between it and the  uterus, so as  to peel it off very care-
         fully and gently.  Great care must be taken on the one hand, not to in-
         jure the surface of the uterus, and, on the other, to remove the whole of
         the placenta; and having done this, the detached mass  should be grasped,
         and the uterus, which by the operation will be excited to action, allowed
         to  expel both it and  the hand.   By so doing we shall  secure its contrac- 
RETENTION  OF THE PLACENTA.
417
tion, and  guard against  hemorrhage, and meanwhile external pressure
should be exerted by the other hand, and maintained  by compresses and
the binder.
   This operation should never be performed without clear conviction of
its necessity, as it is by no means without danger: Dr. Denman observes
that although " it is often mentioned as a slight thing, yet I am persuaded
that every person who attends  to  the consequences of the practice, will
think it  of importance,  and that, if possible,  it always  ought  to  be
avoided."
   After the operation, we must remain some time with the patient  to  be
sure that the uterus does not again relax and hemorrhage ensue, and for
some time watch carefully lest inflammation should set in.
   638. 2. Irregular contraction. — After  the  delivery  of  the child in
ordinary cases, the uterus  closes equally over the after-birth, pressing it
on all sides, and forming a globular tumour in the abdomen.   There are
occasional though rare exceptions, however, to this equal contraction, in
which the uterus contracts unequally and  yet forcibly, and  so far from
effecting the expulsion of the placenta, which is the principal object of its
contraction, it is thereby effectually retained.   This irregular contraction
sometimes follows  natural labour, but more frequently labour with mal-
presentation or instrumental delivery, and it is attributed (not without jus-
tice, I think) in some cases to the  action of the ergot of  rye.
   There  are three kinds  of irregular contraction which may  be briefly
noticed :  1. The first is seldom noticed in books, and yet it is of frequent
occurrence.  It appears to consist in a contraction of the fibres 'of the
cervix uteri to  a greater degree than of those of the body and fundus.   If
the hand be placed upon the abdomen, the uterus is  to a certain degree,
but not firmly,  contracted, whilst if the finger be  passed  into the os uteri,
the cervix is found to be hard and contracted, and the cord when pulled
does  not give.   The placenta is sometimes adherent,  but more frequently
partially or wholly detached, and a portion of it  may often be felt in  the
os  uteri.   In common with other varieties of irregular contraction there
is sometimes hemorrhage, but frequently none at all, and the necessity for
interference chiefly arises  from the indisposition  of the uterus to rectify the
irregularity and expel the after-birth.   The globular  tumour,  moderately
contracted, the narrowed os uteri, and the firm retention of the placenta,
even  when partially or wholly detached, will distinguish these cases from
all others.
   2.  The second irregular contraction is that which has received the name
of " hour-glass contraction."   The band of  fibres around the body of the
uterus are thrown into a state of permanent contraction, the  remaining
portion being  only in a  state of moderate action, giving to the uterus
something of the figure of an hour-glass,  and dividing its cavity into  two
chambers, an upper and  a lower, in  the former of which the  placenta is
mainly or entirely contained.   It may be entirely adherent, or partially oi
wholly detached, though seldom the latter.   Occasionally there is hemor
rhage.   This variety of  irregular  contraction has been attributed  to the
too rapid passage or extraction  of the child; to a lingering labour with
women of an  irritable constitution, and  to the  partial  action  ot  ergot
My friend Dr.  Douglass  thinks that hour-glass contraction rarely or never
occurs without  morbid adhesion of the placenta.   Drs. Campbell and F. 
418
RETENTION  OF THE PLACENTA.
Ramsbotham deem it a very rare occurrence.   It is very  seldom that we
can discover any irregularity of form in the uterus by placing the hand on
the abdomen, and, in consequence, the diagnosis is  very obscure, until
the hand is introduced for the purpose of extraction.
   3. The third irregularity is a preponderating contraction of the circular
fibres of the uterus, throwing the organ into the shape of a long cylinder,
so that it feels narrower than usual; and instead of a globular tumour
just above the pubis, it is often felt reaching up above the umbilicus, and
internally it  may be difficult  to  reach to the  fundus.  As in hour-glass
contraction,  there is not always flooding, and the causes are probably the
same.   The  diagnosis is aided, however, by the shape of the  uterus,
although it is often sufficiently obscure.
   639.  Treatment.—The first variety of irregular contraction can gene-
rally be remedied without the introduction of the hand.  Steady and firm
traction should be made by the cord in the axis  of the brim, and  main-
tained for some time without relaxation: this  in many cases overcomes
the spasmodic action, and the placenta is rather suddenly released.   If it
fail, one or two fingers  introduced within the os uteri  may be  sufficient,
as they may be able to seize a portion of the after-birth, and so  aid in the
traction.  I have seldom found it necessary to  do more than this; but of
course if it do not succeed, the placenta must be extracted by introducing
the hand carefully and gently as before described.
   In the  second and third form  of irregular contraction, traction by the
cord is quite ineffectual, so firmly is the placenta grasped.  We can only
wait, therefore, until we are satisfied that it will not be separated and ex-
pelled naturally, and cannot be withdrawn by  the cord, and then at once
proceed to extract it.*  The introduction of the hand is to be effected in
the way already described, until we arrive at the contraction, which is to
be overcome by gentle but steady pressure of the points of the fingers
gathered into a cone, and when wre reach the placenta, we must remember
to detach the whole, and to allow the hand to be  expelled by the uterus.
In the hour-glass contraction, the lower chamber is so complete, and the
contraction so close, that persons have suspected that the aperture through
which the cord was traced was in fact a laceration : a little patience and
perseverance, however, will show the true state of the case, and, besides,
although the child often escapes through a laceration  into the  abdomen,
it is very rare for the placenta to do so.
   Opium and vensesection have both been recommended for the relief of
irregular contraction; but I quite  agree with Dr. Ramsbotham  that  both
are objectionable.
   Let me again impress upon my readers the necessity of great care to
secure the regular, equal, and permanent contraction  of the uterus  after-
wards.
   640.  3. Morbid adhesion of the placenta to the uterus. — Many of the
diseases of the placenta to which I have heretofore (§ 180) referred, may
occasion adhesion between its  outer surface and the  inner surface of the
uterus.   Thus inflammation may end in the effusion of lymph connecting

   * As in hour-glass  contraction there can be no reasonable hope of a spontaneous ex-
pulsion of the placenta, the moment the existence of such a contraction is  ascertained,
there should be no delay ; the accoucheur should proceed at once to effect  its delivery
by manual interference. — Editor. 
RETENTION  OF THE PLACENTA.
419
the two, or in induration.   Again, the  adhesion  has apparently been ef-
fected by calcareous or scirrhous deposition.
   The space occupied by the adhesion is generally limited.
   This accident is manifestly the result of disease during pregnancy, and
has no relation to the  kind of labour.  It is much more dangerous than
irregular contraction,  because the uterine action generally detaches  more
or less of the placenta; but the adhesion retaining the mass in the uterus,
prevents its contraction and  the  closure of the  bleeding orifices  of the
uterine vessels.  We  find, therefore, more or less flooding, sometimes to
an enormous extent.   Almost the only exceptions are the few cases where
the adhesion is very extensive, and the detached part small.
   The diagnosis is in almost all cases impossible, until the extraction is
attempted:  a strong suspicion will be excited, however, by the occurrence
of pains, without extrusion of the after-birth.
   641. Treatment.—As we cannot be sure that the retention arises from
adhesion, we must only have recourse to the  usual preliminary means,
and, finding them ineffectual, to  extraction.   The  hand is to be  intro-
duced in the usual manner, and on trying to separate the placenta, we
shall discover that some part of it is closely adherent, as it were amalga-
mated with the uterus.  It would be extremely wrong to use violence in
endeavouring to detach it; if, therefore,  we cannot easily effect this, it is
better to peel off the  placenta all round up to the adhesion, and then to
separate the loose  part from the adherent portion close round the adhesion,
leaving the  latter in the uterus to  soften and come away with the lochia.
   In a case of Dr. Smellie's, in which he removed the  indurated  and
adherent portion, the  patient died of hemorrhage; and several such cases
are on record.
   It cannot be denied that danger may arise from the decomposition  of
what remains;  but we have no  means of  avoiding  it, except  by care
afterwards.   If the discharge be very offensive, vaginal injections of tepid
milk and water should be used twice a-day, and any symptoms of inflam-
mation promptly treated.
   642. The extraction of the placenta may be rendered necessary by the
rupture of the  cord, inasmuch as we can  afford  no assistance; but it is
by no means so easy, as we lose the guide it affords us  into the os uteri
and to the situation of the placenta.  In such a case, of course, we must
first try fairly what the natural powers, stimulated by friction, will effect,
and if they fail, the hand must be introduced with  greater caution,  and
the placenta very gently sought for, and detached in the usual manner.
   Once more let me  repeat the necessity of removing all the placenta, for
a small portion left behind may render all our exertions fruitless as  to the
result.
   I have deferred the consideration of the treatment of the hemorrhage
until the next chapter, as I preferred limiting this chapter  strictly to  the
management of retained placenta; the two chapters should, therefore, be
taken together. 
CHAPTER XX.
           PARTURITION. —CLASS III. COMPLEX LABOUR.

                        ORDER 3.  FLOODING.

  643.  There is  no deviation from  the ordinary  course  of  labour  so
trying to the medical attendant, as flooding;  not only on account of the
imminent danger, but from the  sudden and rapid progress  of the attack,
and the  impossibility of waiting  for  assistance.   Nothing  can preserve
our calmness and presence of mind  under such circumstances, but under-
standing the subject clearly beforehand, and being perfectly prepared for
meeting each variety of the accident with its appropriate treatment.
  I have already spoken of the hemorrhage  accompanying  abortion, and
it remains now for us to consider those forms of flooding which occur just
grevious to or during labour,  and afterwards.  During the last month of
pestation and  at the commencement  of labour, patients are exposed to
two forms  of hemorrhage, differing in their causes, but  depending upon
the  situation of the placenta.   The  first has been called " accidental he-
morrhage," because it arises  from a partial and accidental  separation of
the placenta, which occupies its usual situation; and the second is justly
termed  " unavoidable hemorrhage," because, the placenta  being placed
partially or wholly over the os uteri, the dilatation of this orifice will  un-
avoidably separate the  after-birth  and give rise  to  hemorrhage:   as
Naegele has observed, " the very action which Nature uses to bring  the
child into the world is that by which she destroys both it  and its mother."
After  delivery, flooding  may  occur  to any extent and  from various
causes.
  Each of these varieties of hemorrhage will require  a separate and care-
ful consideration.   But first let us ascertain their frequency  and mortality
as far as possible.
(420) 
ACCIDENTAL HEMORRHAGE.
421
644. Statistics :—
			j	.j	.	j	« qJ	^j	»ti
		■5 *	o	o	2 a = ■5	o	3 m> os 2 •o-g	o	I*
Author.	- <* So Ol.	£ 3 rf,u	I		u s	»	a £		
	fro		c s	5	1	s	s V 19	6	aS
		35	6	14					5
		34	13	16	6	3	24	8	3
		18	6	7	8	2	6	3	2
Dr. Bland. •.....	1,897	9	3	8					
Dr. Jos. Clarke ....	10,387	24	5	10	10	4	4	1	10
Dr. Merriman ....	2,947	32	1	14	21		4	1	b
Dr. Granville ....	640	2			1		2		
Dr. Ramsbotham . . .		69	30	13	19	8	44	16	26
Edinburgh Hospital . .	2,452	31	3		1	1	2	1	28
	16,414	131	12	17	13	2	11	2	107
	701	15			6				5
Dr. Maunsell ....	839	110	i				5	1	6
	1,182	6	1				4	0	2
	4,666	51	4	7	16	. .	13	2	35
	89	5					1		
Dr. R. Lee.....		47	10		24	4	23	6	
Dr. Reid......	3,250	52			22		3		27
Mr. Warrington....	110	4		i			2		2
Dr. Churchill ....	1,640	25	6	0	3	6	1	0	21
Drs. M'Clintock and Hardy	6,634	93			29	4	8	3	56
	624	5					5		
A. E. v. Siebold....	730	9	2	l			3	2	6
	29	1	0	l			1	0	
	13,365	11			4		7		
   From this table we find that in 75,596  cases, hemorrhage  occurred
 517 times, or about 1 in  146^; out of 630 cases of hemorrhage, 111
 mothers were lost, or about 1 in b\: out of 443 cases, 109 children were
 lost, or about 1 in 4.
   Further, out of  114  cases of accidental  hemorrhage, 28 proved fatal,
 or nearly 1 in 4 ; out of 182 cases of unavoidable hemorrhage, 51 proved
 fatal, or nearly 1 in 3^; and out of 293 cases of flooding after delivery,
 22 proved fatal, or about  1  in  12.
   645. 1.  Accidental Hemorrhage. —In these cases, as I have said,
 the placenta is in its  ordinary situation; it may be  at  any part of the
 uterine parietes except  the cervix, as then the case would come under the
 class of unavoidable hemorrhage.  The immediate cause of the flooding,
 is the  separation of some portion of the placenta from the womb and the
 laceration of its vessels: as these cannot be closed by the uterine contrac-
 tion, of course the blood is poured out freely.   The amount of the loss
 is said to be in proportion to the extent of the surface exposed, and, per-
 haps, in many cases this may be true, but there are striking exceptions -
 fatal hemorrhage  may  take place from a space not more than an inch
 square.  In some  rare cases, a  portion of the centre of the  placenta is
 detached and a cavity formed which is filled with blood, but as  it is sui-
rounded with adherent  after-birth, of course none escapes externally.  Or
it may extend beyond the placenta, and  be retained by the adhesion of
the membranes  or  other causes.   " In such cases," Dr. Burns  remarks,
" the effusion is accompanied with dull internal pain at the spot where it
takes place.   This pain is something like colic, or like the pain attending
                                2l 
422
FLOODING.
the approach of the menses.   The  part of the womb where the extrava-
sation takes place, swells gradually, and  in a short time the uterus feels
larger.  If the quantity be considerable, the size increases, the uterus is
felt to be firmer and tenser, as well as larger, the strength diminishes, and
some faintings  may come on.   In  course of time, weak  slow pains  are
felt, but if the injury be  great, these decline as the weakness increases.
They may or may not be attended with the discharge of coagula from the
os uteri."   The hemorrhage, in fact, is at first internal, and generally,
though not always, becomes external.  Dr. Burns suggests that in some
cases the bleeding may be the result of a  separation of the decidua, and
a laceration of the vessels running to that membrane from the inner coat
of the uterus, and not from a separation of the placenta.
  646.  Causes. —Violent shocks, such as blows, falls, &c. may have the
effect of detaching a portion  of  the placenta, and in some  cases  a very
slight shock will be sufficient;  I was  called  to a case the other day in
which it was effected by a hearty fit of laughter.  Besides these causes,
fatigue,  over-exertion, violent straining at stool, lifting heavy weights, ex-
cessive  action of the  utero-placental vessels,  disease of  the  placenta,
general  plethora, spasmodic action of that portion of the womb to which
the placenta is  attached, may be equally effective.  Dr. Burns observes,
" we sometimes  find that extravasation is produced by an increased action
of the uterine vessels themselves, existing as a local disease.  In this case,
the patient for some time before the attack feels a weight and uneasy sensa-
tion about the hypogastric region, with slight darting pains about the belly
or back."
  647.  Symptoms.—The exciting cause may be instantly followed by the
discharge,  or preceded by  general or  local  uneasiness,  dull  pain and
aching in  the  belly and back ;  and if the hemorrhage  be retained, by
rigors, tension, and weight in the abdomen, and by faintness.  At length,
with or without a pain, the discharge  commences, varying  in  amount
from  a  few ounces  to a quantity sufficient to compromise the  patient's
safety.
   If it  be profuse, the patient faints, of course, and for  a time the dis-
charge is arrested ; but after she has rallied, it again recurs, and the syn-
cope is  repeated.  The surface becomes blanched and covered with cold
sweat, the countenance sunk, with dark circles around the eyes, the pulse
becomes weak,  quick, and fluttering.  If the flooding be not arrested, all
these symptoms  increase ; the sight becomes dim, there is a ringing in the
ears, frequent sighing, intolerable restlessness, uneasiness, and jactitation,
and death; preceded by fainting or convulsions.
   Labour  pains may come on at some period of the discharge, or they
may be entirely absent;  a good deal will  depend on the period of preg-
nancy at which the complication occurs.   If they do, it will be observed
that during a pain the  hemorrhage  is arrested, but that it returns on the
cessation of the  pain.
   If an internal examination be made, the os uteri will seldom be found
dilated  unless there have been pains for some time, but the cervix is gene-
rally softened and relaxed by the hemorrhage ; and what  is of great im-
portance,  in most cases we can  pass the  finger within the os uteri suffi-
ciently to  ascertain  the presence of the membranes, and that no part of
the placenta is within reach. 
ACCIDENTAL  HEMORRHAGE.
423
  648.  Diagnosis. — The diagnosis of accidental from unavoidable he-
morrhage is of extreme importance, inasmuch as the treatment of the two
is essentially different.   There are three points in which the two varieties
differ remarkably, and which will enable us to distinguish them.   In the
first  place, we  can  generally make out  some definite external  cause for
accidental  hemorrhage, and its occurrence is  accidental and  irregular,
whereas in unavoidable hemorrhage, the only exciting cause is the expan-
sion of  the cervix, and the time of its first occurrence has a certain degree
of regularity.   Secondly, in accidental hemorrhage the discharge  takes
place freely, during an interval, but is at once arrested by a  pain during
its  continuance;  but in unavoidable hemorrhage the discharge,  which
continues also  during the intervals, is greatly increased during the pains.
Thirdly, in cases of accidental hemorrhage, the os uteri is free,  closed by
membranes only, and the cervix is  of equal thickness all round, whereas
in placenta praevia the os uteri is  more or less covered by the after-birth;
or if it  only reach to the edge of the cervix, the  latter is felt to be con-
siderably thickened at that part.
   Lastly, in many cases we  may ascertain the situation of the placenta by
the stethoscope, and its presence in the  body or fundus of the uterus will
decide the case to be one of accidental  hemorrhage.
   649.  Treatment. — The indications of management  must be  drawn
from the period of pregnancy, the  state of the os uteri, and amount  of
discharge.
   Let us suppose that the patient has not arrived at her full time, that she
has no pains, that the os uteri has  not  begun to  dilate, and  that the dis-
charge is  not  profuse.   In  such a case the patient  is not in immediate
danger; and as prompt delivery would  be  difficult, it may be  well to tem-
porise,  and see how far we  can arrest the discharge.   For which purpose
the patient should be placed in a bed on a hard mattrass, and very lightly
covered with bed-clothes; the temperature of the  room should be reduced
very low, and nothing but cold drinks allowed.   Enemata of cold water
exert a  very powerful control in such cases.  The plug may be used (ac-
cording to  the restrictions  formerly laid down),  inasmuch as the  uterus
being full,  there is little danger  of internal hemorrhage to any extent.
The best plug is common tow,  or one or two silk handkerchiefs; and the
object will not be attained unless the vagina be quite filled.
   Internally we may give the  acid mixture, with a large proportion  of
acid; for instance, half an  ounce of dilute sulphuric acid to six ounces
of infusion of roses ; an ounce  to be taken ever}" hour.  To tell the truth,
I think  it is more highly estimated than it deserves.  Lead in large doses
(gr. x. Acet. Plumb. 2dis horis)  has been recommended: Dr. Conquest
speaks  favourably of it.  It may be combined with opium or either may
be given separately.   I have no doubt  of  the beneficial effects  of opium
either in large doses (gr. ii.; or gtt. Ix.  Tree.  Opii), or repeated small
ones.
   Large drinks of cold water alone, or  with the addition of the nitrate  of
potash,  seem beneficial.  Of course the patient cannot be allowed  to  sit
up, or to leave her bed, and it is an advantage to free the bowels by ene-
mata, as involving less  effort in the evacuation.
   650.  There  are  many cases in which, under this treatment, the dis-
charge is diminished, and the patient carried to her full time in safety; but 
424
FLOODING.
in others it will fail, either on account of the increase of the discharge or
because the pains of labour are brought on.   In these cases, as well as in
those where the amount of discharge is great from the beginning, another
line of treatment is necessary, which would be very doubtful in the former
case.  I have said that the discharge is observed to cease during a pain,
and the reason is simple.   During a pain the  placenta is pressed against
the contents of the uterus on  the one hand, and against the bleeding ves-
sels on the other, and by its pressure, as by a tourniquet, the flow of blood
is arrested.   An observation  of this fact  led to the inference, that if the
liquor amnii were evacuated,  the pains would be quickened, the pressure
increased, and rendered more permanent, besides that the labour would
be sooner terminated.   As Dr. F. Ramsbotham has remarked, " the ves-
sels of the uterus are diminished in size by the contractions of the uterine
parietes ; the open orifices are in a degree plugged by the parietes being
brought into closer and stronger contact with that portion of the placental
mass disunited from the uterine  surface; and  the pains are usually in-
creased in frequency and  power by the augmented stimulus impressed
upon the os uteri."  Moreover, in these cases of large flooding, we need
not anticipate the usual delay in the dilatation of the os uteri; for, as I have
mentioned, the hemorrhage softens the cervix  uteri, and prepares it to
yield easily to the pressure of the head.
   In these cases,  therefore, when the flooding is profuse, and  the danger
imminent, the membranes  should  be ruptured  by the finger or a female
catheter.   Soon  afterwards,  we  find  the pains increase, the  flooding
diminish, and the labour advance.
   For the clear understanding of the  principles of this practice and the
cases to which it is suited, we are mainly indebted to the late Dr. Rigby
of Norwich, who published his valuable essay on " Uterine Hemorrhage,"
in 1775, although the  plan was  first  recommended by Julian  Clement
and Puzos.
   That the plan is very successful, we have the testimony of many authors,
as Denman,  Baudelocque, Merriman, Ramsbotham, Blundell, &c.   Dr.
Rigby succeeded by it  in 64 cases, without having occasion to turn the
child.  Dr. Merriman in 30 cases.
   Dr. Ramsbotham in  23 out of 25 cases.
   Some writers, as Hamilton, Burns, Stuart, &c. have opposed the evacu-
ation of the liquor amnii on the following  grounds : 1, that  by it gestation
is suspended : 2, that it is not certain to bring on labour in time to avoid
danger: and,  3, that it may not arrest the hemorrhage, and if not, we must
turn and deliver under  more  disadvantageous  circumstances.  The first
objection is  true,  but of no value, unless the others be true  also ; for if
the operation succeed,  and save the woman's life, which is  in danger, the
shortening of gestation is  of  no consequence.   The second  objection is
contrary to general  experience, which has established the fact, with very
few exceptions, rupturing the  membranes does  bring on labour sufficiently
quicic to escape the danger.   But supposing it do not, then the third  ob-
jection is valueless ;  because, if the uterus be not in action, there will not
be  greater difficulty in delivering the  patient after the  evacuation of the
liquor amnii than previously; and  if it be  so  much in action as to be a
serious obstacle to the operation, we may be sure that  the delivery is in
better hands than  ours, and, with very few exceptions, will terminate well 
ACCIDENTAL HEMORRHAGE.
425
  651.  But suppose we meet with one of the exceptions alluded to, in
which the rupture of the membranes  is not followed by uterine  action.
We  may then try ergot, if the danger be  not  so great  as  to  preclude
delay, or it might perhaps be as well to give it in all cases at the time of
rupturing the membranes, if there be no uterine  action.   If this fail, or in
place of it, we ought to try the effect of galvanism, by which  Dr. Radford
succeeded in cases in which there was no uterine action and a rigid and
undilated os uteri.  Drs. Hseniger and Jacoby and Mr. Cleveland have
also found a favourable result  from its employment.  If this fail, or be
counter-indicated, then we must adopt the plan recommended (without
any  definite notion of  the nature of the  case) by Ambrose Pare,  Guille-
meau, &c. &c, viz. introduce the  hand and bring  down the feet, thus
terminating  the labour.  The operation will be facilitated by the relaxation
produced by the flooding, and though more  dangerous for  the child, if
the mother's safety demand it, it must be done.
   The child may be premature, however, the  os uteri not dilated, or there
may be  other reasons  why this  operation  is  objectionable,  and in such
cases, as the os uteri is generally soft  and dilatable to a certain  extent, I
have found  it the  best plan to perforate the head  and extract with the
crotchet.  The operation is  not  difficult, nor is there any  risk; if the
operator be  careful to protect the  point of the perforator, and afterwards
to extract slowly, cautiously, and at intervals.
   652.  By one or  other of these methods, we may almost  always suc-
ceed in  terminating the labour without incurring an additional loss  of
blood, and if that have not been excessive previously, the mother may be
saved.   As we have seen, nearly  1  in 3 are lost.  There is danger to the
child in  proportion to  the hemorrhage, and additional danger if  we are
obliged to turn.
   There are cases, however, to which we are called after alarming flood-
ing has continued for some time, and although  we succeed  in delivering
the woman,  she may die afterwards from loss  of blood.   In such extreme
cases, and such only, transfusion, as recommended by Dr. Blundell, seems
to be the only resource.  It has succeeded  in 14 cases on record ; but it
has also failed many times.   It is performed  by means of a  syringe and
tube: a small tube is inserted into the median or other vein of the woman's
arm, and blood  from a healthy person is taken up by the  syringe, pre-
viously  warmed, and after expelling  all the  air from the instrument, its
pipe is passed into  the  small tube, and the blood very slowly forced in.
If the lips or eyelids  of the patient  quiver,  or  the  respiration  be more
difficult, we  must stop, or death may result.  If her  countenance and
pulse improve we may continue.   In  this manner blood to  the amount
of sixteen or eighteen  ounces  may be gradually injected, if necessary;
although a much less quantity may save the patient.
   Great care must be taken that the instrument  be clean, and of a proper
temperature, and that the blood be healthy  and  fluid.
  653.  In all these cases, a liberal but judicious allowance of stimulants
is necessary  ; but in giving them we must not forget that the subsequent
re-action will be somewhat in proportion.
  As to the  placenta, it is very often expelled  immediately after the child,
and if it be not,  it will be  much better to extract it, and  secure  a firm
contraction of the uterus, than to  allow the  hemorrhage to continue
                               2l2 
426
FLOODING.
  After the delivery is  completed, the stimulants must  be continued, if
necessary, or chicken broth may be substituted for them.  Notwithstand-
ing the danger of suspending uterine action, I have seen so much benefit
from small doses of laudanum combined with ammonia, that I have no
hesitation in recommending its  exhibition.
  The utmost watchfulness will be needed to suppress any return of the
hemorrhage, and to enable us  to guard against  any subsequent  attack;
for it should always be  borne in mind that hemorrhage is by no means a
guarantee  against inflammation afterwards.
  654.  2. Unavoidable Hemorrhage. Placenta prcevia, placental pre-
sentation, &c.—In this  variety, the flooding is the necessary consequence
of the  dilatation of the os uteri, by which the connection  between the
placenta and uterus is separated, and the more the labour advances, the
greater the disruption,  and the more excessive the  hemorrhage.   From
this very circumstance it follows that the danger is much greater than in
the former cases, and also  that what in them was  the  natural mode of
relief, is here an aggravation of the evil, and cannot be employed as a
remedy.
  In these cases the placenta  may be situated partially, or entirely over
the os uteri (fig. 137), or it may come down only to the edge of the cervix
uteri; and there  is some difference in the management accordingly.

                              Fig. 137.
  That the placenta was occasionally found at the os uteri was known as
early as the time of Guillemeau, Mauriceau,  Deventer, Pugh,  &c, but
they believed that it had originally been situated differently, but had been
detached and fallen down.   Paul Portal first spoke of it as adhering to
this part,  in consequence of which  he was obliged to deliver by art.
Giffard, Levret, Roederer, and Smellie were also  cognizant of this fact,
and they seem to have been aware of the mode in which the hemorrhage 
UNAVOIDABLE HEMORRHAGE.
427
was produced, and of its inevitable occurrence.  But it is undoubtedly
to Dr. Rigby, of Norwich, that the profession is indebted for the full and
clear elucidation of the subject.   Time, which is the great test of merit,
has only confirmed the truth of his observations, and illustrated the value
of his essay.
   655. The cause of the hemorrhage  is  evidently the  separation of the
placenta from the cervix uteri, and the exposure of the mouths of the torn
vessels; and this separation is effected and increased by the uterine con-
tractions, dilating the os uteri.
   656. Symptoms.—The first discharge is usually about three  weeks be-
fore labour commences, coincident with the commencement of the process
of dilatation already noticed.  The amount of the  discharge varies, but
in  general it is "not excessive in the first instance, nor is it accompanied
 with pain.   After its cessation the patient rallies; but in a week or two it
 returns, perhaps in greater quantity, and again ceases, thus continuing  (if
 not interfered with) until the full  term.   With  the first sensible contrac-
 tion of the uterus, the flooding comes  on more profusely,  and is observed
 to  increase during  each pain.  Thus it would  go on until death super-
vened before  delivery in most  cases, if  no  assistance were afforded.   I
 say in most instances, because  there  are some cases on  record in which
" the placenta was forced through  the os uteri before or along with the child,
 decidedly the happiest termination.  Thus Smellie and Lee have recorded
three; Ramsbotham  five;  Hamilton  two;  F.  Ramsbotham  two; Bau-
 delocque, Perfect, Chapman, Merriman,  Barlow, Collins, and  Maunsell,
 one ; &c, &c.
   Thus far the symptoms are alike (supposing the head to present) whether
the placenta be situated  entirely or partially over the  os uteri or  only down
to its margin ;  but the difference is detected on making an internal exami-
nation.   In the former case the  os uteri is felt to be  closed by a thick soft
spongy mass, firmer than a  clot, and not breaking down under  the finger,
through which the presentation cannot be felt; in the second, this spongy
mass stretches over a portion only of the os uteri;  its edge can be dis-
tinctly felt, and also the membranes covering the remaining portion of the
os uteri, through which we  may be able to detect the presentation ; whilst
in the third case  the os uteri is closed by  the membranes  only; but some
portion of the  cervix is found to be much thickened, whilst the rest is of
the usual  thickness;  in  the latter case, after delivery, the perforation in
the membranes is found  close to the os uteri.
   If the feet present, with  only a partial  implantation of  the placenta, or
with it coming  to the margin of the os  uteri  only, they may be drawn
through the os uteri; and although the detachment of the placenta will
increase with the dilatation, yet  the flooding will be  arrested by the pres-
sure of the body of the child upon the placenta.   This may be considered
as the most favourable presentation in " placenta praevia," because it saves
the introduction  of the hand to turn the child.
   The effects  of the  hemorrhage  upon the mother are precisely as before
described, but produced more rapidly, and more speedily fatal.
   657. Diagnosis. — The  sudden  and apparently  causeless  occurrence
of the first hemorrhage, the increased discharge during a pain, and the
detection of the placenta, partially or wholly covering the os uteri, or de-
scending  to its  margin, are  the  distinctive characteristics of placenta 
428
FLOODING.
 praevia;  in accidental hemorrhage, as before observed, there is generally
 some assignable cause, the discharge is arrested during a pain, and the os
 uteri is closed by the membranes.
   There may occasionally be some doubt as to whether the os uteri be
 closed by a clot or by the placenta; but the former is  less firm, and is
 easily broken up by the finger,  and we may  often feel the adhesion of the
 placenta to the cervix within the os uteri.
   658. Treatment. — If we  are called on the  occasion  of  the first or
 second hemorrhages,  and find that the discharge has  not been great, and
 that the term of pregnancy not  being complete the uterus is not in action,
 we may try palliative treatment, as previously recommended  (§ 649), per-
 fect quiet, rest on a hard bed, a cool room,  and light clothing, with cold
 and acid drinks, enemata of cold water, and small  doses  of opium, if
 necessary.  The bowels  must be gently freed.   It is hardly necessary to
 say that in no form of uterine hemorrhage is venaesection admissible.
   But the hemorrhage may be so profuse as  to demand interference, or if
 not  so at first, it will  become so immediately on the commencement of
 labour; and, from the nature of the case, there is  no hope of a natural
 termination, unless the pains be so violent as to force away the placenta
 before the child.   This occurrence, however, is  so  rare,  that it cannot be
 allowed to influence our practice, and not a  moment is to be lost in wait-
 ing for it.  Our only plan, therefore, is to terminate the labour, and before
 the  constitution has been  seriously affected, if possible.   Of course it
 would be very undesirable to have to force the hand through an undilata-
 ble os uteri; but fortunately this is very seldom the case ; the repeated
 losses soften the cervix,  so that when we perform the operation, there is
 seldom more resistance  than can be easily overcome by gentle, steady,
 rotatory pressure.
   The hand is  to be passed  in the usual way into the vagina,  in the axis
 of the lower  outlet, and its direction immediately changed into that of the
 brim, which will bring the points of the fingers near to the os uteri, into
 which they are to be gently yet firmly insinuated, and then passed between
 the placenta  and cervix, on that side on which we believe the placenta
 to be narrowest, until  it arrive at the membranes, which must be pierced,
 and the feet found and brought down.   Some writers, Smellie and Moh-
 renheim, for  instance,  have proposed to perforate  the placenta, instead
 of passing the hand between  it  and the uterus:  this is by no means easy,
 and appears to me extremely objectionable.   When the body of the child
 is in the  pelvis, it will act as a tourniquet,  and  the flooding will cease;
 nevertheless,  it is well not to delay the delivery, as  internal hemorrhage
 might occur.   The mode of completing it I  have already described : it is
 rarely that the child is saved.
   In placental presentation, even more than in accidental hemorrhage, it
 is desirable to extract  the  placenta if it do  not follow the child immedi-
 ately, and the same care  and watchfulness will be  necessary to  secure a
good permanent contraction, and to guard against subsequent hemorrhage.
Pressure  above and over the uterus should be made with  compresses and
the binder, and if  there be much draining,  cold must be applied to the
vulva, or cold enemata administered.
   659. It is an advantage if  the foot present, even when  the  placenta
covers the os uteri, because the operation of turning is  rendered easier; 
UNAVOIDABLE HEMORRHAGE
429
 A when the os uteri is only partially covered, this is still greater, because
by rupturing the membranes we facilitate the descent of the feet, and have
only to seize them in the vagina and extract the child.
  When the placenta reaches only to the margin of the os uteri, the case
is truly one of unavoidable  hemorrhage; but yet it admits of the  same
treatment as  accidental hemorrhage, no matter what be the presentation,
for after rupturing the membranes, the pressure of the head whilst dilating
the os uteri will close the mouths of the bleeding vessels with the placenta,
and so arrest the flooding until  the child is  expelled.  This I have found
by repeated experience, and therefore, when we are certain of the case,
and pains are present, our duty is limited in the first instance to evacuating
the liquor amnii; but if this fail we must turn and deliver the child.
  660.  Such has been hitherto  the mode of proceeding recommended by
practitioners of the highest authority; it remained for my learned and in-
genious friends, Dr. Radford and Prof.  Simpson, to propose another which
at first sight is remarkable mainly for its boldness,  but which Prof. Simp-
son has supported with  his usual  research, and which is  at present  the
subject of fierce controversy.
  I have already stated (§ 656) that the  placenta  is sometimes expelled
before the child, and that the  mother is not always  lost in these cases.
Now, it appears that these  instances are not so rare as  was  supposed.
Dr. Simpson has collected 56 published cases, and he has been furnished
with 74 unpublished ones (130 in all), in which the placenta was either
expelled or extracted first;  and he finds that in all,  10 women died, or
about 1 in 13: and of 110 cases  the  infant was born dead in 73  or 69
per cent., and alive in 33 or 31 per cent., i. e., nearly 1 in 3 children was
saved.  In placenta praevia, under ordinary management, 1 in 3, or there-
abouts, of the mothers are lost, and  more than half of the children.
   Taking this as a basis of his proposal, Dr. Simpson advises us in certain
cases to  substitute extraction of the placenta for turning the child.  In
justice to the Professor, it must be remembered that he does not intend
that  this plan should  in every case supersede either the rupture of  the
membranes or turning the child.
  Dr. Lee, of London, who has entered into controversy with Dr. Simp-
son, with  somewhat less of courtesy and accuracy than might have been
expected, has objected to the proposed plan : — 1. That the mortality, as
stated by Dr. Simpson and me, is exaggerated ;  but, in my opinion, he is
far from having proved this.  2. That  it was never practised by the older
accoucheurs;  but this would equally be an  objection to any improvement.
3. That  the  child  must inevitably be sacrificed;  this would  be  a very
serious  objection, if the mortality among  the  children in  the ordinary
mode of treatment were small, but it is so great that it is an insufficient
argument on  which to reject the operation.
  The probability of hemorrhage after the extraction of the placenta would
most likely occur to anyone as  an objection;  but Dr.  Simpson states that
" in  19 out of 20 cases  in which it  has happened, the attendant hemor-
rhage has either been at once arrested, or it has  become so much dimin-
ished as  not to be afterwards alarming."   This  Dr. Simpson attempts to
explain by the supposition that the bleeding proceeds almost entirely from
the placenta,  and not from the uterus.  But Dr. Lee contends, and I think
correctly, that it escapes from the uterine sinuses laid bare by the detach- 
430
FLOODING.
 ment of the placenta.  Dr. Ashwell advocates this view, and, with others
 of high authority, decidedly opposes Dr. Simpson's plan of extraction.
   661. Let us  next see in what cases it is  proposed to have recourse to
 this novel operation, and then we shall be in a condition to investigate its
 merits better.   Professor Simpson thus states the circumstances in which
 he would recommend it: — " When the hemorrhage is so great as to show
 the necessity of interference, and is not restrainable or restrained by milder
 measures  (such as the evacuation of the liquor amnii), but at the same
 time turning or any other mode of immediate or forcible delivery of the
 child is especially hazardous or impracticable in consequence of the un-
 dilated or undeveloped state  of the os uteri, the contraction of the pelvic
 passages, &c.   Or, again, the death,  prematurity, or  non viability of the
 infant may not require us to adopt modes of delivery, for its sake, that are
 accompanied (as turning is)  with much peril to the mother, provided we
 have a simpler  and safer means, such as the detachment of the placenta,
 for at once commanding and restraining the hemorrhage and guarding the
 life of the  parent  against the dangers  of its continuance.  Hence, as I
 have elsewhere stated, I believe that the suppression of the flooding by the
 total detachment of the placenta, will  be found the proper line of practice
 in severe cases of unavoidable hemorrhage, complicated with an os uteri
 so insufficiently dilated and  undilatable as  not  to allow of version being
 performed with perfect safety to  the mother; — therefore, in most primi-
 parae; in many cases in which placental  presentations are  (as very often
 happens)  connected with premature labour and imperfect development of
 the cervix and os uteri; in labours supervening earlier than the seventh
 month; when the uterus is too contracted to allow of turning ; when the
 pelvis or passages of the  mother  are  organically contracted;  when the
 child is dead ;  when it is premature and not viable, and where the mother
 is in such  an extreme state of exhaustion as to  be unable, without imme-
 diate peril of life, to be submitted to  the shock  and dangers of turning or
 forcible delivery of the infant.   This  enumeration is far from comprehend-
 ing all the forms of placental presentations that are met with in practice;
* but it certainly includes a considerable  proportion of  the cases of this ob-
 stetric complication;  and  among  them,  all, or almost all, of the most
  dangerous  and most  difficult  varieties of  unavoidable  hemorrhage.  In
  adopting the practice, one error, which I would strongly protest  against,
 has been  committed  in some instances.   Besides  completely detaching
  and exhausting the placenta, the child has been subsequently extracted by
  direct operative interference.   If the  hemorrhage  ceases, as  it usually
  does, upon the placenta being completely separated, the expulsion of the
  child  should  be  subsequently left to  nature, unless it  present preterna-
  turally, or the  labour afterwards show any kind of complication, which of
  itself would require operative  interference under any other circumstances.
  Both  to  detach a  placenta and extract  a child would be  hazarding a
  double, instead of a single operation."
     Dr. Radford states that the placenta  ought never to be detached in such
  cases unless, "1.  the danger  to the woman is so great from exhaustion
  as to  render the ordinary plan of delivery by turning the child hazardous.
  2. When there exists some obstacle to the extraction of the child, either
  from distortion in the bones of the pelvis, or tumours connected with it,
  or in  its cavity, but connected with the soft parts.   3. When  the child is 
UNAVOIDABLE HEMORRHAGE.                431
dead.  Subsequently, he protests  against the operation until the cervix
and os uteri will allow the  introduction of the hand, as  that " is the only
instrument by which the placenta should be detached;  indeed, I hesitate
not to say, that it cannot be safely and effectually separated by any other
means."
  Dr. Edwards thus sums  up the cases in which this  practice seems ad-
missible.   1. When the patient is of so weakly and delicate a constitution,
that  loss  of blood  to  any great extent would be attended with present
danger  and  subsequent  injurious effects.    2. When  the child is well
ascertained to  be  dead.    3. In cases in which the powers  of life  have
been excessively lowered  by the hemorrhage, and the os uteri  remains
firm and  unyielding.  4.  In cases in  which, although the os  uteri is
dilatable,  the powers of  life would be unequal to  the  shock of turning.
5. In primiparae, when the soft parts are so  contracted that they would
be liable to be bruised or torn in turning.  6. In contracted pelvis.
  662.  We shall now  examine in  detail the practical value of this opera-
tion  in the cases  proposed, so far  as our facts will  permit, and assuming
the correctness of Dr.  Simpson's statistics.   The rates of mortality by the
ordinary treatment, I believe to be about 1 in 3 of the mothers, and 65
per cent,  of the children, according to  a statement of  Dr. Lees, quoted
by Dr.  Simpson, i. e., of course,  taking large numbers.  According to
Dr. Simpson, when the placenta has been first expelled or detached, the
mortality  is 1  in 14 of the  mothers, and  69 per cent, of the children.  So
far there appears to be an important advantage gained by the new method,
but it will be found on further inquiry, that there  are great difficulties, if
not insurmountable objections to it.
   1.  There appears to me  great practical difference between the placenta
being expelled first, and  extracted first, although  Dr. Simpson makes
none, but includes both equally in  his statistical table.   The former is the
result of vigorous  uterine  action, the latter may or may not be accom-
panied by it, and I think there is  much  force in the doubt expressed by
Mr.  Barnes, as to whether  the results would be as favourable in  cases of
detached  as of expelled placenta.   The  17 cases quoted from Dr. West,
by Dr. Simpson, are much  too few for proof.   Dr. Radford has given two
tables, the first of 41 cases, and  the second of 14 cases, in  which the pla-
centa was separated and detached by the hand, and of these 5 mothers
were lost, or 1 in 11, and  7 children saved, or 1 in 8.   Of 20 no infor-
mation  is given.  We must remember  that  in the one case there is no
irritation,  no force applied  to the cervix  and  os uteri: in the other there
must be.
  2.  This distinction between detached and  expelled placenta, alters the
ratio of mortality among the children fearfully.   Dr.  Simpson has recordeu
in his tables but one case of the child being born alive,  when the interval
after the expulsion or extraction of the placenta was  more than 10 minutes
and 16 of the 17 children, in the cases quoted from Dr. West, were lost.
If any attempt be made  to save the child by artificial  delivery, this wdl
be to " incur the hazard of a double operation," and will defeat the object
of Dr. Simpson's proposal.
  3. In Dr.  Simpson's first table of 47 cases, with an interval  after the
expulsion  or extraction of the placenta of from 10 minutes to 10  hours
before the birth of the child, I find that delivery was completed by art in 
432
FLOODING.
18 cases;  in 14 of them by turning.  In  the  second table of 21 cases,
where the interval was less  than 10 minutes,  in 7 cases by turning, ami
in 1 by evisceration.   In the third table of  27 cases, where  the child
came with  the  placenta, or  followed immediately, there are 5  cases of
turning, and 1 of extraction recorded.  In the fourth table, of 27 cases,
where  the  interval  is  unknown, delivery was  effected  by turning in 15
cases, by the forceps in 2, and by decapitation in 1.
  From this it appears that  in a very large proportion of cases (46 cases
in 119), artificial delivery was necessary, in many no doubt from mal-pre-
sentation ; but still in these cases detachment of the placenta alone would
have been useless, in many injurious;  nor  if the operation were performed
before the dilatation of the os uteri could the mal-presentation have always
been ascertained.  Again, we find that delivery by art was more frequent,
according as the interval after the separation of the placenta was prolonged,
and I should suppose, although  Dr. S. does not mention it in his tables,
that the interval would be  much greater in  cases where the placenta is
extracted, than where it is expelled, and, consequently, that the probability
of a second operation being necessary, would be greater in such cases,
which would constitute  another important difference between  these two
classes of cases, or, as Dr. Simpson admits, would double the hazard.
  Of 41 cases given by Dr. Radford, " in 18 turning was  performed, in
6 it is presumed to have been so, in 1 the child was drawn by the pre-
senting leg, 16 were terminated  by the  natural efforts, 1 by the vectis, 1
by the perforator and crotchet."   In table 2d, of 14 cases, 2 were termi-
nated by the natural efforts, 10 by turning, 2 by the forceps.
  4. The first class of cases in which Dr. Simpson thinks this new method
advisable, is where the hemorrhage is excessive, and the os uteri undilated
and undilatable.  Now although it  is evident that so  long as  this state
continues (fortunately it is rather the exception than the rule) turning is
impracticable, I confess I do not see how the placenta can be easily or
safely detached.  I put out  of the question using any instrument  but the
finger for  this purpose, for I quite agree with  Dr. Radford  that any other
would be extremely hazardous to the mother  under such circumstances.
And I concur with him that " in those cases of unavoidable hemorrhage
which  occur before the expansion of the  cervix uteri, it would  be quite
impossible to force the finger along the cervical canal, and reach the edge
of the placenta, so as entirely to detach it; and in those cases which occur
at the latter part of pregnancy or b ginning of labour with a rigid os uteri,
it appears  to me to  be out of  the power of the operator with the finger
alone to reach so far as the edge of the placenta."  It must also be borne
in mind that Dr.  Simpson's favourable rate of mortality  does not apply to
this class, as there are no statistics of such cases.
   5. " In premature  labours, with  an undeveloped os uteri," there will
be  the  same difficulty in detaching the  placenta, whether the  child be
viable  or not, and we are in the same  ignorance of what would be the
result to the mother.
   6. In a great number  of the cases in Dr. Simpson's tables (23 in 91),
as we have  seen, the  presentation was abnormal, of the shoulder, arm, or
hand and head, and in such cases artificial delivery must take place, and
it may be a question whether if  we first merely removed the placenta, on 
UNAVOIDABLE  HEMORRHAGE.
433
account of the exhaustion of the mother, we should not thereby increase
the difficulty of turning at a subsequent period.
   7. In the cases mentioned by Drs. Simpson, Radford, and  Edwards
of distortion of the pelvis, or tumours in the soft  parts offering an obstacle
to the extraction of the child, the new operation would not be exactly an
alternative, but a substitute, as version would be out of the question in
most instances, and the doubt remains, whether  it could be effected if the
obstacle were  great.   If it could, it might facilitate the use of the  per-
forator  and crotchet.
   8. In cases of extreme exhaustion, where the mother is unable  to  bear
the  shock of turning or any additional  loss of blood, if the os uteri be
dilated or dilatable and the circumference of the placenta within  reach;
as the hemorrhage is said to  cease after  the  removal of the  placenta, the
operation may be admissible for the purpose of gaining time,  even  with
the chance of artificial delivery afterwards.
   9. In cases where the flooding is considerable, the presentation natural,
and the pains strong (the cases in which the placenta is sometimes expelled
before  the child), there seems to be no objection to arrest the hemorrhage
by the  removal of the placenta, leaving the conclusion of labour to the
natural powers, either alone  or stimulated by galvanism, as Dr. Radford
has proposed.  To those two classes the  results  of Dr. Simpson's statistics
almost exclusively apply.
   I have thus examined with care this very difficult subject,  and although
 I would be far from  pronouncing  dogmatically upon  it, I feel  bound  in
 duty to state, that except in the cases I have mentioned, I could not con-
 sent to substitute the new method of treatment  for the  old, and  even  in
 those cases I would recommend the very utmost caution.*
    The necessary stimulants and support must be afforded as in  accidental
 hemorrhage, and if the patient be extremely  sunk and exhausted,  we may
 have recourse to transfusion.
   663. 3.  Hemorrhage after Delivery. — A certain amount of blood
 is always lost after delivery,  nor is this injurious; and it is  only when  it
 is so  great as to produce  an  impression upon the constitution  and the
 pulse  that it  is to be considered as  flooding.   Of course, in all  cases
 it escapes from the mouths of the vessels, exposed by the partial or entire
 separation  of the placenta, not being closed by  firm uterine contraction.
    It sometimes, but rarely, takes  place when an interval elapses between
 the expulsion of the head and body of the child,  but much more  frequently
 after its birth, before or after the  expulsion  of  the placenta.  Secondary
 flooding also sometimes occurs at a  distance of ten or twelve days after
 delivery, generally owing to some imprudence  on the part of the  patient.
    The hemorrhage after the expulsion of the placenta may be  the result

   * "Messrs. Simpson, Radford, and the other gentlemen who advocate  the  new method
 in placenta  praevia," remarks Dr. Meigs (op.  cit.), "very earnestly  recommend the
 prompt separation of the whole of the placenta; and they are persons whose opinions
 are justly to  be esteemed of the greatest weight;  but notwithstanding the  profound
 respect with which I receive any statement of theirs, I cannot but think that in any case
 in which it is possible to detach the whole of the placenta, it would be also possible  to
 introduce the whole of the hand, and thus commence at once the operation of turning,
 which ought to be esteemed as the essential indication of treatment in placenta praevia,
 and which the earlier it is done, so much the greater chance does it give  both of ~es-
 cuing the child and saving the woman from fatal losses of blood."—Editor.
                                   2m 
434
AFTER DELIVERY.
 of want of contraction of the uterus; but there are severe and even fatal
 cases which are caused by a limited rupture of the cervix.
   I  have in the last chapter spoken fully of retained placenta  and its
 treatment, which I shall not now repeat, but shall confine  myself to the
 treatment of the  hemorrhage whose effects  are similar to  those  already
 noticed.
   664. Treatment. — Let us suppose, therefore, that the  placenta has
 been extracted or expelled, but  that the flooding is not arrested.   The
 first  object is to produce a firm and persistent contraction;  and to effect
 this, whilst with one hand we firmly grasp the uterus, with the other cold
 is to be suddenly applied to the genitals by means of cloths dipped in cold
 water.  The advantage of grasping the uterus is, that we thereby secure
 an artificial contraction,  as it were, until the means employed effect a
 real  one.
  Ergot may be given at the same time, and in no case is  it more bene-
 ficial.  Cold enemata and cold drinks are also valuable auxilaries.  If these
 fail,  we may pour cold water from a height  upon the abdomen, and the
 shock will generally succeed in rousing the uterus into action.  Compres-
 sion  of the aorta is said to be effectual in some cases.   It was introduced
 by Saxtorph, and has recently been recommended by MM. Sentin, Chailly,
 and  others.   Dr. Radford recommends galvanism.  When  all has failed,
 Dr. Gooch recommends the introduction of the hand into the uterus, for
 the purpose of exciting it to contract by the irritation.   I have no doubt
 of its success, but it is so hazardous a practice that nothing  would in my
 opinion justify it but the failure of all previous means.
  The internal remedies  advised in  the other forms of hemorrhage (as
lead  and opium) are equally suitable to this, whether primary or secondary.
  The restorative treatment is likewise the same.
  665.  I have met with two cases  of hemorrhage after the expulsion of
the placenta,  arising  from a cause which appears to be very rare, viz. the
presence of a polypus in the uterus, preventing its due contraction.  One
case  proved fatal within twenty-four hours; the other recovered under the
ordinary treatment for hemorrhage.
  If we knew of the presence of such a morbid growth, it would proba-
bly be  better to remove it at once ; but as yet the  cases on record  are too
few to  afford ground for safe concU^-p***- 
CHAPTER XXI.
           PARTURITION. —CLASS III.  COMPLEX LABOUR.
                      ORDER 4.  CONVULSIONS.

   666. The next  complication I shall notice  is that affection  of  the
nervous  system termed convulsions; i. e. a convulsive  seizure of the en-
tire body and extremities; omitting  those partial attacks  mentioned by
different authors, though they be of a convulsive or spasmodic nature.  The
complication is a very frightful and a very dangerous one, and  may occur
either during gestation, immediately before, during, or after parturition.
   The variety of opinions and methods of treatment which have been put
forth, seems mainly to have arisen from confounding the different species
of convulsions; and in order  to avoid this, I shall describe three varie-
ties— the hysteric,  the epileptic, and  the apoplectic convulsion.
   667. 1. Hysteric Convulsions. — This variety  is  confined  to  the
period of gestation, and is  more frequent during the early months than-
subsequently.   Females  of  a  nervous or hysterical  constitution are the
most obnoxious to the  attack.
   Causes. —Want of sleep, or excessive fatigue, may give rise  to hysteric
convulsions, or they may be caused by disordered digestion.
   Symptoms.—The attack is generally preceded by a tightness about the
throat, by sobbing, or repeated attempts at swallowing.   The patient then
becomes still and motionless, or may roll about from side to side.  The
hands  are frequently pressed upon the breast, or carried to  the neck, as
though to remove  some obstruction.   The face is generally, though  not
always, pale, and not distorted ; no froth issues from the mouth, nor are
there the convulsive motions of the lower jaw, by which in epilepsy the
tongue is sometimes severely bitten.   In many cases the muscles of the
back are violently contracted, which Dr. Dewees thinks a pathognomonic
symptom.  The patient is not insensible, though she cannot express  her
feelings or wishes.
   After this state has continued for a longer or shorter  time, the  sobbing
becomes more violent,  or the patient  screams and sheds tears, and the fit
thus terminates.  A great quantity of limpid urine is also discharged.
   The paroxysm may be a single occurrence, or return after a  time, with
the same phenomena.
   It does not generally influence the progress of gestation, though I have
seen premature labour take place during the paroxysm.
   The mother's health  may be rendered rather more delicate, but it is not
seriously compromised  by the disorder.
  668. Diagnosis.   1. From epileptic convulsions. — The  body  is  but
slightly contorted ;  there is not complete insensibility ; there is no frothing
at the mouth, nor biting the tongue, nor stertorous breathing, and after the
                                                         (4!S5) 
436
CONVULSIONS.
fit is over, the patient recovers her usual state — the reverse of all which
symptoms occurs in epileptic convulsions,
   2.  From apoplectic convulsions.—In these the patient loses  conscious-
ness and voluntary motion at first, and ultimately all motion ceases.  This
is not the case in hysteric  convulsions;  besides which in the latter the
breathing is not stertorous, and the patient soon recovers.
   669.  Treatment.— If the pulse be quick (which is not ordinarily the
case), or the head ache, venaesection may be practised, or a few leeches
applied to the forehead ; but this is rarely necessary.   In most cases, an-
tispasmodics,  combined with diffusible  stimuli  (valerian  or assafcetida,
with ammonia), will relieve the patient.  Volatile alkali, held to the nos-
trils, is useful; or cold water dashed upon the face.
   When the paroxysm is over, a moderate dose of opium  may be given;
and after a sound sleep,  the patient will find herself nearly restored.
   The stomach must be attended to.   Tonics may be given if necessary,
and aperient medicine.
   670.  2. Epileptic Convulsions.—This variety is by far more frequent
than either of the others.
671. Statistics. — Frequency.
Authors.							Total Number of Cases.	Convulsion!.
Dr. Bland.......							1,897	2
Dr. Jos. Clarke							10,387	19
Dr. Merriman							2,947	5
Dr. Granville							640	1
Dr. Cusack							398	6
Dr. Maunsell							848	4
Dr. Collins							16,654	30
Dr. Beatty							399	1
Dr. Ashwell							1,266	3
Mr. Mantell							2,510	6
Dr. Churchill							600	2
Mad. Boivin							20,357	19
Mad. Lachapelle							38,000	61
Drs. Hardy and M'Clintock							6,634	13
  Thus we have 172 cases of convulsion in 103,537 cases of labour; or
1 in about 602.
  On the whole, the mortality is considerable, though probably much less
so than formerly.   Jacob states that in his time scarcely any survived.
Dr. Parr, in his  Med. Dictionary, that six or seven out of ten die.   Dr.
Hunter, that the greater proportion were lost. 
CONVULSIONS.
437
Authors.	Cases of Convulsions.	Mothers Lost.
Dr. Bland....... Drs. M'Clintock and Hardy	4 8 14 2 19 36 26 4 30 1 2 6 13	2 2 5 0 6 8 10 2 5 0 0 2 3
  Thus,  out of 165 cases, 45 mothers  were lost, or more than one-
fourth.
  Women of all temperaments may be  attacked, but the  sanguine  are
the  more  liable, especially those with short necks, and of  short,  square
forms.
  Dr.  Ramsbotham has  stated that  "women with  large families  are
equally, or perhaps  more liable to be assailed."  This, however, is  not
borne out  by numerical investigation; for of 36 cases  related by  Dr.
Merriman, 28 were with first  children.   Of Dr. Ramsbotham's, more
than two-thirds were with  first children; and of Dr.  Collins'  30 cases,
29 were with first children.
  672.  Causes.—It is exceedingly difficult to state anything very definite
as to the cause of epileptic convulsions.   Doubtless they arise  from irri-
tation of the spinal  system by some different and  often distant organ; it
may be the uterus, the  stomach, the bowels or bladder.
  Intemperance in eating or drinking may give rise to it.
  Persons previously afflicted with convulsive affections seem predisposed
to them at this time.   Mental emotions and frights  occasionally cause
convulsions.
  In some cases doubtless they are owing to the efforts made during the
labour pains, by which  an accumulation of blood takes place in the head.
  Atmospheric influence appears to have  some effect in determining the
frequency of this disease.  Most persons  must have  remarked  how often
a number of cases occur about the same time, as though depending upon
the same general cause.
  There is a curious case on record of convulsion commencing with con-
ception, and recurring  every fortnight during gestation.
  673.  Symptoms. — The symptoms  in  epileptic convulsions resemble
very closely, if they are not identical with those of ordinary epilepsy.  In
the  majority of cases  there are  certain  premonitory symptoms.  The
patient, for some time previous, suffers from pain  in the head, giddiness,
confusion,  ringing noise in the ears, obscure vision, temporary  loss of
sensation, rigors, nausea, or even vomiting.   The face is flushed, and the
eyes injected.
  Dr. Hamilton, senior, mentions as peculiar, an  intense pain in the fore-
                               2m 2 
438
CONVULSIONS.
 head ; and Dr. Denman, a severe pain in the stomach, and these he thinks
 the worst kind of cases.  Osiander has noticed a tumid state of the hands
 and face  preceding  the  attack.   Dr. Lever, of London, has noticed the
 presence of albumen in the urine.
   As the attack approaches, these symptoms are aggravated; the pupils
 become  dilated, the face more  injected, the eyes fixed, and the patient
 loses consciousness.
   In some few cases, however,  there are no precursory symptoms; the
 patient has no warning until the moment before she becomes insensible.
 The " aura epileptica" is seldom felt.
   During the  attack, the face  is swollen, of a  dark red or violet colour,
 and distorted by spasmodic contractions ;  the eyes are agitated, the tongue
 protruded, and the under jaw repeatedly closed with force, so as to wound
 the tongue.    A quantity of froth is ejected from  the  mouth, which is
 generally  drawn more to one side of the face than the other.
   The muscles of the body are  thrown into violent and irregular action;
 the limbs are jerked in all directions, and with such force that it is  some-
 times difficult  to keep the patient in bed.
   The respiration is at first irregular, and  being forced through the closed
 teeth and the foam at the mouth, has a peculiar hissing sound ;  it subse-
 quently becomes  nearly suspended.  The pulse is  quick, and at the be-
 ginning full and hard, but afterwards small  and  almost  imperceptible.
 The body participates  in the purple  colour of the face.   The urine and
 faeces are often passed involuntarily.
   This  terrible paroxysm, however, is not of very long duration.  After
 a period, varying from five minutes to half an hour, the convulsive move-
 ments become less violent, and gradually subside;  the  countenance is
 less  distorted, and assumes a,more  natural and placid appearance, the
 eyelids close, the respiration becomes more regular, though still  sibilant,
 and  the circulation  is restored, the pulse becoming more perceptible,
 though still very quick.   The patient rests quietly in bed, and the paroxysm
 has terminated for the time.
   During the  interval,  the patient's condition is very variable.   She may
 partially recover consciousness, so as to recognise persons around her, and
to be aware of  something extraordinary having happened, without knowing
 what, and without being  able to  express herself clearly.
   In other cases the return of  intelligence (but without recollection) may
be complete until the approach  of the next fit, accompanied with great
 weakness, head-ache,  and confusion.  These are the more favourable
 cases.
   Others again remain in a state of total insensibility, almost approaching
to coma  or asphyxia with sibilant or stertorous breathing,  and without
 muscular motion, or with a restless throwing about  of the  body and ex-
tremities.
   This calm is however of no very long duration; it may be half an hour,
or two hours,  but sooner or later the paroxysms  return, to be succeeded
by an interval  which in its turn gives place to another paroxysm.   I have
known as many as eighteen paroxysms occur in twenty-four hours.
   Dr. Lever, of London, has pointed out the presence of albumen in the
 nrine of women attacked by convulsions.  He  states, " I have carefully
examined the  urine in every case of puerj>-ral convulsions that has since 
CONVULSIONS.
439
come under my notice, both in the lying-in charity of Guy's  Hospital,
and  in private  practice, and  in every case but one the  urine  has  been
found to  be albuminous  at  the time of the convulsions."—"I further
have investigated the condition of the urine  in  upwards  of fifty women,
from whom the secretion has been drawn during  labour by the catheter;
great care being taken that none  of the vaginal  discharges were mixed
with the fluid:  and the result  has  been that in  no cases  have I detected
albumen  except  in those in which there have been convulsions, or in
which symptoms have  presented themselves which are readily recognized
as precursors of puerperal fits."  This is  most  important, for in doubtful
cases we  have a test, which, together with the symptoms, may enable us
by timely treatment to  prevent so serious a complication.
  The termination of the attack varies in different patients; some remain
in a state  of half stupor and great exhaustion for hours or days, and gra-
dually recover.
  In other cases the patient becomes maniacal, and may remain so for a
long  time, and ultimately recover.   I  had a patient who remained in a
state of mental derangement for several months before  she was restored.
  In a  few cases, the  patient continues comatose, and gradually passes
into a state resembling apoplexy, and dies.
  674.  I  have  already mentioned that convulsions may attack the patients
either during pregnancy, at the time of parturition, or after delivery.
  It will be necessary  to say a few words upon  the occurrence at each
of these periods.
  Pregnant women are more especially obnoxious to this disease during
the two latter  months  of gestation, though  it may occur at  an earlier
period, and at irregular intervals.   The nearer the patient is  to her con-
finement,  the greater  the  risk  of  an attack, on account  of the extreme
distension of the uterus and its increased irritability.
  Although the beginning of labour cannot be  detected, either by an in-
ternal or external examination, at the outset of these attacks, yet during
its continuance labour may commence, and run a natural course.  In such
a case, the fits  will be  found synchronous with the uterine contractions,
though not recurring with each.
  In  many cases, however, the uterus remains perfectly  quiescent, and
gestation may be carried on for a time longer; it is rare, however, for the
full term  to be completed.   In almost  all cases the child is  still-born,
often putrid ; but whether its death preceded the convulsions, or resulted
from them,  is not easily determined.  When the former is the case, may
we not attribute the convulsions to the  dead child acting in some sort as
a foreign  body ?
  The labour runs a natural course generally, and in a fair proportion of
cases the  mother  recovers tolerably well, though there are startling excep-
tions, as in the  following case related by Dr. Blundell:
  ." A lady, in  the end of her pregnancy, was seized with convulsions;
her attendant was sent  for, and decided that there were no indications of
labour, and that a stay was unnecessary.   The midwife left the house, and
returning  early the following morning, the patient was found dead ; the
child, too, the birth of  which no one seems to have suspected, lay lifeless
beneath the clothes."
  When convulsions  occur at the  commencemt^t of labour, it  might 
440
CONVULSIONS.
naturally be attributed, in some cases at least, to mal-presentation of the
 hild, but this  is not the case.  Mal-presentation is observed very rarely
m cases of convulsions.
   675.  During labour, the return  of the  paroxysm takes  place  at the
commencement of a labour pain, although not with every pain.   There
is a greater expression  of suffering from the uterine contraction  than from
the convulsion.   The symptoms I have described apper to be more intense
when the attack comes on during labour than during gestation.
   The uterine contractions do not appear to be impeded by the fits; the
labour generally runs a natural course in the usual time, if not terminated
by art;  neither is it necessarily fatal to the infant, although there is great
danger.
   It is remarkable, and  not easily explicable, that  after the convulsions
have ceased, and the labour is over,  there is a great tendency to abdomi-
nal inflammation, adding fearfully to the mother's risk.  Denman, I be-
lieve, was the first to point  out this fact, which Dr. Collins and others have
confirmed:  and which should  be remembered in the treatment.
   676.  When the patient is attacked by convulsions after delivery, they
generally occur from two to four hours after the birth of the child, some-
times later.   There can be little hesitation in attributing them to some in-
jury received by the brain or  nervous system during  labour, though we
may not be able to  specify the particular mischief.  It  does  not howevei
depend upon the length or difficulty of the labour;  they occur as fre-
quently after natural labour.
   The loss  of  blood at the time of delivery does not necessarily prevent
the occurrence  of the fit, though it adds to the danger by the  debility it
occasions.
   Duges considers cases of convulsions after delivery to be more tractable
than any others, whilst Dr. Ramsbotham  states exactly the contrary.   I
should say that the cases where the convulsions occur during labour, and
continue afterwards, are the least manageable; next to these the attacks
during labour only; then,  those after delivery;  and lastly,  the most fa-
vourable are those which occur during gestation.
   After recovery from the consequences  of the  attack, the patient may
enjoy her usual health, and her subsequent pregnancies do not appear to
be very liable to similar attacks.
   677.  Pathology.—In the majority of <ases a post mortem examination
affords  but  little information.   In many instances  there is no deviation
whatever from the healthy state of the brain.
   Sometimes the vessels of the brain are turgid with blood, and in other
cases there is a quantity of serum effused on the surface and base of the
brain, or into the ventricles.
   The heart is  generally flaccid and empty, and the lungs of a pale colour.
Some fluid is occasionally found in the pleura or pericardium.
   Traces of  inflammation have also  been discovered in the peritoneum.
   In an admirable chapter on this disease, Dr.  Tyler Smith has, I think,
thrown much light on its pathology.   He has proved that convulsions are
not  excited  by irritation of the cerebrum alone, but  by the primary or
secondary effects produced upon the spinal marrow, medulla oblongata,
or tubercula quadrigemina.  And therefore that the causes  giving rise to
convulsions may be either,  1, Centric, such as  pressure on the medulla 
CONVULSIONS.
441
oblongata from congestion, coagula, or serous effusion within the cranium ,
loss of blood, morbid elements in the blood ; emotion.   Or, 2,  Excentric,
acting on the extremities of the excitor nerves, as irritation of the incident
spinal nerves of the uterus and uterine passages; irritation of the excitor
nerves within the  cranium;  irritation of the incident spinal nerves  of the
rectum ; irritation of the ovarian nerves; irritation of the gastric and in-
testinal  branches  of the  pneumogastric nerve ; irritation  of the  incident
spinal nerves of the bladder :  and as probable causes, irritation of the cu-
taneous  nerves,  of the nerves of the  mammae, and of the  hepatic and
renal branches of the pneumogastric.  More  than one of  these  causes
may, of course, act at the same time.
   678.  Diagnosis.  1. From hysteric  convulsions. — In the  attack just
described, there  is a total loss of consciousness, great muscular action,
frothing at the mouth, frequent recurrence of paroxysm, and incomplete
restoration or total insensibility during the intervals.  In hysteric convul-
sions, on the contrary, the  patient scarcely loses consciousness, exhibits
only moderate spasmodic action, has no frothing at the mouth,  does not
suffer from  a  frequent recurrence of the  fits,  and  recovers shortly after
each.   The sobbing,  sighing, weeping, and screaming of the hysteric
convulsion are also peculiar to it.
   2. From  apoplectic  convulsions. — In epileptic  convulsions, the whole
body is  thrown into  violent spasms, which  are  repeated, with intervals of
quiescence,  and often  of partial return of sense.  The  breathing is rather
sibilant  than stertorous, and the muscles preserve their tone even during
the intervals; — whereas in apoplectic convulsions, the spasmodic move-
 ments occur at the commencement, and are not repeated ; sense and sen-
 sibility  are totally lost, the  breathing is stertorous, and the  muscles  lose
 all power, so that the  arm when raised, and allowed to fall, does so  like
 that of  a person  recently dead.*
   679.  Treatment. —At whatever time  the attack takes place, the first
 thing to be done is to  take  away blood from the arm or temporal artery
 largely, and in a full stream.  If  the  paroxysms  continue, this may be
 repeated.   Denman took 40 oz. and Blundell 70 oz. of blood from a
 patient  under these circumstances.   We are  not to be deterred from a
 free  use of the lancet, by the  absence of immediate relief— the  benefit is
 rather in the ultimate and early recovery of the patient, than in the imme-
 diate arrest  of the paroxysms.
    Another good  effect from venaesection is the prevention  of the  abdo-
 minal inflammation, to which we have seen that the patient  is exposed
 subsequently.

   * Instances occur of convulsions happening at each succeeding pregnancy, and per-
 sisting until abortion takes place.   It is then one of the greatest afflictions that can
 befall the married female.  " I have witnessed," says Dr. Huston, in a note to a former
 edition, " the attack twice in the same lady, with only an interval of three months, both
 times terminating, as remarked, in abortion.  She is a remarkably delicate woman,  of
 great nervous impressibility.  During the attacks she had no frothing at the mouth, nor
 stertorous breathing, and yet, after recovery, was unconscious of all that had passed.
 She was  bled freely at the commencement of the first attack, because of pain in the
 head, and had a tedious recovery; the next time, she was treated by the use  of
 excitants, as  sinapisms, wine whey, camphor, morphia, &c, and recovered  rapidly,
 The symptoms were very similar in both attacks;—as the more prominent of these sub-
 Bided, the hyster cal evidences, such as crying, laughing, &c, became more manifest."
 — Editor. 
442
CONVULSIONS.
           If there be any objection to repeating the venaesection, leeches may be
         applied ;  or if the patient be sufficiently quiet, the nape of the neck may
         be cupped.
           A strong  purgative  (calomel  and jalap for example) should next be
         administered, as from the free evacuation of the  bowels great benefit is
         generally derived;  and it may also excite uterine  contractions, and hasten
         the delivery.
           The head may then be shaved, and cold lotion or ice applied.  Denman
         speaks highly of cold  affusion.  A warm bath has been  recommended,
         but it would be very difficult to  use it  in many cases.
           After the lapse of some time, the head and nape of the neck may be
         covered with blistering plaster, as  counter-irritation will materially further
         the restoration of the patient.
           When, after copious bleeding  and purging, the  attack is somewhat
         subsiding, it has been recommended  to give an opiate.   Considerable
         difference  of opinion has  existed upon this point, owing,  I think,  to the
         different parties not specifying with sufficient accuracy the  time at  which
         it should be administered, and the cases suitable  for it.  Under the  cir-
         cumstances I have  mentioned, it seems to  be  the  opinion  of the highest
         authorities that it may be  of service.
           Dr. Collins  remarks, " Many of our  best writers  have actually con-
         demned the  use  of opium in convulsions, stating it to be most injurious—
*        some even destructive.   Ample  experience has convinced  me, that it is
         not only harmless, but highly beneficial in  those cases where the fits con-
         tinue after delivery.  And I  should hope  the  cases adduced will  prove
         satisfactorily that it is also useful under many  other circumstances, when
         proper steps had  been  previously taken.  Its combination  with  tartar
         emetic, and  occasionally with calomel, is most advantageous."
           Calomel, given so as to affect the constitution, has been found  bene-
         ficial.  Dr. Collins speaks very highly of tartar emetic, in doses sufficient
         to produce nausea, but not vomiting.  " In every severe case of convul-
         sions, after having carried into effect the ordinary mode of treatment, as
         bleeding freely, acting briskly on the bowels, with calomel and jalap, and
         at the same time adopting the means usually had recourse to for protecting
         the  patient during  a paroxysm, I endeavoured  to bring her  under  the
         influence of tartar emetic, so as to nauseate effectually, without vomiting.
         With this view, a table-spoonful  of the following mixture was given every
         half hour: —
                             R Aquae Pulegii,   g viii.
                               Tartar Emetici, gr. viii.
                               Tinct. Opii,     gtt. xxx.
                               Syr. Simpl.     § ii.         M.
           " In some cases the  quantity of tartar emetic used was only four  grains
         Co an eight-ounce mixture; and in others, the quantity of opium was  some-
         what inc-eased."*
          * Anaesthesia has been resorted to as a means of controlling  puerperal convulsions,
         by Messrs. Clifford, Wilson, Kite, Hearn, and Clifton, in England, by Chailly, in France,
         and by Dr. Channing and a number of other practitioners, in the United States.  In
         nearly all the cases, the convulsive movements were entirely controlled or essentially
         modified upon the induction of anaesthesia.  The great majority of the patients reco-
         vered.  The facts that have been adduced in favour of this practice in, confessedly, one
         of the most fearful  and dangerous complications of labour, press it strongly upon the
         attention of the practitioner.—Editob. 
CONVULSIONS.
443
  It will be necessary to insert a wedge of leather or wood between the
teeth, to prevent injury to the tongue, and  also  to  remove every thing
out of the way, by  striking  against which, the patient  might hurt her-
self.*
  This treatment applies equally to convulsions occurring before, during,
or after labour — except that in  the  latter  case  the quantity of blood
taken must be modified according to the state of the  patient.
  680. The next  important question is, whether we are to interfere
with the progress of gestation or parturition.
  I believe there is no dispute, that until labour sets in naturally, inter-
ference would be injurious; so  that in convulsions during gestation, we
have nothing to do with the  uterus, but must  confine  ourselves to the
treatment of the convulsive disease.
  If the attack take place at the commencement of labour, some practi-
tioners have been anxious to hasten the operations of nature by manual
dilatation ; but this has been abandoned, and very properly, as likely to
increase the  convulsions, without advancing the progress of the delivery.
Belladonna has been applied to the cervix uteri, for the  purpose of  dila-
tation,  but I should doubt its  utility, and  dread its poisonous  effects.
The older writers, with some moderns,  have proposed incision of the
cervix, but the  risk would outbalance any benefit to be derived from so
" heroic" a remedy.
  But supposing the os uteri to be dilated  or dilatable, are we  then to
proceed to deliver by art?  This  question has been  much debated, and
opposite opinions have been advocated.  Some advise instant interference,
and others no interference at all.
   The true plan seems to be to avoid both extremes. We are not neces-
sarily to interfere at this stage of the labour, beyond rupturing the mem-
branes, which sometimes hastens the progress of the  labour.
  Version or turning, has been often recommended, but, from all the cases
I have seen or collected, it would appear a most hazardous measure.   Dr.
Ramsbotham advises it, and yet the three cases he  relates in which he
practised it proved fatal.   Five patients out  of  seven are  generally lost.
Dr.  Collins is strongly opposed to it.
  We may therefore conclude that version is not to be attempted.
  But when the head has  descended into the pelvis, so as to be within
reach of the forceps, and  there is sufficient space, it will be proper to
apply that instrument, inasmuch as delivery, when it can  be accomplished
without injury, is very desirable.
  The attempt must be made during an interval between the paroxysms,
and should the introduction of the blades bring on a  violent fit, it will be
necessary to withdraw them, lest they should be forced through the vaginal
or uterine parietes, during the struggles of the patient.
  Should the head of the child be so fixed in the pelvis, as  to  defy all
reasonable efforts with the forceps, it may be  necessary to use the perfo-
rator;  but, before  doing this,  the judicious practitioner will consider well
the  amount of benefit likely to be obtained, and the risk certainly incurred
—recollecting that the child may be alive, that the labour  may, if left to
  * A roll of muslin or linen answers as well as leather, and much better than wood;
besides, it is always to be obtained  at the moment. — Editor. 
444
CONVULSIONS.
nature, terminate favourably, and that even if delivered by art, the  fits
may not necessarily cease.
  If we are satisfied that the child is dead, we should be justified in de-
livering by the perforator and crotchet at an earlier period of labour, pro-
vided that the os uteri  be dilated or dilatable, or that the head have passed
through it, and that the convulsions be so formidable as to require speedy
delivery.
  After the convulsions have ceased, Dr. Collins  remarks,  " Should  the
patient become  maniacal, as is  occasionally the result when the fits have
been severe, and have continued for any length of time after delivery, all
local distress, as pain in the head, or any symptom  that would  indicate
abdominal complication, should be diligently  looked after, and treated
accordingly;  as by so doing, keeping her fully under the  influence of
tartar emetic, at the same time  acting well on the bowels, and  excluding
light from  her room,  as  also all other external irritants, the best results
may be expected.   It is a great satisfaction to the friends of the patient
in such a  situation to be assured, that  there  is little  liability to  a  re-
turn of this derangement of mind, as is the case in most other forms of
mania."
  681. 3.  Apoplectic Convulsions.—This  variety seldom or  never
occurs, except towards  the termination or after the conclusion  of labour.
Dr. Burns indeed mentions its occurrence at the commencement of labour,
and MM. Morithon and Menard at the sixth month of pregnancy.
  Causes.—It is evidently caused by the stress upon the cerebral vessels
during the labour pains.
  it is very probable  that anxiety of mind may predispose to the attack;
at least in one case I saw, this appeared to be the case.
  682. Symptoms. — In many cases, the patient  suffers from pain and
throbbing in the head for some  days previously ; but in others there  are
no premonitory symptoms.
  Generally speaking, during the labour the  patient complains of head-
ache ; and during  the second stage, the face maybe observed to be much
flushed, and the eyes  injected.
  Strictly speaking, there is but little convulsion ;  the body  and extremi-
ties are agitated or thrown about for a  short time,  and then the patient
lies in a comatose  state.  There is little  or no distortion of  the face, and
no frothing at the mouth.   The  muscles become flaccid  and powerless;
the  respiration   is stertorous;  there  is  no  return  of intelligence, and
rarely  any repetition of  the  paroxysm,  though such  cases have been
recorded.
  In almost all cases  the condition of the patient remains unaltered until
death; but there are a few cases, answering, I presume, to the congestive
apoplexy of Abercrombie and  Lallemand, where  our timely aid is suc-
cessful, and the patient recovers sense  and  motion; and, if proper care
be taken, is speedily well.
  The pulse  is  full and slow, and the pupils  in  some  cases  dilated, in
others contracted,  but in all insensible to light.
  I do not know that I can give a better illustration of this disease than
by relating the  two following cases.  For the first I  was indebted to  my
lamented friend, the  late  Dr. Aston; it  appears  to  be a simple case of 
CONVULSIONS.
445
apoplexy from congestion :  the  second occurred in the practice of a dis-
pensary to which I was attached.   I quote them from a report I published
some years  ago in  the  Medical Gazette: "Catherine  Costello, aet. 18
years and 9 months, of low stature,  and corpulent figure, complained
first  of severe head-ache on Wednesday, January 2, 1833.  The  pain
was  more violent than any of the kind  she had ever experienced.   Sick-
ness of the  stomach set in nearly at  the  same time, and she continued
throwing up green bilious matter during the entire day ;  the bowels were
confined for four days J the face and extremities were much swelled, which
commenced two days before, and continued gradually to increase as the
head-ache became more intense.  She wanted about seven weeks to com-
plete the usual term of utero-gestation.  I (Dr. Aston) was sent for in the
evening; she was walking about  the  room, but suffering  most acutely ;
the face  was swelled to such a degree as  almost to hide the eyes, and her
speech somewhat thick.  The  motion of the child had not been felt all
day.  As she had  an objection to bleeding, I omitted it for the present,
and directed some  opening medicine  to  relieve the bowels; and having
given the requisite  directions, I left her;  but in a few hours  her husband
came for me in all haste, requesting my immediate attendance, as she had
a fit, and appeared to be in a dying  state.   Upon  further  inquiry, I was
told that the pain in the head got much worse—when  suddenly the eyes
became fixed, the face distorted, convulsive motions ensued, and ended
 with stertor,  which must have been of short  continuance, as no  such
 symptoms existed when I visited her a short time afterwards although she
 was unconscious  of anything that happened until after venisection,  which
 I immediately performed to  the  extent of 18 or 19 oz., from which she
 experienced almost instantaneous relief.   The heat of skin was  much
 greater than natural; thirst extremely urgent; pulse pretty frequent, but
 inclined to  hardness; after venaesection it became quicker;  shortly  after,
 slower and softer,  until it gradually came down to  the  natural  standard.
 From this time all the symptoms subsided, and she was delivered January
 5th, and recovered well."
   « Mary-----, aet. 30, was attended in her first confinement by a pupil
 of the Wellesley Dispensary, on Monday, November 20, 1832.   The
 labour was  natural, and terminated within the  usual period.   She com-
 plained of severe head-ache during the labour, and seemed sleepy towards
 the  conclusion.  After asking some questions of the  attendants, she settled
 to sleep ; some irregular motions of  the limbs were noticed by those in
 the  room, but nothing further, until her breathing became loud and heavy,
 when, as they could not rouse her, I was sent for.  I found her perfectly
 insensible;  pupils  fixed  and contracted;  breathing stertorous; heat of
 head but little increased; abdomen distended with flatus; muscles per-
 fectly flaccid; pulse firm, and tolerably full.  The usual  remedies were
 tried, but unsuccessfully, and she died during the night.   A post mortem
 examination was permitted, and we found great effusion of blood, filling
 both ventricles.  A quantity of serum also was  found  at the base  of the
 skull.
   " On  further inquiry, I learned that  she had  been the victim  of seduc-
 tion and desertion, and that she had suffered from depression of spirits
 and severe  head-aches for some weeks before her confinement."
                                 2n 
446
CONVULSIONS.
  683.  Pathology. — The brain  maybe found greatly congested, but
without any effusion;  but this I believe to be rare.
  There may be great effusion of serum, which by its pressure will cause
symptoms of apoplexy.
  More frequently, blood is poured out into the ventricles, into the sub-
stance of the brain, or at its base.
  Cases of this kind have been noticed by Denman, Targioni, Marchais,
Lachapelle, Leloutre, Schedel, Velpeau, &c.
  684.  Diagnosis.—The entire and persistent  insensibility—the absence
of repeated paroxysms with their  accompanying symptoms, will at once
enable us to distinguish apoplectic  from epileptic or hysteric  convulsions.
  It is not  easy to distinguish that form which arises from congestion from
that caused by effusion — the chief difference being in the intensity of the
symptoms.
  685.  Treatment.—The most active antiphlogistic measures should be
instantly put in requisition; a large quantity of blood should be taken from
the arm, jugular vein, or temporal artery, and repeated if necessary.
This is the  more requisite, as it is from the effect of blood-letting, that we
are mainly  to look for the distinction between apoplexy from congestion
and apoplexy from effusion.  If no relief whatever be afforded, the case
maybe  regarded as nearly hopeless;  but if the patient be at  all benefited,
the head should then be shaved, and ice applied.
  After a short time, a large blister may be  applied to the head or neck,
and a brisk purgative given.
  These remedies will generally afford relief in those cases which are
susceptible of it, and they may be modified or repeated as circumstances
may require.
  Should this variety occur during labour, and  the uterine action be sus-
pended, it will be desirable to deliver the patient as speedily as possible,
so as to save the child; and for this purpose* if the head be within reach,
the long or short forceps should be applied. 
CHAPTER  XXII.
           PARTURITION. —CLASS III. COMPLEX LABOUR.

                       ORDER 6. LACERATIONS.

  686. Under this head I propose to  treat of rupture of the uterus and
vagina, vesico-vaginal and  recto-vaginal  fistula, and laceration of the
perineum.
  1.  Rupture  of the Uterus.—This formidable and very fatal  acci-
dent has long been known to practitioners in midwifery.
  It is  not, however, confined to the time of parturition, but  may occur
during gestation, or at a more advanced period of life.
  687.  Statistics. — The following table  will indicate the frequency of
its occurrence.
Authors.	Total No. of Cases.	Cases of Rupture. i
Dr. Jos. Clarke .... Dr. Merriman .... Dr. M'Keever .... Dr. Collins..... M. Pacaud.....	10,387 2,947 8,600 16,654 4,180	i 8 1 20 34 2
Making a total of 65 cases in 42,768 patients, or about 1 in 657.
  Dr. Burns says that it occurs about once in 940 cases.
  It rarely occurs with first children.

                                    Of Dr.
Of Dr. Jos. Clarke's cases—
        1 was the 2d pregnancy
        1    "   3d
        2    "   4th
        1    "   7th
        1    "   8th
        1    "   9th
Of Dr. M'Keever's cases—
        4 had 2 children.
        6  "  3   "
        4  "  6   «
        2  "  7   ««
        2  "  8   "
        1  «  9
Of Dr. Ramsbotham's cases—
        2 were 2d pregnancies.
        1  "  4th    "
       •8  "  7th    "
Of Dr. Collins' 34 cases—
        7 were 1st pregnancies.
        6  "  2d
Collins' 34 cases—-
6 were 3d pregnancies.
 4th
 5th
 6th
 8th
 9th
10th
11th
cy
                                       Dr. Cathrall's case was  a 1st pregnan-

                                       Dr. Sims's patient had had several chil-
                                     dren.
                                       Dr. Hooper's case was the 4th preenancv.
                                       Mr. Kite's    «  "    2d     «
                                       Dr. FrizelPs  "  "    7th     "
                                       Mr. Powell's  "  "    1st     "
                                       Mr. Birch's cases were the 3d and 4th
                                     pregnancies.
                                       Mr. Partridge's case was the 7th preg.
                                     nancy.

  Thus, of 75 cases, 9 occurred in the  1st pregnancy; 14 in the 2d : 13
in the 3d ;  and 37 in the 4th, or subsequent pregnancies.
      29                                                  (447) 
443
LACERATIONS
   688.  Causes.—Various  causes  may give rise to it, and it may happen
 at different periods—                                            n
   1. During gestation. — The  form of extra-uterine pregnancy which is
 called interstitial fcetation  (§ 250)  may give rise  to it.   The  ovum, in-
 stead of passing direct from the fallopian tube into the uterine cavity, is
 retained in an interstice of  the uterine fibres, where it grows, up to a cer-
 tain point.   As it increases, the outer portion  of the uterine  parietes  be-
 comes gradually thinner by absorption (as in the case of abscess), and at
 length gives way, and the  fcetus is precipitated into the  abdomen, con-
 verting the case into one of ventral fcetation.
 ^ It may also be  the consequence of disease, as in Mr. Else's and Dr.
 Spark's  cases:  from softening, and from abscess in the walls,  as related
 by Duparcque.
   Any violent accident, such as a fall or  a blow, may give rise  to it.
   It sometimes occurs without any assignable cause; the patient, perhaps,
 is awakened from sleep by  it.
   It has been attributed to  irregular action of the uterine fibres. •
   689. 2.  During labour. — a. If the uterus  have been  attacked by in-
 flammation during pregnancy, its tissue may have been so much  weakened
 or disorganized,  that the violent contractions which take place during
 labour may rupture it, from the want of consentaneous action in the part
 affected, or from the  pressure of some part of the child against  it.
   Steidele relates  a case  where rupture occurred in consequence of gan-
 grene.
   My friend, Dr. Murphy, has published an excellent paper illustrative of
 this cause of rupture, with cases where the uterus was atrophied, thinned,
 or softened in texture.
   Duparcque quotes cases of thinning  of the uterine walls,  softening,
 scirrhus, and gangrene.
   In  some cases,  the seat of the laceration corresponds exactly with the
 situation of the previous pain.
   Dr. Tyler Smith believes  that in many cases  violent uterine action is in
 itself the cause of rupture ;  the immediate cause being either emotion or
 volition,  or a reflex, or peristaltic action.
   The period of labour at which the rupture may occur from this cause,
 will vary;  it may be at the beginning, before the rupture of the  mem-
 branes ; during the passage of the  head through the pelvis;  or after the
 delivery.
   *. A certain amount of narrowing of the upper  outlet  may  give rise
 to it.  This is a purely mechanical cause.  The head of the child is forced
 downwards by violent labour pains, but is unable to enter the pelvis, from
 the contraction of  the upper strait;  now if the pains continue with  great
 power, the head is turned to one side or the other,  or posteriorly, and the
 only obstacle here being the  uterine or vaginal parietes, the  head is driven
through them at the weakest part.   They  offer  the less resistance, proba-
bly, from the woman  having generally borne several children.
   In one of Dr. Clarke's cases, the antero-posterior diameter of the upper
 outlet measured but 3 inches; in two others, 3£.
   In case 18 of Dr. Douglas, the pelvis measured but two inches antero-
posteriorly ; and in another  case (20) there was a bony ridge on the top
of the symphysis pubis, to which thf rent corresponded. 
OF THE UTERUS AND VAGINA.
449
	Dr.	Collins found—			
16 years.	7	patients	of the	age	of 30 years
21 "	2	<<	a	<<	32 ««
24 «	1	l i	<(	<<	33 "
25 «	1	(1	k	i<	34 "
26 "	3	!<	i<	k	35 "
27 "	5	(<	<<	i<	36 "
28 "	1	H	<<	K	37 ■"■
29 "	1	Ii	<<	i<	40 "
  In one of Dr. Ramsbotham's cases, the antero-posterior diameter was
only 2 inches;  in another 3 inches; and a third had  always had difficult
labours previously.
  In  one of Dr. Collins' cases, the same diameter measured 2± inches;
and in several it appeared narrower than usual.
  The sex of the  child will  contribute to the increase of this dispropor-
tion—male children having the larger heads.  Now, of the 20 cases men-
tioned by Dr.  M'Keever, 15  children were males, and 5 females; and
of Dr. Collins' 34 cases, 23 were males.
  It occurs at all ages;  but the  proportional frequency is  greater* above
30 years of age than previously.

  Dr. Collins found—
    1 patient of the ag
    ]  "    <<    <
    1  "    <<    <
    3  "    "    '
    2  "    "    «
    1  <<    <<    <
  c. The oblique position of the uterus has  been assigned as a cause,
from its directing the force  of the child's  head against  the side of the
cervix uteri and vagina.
  d. Some one of the tissues of the uterus may give way previous to or
during labour;  perhaps from previous disease; perhaps from some pecu-
liarity of structure; and in some cases, without any appreciable cause.
  Sir Charles M. Clarke published a case, in  which the peritoneal cover-
ing of the uterus alone was torn ;  and similar  cases have  been since
recorded  by  Mr. Partridge,  Mr. White, Dr.  Ramsbotham, Mr. Chatto,
and Dr. Davis.  Dr.  Collins has also met with a case of this kind.
  Dr. Radford  published two cases in which the muscular coat was torn,
the  serous membrane  remaining uninjured.  Dr. Ramsbotham met with a
case nearly similar;  and Dr. Collins met with nine such cases.  Duparcque
relates one, and Velpeau two.
  Through the  kindness of Mr. Custis, of Dublin, I assisted at the post
mortem examination  of a patient, who was attacked with  symptoms of
ruptured uterus; sudden pain in the abdomen, vomiting,  collapse, &c,
and who  died  in a few hours.   We found no rupture in any part, but
extensive effusion of blood beneath the peritoneum  covering the uterus,
and lining the iliac fossae ; the result, probably, of a ruptured blood-vessel.
There were also twelve  or fourteen ounces of sero-sanguineous fluid in
the peritoneal cavity.  A case very similar is related by Dr. Ramsbotham.
  Though the  extent of  mischief is less  in these  cases,  yet they are
equally fatal.
  e. Violence in turning the child may rupture the uterus, and  it may
accompany this operation, in certain states of the cervix, without  any
fault of the operator.
  f. Rigidity of the os  uteri, or imperforation, may occasion laceration.
  g. There are several cases on record where the os  uteri has  been torn
completely off during labour.  Steidele, and Mr. Scott of Norwich, have
each recorded one, and three others  occurred  in  Dublin within a short
                                2n2 
450
LACERATIONS
time of each other.   It appears to be the result of pressure at the brim of
the pelvis, rendering the texture of  the cervix soft, and easily torn.
   Among the direct  causes are enumerated blows, falls, anger, convul
sions, excessive  movements of the child, over-distension, &c.
   In one case, M. Malgaigne attributed it to the mal-administration of
ergot of  rye.
   690.  3. At an advanced period of life.   The structure of the  cervix
uteri is much changed in old age; it becomes close and dense,  resem-
bling cartilage, and the canal through it is always reduced in size, and
sometimes obliterated.  When the outlet  for the escape of the uterine
mucus is thus closed, it accumulates; and  if the quantity be sufficient to
distend the cavity, a process of thinning or absorption commences in some
part of the walls  of the uterus, and proceeds until an opening is made into
the peritoneal sac.
   The same process will take place with any other fluid  thus  deprived
of exit.   Duparcque  quotes two cases  of the kind.
   691. Pathology. — If the laceration be the result of disease, it may
take place at any part of the organ, the  body, fundus, or cervix;  and it
will generally be found to  correspond  to  the  situation of the  pain  felt
by the  patient  previously.   The edges of  the  rent exhibit  marks  of
disease, the tissue is  thinned, softened, and pulpy, breaking down easily
under the finger.
   The colour  may be changed to a  deep red, or brown colour,  and occa-
sionally the  odour is offensive.
   When the laceration is the  result of mechanical causes, it generally
takes  place near the cervix, and involves both  the  uterus and vagina.
It  may run along the  anterior or posterior surface of the uterus, or at one
side.   In six  of Dr. Jos. Clarke's  cases, it was on the  anterior surface,
and in one, posteriorly.   In Dr. Sims'  and Hooper's  cases, it was ante-
riorly ; in Mr. Birch's posteriorly; and in Mr. Cathrail's  case, on  the
right side.  In three of Dr. Ramsbotham's cases, it  was posteriorly;  in
one along the right side ; and in another along the left.  Of 23 cases, Dr.
Collins found one on the right, and one on the left  side—eleven  poste-
riorly, and ten anteriorly.
   The direction  of the rent may be nearly perpendicular, or inclining  to
one or other side, or running transversely.
   In these cases the structure of the uterus is scarcely altered; its texture
is  firm, and its colour natural, except where the blood is ecchymosed.
   The edges of  the rent are jagged and uneven.
   Occasionally,  but very rarely, the bladder has also been torn.
   When the serous  membrane alone is injured, we find numerous small
incisions, resembling scarifications, from a  quarter to half an inch  in
length,  and one or  two lines  in depth, or a smaller number of  larger
lacerations.
   They  are almost  always curved, with the convex  part towards  the
fundus, and may be situated on the  anterior or posterior wall  of  the
organ.
   In all the cases hitherto mentioned, more or less blood is found effused
in  the peritoneal sac,  and  in many,  the usual  products of peritonitis.
   When the muscular structure alone  is injured, it may present either a
simple solution  of continuity,  or evidences  of disease.  Blood may  be 
OF THE UTERUS AND VAGINA.
451
found in the cavity of the uterus, and the serous  membrane may become
inflamed with the usual results.
  The cervix uteri, when separated, has generally a bruised appearance;
is swollen, and of a red colour.  The edges are ragged and  uneven.
The canal of the vagina  is rendered  continuous with that of the uterus,
but the connexion between them is not compromised.
  When the uterus of an old person is ruptured, from the cause assigned,
we  shall discover a  perforation in some part of it, with a considerable
thinning of the walls around it.
  In  all these cases, with the exception of those in which the os uteri is
torn off, or the muscular  structure alone injured, we find marks of exten-
sive peritonitis, unless the patient die of the shock.
  692. Symptoms.—These  vary very slightly, whether the uterus be torn
completely through,  or whether the peritoneal or muscular tissues alone
be injured.
  Certain authors have pointed out  what they deem premonitory symp-
toms ; but these are  exceedingly ambiguous.   The circumstances which
may justly excite our fears are, previous  difficult labours, the  occurrence
of partial hysteritis during gestation ; and during labour, the coincidence
of violent labour pains with  a narrow pelvis.
  Rupture of  the uterus and vagina is marked by a sudden, acute, and
intolerable pain like a cramp ;  a sense of some part bursting, giving way,
or tearing, with  an  audible noise according to the testimony of some
patients;  the  suspension of  the  labour pains;  hemorrhage from  the
vagina ; and a rapidly succeeding state of collapse.
  Of these symptoms, the  excruciating pain and the  collapse are the
most  constant, as in  some cases the bursting or tearing  is not felt; and
when only one tissue suffers, the labour may continue, and there may be
no hemorrhage.
  The pain continues, with little  or no intermission.   The  stomach is
disturbed, and vomiting  ensues, at first, of the contents of the stomach,
then of a greenish, and ultimately of a black matter, the " coffee-ground
vomit."
  The countenance  is pale  and ghastly, with an  expression of intense
suffering and and anxiety; the surface is  cold and clammy.
  The pulse  is very rapid,  small, feeble, and fluttering; the respiration
hurried and difficult; and the patient requires to be raised in bed.
  There is almost always a discharge of blood from  the vagina; some-
times slight, and at others so considerable as to cause death.
  We know,  also, from  post mortem examination, that in  most cases,
hemorrhage takes place  into the abdominal  cavity;  and some authors
have  attributed the state of collapse to  this  cause ; but though it may
aggravate  the collapse, we  know that this is present when there is no
internal hemorrhage.
  When the rupture is complete, the expulsive efforts cease, because tne
child  escapes  partially or wholly from  the  cavity of the  uterus,  into the
abdominal cavity, where it may be felt by the hand through the abdominal
parietes.
  The presentation, which was probably within reach before the accident,
cannot now be ascertained by the finger.
  When the rupture is complete, a loop  of intestine may escape through 
452
LACERATIONS
 it,  and give  rise to the symptoms of strangulated hernia.   Duparcque
 quotes three cases of this kind from Remigius, Percy, and Beauregard.
   A case is related by Dr. M'Keever, where a yard and a half of intes-
 tine became strangulated, and sloughed off.
   This state of collapse may continue  for some time, if it do not prove
 immediately fatal: but at length a certain amount of reaction takes place;
 inflammation  sets in, and the patient exhibits  all the  symptoms of peri-
 tonitis—acute pain, exquisite tenderness of the abdomen on  pressure,
 tympanites, decubitis on the back, with the knees drawn up, quick, small,
 hard pulse, hurried  respiration, &c, &c.
  693. Terminations.—The patient may die  of the shock a few minutes
or hours after the accident, or after delivery;  or she may survive the shock,
and die of the peritonitis;  or lastly, she may be carried off by secondary
diseases, as sub-peritoneal, or lumbar abscess,  &c.
  Of Dr. Jos. Clarke's patients—
          1 died undelivered.
          1  " in  4 hours.
          1  «   20  "
          2  "   24  "
          1  "   30  "
  Of Dr. Ramsbotham's—
      3 died shortly after delivery.
      2 in  1  hour    "
      1 "  3 days    "
  Of Dr. Collins' cases—
4 women died immediately after delivery.
1      "     in 2 hours     "
3 -u        4  a       <(
1      "       10  "       "
  Of Dr. Collins' cases—
2 women died in 14 hours after delivery.
      17
      24
      25
      30
on the 2d
      3d
      4th
      5th
      8th
      9th
    11th
    14th
    24th
day
In a case under my care the patient died in five minutes undelivered.
In-by far the greater number of cases, the accident proves fatal.
 Of Dr. Smellie's
   Dr. Jos. Clarke's
   Dr. Merriman'8
   Dr. M'Keever's
v  Dr. Ramsbotham's
3 cases,  2 died.
8  "    7  "
1  "    1  "
1  "    9  "
3  "   10  "
Of Dr. Collins'       34 cases, 32 died.
   Dr. Beatty's       1  "  • 1  "
   Drs. M'Clintock and
     Hardy's        9  "    9  "
   Some cases, however, are  on record  where  the patient  recovered.
Heister relates a case mentioned  to  him by Rungius; and Spiering, one
cured by Forquosa.   M. Peu,a Dr. Hamilton," Dr. James Hamilton,'6 Dr.
Jos.  Clarke,d  Dr. Douglas,8 Dr. Labatt,f Dr. Frizell,« Mr.  Ross," Mr.
Kite,1 Mr.  Powell," Mr. Birch,1 Mr. Smith," Mr.  Maclntyre," Dr.  Hen-
drie,0 Mr.  Brook," Dr. Davis,* have each recorded one case of cure.
   Dr. M'Keever, and Dr. Collins, have each related two, and Dr. Rams-
botham  three  cases.   Duparcque has collected four from French au-
thorities.
» Pratique des Accouchemens, p. 341.
D Outlines of Midwifery.
" Select Cases in Midwifery, p. 138.
d Trans, of Association, vol. i.
e Essay on  Ruptures  of the Uterus,
    p. 7.
f Dublin Med. Essays, p. 343.
e Trans, of Association, vol.  ii. p. 15.
h Annals of Medicine, vol. iii. p. 377.
1 Mem. of Med. Soc, vol. iv. p. 253.
k Med. Chir. Trans., vol. xii. p. 537.
1 Ibid., vol. xiii. p. 357.
m Ibid., vol. xiii. p. 373.  •
" Med. Gazette, vol. vii. p. 9.
0 American Jour, of Med. Science, vol. vi.
    p. 351.
p Med. Gazette, Jan. 17, 1829.
« Obstetric Medicine, vol. ii. p. 1070. 
OF THE UTERUS  AND  VAGINA.                453
  Osiander states that he has known several cases of recovery.
  Velpeau quotes several cases.
  There are  a very few  instances on record where the patient has  re-
covered, although the fcetus remained in the peritoneal cavity.
  In cases of interstitial fcetation, also, the patient has sometimes survived
both shock and inflammation.
  694.  Diagnosis. — The sudden  acute pain;  the cessation of labour;
the collapse; and the recession of the child, will render it easy to recog-
nise the case.
  But when the rupture is partial, it may be more difficult; and we must
rely mainly upon the sudden pain  and  the collapse for our diagnosis.
The occurrence of peritonitis  subsequently, will serve to  clear up  the
difficulty.
   In  a very  able paper  in the " Dublin Journal," Dr.  M'Clintock has
shown that the life or death of the child  is a  most valuable diagnostic
sign.   In cases of laceration the child dies  almost immediately.
   The sudden occurrence  of peritonitis in old women, may excite a sus-
picion of its  origin; but it will not be easy  to arrive at certainty.
   Prognosis.—From the  details already given, it is  almost unnecessary
to state, that  the prognosis is always grave.  So very few are saved that
there is but a faint hope of the recovery of the patient.
   695.  Treatment. — The first question which presents  itself, when  a
rupture of the uterus  is recognized, is, " shall the patient be delivered at
once, or left to nature1?"   When the os uteri is undilated, instant delivery
may be impossible : but in all cases where if is possible, the testimony of
experience is in favour of immediate delivery.
   And the cases of recovery confirm this  decision; for in all but one or
two, the women were delivered.
   Dr. W. Hunter and Dr. Garthshore advised that the case should be left
to nature; and subsequent to the publication of his Introduction to Mid-
wifery, Dr. Denman came to the same conclusion.  The evidence of facts,
however, must be allowed  to counterbalance even such illustrious names;
and that evidence is unquestionably in favour of delivery.
   The mode  of delivery will depend altogether upon the circumstances of
the case.
   1.  If the head have not receded,  and be  within reach, or be already in
the pelvis, it will be well to deliver with the forceps if  possible;  but if
not, we must have  recourse to the perforator.
   2.  If the child have escaped into the cavity of the abdomen, the hand
must be  introduced into the vagina, and,  if practicable, passed through
the laceration, and  the feet seized  and brought down, so that the child
may be extracted through the rent.
   The placenta is then to  be removed, the vagina cleansed, &c.   In all
these cases the child is born dead.
   3.  If the uterus have contracted very firmly, it may be impossible to
pass the  hand through the rent;  or the pelvis may  be too narrow to
admit of the  child being extracted footling,  or even of the passage of the
hand.
  4. In  such cases we are advised to perform the Caesarean section, and
extract the child and secundines through the abdominal parietes. 
454                           LACERATIONS
   Successful cases are related by Thibault des Bois, Lassus, Haden, Bau-
delocque, Latouche and Jopel, Lambron, Glodat, &c.
   To these may be added cases related by the following:—MM. Coquin,a
Sommer,"  Ceconi,e Ruth,'1  Rust,"  Gais,  Naegele, Weinhardt/ Heim,«
Busch, Demay,h Lechaptois et Lair,1 Velpeau."
   5. This will be the only mode of delivery, in ruptures occurring during
gestation, before the labour has commenced.*
   During the stage  of collapse, it  may be necessary to give  stimulants,
ammonia, camphor, musk, wine, &c.;  but this should be done with great
judgment, so as just to attain our object, and no more ; bearing in mind
that whilst we may be relieving the collapse, we may be aggravating  the
reaction, and increasing the danger at that period.
   A large  dose of opium  may be given after the delivery.
   When inflammation  sets in, of course the  treatment must  be actively
antiphlogistic.   Three or four dozen leeches should be applied over the
abdomen, and  repeated if necessary.

  » Bulletin de la Faculty 1812, p. 86.       ' Ibid.
  b Ibid.                                  e Ibid.
  c Bulletin de Ferussac, vol. v. p. 47.       b Journal Ge*n., vol. v.  p. 58.
  * Ibid., vol. vi. p. 280.                    * Ibid., vol. i. p. 187.
  ■ Luroth, Ibid., vol. xix. p. 85.            k Traite" d'Accouch., p. 355.

  * " In regard to the point of duty in  the  management of such cases (of ruptured
uterus),  I have to remark," says Dr. Meigs (op. cilat.), " that, upon discovering even
the smallest commencement of a laceration of the vagina or cervix  uteri, the earliest
practicable precautions should be taken to ensure delivery per vias naturales, and the
prevention of the escape  of the child into the peritoneal sac.   This should be done,
where it is practicable and convenient, by seizing the head, if it be the head, in the
grasp of the obstetrical forceps ; by bringing down the feet, if it be a breech; by turn-
ing and delivering, if it be a shoulder case; or by turning to deliver, if it be a case of
face  presentation, or departure of  the chin, or any condition  indeed in which the
operation of version would be most likely to rescue the woman  from the dangers by
which she is surrounded.
   " Should the laceration have permitted the child to escape at once into the peritoneal
sac, let  the  attendant lose no time, but bare his arm, and  resolutely, with his hand
passed through the rent, explore the abdomen in search of the feet, which he  should
immediately withdraw through the opening of laceration.  But if this be not done; if
some hours should have elapsed subsequent to the occurrence of the accident; if the
woman be already much exhausted by hemorrhage, by constitutional  shock and irrita-
tion, the question will arise  as to  the properest manner of fulfilling the indication,
which must ever be to extract the child.   The hemorrhage will now have been stayed:
were it not  so, the woman would be already dead: to pass the hand through the rent,
6hould it be in the vagina, would be to  set the hemorrhage again on foot.  It will be
always impossible to pass the hand through the rent in the uterus, because the uterus.
being now contracted, will  have reduced the  size of the rent in proportion to the con-
densation of the organ.  The child  can never be returned through a contracted rent,
having passed through it while the uterus was yet undiminished in size.  I say, then,
the question arises as to the mode in which the indication is to be carried out.
   "I am firmly convinced, that, should  I be called  this day to the  conduct of such a
case, I should feel bound by my conscience to recommend a delivery by a gastrotomy
operation.  I cannot think that a clean incised wound along the linea alba, suflBcient in
length to permit the extraction of the child from the peritoneal sac, however exception-
able in itself merely considered, can be held in the least degree objectionable when com-
pared with the  delay, the fatigue, the  contusion and the renewal  of  the  suspended
hemorrhage, that would inevitably attend an attempt to extract per vias naturales."
   For much valuable information in relation to the subject of rupture  of the uterus,
the reader is referred to the excellent monograph of Dr. James D. Trash, of Brooklyn,
N. Y., contained in the January and April (1848) numbers of the American Journal of
the Med. Sciences. —Editor. 
OF THE UTERUS  AND  VAGINA.
455
  Large bran poultices  are  useful, and  hip baths  are  recommended.
Calomel and opium, or opium alone, are the most valuable remedies we
possess.   It  should be given in large doses, or in smaller ones more fre-
quently, so as to influence the system rapidly.
  If the rupture have arisen  from the narrowness of the upper outlet of
the pelvis, and the patient recover, and again become pregnant, premature
labour should be induced, at such a period of gestation as will allow the
fcetus to pass without difficulty.   It is of  course desirable that the opera-
tion should,  if possible, be deferred until the fcetus is " viable:" but I do
not think  this a  " sine qua non," as it may be worth while sacrificing the
child to  save the mother.   Dr. Collins relates a successful case of this
kind, in which the patient was delivered the first time after the rupture by
artificial premature labour, and afterwards naturally.   In Dr. Douglass'
case, the  patient was  delivered by turning, the first pregnancy after the
accident,  and naturally the second.
   It would,  however,  be much wiser for the patient to avoid the risk of a
subsequent delivery.
    696.  II.  Vesico-vaginal and Recto-vaginal Fistula.—Perforation
of  the  coats  of the vagina, anteriorly or posteriorly, with the subjacent
organs, the bladder or rectum, is not very rare, and it is  one of the most
distressing and  intolerable accidents to which females are subject; and
the more  so, as  a cure is but seldom effected.
   Indeed vesico-vaginal fistula has long  been considered as one of the
opprobria of surgery ;  and, with some exceptions, of late years  the cure
has been  given up as hopeless.
   Vesico-vaginal fistulae are more frequent than perforation of the rectum ;
they are generally found separately, but in some cases co-exist.
   A case was received into the Meath Hospital some years ago, in which
the bladder  and rectum were both perforated, the perineum lacerated, tht:
canal of  the vagina distorted by cicatrices, and closed at its upper part by
adhesions.
   Strictly speaking, we can hardly consider this form of laceration a com-
plication  of  labour; it is rather one of its  sequelae, except in those unfor-
tunate cases where injury is inflicted during extraction of the child, or the
urine is allowed so to  accumulate as to expose the bladder to rupture from
the pressure of the child's head.
   697. Causes. — Various causes may give rise to these accidents:
    1. Either wall of the vagina may be wounded, accidentally or on pur
pose,  by cutting instruments.   Such has  been  the result  of  criminal
 attemps to procure abortion.   In these .cases, however, a cure often takes
 place  spontaneously.
   2. The long retention of a pessary in the vagina may give rise to  in
flammat'on  and  ulceration of the vaginal  tunics, and ultimately to perfo-
ration of  the bladder or rectum.  This, however, but seldom occurs, and
then only in aged females,  for whom little can be done in the way of
cure.
   3. In powerless or difficult labours, where the head of the child is long
retained  in the  pelvis, or where, by its size, it makes  great pressure, the
vagma may be  the  seat of inflammation, ulceration, and perforation, in
volving either of the subjacent organs, but much  more frequently the
bladder. 
456
LACERATIONS.
  In these cases, the vagina is frequently narrowed, or deformed by irre-
gular, circular, or spiral cicatrices, rendering the detection of the fistula
somewhat difficult.
  4. A maladroit use of instruments may occasion this injury.   Cases of
both kinds of fistula could easily be adduced from  authors,  as the result
of carelessness or incompetence  in the operator.
  5. Retention of urine during labour will generally involve  more or less
pressure upon the bladder;  if within certain limits, perforation will be
the  result of subsequent inflammation ; if the distension be excessive, and
the  bladder protrude into  the pelvis, so as  to be pushed  before  it by the
descending head of the infant, then, most probably, rupture of the bladder
and vagina will take place.
  6. The bladder is occasionally  lacerated in  rupture  of  the  uterus,
though there may not necessarily be a perforation of the vagina.
  7. In  corroding ulcer  and cancer  of the uterus, the  ulceration may
involve either or both walls of the uterus, and perforate  the bladder or
rectum,  or both.  For these cases, however, nothing curative can be
attempted.
  698.  The situation of the perforation is of great importance in the cure
of vesico-vaginal fistula?.   It may be at the junction of the  urethra with
the  bladder—in  the  neck of the bladder—or in some part  of its body.
The opening  may be more or less circular in form, or it may be a rent
running longitudinally from before backwards, or transversely.
  The curability of  the fistula will  depend, in a great degree, upon its
being attended with  a loss of substance or not.
  Recto-vaginal fistulae are uncertain in situation and form, occupying
any point of the intermediate septum, and running antero-posteriorly or
transversely.
  699.  Symptoms.—These depend primarily upon the cause of the fistula,
and will vary  according to  it;  and secondarily, upon the escape of the
contents of the  wounded organ.   Whichever organ be wounded, the
result is inexpressible distress  to the patient.  The escape of faeces or
urine is attended with so marked  and irrepressible an  odour, that the
patient  is placed " hors de society."   Obliged to  confine herself to her
own room, she finds herself an  object of disgust to her  dearest friends,
and even to her attendants.   She lives the  life of a recluse, without the
comforts of  it,  or even  the  consolation of its being voluntary.   It  is
scarcely possible  to  conceive an object more loudly calling  for our pity,
and strenuous exertions to mitigate, if not remove, the evils of her melan-
choly condition.
  In  addition to the offensive smell, the escape of the urine gives rise to
excoriation of the vagina, external parts, and thighs.
  The flow of urine is constant when the neck of the bladder is the seat
of  the  injury,  and at  intervals  when   the  wound  is situated  more
posteriorly.
   In all cases  a careful examination should  be  made, by  passing a
catheter into the bladder, and a finger into the vagina ; then placing the
points  of both in apposition, the whole posterior surface of the bladder
should be passed over, and carefully examined.   At some one point the
linger and catheter will come in contact:  the catheter may then  be passed
into the vagina, and the extent  of the damage ascertained. 
VESICO-VAGINAL  FISTULA.
457
  The same process will detect any injury of the recto-vaginal septum.
  When the vagina is  not cicatrised, it is not generally difficult to obtain
the information we desire; but when deformed by cicatrices, it will require
both care and patience.
  It may sometimes be necessary to use the speculum
  In the majority of cases, little is  to be  hoped for from  he efforts of
nature ;  the borders of the wound become thickened and callous, and the
case remains stationary during the patient's life.
   In some few cases, however, the result is  more  favourable; as, for
instance, when the wound has been inflicted by a sharp  instrument.
   In two cases under my  care, where the wound was precise y at the
insertion of the urethra into  the bladder, and was  followed at first by
absolute incontinence of  urine,  a  cure  was obtained naturally,   ihe
wound  slightly contracted,  without healing, and the muscular fibres of
the bladder-assumed  the office  of  a sphincter muscle, and closed the
 orifice, so that the patient could retain urine almost as long as previous to
 the accident,  and could evacuate it at pleasure.
    700.  Treatment.—We cannot wonder that  many methods should
 have been tried to remedy so offensive an accident, nor that so few should
 have succeeded, when we recollect the obstacle presented by the constant
 passage of urine or faeces.  We shall first treat of the cure of—
    I. Vesico-vaginal Fistula, which is by far the most difficult.
    The probability of  relief depends partly upon the situation, and  partly
 upon the character of the  fistula.   When it is  far back in  the posterior
 wall of the bladder, and when  there has been  much loss of substance, a
 cure  is seldom obtained;  but  when near the neck, we  may sometimes
 succeed.                                                     .
    I shall now notice  the principal plans which have been proposed.
    1. DessauWs method, as it has been called, consisted in maintaining a
 catheter constantly in the urethra, so as to afford an outlet for the urine,
 and at the same time  preventing its escape, by plugging the  vagina.
    J. Cloquet has added a kind of syphon to the catheter.
    Chopart succeeded in curing a case by this  means, where the wound
 was  in the neck; but he  failed in  one where it was in  the body of the
 viscus.
    Peu, S. Cooper, and Blundell, each relate a case of cure.
    There is no doubt that  much  relief may occasionally  be  derived from
  this  plan.  I had a case in which the patient was  ultimately enabled to
  retain her urine for two hours, without dribbling, though the wound did
  not entirely close; but in some of  the cases  on record the wound com-
  pletely healed.
     There is  this objection to the plan, however, that m many instances
  the patients cannot  bear  the catheter above  an hour at a time.   I saw
  two examples lately, where this circumstance  proved a  serious obstacle
  to the cure.
     701. 2.  Cauterisation. — This is obtained by the repeated application
  of the nitrate of silver or the strong acids.   Dupuytren,  who, I think,
  first proposed the plan, used the " nitrate acide de mercure," or nitrate
  of silver.
     Relief has occasionally been afforded by this means, but  a cure is very
                                   2o 
458
LACERATIONS.
rarely, if ever, effected.  Where there is much loss of substance, it affords
no chance.   I have seen it fail more than once.
  However, Dupuytren, and Delpecb, and Baravero, are said to have thus
cured several cases.
  The best mode of applying the caustic is by means of a fenestrated
speculum, which will leave the upper surface of the vaginal canal exposed,
or by Lallemand's " porte caustique."  The caustic  should  be lightly
applied, as  the object is not to produce a slough, but merely a contraction.
  702.  3.  Actual Cautery. — If the loss of substance be slight, and the
wound small, there is  no doubt that a cure may be  obtained by this
means.  Dupuytren, who first proposed it, cured several; Dr. M'Dowell,
one ; Dr. Kennedy, two ;  Mr. Liston, four or five ;  and others have been
equally successful.  Dr. Colles has tried it successfully where the orifice
was not too large, but without benefit where the fistula was extensive.   I
witnessed a successful case treated by my friend,  Mr.  Ferral, of St. Vin-
cent's Hospital.
  1 also tried it  in a case under my own  care, but it failed, as I antici-
pated, on account of the large size of the opening.
  The facility with which the operation is  performed,  will depend  upon
the situation of the fistula being more or less anterior.
  The patient may be placed upon her back as  for lithotomy, or upon her
knees and elbows.  Dr. Kennedy adopted  the former;  but I have found
the latter far more convenient, and I think less  offensive to the patient's
feelings.   The  light can reach the part more readily, and the position of
the  operator  is more convenient.   The patient must be placed before a
window, or a candle must be used.
  The next point is to dilate the vagina, so as  to ensure access to the
wound, without  contact with the vagina.  This  may-be  done by  three
brazen spatula?,  sufficiently long to  reach  beyond  the  rent,  and broad
enough to protect the vagina—or by a double-bladed speculum.
  I have also used, with great facility and safety, a metal cylinder, closed
at its extremity, but with an opening in the side, a little distance from the
end, and corresponding to the fistula.
  A catheter should be passed into the bladder, and through the fistula,
to guide the operator, and to keep the mucous membrane of the bladder
from protruding.
  Having these preliminaries  adjusted, the  cauterising iron, at a white
heat, should be lightly  applied around the edges of the wound, and with-
drawn.
  The dilators, or speculum, may then be removed, and the patient placed
in bed.   If it do not occasion irritation, it will  be advantageous to allow
the catheter to remain in the bladder.
  The patient should be kept quiet, and the bowels freed by medicine.
  A certain amount of local irritation generally  succeeds, which subsides
in the course of  a few days; after which the  operation may be repeated
as often as  necessary.
  The operation should not produce a slough, or the patient will not  be
benefited, but merely a corrugation  or  shrivelling of  the edges.  If we
thus reduce the wound, so as to bring the edges in contact, adhesion may
then take place, and the  patient be cured.   But  it must  in candour be 
VESICO-VAGINAL FISTULA.
459
confessed, that whilst it is not difficult or uncommon to benefit the patient
to a great extent, a complete closure of the fistula is very rare.
  703.  4.  The Suture.—This  method is said to have been invented by
Roonhuysen ;  at all events, it has been long known and practised by the
profession, with varying results.
  Of late  years, it has been performed with success by Dieffenbach,
Blandin,  Chanam, and Jobert (who  operated  seven times, and cured
three patients);  Sanson, who failed;  Deyber, who  nearly, if not quite,
cured his patient; Malagodi of Bologna, who has published his success-
ful case ;  by MM. Lallemand, Duges, and Roux, who failed; and by M.
Naegele.
  Mr. Earle cured three cases by this  means.  Mr. Hobart, of Cork,
formerly published a successful case in a London journal, and now states
that he  has since perfectly cured at least ten by the suture.  A successful
case is related in the American Medical Recorder.
  Dr. Evory Kennedy has  succeeded in diminishing the orifice several
times;  and in one case in whieh the twisted suture was used, the cure
was complete.
  Mr. Hayward, of Boston, U. S., has recently published a very interest-
ing case, which was perfectly successful.
  On the  other  hand, Dr.  Colles, of Dublin, (whose name alone  is  a
sufficient guarantee for all that science, and skill, and care could do,) has
allowed me to state that he has repeatedly tried  the  common interrupted
suture ; but though he has by this means lessened the orifice, he has never
succeeded in closing it entirely: and this was the  result under very favour-
able circumstances.
  He has  also seen very unpleasant consequences result from the opera-
tion ; hemorrhage (the edges of the fistula having been  removed by the
knife) to a great amount; fever, hectic, &c.
  I have seen the operation performed very carefully twice; but in neither
instance did union take place. .
  The operation may be performed in  the following manner.   The edges
of the wound are to be renewed, either by paring with a knife, or the
application of caustic; the latter has the advantage of being less liable
to occasion subsequent hemorrhage.   When this is  accomplished, the
patient is to be placed on her back or knees, and the vagina to be  dilated.
If the wound  be  near the insertion  of the urethra, or can be  brought
down by passing a catheter through it, a  curved needle (rather shorter
than usual) may easily  be  passed through the  opposite edges.   If the
wound  be further back, an  instrument must be  used to pass the suture.
Mr.  Hobart fixed a curved needle at the end of a canula, by means  of  a
piece of wire with a hook at the end of it, running through the canula.
The needle is passed through the hook, and held firm by it.
  M. Naegele has contrived a needle, with a long handle, for passing the
ligature.
  He has  also invented a species of  scissors, for the purpose of paring
the  edges.
  Mr. Beaumont has described an ingenious instrument for passing the
sutures :■—
  " The instrument is in  the form of a forceps,  one blade of which is  a
needle,  curved towards  its  point, close to which  is its eye.  The other 
460
LACERATIONS.
blade is broader on its opposing surface, less curved, and at its extremity
has a hole through which the needle-point, and just the loop of the liga-
ture, are carried when the blades  are closed.   On the back of the broad
blade is a spring which, when pushed forwards, the blades being pre-
viously closed, catches the ligature on its point, and holds it.
   " In using this instrument, the operator has  only to seize in its  points,
in the same manner as he would with a pair of forceps, the border of the
fistulous opening; the blades should then be closed, and the ligature will
be carried through one lip of the aperture.  The  opposite border  is then
to be seized,  andthe blades to be closed, and held so.   The  spring  on
the back of the broad blade is now to be pushed  forwards, by which the
ligature is caught, and held at its point.  The  blades  are then to  be
opened, and  gently withdrawn, leaving a double ligature passed through
opposite  points  of the  fistulous aperture, so that a common  or  quilled
suture may afterwards be formed.
  Mr. B. used it once with a quilled suture.
  The instruments I have used were  chiefly copied from some lent me
by Dr. Kennedy, with the addition of one I had made for transverse lace-
rations.   They consist of an instrument for paring the edges of the fistula,
a needle for a fissure running antero-posteriorly, a needle for  transverse
fissures, and of a hook for disengaging the ligature, after it has been passed
through the edges of the wound.
  When the  twisted suture is  used,  short curved needles may be em-
ployed ; it will also be well to keep them in for some time.   In Dr. Ken-
nedy's case they were retained about three weeks.
  Many other modifications of the manner of  applying the ligature (such
as Schrcger's, Ehrmann's, &c.) might be enumerated, but for them I must
refer my readers to Kilian's work already mentioned.
  It will generally be necessary to pass three sutures, none of which  should
be tightened till all are  inserted, and when tied, the ends  should  be cut
off.  The tightening  is easily  accomplished  with two  pair of dressing
forceps.
  When this is done, the dilator, or speculum, may be removed and the
patient put to bed.
  There is considerable soreness  and pain complained of, which may  be
relieved by vaginal injections of warm water twice a day, and the  exhibi-
tion of purgative medicine.
  When the  edges of the wound have  been  pared, we must be on the
watch  against  hemorrhage.  Should  it  occur, cold injections may  be
thrown up, or a plug inserted, and if necessary, the sutures divided.
  The sutures generally come away about the eighth or tenth  day, and
we are then  able to  ascertain the  result  of our operation, which, if not
wholly successful, may be repeated after a week's interval.
  In the majority of  cases, I fear we shall find but little benefit;  though
even less success than has as yet  attended our efforts, would justify the
operation.
  M. Naegele has described an instrument, consisting of two small plates,
joined at the  back like the pages of a book, and fixed in a handle of steel.
The anterior edges are brought together  by a  screw fixed in the handle,
and the edges of the wound  being included, are  retained in apposition,
and the lower part of the handle removed. 
VESICO-VAGINAL  FISTULA.
461
  M. Lallemand has also invented one, which he calls a " sondeeigne,"
by which a similar effect is produced.
  Not having  seen  the instrument, I am  unable to  give  a description
of it.
  He has cured one case with it, partially cured another, but failed twice.
  MM. Langier and Lewiski have also contrived  similar instruments.
  704. 5. Dr.  Blundell saw a fistula in the neck of the bladder, near the
urethra, cured by laying open the urethra to the rent, and then  healing it
up, as is  done in ordinary fistula.  Mr. Porter,  of the Meath Hospital,
performed a similar operation, which terminated successfully.
  705. 6. "Elythro-plastie."—-This name is given to the operation by
which a portion of integument  is taken from a  neighbouring part, and
applied to the vesico-vaginal fistula, and retained by  sutures; the old
connexion being maintained until  union  has taken place.  It is  exactly
similar to the rhinoplastic  operation for repairing noses.
   It  was suggested by Velpeau,  but first practised  by Jobert.  Of his
four operations, one  patient was cured at once; one by a  second opera-
tion ;  one died ; and with one it failed.
   M.  Roux did not  succeed with it.
  I am not aware  that any other surgebn has tried it.
  706. 7.  Closure of the  Vagina.—When using the caustic for the  cure
of vesico-vaginal fistula, in the year 1833, M. Vidal de Cassis  chanced  to
touch the vaginal mucous membrane with it; this caused considerable in-
flammation, and on  making  an examination subsequently, he found the
sides of the vagina adherent.   The patient also observed that the dribbling
of  urine had entirely ceased.  Unfortunately, a careless examination was
afterwards made, andthese adhesions were destroyed.  But the hint was
not thrown away,  for on the next occasion, in the same year, M. Vidal  de
Cassis attempted to relieve the fistula in  this way, and was perfectly suc-
cessful, ■ until  the  clumsiness  of an assistant  destroyed these  adhesions
also.
   There is no doubt that in  many cases this would be  found a valuable
means of relief.
   Caustic of any kind will answer the purpose of exciting inflammation,
though adhesion may not  always take place.
   I have seen a circle of  the  mucous membrane removed, and the parts
brought together by  suture, for the purpose of closing the orifice of the
vagina, but union  did not take place.
   When we have  recourse to this method, care  should be taken to leave
a very minute opening  posteriorly for the  escape  of the menstrual fluid,
if menstruation have not ceased.
   707. 8. The plug. — If none of the means hitherto described afford a
probability of cure, or fail upon trial, it is  at least a comfort to know that
we can still remove a portion  of the distress caused by this frightful com
plaint, provided the  irritability of the vagina be  not  too great to bear a
plug.
  Various cases of relief  by this means are on record.
  Dr. Gooch, in 1814, suggested to Mr. Barnes, of Exeter, the employ
ment of an  India-rubber  bottle, of sufficient size to  fill the vagina, and
having upon one side of it a small piece of sponge, to be  applied to the
fistulous opening.   Mr. Barnes used this with great benefit to  his patient.
                                2o2 
462
LACERATIONS
   M. Duges has proposed a similar plan, but the  pessary was  made of
 different materials.
   Dr. Evory Kennedy has succeeded in taking casts (with wax) of the
 vagina with the fistula, in several cases ;  and from them he made moulds,
 and had caoutchouc bottles cast in the moulds.   These were large enough
 to fill the vagina, and to close both the fistula and the outer opening, so
 as entirely to prevent the escape of urine.
   I have attained the same object by means of a piece of sponge covered
 with thin bladder.   It should be large enough to fill the vagina, and of a
 suitable shape.  A narrow neck, of the dimensions of the vaginal orifice,
 is to be formed, by wrapping it with twine, which  is to be  covered with
 lint.  The whole has much the shape of an egg-cup.  It should be dipped
 in oil previous to  being used, and then it  can easily be introduced, and
 the stalk filling up the  external  orifice, no urine  can escape.   It can be
 removed and replaced by the patient herself.
   Various other suggestions have been  made* but either of these  plans
 will relieve the patient from the  constant dribbling  and  offensive odour,
 and will allow the excoriations to heal.
   If the patient cannot pass water with the plug in situ, she should learn
 to withdraw it and re-introduce it herself.
   708. 2. Recto-vaginal  Fistula. — I  have already mentioned that
 many  of these cases are cured spontaneously; others, however, require
 the resources of art.
   The plans of treatment for the cure of vesico-vaginal fistula, are almost
 all equally applicable to this accident.
   The wound  may be touched  with caustic, or the actual  cautery;  the
 edges  may be pared,  or cauterised,  and  brought  into  contact; or  the
 vagina may be filled with a plug.
   All these methods have been tried, and with much greater success than
 in vesico-vaginal fistula; and the method of operation so closely resembles
 that already recommended that  it would be unnecessarily tedious to re-
 peat it.
   709. 3. Laceration of the  Perineum.—When this accident  is of
 slight extent,  it may not interfere with  the comfort of the  patient; but
 when extensive, it will be a cause of constant distress;  and in either case,
 the proper cure of the wound  is important; as, if callosities form,  or ir-
 regular cicatrices, much impediment may be offered  in subsequent la-
 bours.   It is an accident much more common with first labours than  after-
 wards.
  It will be recollected that when the  head of the child descends  so as
to fill the cavity of the pelvis, it necessarily makes pressure upon the lower
part of the rectum and the sphincter ani; that it then receives  a  direction
forwards and downwards, and successively distends the central  space of
the perineum and its anterior border.
  When the perineum  offers much resistance, as with first  children, the
mucous membrane of the posterior wall of the vagina, owing to  its laxity
of connexion with the  subjacent tissue,  is partially  everted,  and forms a
kind of artificial perineum.  This is almost always torn, but  the rent may
extend no farther;  and if we examine the day after delivery,  we shall find
this mucous membrane retracted, and the true perineum untouched. 
OF TIIE PERINEUM.
463
  This is not to be confounded with the laceration of the true perineum,
of which we are about to treat.
  710.  The situation and extent of the rupture vary according to the cause
and the circumstances of the case.
  1. It may commence at the anterior border, and extend to the sphincter
ani; and this is the most frequent extent.
  2. The  rent may involve the entire perineum, and extend through the
sphincter ani, laying the cavities of the  rectum and vagina into one.
  3. The  central space of the  perineum is sometimes ruptured, leaving
the anterior edge (the fourchette) and the sphincter ani untouched.  Cases
are related by Hernu, Coutouly, Lachapelle, Meckel, Lebrun, Thiebaut,
Frank, Martin, Moschener, Jungmann, Marter de  Konigsberg, Trinchin-
etti, Merriman, Waller, Andrews, Douglas, Mekeln of Kettwig, Joubert.
And a case occurred recently in Dublin.
   The  rent may  run along  the  central raphe of the perineum, on one
side, diagonally ;  or in the form of the letter V or Y.
   In most of the  above cases, the child actually passed  through the cen-
tral opening; but in some cases, by careful management, it was transmitted
through the natural orifice without rupture  of the fourchette.
   4.  The  recto-vaginal septum, sphincter-ani, and part  of the perineum
may be torn, so as to permit the  transit of the  child, leaving the anterior
portion of  the perineum entire.
   711. Causes. — The  accident may arise from a  deviation from the
ordinary mechanism of parturition;  from  mal-conforination of the pas-
sages, or soft parts ; from mal-presentation ; or from mismanagement.
   1.  If  the sacrum be too perpendicular, the head of the child,  instead
of receiving its direction anteriorly, in the direction of the  axis of the
lower outlet, will be forced downwards upon the posterior portion of the
perineum.
   2.  If the arch of the pelvis be too acute,  so as to prevent the presenting
portion filling its upper part, extraordinary dilatation of the orifice of the
vagina will be necessary, and the head will be pressed with unusual force
upon the anterior part of the perineum.
   3. A similar  effect is said to  be  caused by a  thickened  state of the
urethra and circumjacent parts, in the arch of the pubis.
   4.  The  too rapid passage of the  head may be attended with this acci-
dent.  This may depend upon the extraordinary violence of the pains, or
upon the  small size of the head, which prevents it receiving the  succes-
sive changes of direction from the  plane surfaces  of  the pelvis, and the
changes in the  axes of the Cavity and lower outlet.
   5.  Exostosis in any part of the pelvic cavity may so act upon the direc-
tion in which the  fcetal head is propelled, that  rupture  of the perineum
may result.
   6. Excessive  breadth of the perineum, by receiving the force of the
descending head in its centre, may be a cause of laceration;  because the
head rests  in the centre, and distends  it, instead of gliding  forwards to
the anterior edge.
  7. Rigidity of the perineum, or an old cicatrix, may resist the  dilating
power of the  head, and ultimately give way under the  employment  of
greater force. 
464
LACERATIONS
  8. The tissue of the  perineum may be weakened by disease, or by too
much pressure, so as to  offer little or no resistance.
  9.  Occlusion of the lower outlet by the hymen.   As this membrane,
though much thinner than the perineum, is far less distensible, if it do not
give way, the perineum may.   I  attended a case lately, in  which the
hymen resisted the pressure of the head (with strong pains) for two hours
after the perineum was perfectly distensible, and in which there was every
probability that the perineum would have been lacerated, had not the
hymen ruptured.   Laceration of the hymen may also  be  extended into
the  perineum.
  10. Mal-position of the child's  head, by presenting a longer diameter
than usual to the lower outlet, may give rise to this  accident.
  11. Mal-presentations. —  Face presentations, involving  the passage of
the  head in its longest diameter over the perineum;  breech, or footling
cases, which do not receive a proper direction so readily as the head, may
also lacerate the perineum.  Dupuis relates a case,  where  one foot came
through the vagina, and one was forced through the perineum.
  12. The accident may arise from the woman  being awkwardly placed
for  delivery, or from her starting away from the attendant;  or from her
exerting too much voluntary force at the  time the head passes through the
lower outlet.
  13. The perineum  may be torn, in consequence of want of care when
instruments are used.  They ought  generally to  be removed just before
the  head passes through the  vaginal orifice.
  From  this detail of the causes  which may produce or predispose to
laceration of  the perineum,  it will be seen that  it may not always be in
our power to prevent its occurrence.
  712.  Symptoms. — If the  laceration be very slight, no ill consequences
will ensue ;  but if it  extend to the  sphincter, the patient will feel a want
of support at the  lower outlet, and a sense of " falling through."   It is
said to  influence  subsequent cohabitation, and certainly  it will favour
procidentia of the uterus.
  If the recto-vaginal septum be torn, the condition of the  patient will be
very pitiable.   The faeces (for some time at least) pass through the vagina
involuntarily, and  the utmost  attention  to  cleanliness will not suffice to
prevent the  offensive smell, which renders the patient an  object of-dis-
gust to herself and her friends..
  The lochial discharge passing over the wound, will for a time prevent
any natural efforts at cure; and the edges may become callous, or degene-
rate into ulceration.
  When slight, the rent generally contracts, and is healed without our
interference, after a short time ; and even when the  recto-vaginal septum
is torn, partial union may take place, leaving only a fistulous opening, or
a kind of valve may be formed, so that, under ordinary circumstances, the
patient is partly relieved of her infirmity.  But this is the  work of time;
it may be months or years.
  713. Treatment.—1. Preventive  management.—A few words  may
not  be  misapplied in pointing out the best  mode of preventing this
occurrence.
  1. Defects in the passages, which render the mechanism of expulsion 
OF THE PERINEUM.
465
inefficient, may often be remedied by the application of the hand in such
a manner as to give a direction forward to the head.
  2. Direct support should be given  to the perineum when distended;
but this  is frequently carried to excess, and produces the accident it  is
intended to prevent; it should be moderate and gentle, just so much as
to support the parts,  but  no  more.   I must altogether object  to any
attempt to retard the passage of the  child, as  erroneous in theory, and
mischievous in practice.
  3. When the perineum is rigid and undilatable, benefit may be derived
from fomentations with hot water, the  use of warm oil, lard, or pomatum.
  4. Under no circumstances is it justifiable to dilate the external orifice
with the hand, as formerly recommended; on the  contrary, instead of
drawing back the perineum, it ought to be  carried forward.
  5. If laceration be threatened in consequence of the persistence of the
hymen, it may be incised with  a blunt-pointed bistoury.
  6. The patient should always cease forcing, and remain perfectly quiet
during the exit of the  child.
  714.  2.  Curative treatment.—Slight cases, as I  have said, will  often
heal without  assistance.  Even when the rent is more extensive, a cure
may be effected without further interference  than great cleanliness, keeping
the patient in one position, so as to preserve the edges of the wound in
contact, and constipating the bowels after free purgation.
  If this do not succeed, we are advised to use a degree of compression,
passing a binder around the hips, and a pad on either side of the perineum,
so as to secure the apposition of the lips of the laceration.
  Strips of adhesive plaster have been applied, but  they do not answer.
  In many cases either of these plans has succeeded, but in many  cases
also they have both failed, especially when the recto-vaginal  septum  is
involved.   However, we have still another resource —
  In the suture which was  first proposed  by  Ambrose  Pare,  and  prac-
tised by Guillemeau, La Motte, Saucerotte, Trainel, Noel, Dieffenbach,
Roux,&c.
  Before this can be attempted, however, the primary inflammation  must
have subsided; nor is it forbidden, even though  a considerable time
should have  elapsed.  M.  Montain cured  a case on which he operated
thirty-six days after delivery, and others have succeeded at a more distant
period.
  Three different kinds  of suture have been  adopted—the interrupted,
the twisted, and the quilled suture.   Osiander, Dieffenbach,  &c, suc-
ceeded  with the first, but according  to  Duparcque, the success  and
failure have been nearly equal.  Mr. Alcock cured  one, and  Mr. Bayer
two patients  in this way.  Dr. Mettauer, of Virginia (U. S.),  succeeded
with metallic sutures; they were introduced, and the parts approximated.
by twisting the ends together.  They were removed in  six weeks, and
union found to have taken place.
  The great objection to the  interrupted  suture is that the lips of the.
wound are not closely applied in the whole extent, and the union is  often
partial.
  The same observation may be applied to the twisted suture, although t
has succeeded with  Morlanne, Saucerotte, Noel, Dieffenbach, &c. 
466
LACERATIONS
  The quilled suture is evidently better adapted for the purpose, as the
entire surfaces of the laceration may be brought into contact.
  Dupuytren succeeded once ; Roux and Dieffenbach several times; M.
Dubois failed ; but Mr. Davidson succeeded completely.  He thus relates
the case in the Lancet  of May 4, 1839.   " On the 6th of November,
1838, in company with  Dr. Henry Davis, I performed the operation in
the following manner: I passed deeply a strong double ligature, by means
of a common curved needle, close by the edge of the rectum, and another,
rather more than  half an  inch from  the  first, towards the vagina; after
which I pared the edges of the wound, which I had not previously done,
that I might not be annoyed by the oozing of blood, so as to be enabled
to place the ligatures  more accurately.   The ligatures being introduced, I
employed, as cylinders, two pieces of elastic gum catheter,  about an inch
and a half in length, one of which was placed in the loops which the
double ligatures formed on one side, and the other between their separate
ends, tying them  firmly upon the cylinder.   Baron Roux found in his
cases that the use of the quilled suture caused an eversion of the edges of
the wound; to remedy this, he had  recourse to several small sutures, at
different points between the different ligatures.  To effect the same object,
and also with a view  of keeping the divided parts more closely and firmly
in contact,  I adopted the  following  plan, the materials for which I had
prepared previously to the operation.   I armed a curved needle with a
piece  of narrow tape, four inches long, having a knot at one  end; this
was passed down  each  end of both cylinders about  half an inch, and
brought outwards,  the end of the tape being prevented slipping through
by the knot; the tapes were then placed in such a situation as to be inter-
mediate to the ligatures;  this being done, I turned the cylinders gently
towards the edge of the wound, and tied the corresponding tapes over it,
which, I think, rendered it much more solid than any number of  small
ligatures could have done.   The bowels were  constipated by  opium,
the urine drawn off night and morning, and  the diet consisted of  small
quantities of gruel  and hard biscuit.   The ligatures were removed on the
seventh day, and union was found to have taken place throughout.  The
urine was evacuated naturally after nine or ten days;  the bowels relieved
on the seventeenth; and  after six or seven weeks, she was able to go
about as usual."
  Dr. Colles has  rarely succeeded in curing, though he has diminished
the rent.
  If there should be loss of substance, or contraction of the two sides of
the perineum, so  that they will not readily meet  or remain in contact,
Dieffenbach makes an incision through the skin, on each side.
  The bowels should be  well freed before  the operation, and an opiate
given,  so as to constipate them; when union is attained, this may be
remedied by an enema.
  The catheter must be passed morning and evening for some time.
  The diet  should be spare:  a little gruel and biscuit will  answer very
well.   Of course  absolute rest is necessary.
  " If the radical  cure fail," Dr. Burns observes,  " the patient must use
a compress, with a spring bandage, if  the stools cannot be retained.  But
.1 sometimes happens that  the torn extremity of the rectum, or the anterior 
OF  THE PERINEUM.
467
parts, containing a fragment of the  sphincter or a  portion of the  internal
sphincter, as it has been called, forms a kind of flat valve, which  rests on
the  posterior surface  at  the coccyx, so  that  the orifice now resembles a
slit, and the faeces, unless very liquid, remain in the hollow of the  sacrum,
and do  not  pass through  the vulvular orifice  till an  effort be made to
expel.   Sometimes the perineum unites, but the septum does not, and the
inner surface of the  rectum protrudes into the vagina.   In these cases the
edges of the septum must  be made raw,  and stitches used."*
  * Although  laceration of the perineum in the female is easily treated when recent,
yet if  neglected until after cicatrization of the ruptured surfaces has taken place, it is
to be viewed as a serious and very intractable accident.
  Dr.  W.  E. Horner,  Professor of Anatomy in  the University  of  Pennsylvania, suc-
ceeded in affording, in a case under the latter  circumstances, very great relief  to the
patient by an operation.
  The rupture occurred in a young married lady during her first accouchment.  After
the birth of her second child, the case came under the notice of Dr. Horner.   The lace-
ration extended from vulva to anus; the parts were cicatrized over an inch  in depth,
and but one fissure was apparent from near the os coccygis to the clitoris.   The patient^
Fig. 138
1,1. Vulva.
   2. Anus.
3,  4. Lacerated perineum.
   5. Right flap.
   6. Left flap.
   7. Clitoris.
1, 1. Vulva.
  2. Anus.
  3. Upper or left flap.
  4. Lower or right flap.
  5. Clitoris.
of rather a full habit, and well organized in other respects, was rendered miserable and
helpless by a constant tendency to diarrhoea, only to be restrained by the constant use
of opiates.   Her life was unavoidably passed in seclusion, owing to her want of control
over the natural  evacuations.  Much of the fcecal matter passed  forward  through the
rima vulvae, which added to the distress of her situation.
  An operation was performed in the usual way, by paring off the cicatrix of each margin
of the  perineum, and  then fastening it  carefully with interrupted stitches along the
rectal and vaginal edges of the rupture, the sphincter ani muscle being divided on each 
468
LACERATIONS  OF THE  PERINEUM.
pide the anus; a procedure which Dr. H. considers proper in all old cnses of this kind.
Unfortunately, the menstual flux came on prematurely, and with the natural discharges
of the vagina loosened everything like adhesion.   The operation was a failure.
  Nearly fifteen months subsequently a second operation was performed in this case.
Additional difficulties had now to be contended against.   The portion pared off from the
perineum had reduced its extent; the slit from the vagina into the rectum had been elong-
ated or deepened.  If lateral adhesion had failed before, the failure now was still more
probable.   Under  these  considerations Dr. H. determined  to modify the operation, so
that if unsuccessful the condition of the patient should, at least, not be rendered worse
by it.  The  patient being  under the influence of a mixture of chloroform and ether;
two  flaps were made from  the perineum and adjoining parts of the vulva, the one on
the right and the other on the left.
  By placing the base of the right flap below, and the base of the left flap above, upon
crossing the two flaps a partition was formed  between the rectum and vulva;  the free
side of the right flap forming  the upper  part of the rectum, and  the free side of the
left the lower part of the vagina. The approximation of the flaps and  the contiguity of
their raw surfaces were secured by interrupted stitches along the rectum and vagina.
In forming the  left flap, owing to  a sudden contraction, its transverse part being first
made, was not as desired, but fell  short of Dr. H.'s intentions.   For the first ten days
or so  there was a strong indication of success.  A large firm stool now occurred,  and
on examination immediately afterwards the flaps were found not to be  adherent.  They
were, however,  in situ, so  that the partition formed by them between the rectum and
vagina was  still kept up.   In a month  after the operation the  left flap  had become
shrivelled away almost entirely, and the right flap had lost one-half  its original size,
but still remained as a barrier betwen the two canals; and by the introduction of a linen
compress into the  vagina,  upon the flap, so as to keep it in its place, the discharge of
foeces was regulated, so that there was  no diarrhoea.   The patient felt the call for de-
fecation, could make timely provision for it, and  was  really improved in respect to com-
fort.  Upon an examination of the patient six months after the operation, it was found
that the  indications  of an operation having been performed had subsided.   Upon a
superficial  examination there appeared  to be a regular division between  the anus  and
vulva—a reproduction of the perineum.   The latter was only however the claustrum
made by the operation—the edge was  still loose, but had the effect  of directing the
rectal discharges backwards and the vaginal forwards.  The recto-vaginal fissure had
diminished much in depth,  and the condition of the patient had  been much improved.
She could participate in her house-work — had a much better control of flatulent and
foecal discharges than  formerly, and is apprized  of their approach.  "It  yet remains
to try," says Dr. H.,  "whether, by a protracted application of the milder escharotics
to the free edge of the new claustrum/ a perfect  adhesion of it may not be obtained."
  In performing the operation described above, Dr. Horner recommends  that the ver-
tical incisions for the flaps  be first made, as the  relaxation of the tension of the parts
affects much the state of the flap when the transverse cut is first made, and thus inter-
feres with the plan of the operation. — (Amer. Journ. of the Med. Sciences,  Oct. 1850.)—
Eniioa. 
CHAPTER XXI.
           PARTURITION. —CLASS III.  COMPLEX LABOUR.
               ORDER 6. INVERSION OF THE UTERUS.

   715. This is a very rare complication, but a very distressing and dan-
 gerous one.   It is  neither more  nor less than a  turning of  the uterus
 inside out.
   The fundus descends through  the os uteri, forming a cavity lined  by
 the  peritoneum, open  towards the abdomen, and  containing the ovaries
 and  fallopian  tubes,  whilst that  which was formerly the lining mem-
 brane of the uterine  cavity,  has  become the  external covering of the
 tumour.
   The degree of inversion may vary: it may be partial or complete.  Mr.
 Newnham, who has published a valuable monograph  on this subject, has
 spoken of three  degrees — depression, partial, and  complete inversion.
 With  regard to the  first, he observes, " The fundus of  the uterus is de-
 pressed  within its cavity,  but does not  form  a  tumour  in  the  vagina.
 The actual existence of this stage of the disease can  only be  known  by
 introducing the finger  into the uterus and by ascertaining the state of that
 organ by pressure upon the abdomen.  By the former process, the fundus
 of the womb will be found to have approached the os internum, and  by
 the  latter a  corresponding  depression will be observed, instead  of thai
 regular contraction  which  is  so  familiar to every prudent practitioner.
 This state is generally accompanied with an effort to bear down, by which
 it is often converted  into partial or even complete inversion."   Of course
 so slight a change in  the uterus  is only perceptible through the parietes
 of the abdomen,  when  the patient has been recently  delivered.   In the
 unimpregnated uterus,  such an examination would  yield  no information.
   " When the inversion is partial," continues Mr. Newnham, " the fundus
 of the uterus is brought down into the vagina, forming a tumour of con-
 siderable size, presenting a semi-spherical form, and  closely invested  by
 the os uteri.   In  this case the depression of the fundus, observed-through
 the  parietes  of the  abdomen,  will be considerably greater than in the
 former, and the edge of the cavity thus formed will alone be felt.
   " In the complete inversion, the uterus will be found not  only filling the
 vagina, but protruding beyond it,  resembling in its  form that of the uterus
 after recent delivery, only that its mouth is turned towards the abdomen.
 The os uteri may be  felt at  the superior extremity of the tumour, forming
 a kind of circular thickening at its apex, and the uterus is wholly wanting
 in the hypogastric region.  This state is usually accompanied  with inver-
 sion of the vagina."
  716.  Inversion  may occur under very different circumstances;  as, for
example: 1.  Immediately after delivery, as the result  of a peculiar con-
 dition of the  uterine fibres; of too quick  delivery, &c.   2. A few days
after parturition, though Newnham conceives that in these cases depression
                                 2p                     (4GD) 
470
INVERSION OF THE UTERUS.
of the  fundus existed  from the first.  3. Or very gradually, in conse-
quence of a polypus attached  to  the fundus, the uterus not being preg-
nant.   Capuron and Newnham doubt the existence of such cases; but I
witnessed one myself, of the nature of which no doubt could be enter-
tained.
   We may be deceived, however,  and  suppose an inversion  to  have
occurred gradually, because it has remained long undiscovered.   Levret
mentions a case occurring after delivery, which was not detected  for five
years.
   By almost all authors, inversion has been divided into acute and chronic;
not, however, confining the term chronic to cases where the production of
the inversion has  been slow, but including all those where it has existed
for some  time.   The division appears to me to be useful and practical,
though perhaps not conveying as much information as the terms " reduci-
ble" and  "irreducible," which Dr. Radford of Manchester, has  recently
proposed as the substitute.
   717.  Causes.—Various causes are enumerated by authors,  some of
which are real, and some only fanciful.   Most of them, however, are such
as would act merely mechanically.   It has been observed to follow very
quick labours,  especially if the patient be delivered  standing, or if she
make too  violent  efforts.
   It may  occur spontaneously, after the labour has been completed quite
naturally, and in these cases it has been attributed by Dr. Radford to atony
of the uterus, or to active contraction of one part, with  an atonic condi-
tion of another.
   Dr. Tyler  Smith regards inversion as  depending upon an irregularly
active condition of the uterus, by which the fundus is first  depressed, then
carried downward by the annular contraction of the uterus, and, finally,
completely everted.
   It is very creditable, that violence  in  extracting the  placenta may be
followed by inversion; or, as Denman observes, " there  is reason to be-
lieve that the uterus has been inverted, when, on account of a hemorrhage,
or some other urgent symptom, the hand has been introduced within the
cavity of the uterus, while in a collapsed or wholly  uncontracted state,
and the placenta being withdrawn before it was perfectly loosened, the
fundus of the uterus has unexpectedly followed, and a complete inversion
has been  occasioned."  Forcibly  pulling the funis, for the  purpose  of
detaching the placenta, may perhaps, under certain circumstances, give
rise to this accident, but it is not a frequent cause.
   Shortness  of the funis, or the  shortening  of  it by coiling around the
neck of the fcetus, has also been alleged, but I believe without any foun-
dation.   Cords of ten inches  long will permit,  and have permitted, the
exit of the fcetus without displacing the womb, and it is very rare indeed
to find the funis so short.
   As to the shortening of the cord when  it is twisted around the neck,
this can never be the cause of inversion,  since it rarely occurs but when
the cord is longer than usual, and it very seldom  reduces the length of the
cord below twelve inches (§ 181).
   But inversion may occur quite  unconnected with parturition,  contrary
to the assertion of Astruc and some of the older writers.  If a  tumour
form at the upper part  of  the fundus uteri, it will first distend the uterus 
INVERSION OF  THE  UTERUS.
471
mechanically, and then by its weight it may descend through the os uteri,
dragging the fundus after it, and so produce complete inversion.  Such
a case I saw in Jervis-street Hospital, under the care of Surgeon Lynch.
   A curious case of this kind is also related by Dr. Browne, in the Dublin
Medical Journal.
   718.  Symptoms.—We shall first examine the symptoms which arise in
acute inversion, i. e., when it occurs soon after delivery, and when the
displacement is nearly or quite complete.   These are always serious  and
alarming, indicating the important nature of the accident.   The  most
universal symptom is a  sudden exhaustion or sinking, which comes on
immediately after the inversion.   It does not  depend upon flooding, for
it occurs in many cases where there is no hemorrhage.  The countenance
becomes deadly pale, the voice weak, the pulse rapid, small, and flutter-
ing,  nausea and vomitings Occur, &c, so that  the patient is  suddenly
threatened with the extinction of life.
   Several authors speak  of more decidedly nervous symptoms, and even
of convulsions; but by some, at least, the restlessness  and agitation  pre-
ceding dissolution, appear to have been mistaken for convulsions.
   When the inversion is slighter in degree, these phenomena will gene-
rally be found  less strikingly marked.
   Hemorrhage, even  to  a very large amount, not unfrequently  occurs,
aggravating, though not changing, the symptoms already enumerated, and
materially enhancing the danger of the patient.
   Mr. Newnham observes, " When the uterus has  become inverted, im-
mediate  hemorrhage takes place, which  is quickly followed by faintness,
 and  a sense of fulness  in the vagina, and, in the greater number of in-
stances,  almost by immediate dissolution."
   Our suspicions of inversion will be excited when  this persists longer
than usual, and an examination  should instantly be made to ascertain the
cause, if possible.
   In many cases,  however, there is  no hemorrhage at all, or not in  pro-
portion to the inversion, but merely the nervous symptoms and exhaustion;
nor  does the difficulty of rallying the patient seem to be less in these cases
than in those accompanied by flooding.
   There is  generally a very violent uterine contraction, immediately pre-
ceding or accompanying the inversion, leading the patient to  anticipate a
second child:  this supposition is further confirmed by the pressure of the
inverted uterus as it passes through the pelvis.   Even on examination pei
vaginam, we may be deceived, by mistaking the uterus for the breech of
a second child.
   The patient  complains of great pain, with a sense of dragging from the
loins, and occasional  retention  of urine.  If pressure  be  made on the
abdomen, we  shall  not  be able  to feel the  contracted  uterus, and  this
being at a time when it is large,  constitutes a  marked  and valuable
symptom.
   When  the inversion is incomplete, we may often feel the uterus  above
the brim of the pelvis, Wit having a cup-like depression superiorly.
   If we examine per vaginam, we shall find a tumour, either in the cavit)
of the pelvis  or hanging  through the vulva.   This tumour is globular,
sensible,  elastic, with  a  rough and  bleeding surface, wider  below than
above, where it is tightly encircled by the  cervix uteri.   If the displace- 
472
INVERSION OF  THE UTERUS.
ment be not reducible, it sometimes  happens that the tumour is attacked
by inflammation, running on into sloughing and gangrene, owing to the
strangulation caused by the contraction  of the cervix, and  ending in the
death of the patient.   If the placenta have not been previously expelled,
it will be found adherent to some part  of the tumour, adding greatly to
its bulk.
   A considerable difference in the size of the tumour will be observed
according  as  the inversion is complete or incomplete,  recent or of old
standing.
   If quite  complete, we may  acquire further information from a visual
examination.  The tumour is of a red colour when the inversion is recent,
but gradually becomes of  a dull brown.
   If incomplete, we  shall  still  be  able  to detect it in the vagina, though
if there be depression merely, we may not be able to reach it.
   The foregoing are  the most prominent symptoms of acute  inversion;
those which characterize the chronic stage of the disease, whether that
stage be the issue of an acute attack  or  the result of a gradual displace-
ment, are,  of course, much less formidable.
   The  patient is subject  to occasional irregular hemorrhages, and to a
constant and profuse mucous discharge during the intervals.
   Every month the  surface is  observed to be covered with red drops,
which are,  in fact, the menses.
   The patient complains of pain, a sensation  of weight in the pelvis, and
dragging from the loins.
   If the uterus protrude through  the external parts, its sensibility will
gradually diminish in consequence of the formation of a kind of epithelium
upon its surface ; and if it  be  exposed to rude contact, or if acrid secre-
tions be allowed to accumulate upon it,  circumscribed inflammation  may
occur, followed by ulcerations either superficial or profound, and involving
some danger to the patient, if not remedied.
   The constitution of the patient sympathises deeply with so extraordinary
an accident.   After recovery from  the state of exhaustion or nervous de-
pression, into which she was at first  thrown, the repeated hemorrhages and
constant leucorrhcea will render her countenance pale and exsanguined,
and subject her to various secondary symptoms, such as syncope, dropsical
effusions, hectic, &c.
   719.  Terminations. — The  patient may die from exhaustion or from
hemorrhage soon after the  accident, according to Heister, Peu, Levret,
Giffard, Windsor, Clarke,  Denman, Boivin, and Duges;  or from  the
more distant consequences  pf  the repeated  hemorrhages, as related by
Mauriceau, Haighton, Cooper, Windsor.
   Fatal cases  are also related  by  Peu,  Portal, Vanderweld, and  Millot,
Chapman,  Saviard, Heister, Smellie, and Mauriceau.  Boivin and Duges
add, that " death following a very few days after the  inversion, may have
been occasioned by pains, convulsions, and syncope, caused even by the
violence which the uterus has undergone."
   Distension and inflammation of the bladder may occur, involving con-
siderable danger.
   The inverted uterus may be strangulated, and be separated by sloughing
or gangrene with great danger, although cases are on record where this
termination issued favourably. 
INVERSION OF  THE  UTERUS.
473
  Or, if the patient do not sink from the primary shock, and if no destruc-
tive process take place in the  tumour, it will, after a while, shrink very
much in size, and the patient may suffer comparatively very little annoy-
ance.  Denman mentions the case of a pattent who consulted him for an
inverted uterus, twenty years before her death;  and Lamotte (Obs.  412)
another, " in which the inversion was complete thirty years before."
  Very rarely, the detruded organ has become the  seat of  malignant dis-
organization, either cancer or corroding ulcer.
  720. Diagnosis.—The facility of the diagnosis will depend very much
upon the  extent of  the inversion; when incomplete, it is very difficult,
and, even when complete, it will often require great care.  It is less ob-
scure if the examination be made soon after the accident.
   1.  If incomplete, it may be  mistaken  for polypus  uteri, but  it will be
distinguished by its  bleeding and rough surface, by  its insensibility, and
by the " cul de sac" within the os  uteri.
   2.  If complete, it  will resemble prolapse of the uterus; but may be dis-
tinguished by the period of its occurrence, by the flooding, by the absence
of the smooth vaginal covering of the bladder anteriorly, and of the os
uteri inferiorly.
  3.  It may be distinguished from prolapse of the vagina by its hardness,
its rough flocculent and bleeding surface, and by its unvarying size.
  The value of some of these characteristics, such  as the hemorrhage, the
state of the surface, and the size of the tumour, is limited to a short period
after the accident,  and to  those cases which occur after delivery.
   721. Treatment. — 1. Of  acute inversion.  Our first object is un-
questionably to reduce the displaced organ; and if we  are  on the  spot
when the accident occurs, it is  in general not very  difficult.  It is of the
last importance  that the reduction be attempted instantly.   Every hour
increases the difficulty, and the  lapse of four or five, according to Denman,
may render it impossible.  The period when the inversion becomes irre-
ducible, will be found to vary somewhat in different cases, and  according
to the  experience of different practitioners.
  There is also a great difference  according as  the inversion is complete
or incomplete.   It has  been stated to have been reduced spontaneously,
when the fundus uteri was merely depressed, and even when the displace-
ment was complete.
   But no anticipation of such an occurrence will justify our losing a mo-
ment in attempting to re-invert the uterus.   The protruded organ should
be grasped firmly and  passed  in through the vaginal orifice, followed by
the hand  (previously well oiled) which, when in  the vagina, should be
closed and formed into a cone, and made to press mainly upon the fundus
uteri.   No  effect will be produced upon the inversion until the vagina,
shall have been put upon the stretch ; but then, after  some time, it will be
found  to recede, and on being still further pressed, it suddenly starts from
the hand (like a bottle of India rubber when turned  inside out), and the
organ  is restored to its natural condition.
  The hand (now in the cavity of the uterus) is not to be withdrawn, but
rather  expelled by the uterine contraction.   This will ensure the  patient
against a repetition of the accident.  We should  also assure ourselves,
before the removal of the hand, that the restoration has been complete.
  Mr.  Newnham advises  that we should endeavour to " return first that
                                2p2 
474
INVERSION OF  THE UTERUS.
portion of the uterus which was last expelled from the os uteri."  It will
be found very difficult to attend to this minutely when the hand with the
uterus is in the cavity of the pelvis, for want of room ; and whilst the
tumour is external, the re-inversion does not take place ; it is  expressly
stated by several authorities, that they did not feel the reduction properly
commence until the vagina was stretched to  its full extent.
  722. In many cases the placenta remains  attached to the womb  at the
period of inversion, and  different opinions have  been held as to the pro-
priety of removing it before reducing the displacement.  Baudelocque,
Gardien, Capuron, Boivin and Duges, Radford, and others, recommend
its prior removal, but Denman, Clarke, Burns, Carus, Newnham, Blundell,
Gooch, &c, as decidedly oppose  it.  Mr. Newnham  remarks, " It  has
been  recommended by several respectable authorities to remove first the
placenta, in order  to diminish the bulk of the inverted fundus, and thus
facilitate the reduction.   But it is  surely impossible that this  proceeding
can be attended with any beneficial consequences, whilst the irritation of
the uterus would necessarily tend to bring on those bearing-down efforts,
which would present a material obstacle to its reduction, and would in-
crease the hemorrhage, at a period when every ounce of blood is of infi-
nite  importance."   "Besides, returning the placenta  while it remains
attached to the uterus, and its subsequent judicious treatment as a simply
retained placenta, will have a good effect in bringing on that regular and
natural uterine contraction which is the hope of  the practitioner and the
safety of the patient."
  It may be doubted, I think, whether the removal of the placenta is at-
tended with so much danger; for  in  many instances  it has been  found
impossible to reduce the uterus in consequence of the  great addition to
its bulk, which the adhesion of the placenta occasions ;  and in such cases
there is no hesitation about  the propriety of removing the placenta, nor
have  I met with any evil effects recorded as the result of so doing.
  723. When the tumour is in danger of strangulation  from the circular
band of  the  fibres of the cervix uteri, or in  case such  band should
seriously impede the reduction, it has been recommended  to  divide it
with a bistoury.
  Of course the bladder and rectum should be  emptied previous  to re-
turning the uterus, unless we are present at the moment the accident
occurs ; at that time, the operation occupies so short a time, that catheter-
ism  may be deferred until afterwards, and  constipation for twenty-four
hours will rather be an advantage.   If the inverted uterus and the neigh-
bouring parts  should be much swollen, or  if the patient be feverish, it
may be necessary to take away some blood and foment the parts before
attempting the reduction.
  724. But should the disease be of some days' standing, are we to look
upon the reduction  as  hopeless ?   Certainly not.   There  are  cases  on
record of the  attempt having been successful after days and weeks have
elapsed, and the condition of the patient is  so distressing that no means,
however  apparently unlikely, should be left untried.  In Loffler's case, 6
or 7 hours bad elapsed ;  17 in Mr. White's  case ;  24 in Mr. Wynter's ;
27  in Mr. Dickenson's; 3  days  in  Mr. Cawley's;  7 in  Dr. Radford's
(case 6),  8 in MM. Choupart's and Ane's; 8  in Mr. Ingleby's; 10 or 
INVERSION OF  THE  UTERUS.
475
12 in M. Lauverjat's; 13  in  Mr. Hoin's;  and  12 weeks  in  Dr. Bel-
combe's.
  Plenck advises dilatation of the os uteri before attempting the reduction,
and perhaps in some cases this  may be possible.
  If we succeed in restoring the womb to its natural state and situation,
great care will be requisite to avoid a recurrence of the accident, or, what
is more likely, a prolapse of the uterus.
  The patient should remain longer than usual in the horizontal position,
with the head low, the pelvis elevated, and  the knees bent.  A dose of
opium will  be  found very  useful,  and, if there be  much exhaustion, it
must be repeated, and stimulants in proper quantity be given.
  A pessary  has  been  advised, in order to maintain the uterus  in its
place,  but this will very rarely be necessary.   When  the lochial discharge
has entirely ceased, it may be beneficial to use some astringent injections
into the vagina once or twice a day, especially if leucorrhcea be present.
  725. If the inversion be irreducible, we must then consider how far it
may be advisable  to  content ourselves with  palliative remedies, such as
returning the tumour into the vagina to protect it from injury, and sup-
porting it either by a bandage and  compress, as recommended by  Dr.
Hamilton for prolapsus uteri, or by a pessary.
   Should this plan not be practicable, or fail of success, it may then be a
question as to the  propriety of  extirpation.  There is  abundant evidence
to prove that life may be preserved after the loss  of  the womb.   Rousset
relates a case when the uterus was destroyed by gangrene, and the patient
recovered;  and Rousset, Primrose,  Radford, and  Cooke, have  given
cases in which the uterus appears to have sloughed  off, without compro-
mising the patient's life.
   This being the case, there is every encouragement, within certain limits,
to effect that removal by art which nature thus so beneficially accomplished.
In  this  opinion Sir  C. Clarke fully coincides;  he  observes, " In those
cases of inversion of the uterus where the woman has passed  the menstru-
ating age, when her comfort is destroyed by the disease, and when  the
profuseness of  the discharge threatens her with  death, from the debility
which it produces;  it may be  advisable to  recommend the  performance
of  an  operation, which has been  attended with success, viz., the removal
of  the inverted uterus itself."  " How far it may be  right to  resort to  this
operation during the  menstruating part of a woman's life, the author  has
no means of judging."
   The operation, however, has been performed during the " menstruating
part of a woman's life," with complete success.
   We  may therefore conclude that the operation is perfectly justifiable,
provided 1st, that the patient  is  in a fit state of health for an operation;
and 2dly, that the uterus be not affected with schirrus or cancer.
   The operation has been successfully performed by Ambrose Pare, Petit,
Carpi,  Sclevogt, Vater, Laumonier,  Bouchet, Boudol, Dessault, Hunter
of Dumbarton, Chevalier, Johnson, Hamilton, Clarke of Dublin, Newn-
ham, Windsor, Davis, Hull, Blundell, Moss, Lassere, &c.
   Other cases less fortunate are on record.
   The  operation consists in applying a ligature of silk, whipcord, fishing-
line, or silver wire, around  the uterus at its highest part, and gradually
tightening it, as the  patient may be able to  bear it, until the  uterus  is 
476
INVERSION OF  THE  UTERUS.
entirely  separated.   Or a double ligature  may be  passed through the
centre of the neck of the uterus, and each half  included in a  separate
ligature.
   Or, lastly, we may prefer,  after tightening  the  ligature to a certain
degree, to remove the  uterus immediately by cutting below the  ligature.
Before doing this, it will be necessary to satisfy  ourselves of the adequacy
of the ligature to restrain any hemorrhage.
   The symptoms which  arise after the application of the ligature are just
such as we  might expect from  the strangulation of so important a viscus.
The patient suffers from nausea,  vomiting, and  pain, which gradually
diminish in the  more favourable cases, but which  are the prelude to peri-
tonitis in the fatal ones.   When these symptoms are violent, it will be
necessary to loosen the ligature, and wait some  hours before again tight-
ening it.   A dose of opium should also be given, and the bowels kept
free by enemata.   The  strength of the patient should be maintained by a
nutritious, though not stimulating diet.
   If the inversion be caused by or complicated with polypus, it may be
necessary to  remove  both,  and the  polypus should be  excised before
applying the ligature to the uterus.*

  * Extirpation of the uterus, when it is the seat of no malignant disease, is a terrible
operation, and, under the circumstances mentioned  in the text, of doubtful propriety.
Not only have some women  lived many years afflicted with inversion, but iii several
instances without  any great pain or suffering in their general  health.  In some  cases,
too, the uterus has returned spontaneously,  after the lapse of  considerable time, to its
natural condition,  and the individuals have conceived and borne children.  Several very
instructive cases of the kind are related by Professor Meigs, in his edition of Colombat,
two of which  occurred under his own notiee.  — Editor. 
CHAPTER XXIV.
                      PUERPERAL FEVER.

  726.  Having now terminated the series of abnormal deviations from
natural labour,  and the various accidental complications of that process, I
shall add a chapter or two upon some of the more formidable diseases of
childbed, referring the  reader for fuller details and references to my work
on diseases of women.
  Puerperal Fever is probably the most fatal disease to which wromen
in childbed are liable, and is by no means of rare occurrence.
  Its phenomena vary very much, and it has consequently been differently
described, and under various names, such as Puerperal Fever, Childbed
Fever, Peritoneal Fever, Low Fever of Childbed, &c.
  Another source  of apparent contrariety has been the prevalence of the
disease  epidemically, and the varying characteristics of these epidemics.
Unfortunately the uniformity of the  disease was assumed  until compara-
tively recent times ; and, as Dr. John Clarke observes, each author erected
his own experience into a standard by which to judge of the descriptions
and practice of others.
  According to Dr. Hulme's researches, the older writers were not igno-
rant of this  disease.   It is described by Hippocrates  and  Avicenna.
Plater (1602) makes it to consist in  inflammation of the uterus.  Sennert
(1656)  describes  it, and recommends bleeding.  Riverius  (1674) attri-
butes it to suppression of the lochia, and Sylvius (1674) to deficiency of
the lochia.-  Willis (1682) takes the same view of its nature as Plater.
  It is  mentioned by  Raynalde, Pechey, Strother (by whom it was  first
called Puerperal Fever) and  other early English writers ; by Viardel, Peu,
Mesnard, and other ancient French  authors, and by the Germans.
  727.  From careful  investigation  it has been proved that  the disease
prevails epidemically,  and that it is more virulent in hospitals.  It  is
everywhere more frequent among the lower classes than  the higher.   In
Dublin  this is even more remarkably the case than in London.
  That the cause of the prevalence  in lying-in hospitals is the number of
patients in a ward, the want of proper ventilation, and the too rapid sue
cession  of fresh patients before the wards have been properly cleansed, is
rendered almost  certain by the success which has followed attempts at
remedying this evil.
  These four points—isolation of patients, cleanliness, ventilation,  and
allowing the ward in  which the  disease  has  appeared to be idle for a
while, are the chief means of guarding against the disease in hospitals;
and in private practice  we can do little more than has been laid down in
the  Rules for the Management of Lying-in Women.
  For the purpose of  giving a more  distinct view of the prevalence of
puerperal fever, I have made out (as  accurately as possible) a chronolo-
gical  list of the different epidemics, with  the names of the authors by
whom they are noticed or described, and the pathological characteristics
when ascertained.
                                                         (477) 
478
PUERPERAL  fever.
Date of			
Epidemic.	Place.	Author.	Local Affectiom.
1664	Paris,	Peu (Lee),	
1746	Paris,	Malouin,	Peritonitis, Hysteritis, &c.
		Jussieu,	Disease of Ovaries.
1750	Lyons,	Doulcet,	Peritonitis, U. Phlebitis.
1750	Paris,	Pouteau,	Hysteritis erisipelatous.
1760	London,	Leake,	Inflam. of Omentum, &c.
1760-61	Aberdeen,	Gordon,	
1761	London,	White,	Peritonitis.
1767	Dublin,	Jos. Clarke,	
1770	London,	Leake,	Peritonitis (partial).
1771	London,	White,	
1773	Edinburgh,	Young,	
1774 to 81	Paris,	Tenon, Doul-cet, &c.	
1774-87, 88	Dublin,	Jos. Clarke,	Peritonitis.
1782	Paris,	Doulcet,	Peritonitis, Hysteritis.
1783	London,	Osborn,	Peritonitis.
1795	Vienna,	Dr. Jaeger,	Peritonitis, Phlebitis.
1786	Paris,	Tenon,	
1787	Gottingen,	Osiander,	
1788	London,	Jos. Clarke,	Hysteritis, Peritonitis, &c.
1787-8	London,	Do.	Peritonitis, Hysteritis, &c.
1789-90, 91, 92	Aberdeen,	Gordon,	Peritonitis.
1803-10,12, 13	Dublin,	Collins, Douglas,	Peritonitis.
1808	Barnsley, Yorkshire,	Hey,	Peritonitis.
1812-13 f	Leeds, Yorkshire, Sunderland, counties	Hey,	Peritonitis.
1813 J	of Durham and Northumberland,	y Armstrong,	Peritonitis.
1811	Heidelberg,	f Naegele, \ Bayrhoffer,	
1812	Holloway, London,	Dun,	Peritonitis.
1814-15	Edinburgh,	Hamilton,	
1816	Paris,	Tenon,	U.Phlebitis, Hyster. Perit.
1817-18	Pennsylvania, U. S.	Dewees,	Peritonitis.
1818-19, 20-23	Dublin,	Collins,	Peritonitis.
1819	Vienna,	Boer,	
1819	Glasgow,	Burns,	
1821-22	Edinburgh,	Campbell,	Peritonitis.
1821-22	Glasgow, Stirling,	Campbell,	Peritonitis.
1827-28	London,	Gooch,	Peritonitis.
1827-28, 29	London,	Ferguson,	Peritonitis, Hysteritis.
1835-36, 38	London,	Do.	Phlebitis, &c.
1825-27,28,291	Dublin (Lying-in- "1 Hospital), j	Collins, f	Inflam. of Peritoneum,
1829	Paris (Maternite"),	Tonnelle, 1	Uterus and appendages, and Uterine Phlebitis.
1829-40, occa-sionally.	Dublin (Lying-in- 1 Hospital^. J	E. Kennedy,	
1831	Aylesbury,	Ceeley,	
1833-34	Vienna,	Bartsch,	Uterine Phlebitis.
1836-37 {	Dublin (New Lying-in-Hospital),	I Beatty,	Peritonitis, Pleuritis, &c.
  728.  An examination of the foregoing table will render it no matter of
surprise that  authors should differ as to the pathology of this affection, 
PUERPERAL FEVER.
479
and as each appears to have regarded his  own experience as a standard
for all, we cannot wonder  at, though we must  ever regret,  that various
and bitter  controversies should  have arisen  in consequence.   It would
occupy far too much time to enter upon various arguments  adduced by
different writers in favour of their own views;  it will  be quite  sufficient
to enumerate the  opinions, and  to classify the  authorities,  referring  the
reader to the various sources of minute information already quoted.
   Puerperal fever, then, has been regarded as
Hippocrates,
Gaien,
Celsus,
iEtius,
Paulus Avicenna,
Raynalde,
Inflammation of the Uterus, by
F. Plater,        La Motte,            Villars,
Sennert,         Sydenham,           Astruc,
Riverius,        Boerhaave,           Pouteau,
Sylvius,         Van Swieten,         Denman.
Strother,        Hoffmann,
Mauriceau,      Jussieu,
       . Inflammation of the Omentum and Intestines, by
Hulme,                  Leake,               La Roche.
Waller,
Johnson,
Forster,
Cruikshank,
        Peritonitis, by

Bichat,         Gordon,
Pinel,          Hey,
Gardien,        Armstrong,
Capuron,       Clarke,
Campbell,
Collins.
Peritonitis, connected with Erysipelas, or of an erysipelatous character* by
   Pouteau,                Young,                Armstrong,
   Home,                  Abercrombie,           Hey,
   Lowder,                 Gordon,               Campbell.
Willis,
Puzos,
Peu,
Petit,
Selle,
  Fever of a peculiar nature, by

         Doublet,
         Levret,

 Disorder of a putrid character, by

 Tissot,               Le Roi,

Disease of a complicated nature, by
Hamilton.
White.
Kirkland,
Walsh,
Tenon,
Tonnelle,
Finch,
Fever with Biliary disorder, by
         Stoll,
Lee,
Ferguson.
Doulcet.
  729. Causes.—Various are the causes  assigned by different authors,
for the production of this disease.                       . .
  « We also " says Mr. Moore,  " find fever after parturition  ascribed to
difficult labou'r;  to inflammation of the uterus; to accumulation of noxious
humours, set in motion by labour; to violent mental emotion  stimulants,
and obstructed perspiration;  to miasmata; admission  of cold air to  the
body, and into the uterus;  to  hurried circulation; to suppression of lacteal
secretion; diarrhoea; liability to  putrid contagion,  from changes in  the

  * At the time of the prevalence of puerperal fever described by many of these authors.
there was also an epidemic of erysipelas.

         31 
480
PUERPERAL FEVER.
humours during pregnancy;  hasty separation of the placenta , binding
the abdomen  too  tight;  sedentary employment;  stimulating, or  spare
diet;  fashionable dissipation ; retained  portions of placenta;  floodings,
from non-contraction, according to one ; from violence, but not from non-
contraction, according to another; to  inflammation of the intestines and
omentum, from the pressure of the gravid uterus against them ;  to atmos-
pheric distemperament;  to internal erysipelas;  metritis, phlebitis; and
contagion of a specific kind.   It will be seen that some of the symptoms
of the malady are mistaken for causes."
  We cannot  regard difficult labour as a frequent cause, though the con-
dition in which the woman is  left, will undoubtedly render her more ob-
noxious  to  the epidemic.  Mental emotion is undoubtedly an efficient
predisposing cause.  Under its influence, females are peculiarly exposed
to puerperal fever and  are rendered less able to bear it.   Several  of the
worst cases I have  ever seen were  evidently attributable to this  cause.
Under its influence, females are peculiarly exposed to puerperal fever and
are rendered less able to  bear  it.   Several of the worst cases I have ever
seen were  evidently attributable to this  cause.  Cold may be fairly ad-
mitted into this list.  Whether portions of placenta remaining in the
uterus, give rise to this disease, is as yet doubtful;  I am inclined to think
they may, but it is difficult to  decide  between the conflicting evidence.
   Irritation of the intestines  may certainly be propagated to  the  neigh-
bouring tissues, and under the  influence of an epidemic, may originate
puerperal fever.
   That hemorrhage during or  after  labour  does  not prevent puerperal
fever there is abundant proof; but that it renders the patient more  liable
to it may be questioned.
   To a certain extent atmospheric influence has a control over the disease;
in damp, moist weather, it is  much more prevalent, and less so in  warm
dry weather.
   The  following tables, showing the frequency of  the  disease during
different months, are of considerable value in determining this question :—
TABLE I. (Dr. Gordon's.)
Cases of Puerperal.		Cases of Puerperal.		
October .	13	April	6	
November	8	May .	6	
December	12	June . . .		
January .		July .		
February.	8	August . .	5	
March	6	September.	5	
	TABLE II. (J	Or. CampbelVs.)		
Cas	es of Puerperal.		Cases of Puerperal	
1821 March	1	1822 January	7	
" April	7	" February ,		6
" May .	2	" March .		5
" June	2	" April .		4
" July .	3	" May		4
" August	1	" June		3
" September	1	" July .		2
" October .	7	" August .		I
" November	13	" September		8
" December	11	" October		2
 
   PUERPERAL FEVER.


TABLE III.  (Dr. Ferguson's.)
481
---			2	1		00	m m CO	00	CO OD	CO CD	CD	CD S3	a 0 fr 34 17 22 34 20 16 5 4 12 11 9 21	
January . February . March . . April . . May . . June . . July . . August. . September October November. December .	1 3 4 2	2 2 *4 3 3 3 8 4 8	3 7 3 1 1 3	3 2 1 1	*4 1 2 2	2 i l 2 2	2 1 2 2 1 i	3 '4 2	2 2 *2 5 6 5 2 2	4 6 6 6 2 4 3	3 *3 2 1	9 8 9		Hospital closed, Feb. 1838. Closed from April to Nov. 1838.
Attacked . Died . . i	10 1	37 7	24 6	7 2	9 2	8 5	9 3	9 5	26 10	31 9	9 2	26 20	205 68	Total attacked. Total died.
TABLE IV.  (M. Duges, Journ. Hebdom. de Midecine.)
1819 January
 "  February
 "  March -
 "  April
 "  May  -
 "  June
Cases,
 81
 82
 65
 47
 67
 35
1819 July-
 "  August -
 "  September
 "  October -
 "  November
 "  December
TABLE V.  (Delaroche, of Geneva.)
January
February  -
March -
April -
May
June  -
Cases.
 77
 43
 76
 55
 35
 40
July  -
August  -
September -
October -
November -
December
-  40
   40
-  53
   69
-  74
   65
Cases,
 37
 36
 51
 51
 66
 61
  Thus the most injurious months in Aberdeen were October, December,
November;  in Edinburgh, November, December, January; in London,
January, March, February, December, May; in Paris, November, Octo-
ber, February, in Geneva, January, March, February.
  " In general, the cold months are most fatal.   No death has occurred
in the month of  July, in the  General  Lying-in Hospital.   The  most
favourable month in Paris and Geneva, is June ; and August in Scotland,
where the summer is  about three weeks  later than in England.   Hence
we may say that the warm months are beneficial."*
  Whatever the epidemic influence may be, there  can  be no  doubt that
to it the majority of cases  are attributable, especially the worst and  most
fatal.
  730.  Much has  been written concerning the contagion or noncontagion
of puerperal fever.  Drs. Hulme, Hall, and Campbell, MM. Tonnelle, and
* Ferguson on Puerperal Fever, p. 278, note.
                 2 Q 
482
PUERPERAL FEVER.
Duges, &c, are in favour of the  latter opinion, and Drs. Gordon, Hey,
Walsh,  Birns, Armstrong,  Douglas, Robertson,  Hamilton, &c., of  the
former.
  In  all diseases which are epidemic, it is  extremely difficult to decide
upon  the question of contagion, inasmuch as the cases which support most
strongly the contagiousness of the disease, may almost all be  explained
by the prevalence of the epidemic causes.
  Nevertheless, there  are  some cases  so marked, that  I should not feel
justified in denying that puerperal fever  may be  communicated by con-
tagion.
  731. We have seen that there are several varieties of puerperal fever,
which have been differently  classified by different authors, some from the
symptoms, others  according to the pathology.   Thus  Dr. Douglas  de-
scribes three forms —
  1.  The inflammatory.
  2.  The gastro-bilious.
  3.  The epidemic or contagious (typhoid).
M. Tonnelte —
  1.  The inflammatory.
  2.  The adynamic.
  3.  The ataxic (irregular or nervous).
M. Martens.   Neue Zeitschrifl, &c, b. ii.
  1.  The inflammatory (where one organ only is affected).
  2.  The nervous (beginning with delirium).
  3.  The putrid.
Vigarous.  (Moore on Puerperal Fever.)—
  1.  Gastro-bilious.
  2.  Putrid bilious.
  3.  Pituitous (vomiting of pituitous matter).
  4.  Hysteritis (phlogistic).
  5.  Sporadic (arising from cold).
Gardien —
  1.  Angiotemic fever, strictly inflammatory.
  2.  Adeno-meningic, slow, insidious fever, slimy tongue.
  3.  Meningo-gastric, bilious derangement, yellow skin, &c.
  4.  Adynamic.
  5.  Ataxic or nervous.
  6.  Fever, with local phlegmasia?.
Dr. Gooch—
  1.  Inflammatory.
  2.  Typhoid.
Dr. Blundell —
  1.  The mild epidemic, with little peritonic tendency.
  2.  Malignant epidemic, with great pain.
  3.  Sporadic. Peritonitis limited.
Dr. John Clarke —
  1.  Inflammation of the uterus and ovaria.
  2.  Inflammation of the peritoneum. 
PUERPERAL FEVER.                     483
  3. Inflammation of the uterus,  fallopian  tubes, or  peritoneum,  con-
        nected with inflammatory affection of the system.
  4. Low  fever, connected with affection  of the abdomen, which is
        sometimes epidemic.
Dr. Lee —
  1. Inflammation of the uterine peritoneum, and peritoneal sac.
  2. Inflammation of the uterine appendages, ovaries, fallopian tubes, and
        broad ligaments.
  3. Inflammation of the mucous, and  muscular, or proper tissue of the
        uterus.
  4. Inflammation and suppuration of the  absorbents and veins of the
        uterine organs.
Or, in other words —
  1. Inflammatory puerperal fever, dependent on peritonitis.
  2. Congestive, dependent on  inflammation  of the uterine muscular
        tissue.
  3. Typhoid, arising from  venous inflammation.
Dr. Ferguson —
  1. The peritoneal form.
  2. The gastro-enteric.
  3. The nervous.
  4. The complicated.

  732.  It appears to me, that neither of these classifications is alfogether
free from objections;  but upon  the whole, I prefer the plan  adopted by
Dr. John Clarke and Dr. Robert Lee, of  making the  local affection the
basis of arrangement, as at  least developing most strongly the essential
facts of the disease.
  The great defect of this plan is the coincidence of the diseases, which
it places separately; thus, hysteritis,  and  affections of the ovaries, &c,
are very often accompanied by peritonitis.   Still, however, there is a
broad line  of distinction between  them in many epidemics;  and I  must
only guard against the  defective arrangement, by stating strongly at the
commencement, that it is not intended to describe the varieties as neces-
sarily and widely distinct, as to symptoms and causes, in every epidemic;
and in the  course of my description, endeavour to point out  the concur-
rence of the different local affections.
  I shall thus divide puerperal fever, according to the predominant  local
affection, into five varieties, which I have placed in the order of frequency
of occurrence.
  1. Peritonitis.
  2. Inflammation of uterine appendages.
  3. Hysteritis.
  4. Uterine phlebitis.
  5. Inflammation of uterine absorbents.

  733.  1.  Inflammation  of the Peritoneum.—-This variety of the
disease  was the one observed in  the epidemic in London, at Aberdeen,
Leeds, Edinburgh, and Dublin ; and  it has  occurred in other epidemics.
It appears to affect the peritoneum covering  the uterus primarily, and to 
484
PUERPERAL PERITONITIS.
extend from  thence to the remaining portion of the serous membrane,
involving not unfrequently the uterine appendages.
  The attack may commence even before  delivery, of which I had an
example ;  but more generally from twenty hours to three days afterwards.
The first symptom is either sudden rigors, pain, or some variation in the
pulse.   Dr.  Campbell has remarked that  in some who  were  attacked
early, the  sinking of the pulse which takes place after delivery, in ordi-
nary cases, was absent, and its frequency rather increased.
  Generally speaking, the rigors are first noticed ;  to these succeed heat
of skin, thirst,  flushed face,  quickened pulse,* and hurried respiration.
The heat of skin, however, soon subsides, and during  the course of the
disease, it may  not exceed the natural standard.
  To these symptoms succeed  nausea, vomiting, pain  in  the head, and
increased sensibility of the uterus.   In some cases the uterine tenderness
(not amounting to pain) is contemporary with the rigors, or immediately
succeeds them.
  Pain in the abdomen soon attracts notice.   It generally commences in
the  hypogastrium, or in one of the iliac regions,  gradually radiating  over
the  abdomen.
  The pain  may be slight or severe, continuous, or in paroxysms — the
intermissions being more remarkable as the disease advances.  After the
remission, the pain shortly returns with increased violence.
  We are not, however, to consider the  pain as pathognomic of the
disease, for we sometimes see abdominal pain resembling that in puerperal,
which -afterwards  disappears altogether.  And  in certain cases of un-
doubted puerperal fever, there is no pain,  or pain of slight duration.   1
have seen three cases of intense  puerperal peritonitis (as shown by dis-
section) in which there was neither pain nor tenderness.
  Dr. Ferguson has carefully estimated the frequency of this symptom,
and he has found that
           The number of his patients who had no pain was .   .  19
                 "           "  who had pain for 1 day was 51
2	ii	48
3	k	22
4	a	18
5	(<	6
7	(«	5
8	a	4
  The pain from the first is accompanied with more or less sensibility of
the hypogastrium ; this tenderness becomes exquisite as the inflammation
extends, until at length the patient  cannot bear the  slightest pressure;
even the weight of the bed-clothes  is intolerable,  and the tension  and
pressure of the parietes are avoided, by lying on the back, with the knees
drawn  up.
  The  enlarged uterus can frequently be felt through  the integuments,
above the brim of the pelvis, at an early stage of the disease.
   Shortly after the disease is  established, the abdomen becomes  tumid
and  tympanitic,  and in  some  cases, at a  more  advanced  stage, the
presence of effusion may be detected.
   The air which gives rise to the tympanites, may be contained either in
the intestines, or the  peritoneal sac.
   The  effect  of the disease upon the lochia! discharge varies; in the 
PUERPERAL PERITONITIS.
485
majority of cases, it continues to flow as usual.   In some, the quantity is
diminished.  And in  a very few, it is suppressed.
  The secretion of milk is much more uniformly influenced by the attack.
If it have commenced before the incursion of the disease, it is suspended,
and the mammas become flaccid; if the disease precede, the secretion is
generally  prevented.   It is  remarkable, that a  great  number of the
patients lose all interest in their infants, and even refuse to give them suck.
  The pulse  is uniformly high throughout the disease, varying  from 110
to 140 in a minute, and towards the termination, to 160 and  upwards.
It is generally small  and wiry, but is liable to  modifications, from treat-
ment, and from the peculiar character of the epidemic.
  The tongue is generally coated  with a whitish  film in the centre, but
red around the edges.  In some few cases, it is  dry and brown in the
centre, with a yellowish or white fur at the edges.
  The thirst is considerable at the beginning, and towards the termination
of the disease, but much less during its height.
  The stomach is  disturbed  at a very early period, and the nausea and
vomiting continue at intervals throughout the attack.  At first, the matter
voided is merely the contents of the stomach, mixed with mucus;  after-
wards, bilious matter is ejected;  and lastly,  green, brown,  and black
fluids, constituting what is  called the  " coffee-ground vomit."
  In many cases, the  intestinal canal shares in the irritation,  and diarrhoea
results.  This, by some, has been held as a favourable symptom; but by
others, as an  aggravation of the puerperal fever.   My own observations
would lead me to the latter conclusion.
  The  dejections vary in character and consistence, becoming very dark
and foetid towards the termination  of bad cases.
   The  urine  is  generally  turbid,  or  high-coloured,  and   somewhat
diminished in quantity, and the  patient has  occasionally difficulty in
voiding it.
  Throughout the course of the disease, the skin  is generally about  the
natural heat, and dry; but  as it approaches a fatal termination, it becomes
cold and clammy.
   The  intellectual  faculties  are rarely affected; the patient retains  her
consciousness and senses, till very  near the end.
   The countenance is much  altered; the features  are all drawn up, and
expressive of great anxiety and suffering.   A patch of crimson is observed
on  the cheeks sometimes, and is an unfavourable symptom.
   Such are the symptoms, as laid down by those who have  had the most
ample experience in this fatal disease.
   Its  duration will vary,  according to  the virulence of the  epidemic.
Some cases  have terminated fatally, on  the first, second, or  third day ;
others from the fifth to the tenth.
   734. Morbid appearances.—The peritoneum may exhibit no sign of
inflammation; but  generally it is found more  or less vascular, especially
that portion of it covering the uterus.
   Its substance is thickened,  and in some instances softened.
   The longer the duration of the  pain, the  more intense will be the red-
ness, and the greater the thickening of the peritoneum.
   It is frequently covered  with a layer of lymph, which agglutinates the
omentum and intestines together.
                                2 q2 
486
PUERPERAL PERITONITIS.
   The omentum generally exhibits marks of inflammatory action, and m
 some cases the disease appears confined to it.
   The organs covered by the serous membrane may participate in  the
 inflammation.
   More or less  serum and  lymph are found effused  into the peritoneal
 sac.   It does not  vary in chemical  composition from that in  ordinary
 peritonitis.
   It may be clear or turbid, of a yellowish white colour, with shreds of
 lymph floating in it.
   Blood may be effused into the peritoneal sac, alone, or mixed with the
 serosity.
   Puriform matter is  frequently found, especially in the pelvis, around
 and behind the uterus, where the inflammation has apparently been  most
 intense.
   It is often contained in a cyst, which apparently is merely a concretion
 of the outer surface of the pus.
   Effusion of puriform matter, or a reddish serum, is sometimes observed
 beneath the serous  membrane.
   735. Diagnosis. — 1.  From after-pains or hysteralgia.  These affec-
 tions occur soon after  delivery, and diminish or disappear by the third or
 fourth  day — about the period when puerperal fever commences.
   After-pains are accompanied by a perceptible contraction of the uterus,
 which  is absent  in puerperal  fever.
   The pulse is sometimes accelerated by after-pains, but is seldom steady
 in its frequency; in puerperal it never falls below its frequency at first,
 but generally increases.
   The hypogastric  tenderness  in after-pains is  not great, except during a
 pain, and it goes on decreasing—whilst in puerperal peritonitis, it rapidly
 increases.
   The  constitutional disturbance is  incomparably greater in  puerperal
 fever, and it augment's every day; whilst in hysteralgia it diminishes.
   The  sedative, which generally relieves after-pains,  has little or no  in-
 fluence upon the pain in puerperal fever.
   Notwithstanding these  distinctions, there are undoubtedly many cases
 in which the diagnosis is by no means easy at first;  and our treatment
 should be arranged so as to err (if we be in error) on the safe side.
   2. From intestinal irritation.—This affection frequently assumes many
 of the   characteristics of puerperal fever.   There are, however, several
 points  of difference.   It  is generally accompanied by marked evidences
 of  gastric and  intestinal disorder.   The  tongue is loaded — there is
 flatulence,  nausea, and vomiting, constipation,  or diarrhoea.  The abdo-
 minal pain is diffused, and does  not  radiate from the  uterus, as  in puer-
 peral ;  neither is the uterus  enlarged, or tender.  The abdomen is not
 tense, nor very sensible to pressure.   Puerperal fever sets in at an earlier
 period  after delivery than  intestinal irritation, and it causes greater  con-
 stitutional disturbance.
   3. From ephemeral fever or weed.   The  commencement of ephemeral
fever may excite  some alarm, from its resemblance to puerperal; but its
duration is shorter, its  decline rapid,  and its constitutional symptoms less
severe, than in puerperal fever.  There is also far less abdominal irrita-
tion, and the breasts continue distended. 
PUERPERAL PERITONITIS.
4S7
13 cases	out of	19
31	(1	32
21	it	28
28	(<	77
22	it	79
4	(<	44
40	((	100
56	"	88
68	it	205
  4. From hysteritis.—The main distinction is the character and situation
of the tenderness ; in puerperal peritonitis, the slightest touch on the abdo-
minal parietes causes acute torture ;  whereas, in hysteritis, the patient can
bear pressure very well, until we can feel the enlarged uterus.  Any in-
crease of pressure, after the abdominal  parietes  are  in  contact with the
uterus, gives acute pain.
  The symptoms of hysteritis are also more local.
  736.  Prognosis. — The general  prognosis is unfavourable, even in
sporadic cases, but still more so  when the disease is epidemic.
  Dr. Hulme declares it to be as bad as the plague.

                  Dr. Leake lost
                  Dr. W. Hunter
                  Dr. Clarke
                  Dr. Gordon
                  Dr. Campbell
                  Dr. Armstrong
                  Dr. Lee
                  Dr. Collins
                   Dr. Ferguson

   In the epidemic in Paris (1746),  in Edinburgh (1773), and in Vienna
 (1795), none recovered.                                           .
   Dr. Ferguson states, "If we take the results  of treatment adopted in
 various puerperal epidemics, by various practitioners, we shall find that
 on a large scale, one in every three will die, with all the resources  which
 medicine at present offers.  To  save two out of three, then, may be termed
 good practice in an epidemic season."*
 D 737. Treatment.—It must be borne in mind, when any peculiar mode
 of treatment is  advised, that the character of the epidemic is the test of
 its propriety.  Forgetfulness of this rule has been the source of much
 controversy, and no slight acrimony.  As Dr. John Clarke remarks, each
 author takes the epidemic he-has witnessed as the type of all, and remorse-
 lessly condemns all treatment which does not agree with  that which he
 has found successful.  There is no question that the employment of anti-
 phlogistic remedies, by Gordon, Hey,  Armstrong, &c.  was  a  great im-
 provement upon the old methods ;  but in many  epidemics this plan must
 be strikingly modified, or altogether abandoned.  Having premised  thus
 much, I shall describe the treatment which has  ordinarily been found the
 most efficacious.
    If the pulse be firm, a large  quantity of blood  should be taken from
 the arm    Dr. Gordon recommends from 20 to 24 ounces, at the begin-
 ning, and, if necessary, this may be repeated.  The blood generally ex-
 hibits the buffy coat.
    Should  any circumstances forbid a repetition  of the venaesection, a
 number  of leeches (from 60 to 100, Campbell) may be applied  to the
 abdomen,  and when they fall off,  the  abdomen should be fomented, oi
 covered with a light bran poultice.
    The fomentation, or poultice, may be repeated at intervals, as it has a
 very soothing effect.                                             ,
    After full depletion, the next most powerful remedy is mercury, alone
 or in combination with opium.   Without  explaining its modus operandi,
                        * On Puerperal Fever, p. 112. 
488
PUERPERAL  PERITONITIS.
it is sufficient to state the fact, that it  has been found  to exercise a re-
markable influence over inflammation  of serous membranes.   It may be
given in large doses (gr. x. every three or four hours), or in smaller ones
more frequently repeated (gr. ii.  every hour); and it should be continued
until  an impression  is  made  upon the disease, or  until  the mouth is
affected, unless purging be induced.
  After a decided effect is  produced, the dose may be diminished, and
the intervals lengthened.
  For the purpose of preventing intestinal irritation, it is  usual  to com-
bine it with Dover's  powder of  opium.  Perhaps it is  not too much to
say, that the  benefit of the opium in this combination is not confined  to
the prevention of intestinal disturbance, but that it exerts  a positive and
beneficial influence upon the inflammation.
  Mercurial frictions are a valuable mode of affecting the system.  They
were  first employed, I  believe,  by Velpeau, in this  complaint, and  are
now generally used.
  When the  calomel acts on the  bowels, it may be omitted, and the opium
alone continued ; and I have seen as much benefit from it alone, as from
the calomel.   Some  years ago, I saw  a case of puerperal peritonitis, in
consultation with a friend, and  we administered large  doses of opium
(gr. i. every hour), with the  greatest benefit.  Since then, several similar
cases have occurred to me.
  My friend, Dr. Stokes, was the first to point out the value of opium, in
bad cases of peritonitis, where  bleeding was  inadmissible; and I have
repeatedly verified his observations.
  Tartar emetic was recommended by  Hulme, and used by several since
his  time, with apparent benefit.   The state of the stomach, in many cases,
however, will prevent its exhibition.
  Purgatives have been warmly  recommended by some  writers, (Hulme,
Denman,  Gordon, Hey, Armstrong,   Chaussier, Stoll) and as strongly
reprobated by others (Baglivi, John Clarke, Cederslciol, Thomas, Camp-
bell).
  " My own  experience," says Dr. Ferguson,  " with regard to aperients,
is, that whenever they create tormina, there is  the greatest risk of an at-
tack of metro-peritonitis succeeding.   This so constantly occurs, that  I
invariably mix some anodyne — usually Dover's powder, or hyosciamus,
or hop,  with  the purgative."
  If the bowels be  constipated, an enema  of turpentine  and castor oil
will be useful.
  The spontaneous diarrhoea is not always beneficial, but will often need
to be  restrained by astringents, or opiates.
  Emetics were employed before 1782, by English practitioners, and  in
1782, they were recommended  by  Doulcet, of Paris, who  relied upon
them exclusively, and derived from them extraordinary success.   Other
practitioners  have  also used them successfully;  but they  have failed so
often, as to have gone out of use, especially in these  countries, perhaps in
consequence  of our mistaking the proper cases.
  In  1814,  Dr. Brennan,  of Dublin,  proposed the use of  turpentine,
which he praised, as  almost a specific.   He gave it in doses of a table-
spoonful at  a time,  in  a little water,  sweetened.   Drs. Douglas,  J. A. 
              INFLAMMATION OF  UTERINE APPENDAGES.          489

Johnson, Dewees, Payne, Kinneir, Blundell, and  WTaller,  have found it
more or less useful.
   Dr.  Clarke, and other practitioners, tried it, but without success.
   It is certainly beneficial, when the intestines are tympanitic, especially
in the form of an enema, and as a  counter-irritant to the abdomen; but I
have never seen it exert any remarkable influence upon the disease.
   At an advanced stage  of the disease, blisters  are very useful.  They
may be applied to any part or the whole of the abdomen, and dressed
with mercurial ointment.
   Recolin, Dance, and Tonnelle, have recommended injections of warm
water into the vagina and  uterus, three or four times a-day.
   Drs. Lee and Campbell have tried them in a few cases with decided
advantage.   I have frequently syringed the vagina with warm water, with
benefit; but I never threw the injections into the uterus.
   Hip baths have been found useful  by Desormeaux and Collins;  but
the pain of  moving the patient is an insurmountable obstacle to their
frequent use.
   Loeffler, and Ceeley of Alesbury, have seen good effects result from the
application of cold to the  abdomen.
   The irritation of the stomach may be allayed by effervescing draughts,
containing a few drops of laudanum, or by a few grains of the subcarbo-
nate of potash, dissolved in aq. menth. virid.
   A selection of these  remedies will afford a tolerably good chance to the
patient, if we are called early; but in many instances we shall fail, either
in cutting short the disease, or in curing it ultimately.  It is of the greatest
importance, however, that all the means at our command should be tried
perseveringly, and that our forebodings should not be allowed to diminish
our exertions.
   738. 2.  Inflammation  of  the  Uterine Appendages.—Under this
head is included inflammation of the serous membrane, and proper tissue
of the  ovaries, fallopian tubes, and broad ligaments.
   It is not always possible to separate the affections from inflammation of
the peritoneal cavity, with which they are so often conjoined; but there
are cases in which they exist afone, or predominate in a striking manner,
or where the  consequences of the disease continue longer in these parts.
   Puzos has described such  cases by the term, "Depots  laiteux dans
Vhypogastre" and Levret, as "Engorgemens laiteux dans le bassin."
   The observations of MM. Husson and Dance likewise prove, that this
is a frequent, and often fatal termination of inflammation of the peritoneal
coat of the uterus, and its appendages.
  M. Tonnelle found  58  cases  of inflammation  of the ovary, and 4 of
abscess, out of 190 cases of puerperal fever.
  739. Symptoms.—As inflammation of the uterine appendages is gene-
rally combined with  more  or less  inflammation of the  peritoneal sac, it
consequently presents similar symptoms;  but in addition, we find local
distress in the situation of these appendages.
  The pain is somewhat less acute than in general peritonitis, and is seated
in  one  of the iliac fossae, or the lateral parts of the hypogastrium, extend-
ing to the groins, and down the thighs, accompanied with great tenderness
on pressure.
  An examination per vaginam, will often throw light upon the disease; 
490
INFLAMMATION OF  UTERINE APPENDAGES.
 that canal will be found hot and painful at  the upper part, and in some
 cases a tumour may be discovered through the parietes,  laterally.
   The  disease generally commences with rigors, thirst,  head-ache, quick
 pulse, &c, presenting an array of constitutional symptoms very similar to
 those in peritonitis, which, therefore, I need not repeat.
   If the disease  be extensive, there is  generally observed  much exhaus-
 tion following the first stage, and the attack  may prove quickly fatal.
   Should the disease not prove fatal, the attack may terminate —
   740. 1.  In resolution, without the  organs being seriously injured ; or
 in some cases, adhesions may be formed between contiguous portions of
 the  serous membrane, which, though for the present innocuous, may be
 injurious subsequently.  Boivin and Duges  relate  a case, in which ante-
 version was caused by these adhesions.
   If the fallopian tubes have  been involved, the  cavity of  one or both
 may be obliterated, or they may become adherent  to some neighbouring
 part, so as to prevent altogether their ordinary functions.
   2. In suppuration.  Matter may form  in either ovary or broad  ligament,
 and may escape into the peritoneal sac;  through the parietes of the
 vagina or rectum; or through the abdominal parietes, near Poupart's liga-
 ment.
   A number of such cases are on  record, and several  have  occurred to
 myself, which I published in the Dublin Journal for Sept., 1843.
   741.  Morbid Anatomy. — In  some cases, we find on dissection, that
 the disease has been confined to the serous membrane, presenting similar
 phenomena to those already noticed — thickening, effusion of lymph, or
 serum, &c.
   The broad ligaments, fallopian  tubes,  and  ovaria, are red  and vascular.
 The morsus  diaboli is of a vivid red  colour, and sometimes  softened,
 and in its cavity, or under the  peritoneum,  deposits of  pus may be dis-
 covered.
   Effusion of serum, or purulent matter, may also  be found between the
 folds of the broad ligaments.
   The ovaria may be imbedded in lymph, the  product of inflammation
 of their serous coat.  Sometimes  they are swollen,  red, and pulpy.   One
 or both of these organs may be affected.  Dr". Gordon mentions that in
 his cases of puerperal, the right ovary was always  diseased, and the  left
 healthy.
   Upon laying open the ovaries, their structure will be found more or less
 diseased.  There is a great increase of vascularity, and frequently a soften-
 ing of  the proper tissue.   In a few cases it is utterly disorganized.
   Blood is sometimes effused into the Graafian vesicles, so as to destroy
 their texture.
   Pus may be found in small masses throughout the ovary, or that organ
 may be reduced to a sac, containing purulent matter, which  often escapes
through artificial openings, as already noticed.
   742.  Diagnosis. — The  situation of the pain and tenderness, and the
information obtained by an internal examination, are the only ground of
 diagnosis—and an uncertain one, it must be  confessed—during the acute
state.
   If the disease pass into a chronic stage, and an abscess form, this will
render the case sufficiently clear.   The  case in the Meath  Hospital was 
PUERPERAL HYSTERITIS.
491
detected in this way,  before the matter could be  discovered from the
surface.
  743.  Treatment.—Venaesection; but after one bleeding from the arm,
it will be more beneficial to apply leeches to the tender part, followed by
poultices.  Calomel and  opium will be necessary, and as  useful here,
during the  acute stage, as in the form of disease previously described.
  Vaginal  injections of warm water, and hip baths, will be found very
soothing
  If there  be  evidence of matter being within reach, it will  be advisable
to make an opening for its escape.
  If much pus be discharged, so that the constitution suffer, tonics, with
wine, and generous diet, should be given.
  744.  3.  Hysteritis. — Inflammation affecting the proper tissues of the
uterus has been frequently described.   It is mentioned by Astruc, Vigar-
ous, and Primrose.   Pouteau met with it in the epidemic of 1750.   Boer,
and Ricker, have termed it Putrescirung, or Putrescenz der Gebarmutter;
and Smith, Danyau, and Tonnelle, have recorded cases of it.
  In certain epidemics, it is by no  means infrequent.   Out  of 222 fatal
cases of puerperal fever, M. Tonnelle found

                    Simple metritis    .   .    in 79.
                    Superficial softening   .    in 29.
                    Deep softening    .   .    in 20.

  M. Duges found the womb affected in 3 cases out of 4.
  Dr. Robert  Lee  states that  in 45 dissections, the muscular coat of the
uterus was softened in 10 cases.
  745.  Symptoms. — These vary somewhat, according to the epidemic,
and a great deal  according to  the severity of the attack. In the milder
forms,  where  the disease  has  not  proceeded so far as to disorganise the
uterine  tissue, I have usually found it to commence on the third or fourth
day, and generally with rigors — followed by heat of skin, thirst,  and
head-ache.
  The pulse rises to 100 or 110.  The tongue is  dry and furred.  The
countenance expressive of suffering, but without the  pinched, drawn-up
character we find in puerperal peritonitis.
  The patient complains  of pain,  and tenderness  in the uterine region;
and upon examination, we find the uterus enlarged, hard, and tender.
  The abdomen at first is soft, and without tenderness, which is first felt
when we perceive that we are making pressure upon the uterus.
  As the disease advances, the abdomen often becomes tympanitic ;  and
in some cases the inflammation extends to the peritoneum.
  The lochia  are sometimes suppressed, but often unaltered.   The secre-
tion of  milk is generally arrested.
  Dysuria occasionally causes much distress.
  746.  The  severer form of hysteritis — such as described  by M.  Ton-
nelle and Dr.  Lee — is ushered in by rigors, followed by increase of heat,
and head-ache.  There  is occasionally delirium, or other evidences of
cerebral disturbance.
  The  countenance is pallid, anxious, and disturbed.  The  skin, at
first hot and  dry becomes cold, and  sometimes of a blue  or yellowish
tinge. 
492
PUERPERAL HYSTERITIS.
  The respiration is hurried, the pulse rapid and feeble, and there is great
prostration of strength.
  The tongue soon becomes foul, and the lips covered with sordes.  Nau-
sea, vomiting, and diarrhoea are generally present.
  The patient complains of pain at the hypogastrium, where the enlarged
uterus may easily be felt, and is tender on pressure.
  The lochia are either  diminished or suppressed ;  and occasionally their
quantity is changed, and they become acrid and foetid.
  747. Hysteritis may terminate — 1.  In resolution; as  in the case with
the mild variety which I have described, and in which there is a gradual
subsidence of the symptoms.
  2.  In abscess : which may open into the uterine cavity, or into the perito-
neal sac.  I had an opportunity of seeing a case of the latter kind, some
time ago,  in a patient, whose case  has  been published by my friend, Dr.
Beatty.
  3.  In softening.  This termination was  observed 49 times by M. Ton-
nelle, and 10 times by Dr. R. Lee.
  4.  In gangrene.  This has been described by M. Boer, in his valuable
work, and by  Ricker, and noticed by Siebold,  Busch, Boivin and Duges,
Danyau, &c.
  748. Morbid Anatomy.—The peritoneal coat of the uterus very often
exhibits marks  of inflammation.  It  may be vascular, and coated with
lymph, or softened.
  Its  size is manifestly increased, and its substance soft and flabby.  Small
collections of purulent matter are sometimes found  in its parietes,  which
in these spots  exhibit  various degrees of absorption.
  The substance of the uterus may  be, in patches, reduced to a mere
pulp,  of a dark purple, yellowish, or greyish colour, and occasionally
of a  bad  odour.   This  softening generally commences at  the  inner
membrane,  and penetrates  more  or  less through  the substance  of the
uterus.
  " The point of insertion of the placenta is the most ordinary seat of all
uterine lesion, whether of abscess,  softening, or phlebitis; the next  point,
the large and congested, lead-coloured cervix uteri."
  False membranes of  coagulable lymph are found on the  lining  mem-
brane of the cavity, mixed with  blood and lochia.
  The cause of this peculiar softening has been  much debated—some
attributing it to a specific action  of the parts, or to alteration  of the blood,
and others to  inflammation; with the  latter of whom I am disposed to
agree.
  749. Diagnosis. — When complicated with peritonitis, the diagnosis
is very difficult; but when the uterus  is alone  affected, it is easier to  dis-
tinguish it.
  1.  From after-pains,  weed, &c. it differs very widely, in its persistence,
and in the gravity of  the accompanying constitutional symptoms.
  2.  From puerperal peritonitis.  The most marked distinction between
them  is the tenderness on pressure; which,  when the peritoneal sac is in-
flamed, is general and superficial, rendering the slightest  pressure intoler-
able ; whereas, in hysteritis, the abdomen will bear pressure very well all
over,  until we ourselves  feel that we are pressing the enlarged and hard- 
UTERINE PHLEBITIS.
493
ened uterus.  The only exceptions to this rule, I have  met with, are those
cases of peritonitis where there is no abdominal tenderness.
  The pulse, in hysteritis, is  weaker, and the patient  sinks more rapidly
than in peritonitis; the lochia are also more frequently disordered.
  Prognosis. — In the severe form, the prognosis is in almost every case
unfavourable ; but of the milder cases, I have seen many recover.
  750.  Treatment.—In the mild variety, vensesection will be necessary,
followed by leeches, poultices, and fomentations.  The benefit of calomel
and opium  is  seen here, even more  strikingly than irt peritonitis; most
patients recover who  are  brought fairly under their influence.  If the
calomel disturb the  bowels,  it should be omitted, and the opium given
alone.
  When the acute stage  has passed, I have seen great benefit from a suc-
cession of  blisters over the region of the uterus.
  The bowels should be kept free ; but active purging is injurious.  Ene-
mata of castor oil and turpentine answer the purpose very well.
  None  of our remedies  seem  to have much power over the severe
form ; but  antiphlogistics must be tried in the early stage; subsequently,
opium, and tonics,  or  stimulants, with counter-irritation, are  our only
resources.
  751. 4.  Inflammation  of  the  Veins of  the  Uterus.   Uterine
Phlebitis. — This form of  disease  has been  frequently noticed  by
authors; amongst others, by Dr. J. Clarke, Mr. Waller,  Meckel, Ribes,
Louis,  Dance,  Tonnelle,  Burns, Lee, Boivin and  Duges,  Ferguson,
&c. ; and  recently in a  series  of papers  on  " Metro-peritonite," by M.
Nonat.
   Nor is it very rare ; for M.  Tonnelle found pus in the veins in  93 cases;
and in the thoracic duct in 3 cases out of 134; and Dr. Robert Lee, in
45  cases, had 24 of  uterine phlebitis.
   752. Causes. — Dr. Robert Lee considers that  it may be the result of
mechanical injury to the uterus, either during the  labour, or by the force
used to extract the placenta.
  It may follow after hemorrhage, or arise from cold, or the decomposition
of  retained portions of the placenta.
   It may be excited by any  of the causes of the other varieties of puer-
peral fever.
   753. Symptoms.—In women of previous good health, the attack com-
mences generally in 24 or 36 hours after delivery.  The patient generally
complains  of pain in the uterus, more or less acute, preceded,  accompa-
nied, or followed by rigors.
   The uterus  is tender on  pressure, and the lochia and milk are both
suppressed.
   There is head-ache, and  slight incoherence;  a sense  of general un-
easiness, and  sometimes nausea and vomiting, with  acceleration of the
pulse.
   After a time, these symptoms  are  succeeded by increased heat of sur-
face, tremors of the muscles of the face and extremities, rigors, great
thirst, dry brown tongue, frequent vomiting of green fluid, rapid full pulse,
hurried respiration, &c.
   The head becomes more involved, and we find the  patient in a state of
                                2r 
494
UTERINE PHLEBITIS.
 drowsy insensibility  or violent delirium  and  agitation, followed by ex-
 treme exhaustion.
   The surface of the body assumes a deep sallow, or yellow colour;  and
 occasionally petechial or vesicular eruptions have been observed on dif-
 ferent parts of the body.
   The pain may or may not increase, but the uterine tenderness is  cer-
 tainly augmented, and the abdomen is often swollen and tympanitic.
   In some very rare  cases, there is little or no local distress, and the ex-
 istence of the disease could not be discovered except for the  secondary
 affections.  Such wTas the case with a patient  under my care.   She had
 no uterine pain or disturbance — no tenderness on pressure; and yet, on
 the  seventh day  after delivery, a smart febrile attack preceded  the forma-
 tion of a large abscess, near the left elbow joint.  Since then, a second
 has  followed, on the top of the shoulder, and  a third  in the  right  arm,
 above the elbow.
   754. The patient may die during the acute stage, but the majority live
 longer, and exhibit the most interesting phenomena, connected with this
 variety of puerperal fever, and distinguishing it from all others.  I allude
 to the secondary  diseases of other organs.
   The brain, though often functionally disturbed (135 in 304, Lee and
 Ferguson), is not frequently the scat of organic disease.   Its vessels are
 sometimes congested, and lymph diffused in the pia mater, or serum,  into
 the ventricles.   According to M. Duges, there is arachnitis once in  266
 cases.
   Portions of the brain are occasionally softened and disorganised; or
 there is purulent infiltration into the cerebral substance.
   In the  chest, we find evidences of inflammation of the pleurae, effusion
 of serum of the  same character as  that in  the  peritoneal  sac, and occa-
 sionally effusion of blood.
        M. Tonnelle found Pleurisy  .     .     .  in  29 cases.
                           Effusion of serum    .  in   8   "
                           Effusion of blood    .  in   6   "
   The lungs are often greatly condensed, of a dark  red colour, with in-
 filtration of purulent  matter.   Or they may be  in a  state of " complete
 dissolution, having all the characteristics of gangrene, except in many
 cases its peculiar fcetor."
        M. Tonnelle found Pneumonia    .     .  in 10 cases
                           Tubercles     .     .  in  4   "
                           Abscess       .     .  in  8   "
                           Gangrene      .     .  in  3   "
                           Pulmonary apoplexy   in  2   "
   The symptoms of the secondary affection  in these cases (cough, dysp-
noea, &c.) are but slight, and are completely masked by the more  serious
primary disease.
   "The.heart  is often enlarged, softened, and friable; its inner mem-
brane deeply stained ;  lymph and serum are also occasionally found in the
pericardium.   There  are white patches on the outer covering of the heart.
I have never remarked any peculiar disorganization of the great arteries ;
they are often intensely stained." 
UTERINE PHLEBITIS.
495
  The intestinal canal is not frequently the seat of organic change.  The
mucous membrane of the  stomach is  sometimes inflamed, softened, and
occasionally its coats are perforated, giving rise to peritonitis.
  Between the mucous and muscular tissues, there is an effusion of clear
reddish serum, when the vomiting has been excessive.
  The mucous membrane of the  intestines, also, may be softened, and
the walls of the canal perforated.

        M. Tonnelle found Gastro-enteritis     .   in 1 case.
                          Enteritis     .        in 4 cases.
                          Entero-colitis      .   in 1 case.
                          The stomach softened in 8 cases.
                          The stomach ulcerated in 5   "
                          The stomach perforated in 5   "

  The liver  is occasionally diseased — its  substance may be  congested,
softened, or contain abscesses.  M. Tonnelle met three cases of abscess
in the liver.
  The structure of the spleen may be  softened and  disorganised.   M.
Tonnelle relates two cases of abscess.
  " The kidneys present inflammation of their peritoneal coat, depositions
of pus, and flakes of lymph, alterations in their veins, softening, and great
engorgement: both kidneys are rarely attacked at once."   " The ureters
and bladder are more often the seat of pain  and congestion, than of dis-
organised structure."
  The eyes are also  affected.  The conjunctiva becomes  inflamed, the
eyelids swollen, lymph is effused into the anterior chamber,  and the sight
is destroyed.   Cases of this kind  are related by Dr. M. Hall  and Mr.
Higginbottom, although not  by them attributed to uterine  phlebitis.
  The joints are attacked by inflammation, and sometimes  the cartilages
by ulceration ;  and the various products of inflammation are found within
the capsular ligaments.  M. Duges has thus placed the joints in the order
of frequency of disease:  1, the  hip ; 2, the elbow; 3, the  knee ; 4, the
foot;  5, the  metacarpus; 6, the shoulder.   Dr. Ferguson has found the
elbow and knee more frequently affected than the hip.
  M. Tonnelle met six cases of abscess of the knee; two of the elbow;
and two of the symphysis pubis.
  Sero-sanguineous fluid may be effused into the muscles  or cellular sub-
stance  of the limbs, giving  to them the appearance of erysipelas.   M.
Tonnelle mentions three such cases.
  As to the extent of this infiltration, it may be circumscribed within, a
few inches, or  it may extend between two joints, rarely occupying  the
whole limb.
  An abscess may be formed in the muscles or  cellular membrane of a
limb ; or a succession of abscesses  may occur, as in the case I have men-
tioned ; or the pus may be diffused through the various soft structures.
  The quantity is sometimes enormous; the patient suffers much pain,
and may be seriously injured, if the discharge continue long.
  The symptoms in the latter case are those met with  ordinarily in abseess,
except that at the beginning  they sometimes resemble a rheumatic attack.
  755.  Morbid Anatomy. — The  primary morbid change is evidently in
          32 
496
INFLAMMATION OF
the veins of the uterine region ; their coats are thickened, and sometimes
so much contracted as to render the canal impervious.  The lining mem-
brane is generally paler, and coated with lymph or pus, which may extend
to a considerable distance.
   The disease may be confined to the veins of the uterus, or may involve
those of neighbouring parts.   The  spermatic vein is the  one more fre-
quently affected — then the hypogastric;  but it may involve the  renal
veins, as far as  the kidneys, or even the vena cava.
   It is remarkable, that it is generally the veins of one side only that are
affected, and that side is  the one to  which the placenta was attached.
   When the disease affects veins distant from the uterus, the surrounding
cellular tissue is hardened,  and contains puriform matter.
   " In a certain number of cases, no lesion can be discovered in the vein,
but the presence of  some unnatural fluid.   It  is disputed whether it is
absorbed,  or the product of venous  inflammation.  It is of little  moment
which of the two  opinions be  adopted; the disease depends not  upon
how the matter is produced, but whether it enters the circulation.   Whe-
ther this be  by absorption or  by inflammation, puerperal fever is the
result."
   756.  Diagnosis. — It  may in many cases be extremely difficult to dis-
tinguish this from the other varieties, at least in the early stage.
   Generally speaking, the pain and tenderness are more local and limited
than in peritonitis, and at an advanced period the presence of the second-
ary disease will at  once indicate its true character.
   757.  Treatment. — Severe cases  of this species of puerperal  fever
appear to  defy all our resources.  When it is the prevailing characteristic
of an epidemic, the vast majority will die.
   " The two indications," says Dr.  Ferguson, " are,  1.  To attend to
the local lesions.   2. Never to forget that these are not the disease, but
merely the effects of a  more diffusive, though concealed cause, to act on
which our remedies should  be  directed.  The  rationale of the treatment,
therefore,  consists in the exhibition of such remedies as will  act on this
cause, and such as will alleviate or remove the local affections; taking
care that in our attempt to effect the latter end, we do not  so act on the
constitution as to give additional energy to the more  deadly power of the
concealed cause."
   This  rule  should  direct  our employment of leeches, blisters,  calomel,
and opium, &c, in the early stage, and stimulants and tonics in the latter.
   758.  5.  Inflammation  of  the Uterine Lymphatics.—This variety
of puerperal affection was first noticed in France by M. Dance ; and  since
by Boivin  and Duges, Tonnelle, Duplay, Cruveilhier, and  Nonat ;* the
former found pus in the lymphatics  in 32 cases,  and in the  thoracic
duct in 3.
   In this  country, it was first recorded by Dr. R. Lee, in the following
case, published in the Medico-Chirurgical Transactions.
   " A woman,  set. 30, in an advanced stage of pregnancy, was admitted
into St. George's Hospital, July 1, 1829, under  the  care  of Mr. Caesar
Hawkins,  in  consequence of sloughing of the skin  covering a diseased
bursa of the  patella.  The removal  of the bursa was followed by great
* Revue Med. Franc, et Etrang. for 1837. 
THE UTERINE LYMPHATICS.
497
constitutional disturbance, and on  the 14th labour came on.  Two days
after, symptoms of uterine inflammation made their appearance, and on
the 18th day death took place.  Though the pain was relieved by bleed-
ing, she never  rallied after the attack.   On  examining the body,  some
puriform lymph was found in the pelvis, but there was no increase of
vascularity in the peritoneum.  In the  broad ligaments, some fluid was
also effused, and on each side numerous large absorbent vessels  were
observed, passing up with  the  spermatic vessels,  to the receptaculum
chyli, which was  unusually distended.   All  these vessels,  and the reser-
voir itself, were filled with pus;  but that in the receptacle was mixed
with lymph, so  as to be more solid ; the vessels themselves were firmer
and thicker than usual.  The thoracic duct was  quite healthy.   The
uterus was scarcely contracted, and the internal surface of  the lower half
was soft and shreddy, and in a state of slough.   The upper part, where
no pus was found externally, was  also healthy, or nearly so, on its inner
surface.*
   The local symptoms are  exceedingly obscure, and the constitutional
ones very like those in uterine phlebitis,  and  quite as severe.
   759.  On dissection, th'e lymphatics are found  distended with pus, and
generally at intervals, so as to give them a beaded appearance.
   The secondary lesions are much the same as in phlebitis.
   Treatment. — As yet we  know of no remedies capable of controlling
the disease.
        * Med. Chir. Trans., vol. xv. p. 64.  Lee, Diseases of Women, p. 46.
2r2 
CHAPTER XXV.
                        PHLEGMASIA DOLENS.

   760. This disease, under various appellations,* has been long known to
 the profession, although there has  been much difference of opinion as to
 its nature.   It was described by  Roderick a Castro, in 1603, and sub-
 sequently by Mauriceau, Puzos,  Levret, Petit,  Leake, White, Hull,
 Trye, &c.
   It consists in a swelling of one or both legs (simultaneously or  succes-
 sively), shortly after delivery, with pain  and tenderness, and running a
 definite course.  The left leg is more frequently affected than the  right.
   It may occur with first children, but it is more frequent after subsequent
 deliveries.
   Women of a delicate constitution, or lymphatic temperament, are said to
 be the most  liable  to  the attack, but especially those who have  suffered
 from uterine irritation after delivery.  Mr. Chatto's case followed extrac-
 tion of the placenta.
   It generally commences within a fortnight after delivery, sometimes on
 the third or fourth day, in other cases not till some weeks have elapsed.
 Of 22 cases observed by Dr.  R. Lee, 7 were attacked between the fourth
 and twelfth day,  and 14 after the second week.
   761. Pathology. — Successive  authors have  given  different  theories
 touching  the essential nature of this disease; and though  we have re-
 cently become acquainted with the most important points of its pathology,
 it is not quite certain  that even yet our knowledge embraces the whole
 series of facts connected, with it.
   Mauriceau considers it to  be owing to a reflux upon the lower ex-
 tremities,  of  certain matters which  ought to have been evacuated  by the
 lochia.
   Puzos and Levret attributed  it to deposits of milk (dSpots du  lait)  in
 the legs.  This opinion has prevailed extensively in these countries; and
 with some practitioners it was customary to keep the child constantly to
 the breast, to prevent  this metastasis when threatening, or  to remove it
 when it has occurred.
   In the year 1794, Mr. White, of  Manchester, published an inquiry into
 the nature  and cause  of  that swelling  in one or both of the lower ex-
 tremities, which sometimes happens to lying-in women; and he suggested
 or adopted the opinion, that  the disease  depends  on obstruction, or on
 some other morbid  condition of  the lymphatic vessels and glands of the
 affected parts.
   Mr. Trye, of Gloucester, in an essay on this subject (1792), attributed
 it to a rupture  of the  lymphatic vessels, as they  cross the  brim  of the
pelvis, under Poupart's ligament.  Soon  after this, Dr. Ferrier  main-

  * As milk leg, white  leg, swelled leg, puerperal tumid leg,  &c.  By Dr. Hull, Phleg-
masia dolens; by Dr. Cullen, Anasarca serosa ; by Dr. Good, Bucknemia sparganosa;
by others, phlegmasia lactea, oedema lactium, &c.
                                                         (498) 
PHLEGMASIA D0LENS.
499
 tained that there is a general inflammatory  state of the absorbents in this
 disease.
   Dr. Hull (1800) considered  the proximate cause  of this  disease to be
 an inflammatory affection, producing  suddenly a considerable effusion of
 serum and coagulable lymph into the  cellular membrane of the limb.  AU
 the textures, muscles, cellular membranes, lymphatics, nerves, glands, and
 blood-vessels, he supposed to become affected.
   So far, the theories depended  upon d, priori reasoning, not upon patho-
 logical facts; and the first light thrown upon the subject by post mortem
 examination was by the late Dr. Davis, Professor of Midwifery in Univer-
 sity College, London, who, in 1817 examined the condition of the veins
 in a patient who had died with the disease, and found  that they had evi-
 dently been the seat of extensive inflammation.*
   After  this he  taught that  phlegmasia dolens resulted from this cause,
 and in May, 1823, published a paper with cases and  dissections in the
 Med. Chir. Trans, vol. xv.
   " In January, 1823, M. Bouillaud related several cases and dissections,
 in which  the crural veins were  obliterated  in women who had  suffered
 from  oedema of  the lower  extremities after delivery; and M. Bouillaud
 distinctly stated  that he considered  obstruction of the crural veins  to be
 the  cause, not only of the oedema of lying-in women, but of many partial
 dropsies."
   It is  but just  to remark, that  although  this bears an earlier date than

   * " Morbid appearances observed on examining the body of Caroline Dunn, March 6,
 1817: — The left lower extremity presented an uniform oedematous enlargement, with-
 out any external discoloration, from the hip to the foot. This was found, on further
 examination, to proceed  from the ordinary  anasarcous effusion  into the ceUular sub-
 stance.  The inguinal glands were a little enlarged, as they usually are in a dropsical
 limb, but pale coloured, and free from the slightest sign of inflammation.  The femoral
 vein, from  the ham upwards, the external iliac, and the common iliac veins, as far as
 the junction of the latter with the  corresponding  trunk of the  right side,  were dis-
 tended, and firmly plugged with what  appeared externally a coagulum of blood.  The
 femoral portion of the vein, slightly thickened in its coats, and of a deep red colour,
 was filled with a firm bloody coagulum, adhering to the sides of the tube,  so that it
 could not be drawn  out.  As the red colour of the vein might have been caused by the
 red clot everywhere in close contact with it,  it cannot be deemed a proof of inflamma-
 tion.  The trunk of the profunda was distended in the same way as that of the femoral
 vein; but the saphena and its branches were  empty and healthy.   The substance filling
 the external iliac, and common iliac portions of the vein was  like the laminated coag-
 ulum of an aneurismal sac, at least with a very slight mixture of red particles; the
 tube was completely obstructed by this matter, more intimately connected to its surface
 than in the femoral  vein; adhering indeed  as firmly as the coagulum does to any part
 of an old aneurismal  sac; but in its  centre there was a cavity containing about a tea-
 spoonful of a thick fluid of the consistence of pus, of a lightish brown tint, and pulta-
 ceous appearance.  The  uterus, which had  contracted to the usual degree,  at such a
 distance of time from  the delivery, its appendages and blood-vessels, and the vagina,
 were in a perfectly healthy state.   There was not the least appearance of vascular con-
 gestion  about the organ, nor the slightest distension of any of its vessels.  Its whole
 substance was, on the contrary, pale, and the  vessels everywhere contracted and empty.
 The  state of the abdominal cavity and its  contents  were perfectly natural.  That the
 substance  occupying the upper part  of the venous  trunk and the fluid in its central
 cavity,  had been deposited there during life, from inflammation of the vessels, does not
 admit of doubt.  I  am also decidedly of opinion, in consequence of its firmness, and
 close adhesion to the vein, that the red  coagulum in the femoral vein was the result of
a similar affection extending along the tube, and that the passage of the blood through
it, in the whole tract submitted to examination, must have been completely obstructed
before death." 
500
PHLEGMASIA  DOLENS.
Dr. Davis' paper,  yet the latter gentleman had been promulgating his
views for six years previously.
  In 1829 (I believe), Dr. Robert Lee, acting upon a suggestion of Mr.
Guthrie's, succeeded in tracing  the  affected veins to their origin  in the
uterus, and found the disease equally marked  there.   He  then  added  to
Dr. Davis' observation, the fact  that (at least in many cases) crural phle-
bitis is but an extension of uterine phlebitis.
  MM. Petit, Gardien, and Capuron, regard  the disease as inflammation
 >f the lymphatic vessels and glands.
  Dr. Burns considers the nerves as involved in the disease.
  Dr. Campbell coincides rather with Dr. Davis and Dr. Lee.
  Dr. Dewees rejects the pathological view, and is rather inclined  to
adopt that of Dr. Hull.
  M. Bouillaud has written a very able  article on this subject in the Diet.
de Med. et de Chir.  Prat. (1834), in which he  includes inflammation  of
the  symphyses,  veins, lymphatics, and  nerves,  among  the  proximate
causes of phlegmasia dolens.
  It is evident  that if we take pathological anatomy for our  guide, we
must conclude the disease to consist in inflammation of the veins of the
lower extremities, in many cases propagated from the veins of the uterus;
and that the interruption of the  circulation through these vessels gives rise
to the  effusion of serum in the cellular tissue.   This view also derives
some support from the phenomena which result  from phlebitis in other
situations.
  At the same time it is not  impossible  that  some further information
may be  necessary, before we  fully comprehend  the  true theory of the
disease.
  762. Causes.—The exciting cause is generally the impression of cold;
and if Dr. Lee's views be of general application, we may add  disease  of
the uterus, especially of that part to which the placenta is attached.
  763. Symptoms.—As this disease generally occurs in women who have
suffered from uterine irritation,  or inflammation, and may  even  be  caused
by  such condition of the uterus, it is not surprising that the ordinary pre-
monitory symptoms should commence with pain or uneasiness in the
lower part of the abdomen, extending  along the brim of the pelvis: the
patient is irritable, depressed, and complains of great weakness.
  Sometimes, however, there  are  no precursory  symptoms, the  patient
being suddenly seized with pain in  the calf of the leg; or it  may com-
mence like rheumatism, affecting the back and hip joint.
  When the disease begins in the pelvis, the pain speedily extends below
Poupart's ligament down the thigh, to the ham, calf of the leg, and foot.
  It is constant, but occasionally remitting,  and not much relieved  by
posture, though  a  depending position materially increases it.
  Shortly after the commencement, the inguinal region is  tumefied and
tense, and in a day or two the  thigh becomes swollen, tense, white, and
shining.   This swelling may be confined to the thigh, or extend down to
the heel, and it will vary much  in amount; occasionally the leg is enor-
mously increased in  size, which is rather a favourable occurrence.
  When the pain  originates in the back  and  hips, the nates and vulva
become swollen, glassy, and tense.
   When the disease commences in  the calf of the leg, the swelling is first 
PHLEGMASIA DOLENS.
501
observed there, or at the ankles, gradually extending itself up the leg
and thigh.
  The temperature of the limb is generally increased, though sometimes
it is below the natural standard.
  At the commencement and decline of the disease, the  limb pits upon
pressure; but when the distension is great, it does not.
  In most cases the femoral vein may be traced from the groin down the
thigh, feeling hard, and rolling under the finger like a cord.  When the
attack is limited to the leg, however, this is not the case.
  There is a degree of tenderness all over the limb, but it is very marked
along the course of the inflamed vessel; there is neither redness nor dis-
coloration.
  The inguinal  glands are  generally swollen and  hard;  in some rare
cases they suppurate.
  Abscesses may form in the cellular membrane; and Burns states that
mortification has occurred.
  Either leg may be  affected, though the  left appears to  be more fre-
quently attacked; and it  not unfrequently happens that the sound leg
participates in the disease before the  other is perfectly well,  and then the
disease runs a similar course a second time.
  When once the swelling takes  place the  limb becomes useless; the
patient can neither bend it nor place it on the ground.
  The constitution, as  might be  expected, suffers considerably during the
attack; the  pulse becomes quick (100 to 140) though weak, the tongue
white and coated, the thirst considerable, the countenance pale, the appe-
tite is lost, the bowels deranged, the urine turbid.  The patient is restless,
and generally sleepless.
  The internal genitals are tender, and  the lochia sometimes diminished,
or offensive, but more frequently unaltered.
  Of course, these symptoms will vary in intensity, according to the vio-
lence of the attack; and when the acute stage is over (in ten days or a
fortnight), the constitutional disturbance subsides, and the affection becomes
local, and chronic.
  764. Terminations.—1.  It may terminate in resolution—the symptoms
altogether subsiding, the effusion disappearing, and the patient recovering
the use of her limbs.
  2. The subsidence may be more gradual, the limb continuing swollen
for months,  and the patient being unable to use it freely.
  In these cases there may be some thickening of the cellular tissue, and
sometimes the veins remain varicose.
  3. As already stated, suppuration may take place, even to a great
extent, so as to change the character of  the disease, and even to threaten
danger from exhaustion.
  4. Death may occur, either suddenly — perhaps  as the  patient raises
herself in bed — or more gradually, from  the secondary diseases conse-
quent on phlebitis.
  765. Morbid Anatomy. — On opening the limb, it is found to be dis-
tended by serum  effused into the cellular membrane.
  The vein  is obliterated by clots of blood firmly adherent to its panetes,
which are thickened;  its inner  membrane  is of a deep  red colour, the
result, either of staining from the clots, or of inflammation. 
502
PHLEGMASIA  DOLENS.
   A membrane of coagulable lymph may be found, instead of the clot,
lining different vessels.
   The veins may contain purulent matter.
   The vessels which have been noticed as participating in these changes,
are the femoral, the external, internal, and common iliacs of either side,
the epigastric, spermatic, circumflexa ilii, the uterine, vaginal and saphena
veins, and the vena cava.
   Pus is also met with in the absorbents, and evidences of inflammation.
The nerves are also inflamed in some cases.
   A series of small abscesses may be found in the substance of the limb,
or a single one of large size.
   Traces of secondary disease may be discovered in the different cavities,
joints, &c.
   766.  Prognosis. — Though we cannot say that the disease is without
danger altogether, when severe, yet the proportion of  deaths is so  small,
that in  the  great majority of even  severe cases, our  prognosis may be
favourable ;  still more decidedly when the attack is slight.
   767.  Diagnosis.—The characteristic marks of the disease are, the time
of its occurrence — after delivery; the uterine symptoms preceding—the
pain down the  thigh and leg — the  swelling; but especially the painful,
hard, cord-like femoral vein.
   When the greater part of these  symptoms is present, there can be  no
doubt of the nature of the  disease.
   768.  Treatment.—The condition of the patient after confinement will
of necessity somewhat modify the activity of  the treatment.
   Generally speaking, venaesection will not be required; but if the patient
be of a plethoric habit, if she have in some degree recovered her confine-
ment, and if the  disease  set in with great violence, it may be  ad-
visable.
   Leeches, in numbers proportioned to the severity of the attack, should
be  applied along the course of the femoral vein, to the groins, or to the
calf of the leg, and a  poultice  applied when they fall off.  If decided
relief be not obtained, they may be  repeated in smaller numbers, once,
twice, or thrice.
   Calomel in small doses, alone or with opium,  may be given with great
benefit after leeching.
   As the  bowels  are  almost always in some  degree  disordered, appro-
priate remedies must  be tried.   If diarrhoea  be not  present, purgatives
may be given, and we are advised to prefer the  saline.  I have certainly
seen benefit result from small doses of Tartar emetic, given along with
the cathartic.
   Saline effervescing draughts may also be given.
   Different statements have been  made as to the effect of  blisters; some
regarding them as specifics, and  others altogether rejecting them as mis-
chievous.   My own experience is in  favour of them.
   Turpentine fomentations are also decidedly useful.
   When the pain is severe, or the patient irritable, restless, and sleepless,
opiates will be necessary.
   The diet should be bland, and  chiefly farinaceous.
   When by these means the acute stage  has been terminated,  and the
constitutional symptoms relieved, we may change our local and general 
PUERPERAL MANIA.
503
treatment.   Gentle support may be afforded to the limb by a light flannel
bandage, and slightly stimulating friction employed.
  In this stage the frequent application of small blisters has been  espe-
cially recommended.
  Tonics  may also be given;  bark, or quinine and sulphuric acid, will
be found the most serviceable.
  The diet may be improved; meat may be allowed, and a moderate
portion of malt liquor, or wine.
  If at any time the lochia should be offensive, vaginal injections of tepid
milk and water, twice a day,  should be employed.
  After some time, air  and  slight exercise, with  sea-bathing,  will be
found to conduce to the perfect restoration of the patient.
                        CHAPTER XXVI.

                      PUERPERAL MANIA.

  769.  Females may suffer from an  attack of mania  during gestation,
during labour, or after parturition.   The two latter cases will occupy our
attention in this chapter.  The temporary delirium,  or  mania, which
occurs during labour, was, I  believe, first  recorded by my friend  Dr.
Montgomery.   It appears at two particular periods of  the  labour;  first,
as the head passes through the os uteri, and again, at its exit through
the os externum.   It would  appear to be owing to the extreme suffer-
ing at these times,  acting upon an irritable and nervous temperament.
It is  very  temporary, generally lasting but a  few minutes, and  then
subsiding.
  The most curious point about it is, that  the  patient is often conscious
of her incoherence.  A lady whom I attended, and in whom this delirium
occurred, assured me that she knew  she was  talking nonsense, but that
she could not resist it.
  770.  Puerperal mania, in the usual sense of the term, is by no means
a rare disease.   It  may attack the patient a few hours  or days after deli-
very,  and more frequently before the lacteal secretion is fully established,
although cases occur at a later period, and  even appear to be the result
of weaning.
  Females of a nervous, irritable temperament, seem peculiarly obnoxious
to it,  and occasionally those of plethoric habit and of  sensitive feelings.
It is said to prevail especially during summer.
  771.  Causes. — It was formerly attributed  to the suppression of the
lochia, or to a metastasis of the milk.
  More recently it has been attributed to local irritation of the breasts or
other  parts; to  irritation and loss  of blood combined; to  the  peculiar
condition of the sexual system ; to the disturbances of the vascular system,
occasioned by delivery;  or to the effects of suckling. 
504
PUERPERAL MANIA.
   No doubt, also, it may be partly attributable to the shock  which the
 nervous system receives at the time of labour.
   Hemorrhage has been enumerated among the predisposing causes, and
 the exciting causes  are said to be fright, anger, sorrow, or any species
 of mental emotion, disordered digestion, &c.
   There is no reason to  believe that it arises from  inflammatory action
 in the brain. .
   772.  Symptoms. — The attack  may either come on suddenly, or gra-
 dually ; in the former case the patient  may, perhaps, awake out of sleep
 in a fright, and commence talking incessantly and incoherently; in the
 latter, she may have complained of head-ache for some days; of vigil-
 ance ; or even entire sleeplessness.  The loss of rest produces  exhaustion
 and  irritability, and  her  mind  becomes  depressed and  fretful.   In this
 condition, some fancied inattention or unkindness, or some annoyance,
 fixes itself, as it were, in  her mind, and from talking constantly of it, she
 soon proceeds to talk irrationally about it.   Once  the mental  integrity is
 broken, she ceases to be rational on any point except for  a few moments,
 and, in  fact, becomes insane.
   As to the insane  phenomena, they  do  not  differ under these circum-
 stances  from insanity  generally,  and  therefore I  need  not enter  upon
 them.
   There are two distinct classes of cases;  those which are accompanied
 by fever and quick pulse,  and those which are not; and  this is, perhaps,
 the most important point  in the  history of the disease.
   We find the former class of patients  complain of head-ache,  and throb-
 hing in  the head;  the face is flushed, the eye unsettled and intolerant of
 light, the raving is incessant, and the patient difficult to restrain.
   In the latter we  find the pulse but little quicker than usual,  and weak,
 the surface natural, and very little  head-ache.   The tongue is generally
 white and loaded,  the stomach disordered,  and the bowels confined.
   773.  Terminations. — 1. It may cease suddenly after twenty-four
hours.
   2. It may continue an indefinite time, and the  patient  ultimately
recover.
   3. It  may terminate in  death.   This is almost peculiar to those cases
where the pulse is  quick,  and fever is present
   4. A  few patients  continue in a state of permanent insanity, in whom
it occurs after delivery.
   774.  Treatment. — It seems to be  pretty generally agreed, that there
are but  few cases  which  require venaesection, and that in those cases  it
should be used most cautiously.
   Leeches  to the  forehead or  temples is  a better mode of abstracting
blood, if it be necessary.
   If the loss of blood  do no good, it is quite certain  to  do mischief, by
weakening the patient,  and increasing the irritability.
   Some benefit will be derived from shaving the head, and applying cold
lotions,  or a bladder  of pounded ice.
   But more decided relief seems to be afforded by thoroughly freeing the
 bowels  by  purgatives and enemata, and then  administering  an  opiate,
 when not counter-indicated by the  state of the pulse.
   Emetics  have been  recommended,  but their value seems  doubtful, 
PUERPERAL MANIA.
005
unless there be a necessity for evacuating some offensive  matter in the
stomach.
   Antispasmodics — especially camphor, are said to be very useful.
   Diffusible stimuli, in combination with the opiate, have been  found
very beneficial.
   Tartar emetic, in small doses, will be of use, especially in cases where
the pulse is quick, and  may probably  supersede the necessity for blood-
letting.
   Tonics will be beneficial when the mania subsides.
   The utmost  quiet will be  necessary.   The  diet should  be bland and
nutritive.
   Great skill must be exercised in the moral management of the patient,
so as not to increase the irritation.   There is  more to be gained  by the
appearance of yielding  to  the wishes  or whims  of the patient, than by
resisting them.
   Some authors recommend that the patient  should cease nursing, as the
suckling may prolong the irritation.
   " The first signs of recovery are to be observed in the abatement of the
fits of agitation, in their violence, or the return of the right understand-
ing, though for short intervals.   It seems that peculiar address is required
to foster any tendency to their natural habits, and by a sensible and wise
management of these tendencies, the recovery may be  much promoted."*

  * It will be consolatory to the medical attendant as well as to  the friends of the
patient to know that these cases, alarming as they appear, almost invariably recover
under judicious treatment.  It has been very properly said that, ,"the question is not
bo much whether the patient will get well, as when she will get well." — Editor.
2s 
CHAPTER XXVII.
                   EPHEMERAL FEVER OR WEED.

   775. This  is a short attack of fever, to which females  are especially
 liable during the early part  of their convalescence, though it may occur
 at a later period...
   Females of sensitive constitutions are most obnoxious to  it.
   776. Causes. — The most  frequent cause is the impression of cold,
 perhaps on rising from bed, or changing the room, &c.
   Indigestion, or irregularity of the bowels,  may also  give rise to it.
 Fatigue, mental agitation, and want of rest, are also enumerated  among
 the exciting causes.
   777. Symptoms.—The attack commences by general uneasiness, palpi-
 tation, and shivering, with head-ache, pain in the back and limbs, sore-
 ness of the skin, thirst, rapid and sometimes irregular pulse, &c.
   To this succeeds a well-marked hot stage, with flushed face, throbbing
 temples, pain  over the  eyes, rapid full pulse, pain of the breasts, soreness
 of the abdomen, &c, and it terminates in a profuse sweat, which removes
 the fever, and relieves the other symptoms.
   The tongue is  coated, the stomach is often disturbed, and  the  bowels
 confined.
   During the paroxysm, the fever often runs very high, and the distress
 is proportionally great.   Occasionally the mind is confused and distressed;
 and in some cases the patient is delirious.
   For the time, the secretion of milk is diminished or suspended, and the
 lochia also, but they return  after the paroxysm.
   The fit is  generally completed in twenty-four hours, always in forty-
 eight ; and if properly treated,  it seldom returns.   If neglected, however,
 it may assume the form of an intermitting, or continued fever.
   Unless it assume this character, it is of very little consequence, and
 very easily managed.
   778.  Diagnosis.—From  the violence with which it commences, it may
 easily be mistaken for puerperal fever; but the cessation of the paroxysm
 after some hours, and the absence of marked abdominal tenderness, will
 generally enable us to distinguish it.  Indeed, the peculiar violence  with
 which it commences, is itself more characteristic of weed than puerperal.
   779. Treatment.—During the cold stages, hot bottles and warm bed-
 clothes may be applied, so as to  relieve the distress.   Warm drinks and
 cordials may also be given.
  During the  hot stage, a comfortable quantity of clothing must be con-
tinued, and diaphoretics given, so as  to favour perspiration; and  during
the sweating stage, we must guard against cold, and  diminish the clothing
veiy gradually.
  As for purgative medicines, which  are necessary,  I have  found the
combination of Salts, Senna, and Tartar Emetic, the most useful; but
                                                        (506) 
EPHEMERAL FEVER OR WEED.
507
any other purgative may answer the purpose.  If the tongue be foul, and
the stomach loaded, an emetic may be advisable.
  Very rarely will it be  necessary to take away blood, and then only if
there be much local pain.  A few leeches to the head, or to the breasts
if they be painful, may be of use; but in the majority of cases they are
unnecessary.
  We should carefully examine the state of the uterine system, as irrita-
tion  may otherwise go on unsuspected, and be the cause of much subse-
quent distress.
  The diet may be nutritious after the  paroxysm is over, and even mild
tonics  be given,  if necessary.   Dr. Campbell recommends  five-grain
doses of camphor, four or five times a day for some days, to allay nervous
irritability.
   Great care must  be taken, after the fever has terminated, to avoid all
occasion of  cold, or any  cause which may reproduce the  attack. 
INDEX.
                  A.
                                PAGE.
Abortion........................  179
Abdomen, enlargement of.........  150
Accidental hemorrhage...........  421
      »        »  treatment of...  423
      "        "  transfusion in .  425
After-pains.....................  228
Allantois.......................  121
Amenorrhoea....................   86
Amnii,liquor...................  122
Amnion........................  114
Amputation of fcetal limbs in utero.  144
Anaethesia......................  284
Apoplectic convulsions...........  444
Apoplexy of child at birth........  225
Arm presentations...............  394
Ascites........................  382
Asphyxia of child at birth.........  224
Auscultation in pregnancy........  152

                  B.
"Ballottement».................  152
Breech presentations.............  384
" Bruit placentaire ".............  153

                  C.
Callipers (Note).................   57
Caesarean section.................  358
     "     mode of operating......  368
Canal of the pelvis...............   46
Carunculse myrtiformes...........   61
Cephalaematoma................  225
Cephalic version.................  297
Cervix uteri in pregnancy.........  107
Changes in child after birth.......  143
Child, position of, in utero........  137
   "  condition at  birth..........  224
   "  abnormal condition........  225
Chloroform.....................  284
Chorion........................  112
Circulation in fcetus..............  142
Clitoris.........................   60
Coccyx.........................   39
     ,   i v           S  409, 414, 420
Complex labour.......  -J  435; 447J 469
Conception......................   98
Convalescence after labour, normal.  226
       »         »     abnormal.  231
Convulsions.....................  435
     m      hysteric.............. 435
     0      epileptic.............  436
     "      apoplectic............  444
Corpus luteum...................  102
Craniotomy..............•......  341
     »      mode of operating....  354
                 D.
                                PAGE.
Death of fcetus, signs of..........  177
Decidua vera...................  109
Decidual cotyledons..............  110
Development, laws of............  143
Diameters of fcetal head.....  139, 200
     »    of pelvis........... 42,  43
Distortions of pelvis.......... 49, 268
     "         "  effects on labour, 271
     "         "  treatment.....  271
Duration of pregnancy...........  158
Dysmenorrhcea..................   90

                 E.
Embryo, formation of........  122, 127
Ephemeral fever.................  506
Epileptic convulsions.............  436
Ergot of  rye....................  241
External organs of generation.....   58
Extra-uterine pregnancy..........  169
Extremities, inferior, presentation of,  390
     "      superior    "      "  394

                 F.
Face presentations...............  377
Fcetal life, physiology of.........  141
   "  circulation................  142
   "  heart, pulsation of.........  154
   "  head, diameters of.....  139, 200
Fcetus, signs of death of..........  177
   "  measurements of..........  139
   "  pathology of..............  176
   "  position of, in utero.........  138
   "  laws of developement of .. .  143
   "  movements of.............  15]
   "  viability of................  274
Fallopian tubes..................   71
Fever, puerperal................  477
Fistula, vesico-vaginal and  recto-
   vaginal .......................  455
Flooding........................  420
Foot presentations...............  390
Forceps........................  312
    "   mode  of operating........  327
Forehead under pubic arch........  382
Fourchette......................   62
Funis..........................  120
   "  presentations...............  409
Funic souffle....................  155

                  G.
Generation, external organs of.....   58
     "      internal organs of......   63
     "      conception............   98
                        (508) 
INDEX.
509
                                PAGE.
Gestation.......................  105
Graafian vesicles................   72

                  H.
Hemorrhage.....................  420
      "     accidental...........  421
      "     unavoidable..........  426
            after delivery........  433
Hydrocephalus, effect on labour .. .  407
Hysteric convulsions.............  435
Hysteritis, puerperal.............  491
Hysterotomy.................... 358

                I.—J.
Ilium, os.......................   36
Imperforate os uteri..............  256
Induction of premature labour..... 179
Inflammation  of peritoneum....... 483
       "      of uterus........... 491
       "      of uterine appendages, 489
       "      of uterine veins.....493
              of lymphatics......  496
Innominatum, os.................   35
Instrumental labour.............. 253
Introduction....................   33
Internal organs of  generation......   63
Interstitial fcetation.............. 172
Inversion of the uterus........... 469
Ischium, os.....................   36
Jacquemin's  test of pregnancy.... 157
Joints of pelvis..................   39

                  K.
 Kiesteine....................... 156
Labia majora........»...........   59
   "  minora...................   59
Labour, premature...............  179
   "    natural stages of..........  191
   "    symptoms of..............  212
   "    management of..........  218
   »    tedious..................236
   »    powerless................  270
   »    obstructed...............  255
   »    unnatural................  377
   »    with distortion...........  268
   »     "  malposition..........  377
   "     "  mal-presentation.....  384
   »     "  prolapse of funis.....409
   »     "  retained placenta ....  414
   »     »  flooding............420
   »     "  convulsions..........435
   »     »  lacerations..........  447
   »     "  inversion of uterus...  469
Lever or vectis..................  303
  v        »  mode of operation..  308
Liquor amnii....................  122
   »     »   excess of............  246
   "     »   premature discharge of 247
                                PAGE.
Lochia......................... 228
Lymphatics, uterine, inflammation of, 496

                 M.
Mal-position of child............. 377
     "     face presentations .. . 377
     "     forehead to pubis___ 382
Mal-presentation---'............. 384
     »     breech.............. 384
     "     inferior extremities .. . 390
     "     superior     do.    ... 394
     "     compound presentation, 399
Mammary changes in pregnancy ..  147
Mania, puerperal................  503
Maturity of child................  140
Measurements of pelvis....... 47,  57
Mechanism of parturition.........  192
Membranes, toughness of.........  246
Menstruation....................   75
      "     cessation of..........   78
            causes of............   79
      "     disorders of..........   86
            vicarious.............   90
Milk, the.......................  229
Menorrhagia....................   94
Morning sickness................  147
Mons Veneris...................   59
Monsters.......................  406

                  N.
Natural labour...................  210
      "       symptoms of........  212
      "       management of......  218

                  O.
nu * ♦ ■       *•    ( 272, 290,303,
Obstetric operations, -j ^ 341;358; 370
Obstructed labour................  255
Os coccygis.....................  39
Os ilium........................   36
Os innominatum.................   35
Os ischium.....................  36
Os pubis.......................   37
Os sacrum......................   38
Os uteri, rigid................... 244
    "    imperforate............. 256
 Ovaries, the....................   71
    "    physiology of the........   75
 Ovarian fcetation................. 170
 Ovum, changes in................ 100

                  P.
 Parturient female,  management of,
   after labour................... 230
 Parturition...................... 188
     "    classification of......... 189
     "    mechanism of..........  r»2
 Pathology of fcetus...............  17f
 Pelvis, bones of, collectively ... 35,  4] 
510
INDEX.
                                PAGE.
Pelvis, joints of the..............   39
   "   cavity of the.............   44
   »   outlet of the..............   44
   "   axes of the...............   45
   "   canal of..................   46
   "   diameters of.......... 42,  43
   "   external measurements ....   47
   »      »        »     (Note).   57
   »   distortions of...........49,  268
   "   planes of the, (Note).......  194
Peritoneum,inflammation of.......  483
Phlegmasia dolens...............  498
Phlebitis,uterine.................  493
Physiology of uterus.............  188
Perineum.......................   62
     "    laceration of...........  462
Placenta, the.........:.......... 114
Placental souffle................. 153
Placenta, management of.........  223
    "   retained............... 414
    "   praevia..................  426
    "   extraction of............428
Plural births.................... 400
Podalic version.................. 298
Position of  fcetus in utero......... 138
Powerless  labour................ 270
Pregnancy, signs of..............  145
            duration of...........  158
      »     twin.................  157
      "     extra-uterine..........  169
Premature labour................  179
      »      »  induction of......  272
Presentation, breech..............  384
      "      of inferior extremities  390
      "      superior       do. .. .  394
      "      compound    do. ...  399
 Prolapse of funis................  409
 Pubis, os........................   37
   "  symphysis.................   40
 Puerperal  fever................. 477
      "     peritonitis.............  483
      »     hysteritis..............  491
      "     mania.................  503
 Pulsation of fcetal heart...........  154
      "     funis................  155
Q.
Quickening
150
R.
Recto-vaginal fistula.............  455
Retention of placenta............  414
Rupture of uterus...............  447
Sacrum, os......................   38
Salivation.......................  147
                                 AGE.
Scalp, tumour of, at birth.........  225
Signs of pregnancy..............  145
Sexes, proportion of..............  140
Superfcetation...................  166
Suppression of the menses........   89
Sterility........................  162
Symphyseotomy................  370
Tedious labour..................  236
Tubal fcetation...................  171
Tumour of scalp................  225
Tunica media...................  113
Turning........................  293
Twin pregnancy.................  157
Twin births.....................  400
                 U.
Umbilical cord..................  120
    "     pulsation of the........  155
Unavoidable hemorrhage.........  426
Unnatural labour... . 255, 268, 377, 400
Urethra.........................   61
   "   orifice of.................   60
Utero-gestation..................  105
Uterine-souffle...................  153
   »   phlebitis................  493
   "   appendages, inflammation of 489
   "   lymphatics      do.        496
Uterus..........................   64
   "    arteries of............  68, 106
   "    nerves of.............  68, 106
   »    double..................   69
   "    physiology  of........ 75, 188
   "    inertia of................  251
   "    inflammation of..........  491
   "    inversion of.............  469
   »    obliquity of..............  247
   »    rupture of...............  447
Vagina.........................   62
   "    orifice of................   61
   "    examination of, in labour..  214
Vectis..........................  303
Veins, uterine, inflammation of---493
Version.........................  293
Vesico-vaginal fistula—..........  455
Vesicula alba....................  113
Vestibulum.....................   60
Vicarious menstruation...........   90
                 W.
Weed..........................  506
Weight of child.................  139
THE END. 
                  BLANCHARD  &  LEA'S

    MEDICAL  AND  SURGICAL  PUBLICATIONS.



                  TO  THE MEDICAL PROFESSION.
  In the present catalogue we have affixed prices to our  publications, in obedience
to the repeated  requests of numerous members of the profession.  While books,
like all other articles, must necessarily vary somewhat in cost throughout the ex-
tended territories of this  country, yet our publications will generally be furnished
at these rates by booksellers throughout the Union, who oau  readily aad speedily
procure any which they may not have on  hand.         ^
  To accommodate those  physicians who have not  convenient access to bookstores,
or who cannot order through merchants  visiting the larger cities, we will forward
our works  by mail,/** of postage, on receipt of the printed prices in current funds
or postage stamps.   As our business is wholesale, and  we open account* with book-
sellers only, the amount must in every  case, without  exception, accompany the
order, and we can assume no risks of the mail, either on the money or the books;
and  as we only sell our  own publication, we can supply no others.  Physicians
will, therefore, see  the convenience and advantage of makiDg their purchases, when-
ever practicable, from the nearest bookseller.
  We can only add that no exertions are spared to merit a continuance  of the
gratifying confidence hitherto manifested by the profession in all works bearing our

imprmt'                                         BLANCHARD &  LEA.
  Philvdelphia, August, 1857.

  * * We have now ready a new Illustrated  Catalogue of our Medical and
Scientific  Publications, forming an  octavo pamphlet of  80 large pages, containing
specimens of illustrations, notices of the  medical press, &c. &c.   It has been pre-
pared without regard to expense, and will be found one of the handsomest specimens
of typographical execution as yet presented in this country. Copies will be sent to
any address, by mail, free of postage, on  receipt of nine cents in stamps.
   Catalogues of our numerous publications in miscellaneous and educational litera-
ture forwarded on  application.
   TWO MEDICAL PERIODICALS,  FREE OF  POSTAGE,

          FOR  FIVE DOLLARS PER  ANNUM.

THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, subject to
  postage, when not paid for in  advance,.......$5 00
THE MEDICAL NEWS AND LIBRARY, invariably in advance,   -    -    1 00
  or, both periodicals furnished, free of postage, for Five Dollars remitted
  in advance.                      _____

  THE AMERICAN JOURNAL OF  THE MEDICAL SCIENCES,
                 Edited by ISAAC  HAYS, M. D.,
    m; h<.A Onarteriv on the first of January, April, July, and October.  Each number  contains
".Cst* wJ^hundred'and eighty large octavo pages, handsomely and appropriately illustrated,
at least two nunarea arm  « ^   *j   d reg£lariy fot more than thirty-five years, and it has
^^fo^Ho\o{^£££t editor for more than a quarter of a century   Throughout
^ "  ~ri™? ft has maintained its position in the highest rank of medical penod.cals both at home
tins long period, " ""L'^^J'ieeordial support of thl entire profession in this country. Its list of
and abroad, and has.weededt neeora   P£    ^   ^^ disti  ished nai„eS of the pro-
ta!!£k. e°very SlSSoStto United Statefrendering the department devoted to
                ORIGINAL  COMMUNICATIONS


varieties of periodicals, in its 
2
BLANCHARD & LEA'S MEDICAL
                         REVIEW  DEPARTMENT
will be found extended and impartial reviews of all important new works, presenting subjects of
novelty and interest, together with very numerous

                   BIBLIOGRAPHICAL  NOTICES,
including nearly all the medical publications of the day, both in this country and Great Britain, with
a choice selection of the more important continental works.  This is followed by the

                           QUARTERLY  SUMMARY,
being a very full and complete abstract, methodically arranged, of the

           IMPROVEMENTS  AND DISCOVERIES IN THE  MEDICAL SCIENCES.

  This department of the Journal, so important to the practising physician, is the object of especial
care on the part of the editor.   It is classified and arranged under different heads,  thus facilitating
the researches of the reader in pursuit of particular subjects, and will be found to present a very
full and accurate digest of all observations, discoveries, and inventions recorded in  every branch of
medical science.  The very extensive arrangements of the publishers are such as to afford to the
editor complete materials for this purpose, as he not only regularly receives
     ALL  THE AMERICAN  MEDICAL AND SCIENTIFIC PERIODICALS,
but also twenty or thirty of the more important Journals issued in Great Britain and on the Conti-
nent, thus  enabling him  to present in a convenient compass a thorough and complete abstract of
everything interesting or important to the physician occurring in any part of the civilized world.
  To their old  subscribers, many of whom have been on their list for twenty or thirty years, the
publishers feel  that no promises for the future are necessary; but those who may desire for the
first time to subscribe, can rest assured that no exertion will be  spared to maintain the Journal in
the high position which it has  occupied for so long a period.
  By reference to the terms it will be seen that, in addition to this large amount of valuable and
practical information on every branch of medical science, the subscriber, by paying in advance,
becomes entitled, without further charge, to

            THE MEDICAL NEWS  AND  LIBRARY,

a monthly  periodical of thirty-two large octavo pages.  Its "News Department" presents the
current information of the day, while the " Library Department" is devoted to presenting stand-
ard works  on various branches of medicine.  Within a few years, subscribers have thus received,
without expense, the following works which have passed through its columns:—
WATSON'S LECTURES ON THE  PRACTICE OF PHYSIC.
BRODIE'S CLINICAL LECTURES ON  SURGERY.
TODD AND  BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN.
WEST'S LECTURES ON THE DISEASES OF INFANCY  AND CHILDHOOD.
MALGAIGNE'S OPERATIVE SURGERY,  with wood-cuts.
SIMON'S  LECTURES ON GENERAL PATHOLOGY.
BENNETT ON PULMONARY TUBERCULOSIS, with wood-cuts,
WEST ON ULCERATION OF THE OS UTERI, and
BROWN  ON  THE SURGICAL DISEASES  OF FEMALES, with wood-cuts.
  While in the number for July, 1856,  was commenced a  new and highly important work, which
is continued throughout 1857.
        WEST'S LECTURES  ON THE DISEASES OF  WOMEN.
  The very favorable reception accorded by the profession to the valuable " Lectures  on  the
Diseases of Children," by the same  author, which likewise  appeared in this  periodical, has in-
duced the publishers to secure the present work for their subscribers, from advance sheets, supplied
by the author.   The very high reputation of Dr. West, and the unusual clinical  advantages which
he has enjoyed, sufficiently indicate the practical value of a systematic work from his  pen on so
important a subject.  The publishers, therefore, trust that its appearance in the " News" will afford
entire satisfaction to their numerous subscribers, who will thus receive it free of all expense.
  I3P For a more extended advertisement, see p. 32.
  It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber
will obtain a Quarterly and a Monthly periodical,

            EMBRACING  ABOUT FIFTEEN HUNDRED LARGE  OCTAVO  PAGES,
mailed to any part of the United States, free of postage.
  These very favorable terms are now presented by the publishers with the view of removing all
difficulties and objections to a full and extended  circulation of the Medical Journal to the office of
every member of the profession throughout the United States.  The rapid extension of mail facili-
ties will now place  the numbers before subscribers with a certainty and dispatch not heretofore
attainable; while by the system now proposed,  every subscriber throughout the Union is placed
upon an equal footing, at the very reasonable price of Five Dollars for two periodicals, without
further expense.
  Tho^-e subscribers who do not pay in advance will bear in mind that their subscription  of Five
Dollars will entitle them to the Journal only, without the News, and that they will be at the expense
of their own postage on the receipt of each number.  The advantage of a remittance when order-
ing the Journal will thus be apparent.
  As the Medical News and Library is in no case sent without advance payment, its subscribers
will always receive it free of postage.
  Remittances of subscriptions can be mailed at our risk, when a certificate is taken from the Post-
master that the money is duly inclosed and forwarded.
                                  Address      BLANCHARD & LEA, Philadelphia. 
AND SCIENTIFIC  PUBLICATIONS.                   3
                              ALLEN  (J.  M.), M. D.,
                  Professor of Anatomy in the Pennsylvania Medical College, tec.

THE PRACTICAL  ANATOMIST;  or, The Student's Guide in the Dissecting.
  ROOM.  With 266 illustrations.  In one handsome royal 12mo. volume, of over 600 pases, lea-
  ther.  $2 25.  (Now Ready.)
  In the arrangement of this work, the author has endeavored to present a complete and thorough
course of dissections in a clearer and more available form for practical use, than has as yet been
accomplished.  The chapters follow each other in the order in which dissections are usually con-
ducted in this country, and as each region is taken up, every detail regarding it is fully described
and illustrated, so that the student is not interrupted in his labors, by the necessity of referring from
one portion of the volume to another.
  However  valuable  may  be the " Dissector's
Guides" which we, of late, have had occasion to
notice, we feel confident that the work of Dr. Allen
is superior to any of them.  We believe with the
author, that none is so fully illustrated as this, and
the arrangement of the work is such as to facilitate
the labors of the student in acquiring a thorough
practical knowledge of Anatomy.  We most cordi-
ally recommend it to their attention.—Western Lan-
cet, Dec. 1856.
  We believe it to be one  of the most useful works
upon the subject  ever written.  It is handsomely
illustrated, well printed, and will be found  of con-
venient size for use in the dissecting-room.—Med.
Examiner, Dec. 1656.
    From Prof. J. S. Davis, University of Va.

  I am not acquainted with any work that attains go
fully the object which it proposes.

From C. P.  Fanner, M. D., Demonstrator, Uni-
            versity of Michigan.

  I  have examined the work briefly, but even this
examination has convinced me that it is an excellent
guide for the Dissector.  Its illustrations are beau-
tiful, and more than I have seen  in a work  of this
kind.  I shall take great pleasure in recommending
it to my classes as the text-book of the dissecting-
room.
                         ANALYTICAL  COMPENDIUM
OF  MEDICAL  SCIENCE, containing Anatomy, Physiology, Surgery, Midwifery,
  Chemistry, Materia Medica, Therapeutics, and Practice of Medicine. By John Neill, M. D.,
  and F. G.  Smith, M. D.  New and enlarged edition, one thick volume royal  12mo. of over
  1000 pages, with 374 illustrations.  OP See Neill, p. 24.
               ABEL (F.  A.),  F. C.S. AND  C.  L.  BLOXAM.
HANDBOOK OF  CHEMISTRY,  Theoretical, Practical, and Technical;  with  a
  Recommendatory Preface by Dr. Hofmann. In one large octavo volume, extra cloth, of 662
  pages,  with illustrations.  $3 25.
  It must be understood that this is a work fitted for
the earnest student, who resolves to pursue for him-
self a steady search into the chemical mysteries of
creation.  For such a student the ' Handbook' will
prove an  excellent guide, since he will find in it,
not merely the approved modes o( analytical investi-
gation, but most descriptions of the apparatus ne-
cessary, with such manipulatory details as rendered
Faraday's ' Chemical Manipulations' so valuable at
the time of its publication.  Beyond this, the im-
portance of the work is increased by the introduc-
tion of much of the technical chemistry of the manu-
factory.—Dr. Hofmann's Pre/ace.
                         ASHWELL (SAMUEL), M.  D.,
                   Obstetric Physician and Lecturer to Guy's Hospital, London.

A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN.
  Illustrated by Cases derived from Hospital and Private Practice.  Third American, from the Third
  and revised  London edition.  In one octavo volume, extra cloth, of 528 pages.  $3 00.
  The most useful practical work on the subject in j  The most able, and certainly the most standard
the English  language. — Boston Med.  and Surg,  and practical, work on female diseases that we have
Journal.                                     \ yet seen.—Medico-Chirurgical Review.
                            ARNOTT  (NEILL),  M. D.
ELEMENTS   OF   PHYSICS;  or  Natural Philosophy,  General  and  Medical.
  Written for  universal use, in plain or non-technical language.  A new edition, by Isaac Hays,
  M. D.  Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra-
  tions.  f2 50.                    ________    __

                        BUDD (GEORGE),  M. D., F. R. S.,
                       Professor of Medicine in King's College, London.

ON  DISEASES OF THE  LIVER.   Second American, from the second  and
  enlarged London edition.  In one very handsome octavo volume, extra cloth, with four beauti-
  fully colored plates, and numerous wood-cuts.  pp. 468.  $3 00.
  For many years, Dr. Budd's work must be the I the subject has been taken up by so able and experi-
authority of the great mass ol British practitioners i enced a physician.—British and  Foreign Medico-
cm the hepatic diseases; and it is satisfactory that i Chirurgical Review.

                                  BY THE SAME AUTHOR.

ON  THE  ORGANIC  DISEASES  AND FUNCTIONAL DISORDERS  OF
  THE STOMACH.  In one neat octavo volume, extra cloth.  $1 50.
  From the high position occupied by Dr. Budd as  style, the subjects are well arranged, and the practi-
se teacher, a writer, and a practitioner, it is almost  cal precepts, both of diagnosis and treatment, denote
needless to state that the present book may be con-  the character of a thoughtful and experienced  phy-
sulted with great advantage. It is written in an easy  sician.—London Med. Times and Gazette, Dec. 1855. 
4
BLANCHARD  <fe  LEA'S  MEDICAL
                          BROWN  (ISAAC  BAKER),
                       Surgeon-Accoucheur to St. Mary's Hospital, tec.

ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT-
  MENT.  With handsome illustrations.  One vol. 8vo., extra cloth.   (Now Ready.)  $160.

  Mr. Brown has earned for himself a high reputa- I and merit the careful attention of every surgeon-
tion in the operative treatment of sundry diseases j accoucheur.—Association Journal.

wlSn'trl'y°^                            We have no hesitation in recommending this book
addition  to ffitrcal* uSaSre.' The" VpSve to the careful attention of all  surgeons who make
suggestions and contrivances which Mr. Brown de- 1 female complaint! a part of their study and praotwe.
scribes, exhibit much practical sagacity  and  skill, i —Dublin Quarterly Journal.
               BENNETT  (J.  HUGHES),  M. D.f  F. R. 3. E.,
               Professor of Clinical Medicine in the University of Edinburgh, &c.

THE  PATHOLOGY AND  TREATMENT OF  PULMONARY TUBERCU-
  LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken
  for or associated with, Phthisis.  In one handsome octavo volume, extra cloth, with beautiful
  wood-cuts.  pp. 130.  (Lately Issued.)  $1 25.
                          BENNETT (HENRY), M. D.
A PRACTICAL  TREATISE  ON  INFLAMMATION OF THE UTERUS,
  ITS CERVIX  AND APPENDAGES, and on its connection with Uterine Disease.  Fourth
  American, from the third and revised London edition.  To which is added (July, 1856), a Review
  of the Present State of Uterine  Pathology.  In one neat octavo volume, extra cloth, of
  500 pages, with wood-cuts. $2 00.
  The addition of the "Review" presents the most recent aspects of the questions discussed in
this well-known work, bringing it down to the latest moment.
  This edition has been carefully revised and altered, i   When, a few years back,  the first edition of the
and various additions have been made, which render  present work was published, the subject was oneal-
it more complete, and, if possible, more worthy of most entirely unknown to the obstetrical celebrities
the high appreciation in which it is  held by  the ! of the day: and even now we have reason to know
medical profession throughout the world.  A copy  that the bulk of the profession are not fully alive to
should be in the possession of every physician.—  the importance and frequency of the disease of which
Charleston Med. Journal and Review.           [ it takes cognizance.  The present edition is so much
  We are firmly of opinion that in proportion as a  enlarged, altered, and improved, that it can scarcely
knowledge of uterine diseases becomes  more appre-  be considered the same work—Dr. Ranking's  At)-
ciated, this work will be proportionably established , struct.
as a text-book in the profession.—The Lancet.     I

                               ALSO, FOR SALE SEPARATE,

A REVIEW OF THE PRESENT STATE OF UTERINE PATHOLOGY.
  1 small vol. 8vo.  50 cents.
                     BIRD (GOLDING), A. M., M. D., &.C.

URINARY   DEPOSITS:   THEIR   DIAGNOSIS,  PATHOLOGY,  AND
  THERAPEUTICAL INDICATIONS.  A new and enlarged American, from the last improved
  London edition. With over sixty illustrations. In one royal 12mo. vol, extra cloth, pp. 372. f I 30.
  It can scarcely be necessary for us to say anything
of the merits of this well-known Treatise, which so
admirably brings into practical application the re-
sults of those microscopical and chemical researches
regarding the physiology and pathology of the uri-
nary secretion, whieh nave contributed so much to
the  increase of our diagnostic powers, and to the
extension and satisfactory employment of our thera-
peutic resources.  In the preparation of this new
edition of his work, it is obvious that Dr. Golding
Bird has spared no pains to render it a faithful repre-
sentation of the present state of scientific knowledge
on the subject it embraces.—The British and Foreign
Medico-Chirurgical Review.
BY THE SAME AUTHOR.
ELEMENTS OF  NATURAL  PHILOSOPHY; being an Experimental Intro-
  duction to the Physical Sciences.  Illustrated with nearly four  hundred wood-cuts.  From the
  third London edition.  In one neat volume, royal 12mo, extra cloth,   pp.402.  $125.
BLAKISTON'S PRACTICAL OBSERVATIONS
  ON CERTAIN DISEASES OF THE CHEST,
  and on the Principles of Auscultation. In one vol.,
  cloth, 8vo  pp.384.  81 25.
BURROWS ON DISORDERS OF  THE CERE-
  URAL CIRCULATION, and on the Connection
  between the Affections of the Brain and Diseases
  of the Heart.  In one 8vo. vol., extra cloth, with
  colored plates,  pp. 216. SI 25.
BEALE ON  THE  LAWS OF  HEALTH IN RE-
  LATION TO MIND AND BODY.  A Series of
  Letters from an old Practitioner to a Patient.  In
  one volume, royal 12mo., extra cloth,  pp. 296.
  80 cents.
BUSHNAN'S PHYSIOLOGY OF ANIMAL AND
  VEGETABLE LIFE; a Popular Treatise on the
  Functions and Phenomena of Organic  Life.  In
  one handsome royal 12mo.  volume, extra cloth,
  with over 100 illustrations,  pp.234.  80 cents.
BUCKLER ON THE ETIOLOGY, PATHOLOGY,
  AND TREATMENT OF  FIBRO-BRONCHI-
  TIS AND RHEUMATIC  PNEUMONIA,  hi
  one 8vo. volume, extra cloth,  pp. 150.  SI 25.
BLOOD AND  URINE (MANUALS ON).  BY
  JOHN  WILLIAM  GRIFFITH,  G.  OWEN
  REESE, AND ALFRED MARKWICK.   One
  thick volume, royal 12mo., extra cloth, with
  plates, pp. 460. SI 25.
BRODIE'S  CLINICAL LECTURES ON SUR-
  GERY.  1 vol. 8vo., cloth.  350 pp. $125. 
AND SCIENTIFIC  PUBLICATIONS.                   &
                          BARLOW  (GEORGE H.),  M. D.
                           Physician to Guy's Hospital, London, &.c.
A MANUAL OF  THE  PRACTICE  OF MEDICINE.  With Additions by D.
  F. Condie, M. D., author of" A Practical Treatise on Diseases of Children," &c.  In one hand-
  some octavo volume, leather, of over 600 pages.  (A new work, just issued, 1856.)  $2 75.
  We most emphatically commend it to the attention
of the profession, as deserving their  confidence—a
depository of practical knowledge, from which they
may draw with great benefit.—Cincinnati Med. Ob-
server, Mar. 1856.
  The student has long been in want of a good ele-
mentary work on the Practice of Medicine.  In Dr.
essential, and avoiding useless theoretical discus-
sion.  The work supplies what has been for some
time wanting, a manual of practice based upon mo-
dern discoveries in pathology and rational views of
treatment of disease.  It is especially intended for
the use of students and junior practitioners, but it
will be found hardly less useful to  the experienced
physician.  The American editor has added  to the
Barlow's Manual that want is supplied:  and we  physician,  l
have no quesiion that it will at once be installed ' work three chapters—on Cholera Infantum, Yellow
        quesn
bis the favorite text-book in all Medical Schools.—
Medical Times and Gazette.

  We recommend Dr. Barlow's Manual in the warm-
est manner us a most valuable vade-mecum.  We
have had frequent occasion to consult it, and have
found it clear, concise, practical, and sound.  It is
eminently  a practical work, containing all that is
Fever, and Cerebro-spinal Meningitis. These addi-
tions, the two firBt of which are indispensable to a
work on practice destined for the profession in this
country, are executed with great judgment and fi-
delity, by Dr. Condie, who has also succeeded hap-
pily in imitating the conciseness and clearness of
style which are such agreeable characteristics of
the original book.—Boston Med. and Surg. Journal.
                           BARTLETT (ELISHA), M. D.
THE  HISTORY,  DIAGNOSIS, AND  TREATMENT  OF  THE  FEVERS
  OF THE UNITED  STATES.  A new and revised edition.  By Alonzo Clark, M. D., Prof.
  of Pathology and Practical Medicine in the N. Y. College of Physicians and  Surgeons, &c.  In
  one octavo volume, of six hundred pages, extra cloth. (Now Ready.)  Price $3 00.
  The position which this work has obtained as one of our medical classics, renders unnecessary
any remark further than to say that the editor, in executing  the task assigned  to him by the late
author, has endeavored to render the work a faithful exposition of the subject in its most advanced
condition.  To effect this, a considerable amount of matter has been introduced, but by a slight
enlargement  of the page it has  been accommodated without unduly increasing the bulk  of the
volume.  The reputation of the editor as an accurate observer and philosophical writer is sufficient
guarantee that, in his hands, the work will fully maintain its former character.
  It is the best work on fevers which has emanated
from the American press; and the present editor has
carefully availed himBelf of all information exist-
ing upon the subject in the Old und New World, so
that the doctrines advanced are brought down to the
latest date in the  progress of  this department of
Medical Science.—London Med. Times and Gazette,
May 2, 1857.
  This excellent monograph on febrile disease, has
stood deservedly high since its first publication.  It
will be seen that it has  now reached its fourth edi-
tion under the supervision of Prof. A. Clark, a gen-
tleman who, from the nature of his studies and pur-
suits, is well calculated to appreciate and discuss
the many intricate and difficult questions in  patho-
logy.  His annotations  add much to the interest of
the work, and have brought it well up to the condi-
tion  of the  science as  it exists at the present day
in regard to this class of diseases.—Southern Med.
and Surg. Journal, Mar. 1857.
  It is a work of great practical value and interest,
containing much that is new relative to the several
diseases of which it treats, and, with the additions
of the editor, is fully up to the times. The distinct-
ive features of the different forms of fever are plainly
and forcibly portrayed, and the lines of demarcation
carefully and accurately drawn, and to the Ameri-
can practitioner is a more valuable and safe guide
than any  work on fever extant.—Ohio Med. and
Surg. Journal, May, 1857.

  The plan of the work is exceedingly compact and
comprehensive.  The style of the author  is  clear,
his  reasoning logical,  and his deductions philoso-
phical,  while the spirit that pervades the work is,
in the main, unexceptionable. The frequent addi-
tions by the editor, are what might be looked for
from their distinguished source, able, judicious, and
timely. We heartily commend it to the attention of
our readers as the only work on fevers that is fully
adapted to this country  and climate.  We predict
for ihe  present edition  even a more rapid sale than
the former ones.—N. J. Med. Reporter, Mar.  1857.
                           BOWMAN (JOHN  E.), M.D.
PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.   Second Ame-
  rican, from the third and revised English Edition.  In one neat volume, royal 12mo., extra cloth,
  with numerous illustrations,  pp. 288.  $1 25.
                                  BY THE SAME AUTHOR.

INTRODUCTION  TO   PRACTICAL  CHEMISTRY,   INCLUDING  ANA-
  LYSIS.  Second American, from the second and revised London edition.  With numerous illus-
  trations.  In one neat vol., royal 12mo., extra cloth,  pp. 350.  $1 25.


                           CURLING   (T.   B.),  F. R.S.,
              Surgeon to the London Hospital, President of the Hunterian Society, &c.
A  PRACTICAL TREATISE ON DISEASES  OF THE TESTIS,  SPERMA-
  TIC CORD  AND  SCROTUM.  Second American, from the second and enlarged English edi-
  tion.  In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. (Jtist
  Issued, 1856.)  $2 00.
  In the revised English edition, of which this is  a reprint, the author, for want of space, omitted
the Anatomical Introduction.   By a more condensed style of printing, room has been found in the
present volume to retain this  important portion without rendering the work inconveniently large.
Some of the notes of the former American editor have also been incorporated, and a number of new
illustrations introduced.   With these improvements, and the thorough revision which it has enjoyed
at the hands of the author, it will be found fully worthy to retain the authoritative position which
it has acquired with regard to this class of affections. 
6
BLANCHARD & LEA'S MEDICAL
              CARPENTER (WILLIAM  B.), M. D., F. R. S., &.C.,
           Examiner in Physiology and Comparative Anatomy in the University of  London.

PRINCIPLES  OF  HUMAN  PHYSIOLOGY; with  their chief applications to
  Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine.  A new American, from
  the last and revised London edition.  With nearly three hundred illustrations.   Edited, with addi-
  tions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl-
  vania Medical College, &c. In one very large and beautiful octavo volume, of  about nine hundred
  large pages, handsomely printed and strongly bound in leather, with raised bands.   (Just Issued,
  1856.)  $4 25.
  In the preparation of this new edition, the author has spared no labor to render it, as heretofore,
a complete  and lucid  exposition of the most advanced condition  of its important  subject.   The
amount of the additions required to effect this object thoroughly, joined to the former large size of
the volume, presenting objections arising from the unwieldy bulk of the work, he has omitted all
those portions not  bearing directly upon  Human Physiology, designing  to incorporate them in
his forthcoming Treatise on General Physiology.   As a full and accurate text-book on the Phy-
siology of Man, the work in its present  condition therefore presents  even greater claims  upon
the student and physician than those which have heretofore won for it the very wide and distin-
guished favor which it has so long enjoyed.  The additions of Prof. Smith  will  be found to supply
whatever may have been wanting to the American  student, while  the  introduction  of many new
illustrations, and the most careful mechanical execution, render the volume one of the most at-
tractive as yet issued.

  For upwards of thirteen years Dr. Carpenter's I   To eulogize this great work would be superfluous
work has been considered by the profession  gene-  We should  observe, however,  that  in this edition
rally, both in this country and England, as the most ! the author  has remodelled a large portion of the
valuable compendium on the subject of physiology I former, and the editor has added much matter of in-
in our language. This distinction it owes to the high : terest, especially in the form of illustrations.  We
attainments and unwearied industry of its accom-  may confidently recommend it as the most complete
plished author.  Thepresent edition (which, like the ! work  on Human  Physiology  in our language.—
last American one, was prepared by the author him-
self), is the result of such extensive revision, that it
may almost  be  considered a new work.  We need
hardly say, in concluding this brief notice, that while
the work is indispensable to every student of medi-
cine in this country, it will amply repay the practi-
tioner for its perusal by  the interest and value of its
contents.—Boston Med.  and Surg. Journal.

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

  The greatest, the most reliable, and the best book
on the  subject which we know  of in the English
Language.—Stethoscope.
Southern Med. and Surg. Journal, December, 1855.
  The  most complete work on the science in our
language.—Am. Med. Journal.
  The most complete work now extant in our lan-
guage.—N. O. Med. Register.
  The  best text-book in the language on this ex-
tensive subject.—London Med. Times.
  A complete cyclopaedia of this branch of science.
—N. Y. Med. Times.
  The  profession of this country, and perhaps also
of Europe, have anxiously and for some time awaited
the announcement of this new edition of Carpenter's
Human Physiology. His former editions have for
many years been almost the only text-book on Phy-
siology in all our  medical schools, and  its circula-
tion among the profession has  been unsurpassed by
any work in any department of medical science.
  ft is quite  unnecessary for us to speak  of this
work as its merits would justify.  The mere an-
nouncement of its appearance will afford the highest
pleasure to every  student of Physiology, while its
perusal  will  be of infinite  service in advancing
physiological science.—Ohio Med. and Surg. Journ.
                          by the same author.  (Lately Issued.)

PRINCIPLES OF COMPARATIVE PHYSIOLOGY.  New  American, from
  the Fourth and Revised London edition.   In one large and handsome octavo volume, with over
  three hundred beautiful illustrations,  pp. 752.  Extra cloth, $4 80; leather, raised bands, $5 25.

  The delay which has existed in the appearance of this work has been caused by the very thorough
revision and remodelling which it has undergone  at the hands of the author, and the large number
of new illustrations which have been prepared for it.  It will, therefore, be found almost a new
work,  and fully up to the day in every department of the  subject, rendering it a reliable text-book
for all  students engaged in this branch of science.   Every effort has been made to render its typo-
graphical finish and mechanical execution worthy of its exalted reputation, and  creditable to the
mechanical  arts of this country.

                                               no man, we believe, could have brought to so suc-
                                               cessful an  issue as Dr. Carpenter.  It  required for
                                               its production a physiologist at once deeply read in
                                               the  labors  of others, capable  of taking a  general.
                                               critical, and unprejudiced view of those labors, and
                                               of combining the varied, heterogeneous  materials at
                                               his disposal, so as to form an harmonious whole.
                                               We feel that this abstract can give the reader a very
                                               imperfect idea of the fulness of this work, and no
                                               idea of its unity, of the admirable manner in which
                                               material has  been brought, from  the most various
                                               sources, to conduce to its completeness, of the lucid-
                                               ity of  the reasoning it contains, or of the clearness
                                               of language in which the whole is clothed.  Not the
                                               profession  only, but the scientific world at large,
                                               must feel deeply indebted to Dr. Carpenter for this
                                                freat work. It must, indeed, add largely even to
                                                is high reputation.—Medical Times.
  This book should not only be read but thoroughly
studied by every member of the profession.  None
are too wise or old, to be benefited thereby.  But
especially to the younger class would we cordially
commend it as best fitted of any work in the English
language to qualify them for the reception and coin-
prehension of those truths which are daily being de-
veloped in physiology.—Medical Counsellor.
  Without pretending to it, it is an encyclopedia of
the subject, accurate and complete in all  respects—
a truthful reflection of the advanced state at which
the science has now  arrived.—Dublin  Quarterly
Journal of Medical Science.
  A truly magnificent work—in itself a perfect phy-
siological study.—Ranking's Abstract.
  This work stands without its fellow.  It is one
few men in Europe conld have undertaken; it is one 
AND  SCIENTIFIC  PUBLICATIONS.                   7
                CARPENTER (WILLIAM  B.),  M. D., F.  R. S.,
          Examiner in Physiology and Comparative Anatomy in the University of London.

                                   (Just Issued, 1856.)

THE MICROSCOPE AND ITS REVELATIONS.    With  an Appendix con-
  taining the Applications of the Microscope to Clinical Medicine, &c.  By F. G. Smith, M. D
  Illustrated by four hundred and thirty-four beautiful engravings on wood.  In one large and ver-
  handsome octavo volume, of 724 pages, extra cloth, $4 00; leather, $4 50.
  Dr. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher
eminently qualify him to produce what has long been wanted—a good text-book on the practical
use of the microscope.   In the present volume his object has been, as stated  in his Preface,  "to
combine, within a moderate compass, that information with regard to the use of his 'tools,' which
is most essential to the working microscopist, with such an  account of the objects best fitted for
his study, as might qualify him to comprehend what  he observes, and might thus  prepare him to
benefit science, whilst expanding and refreshing his own mind "  That he has succeeded in accom-
plishing this, no one acquainted with his previous labors can doubt.
  The great importance of the microscope as a means of diagnosis, and the number of microsco-
pists who are also physicians, have induced the American publishers, with the author's approval, to
add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument to
clinical medicine, together with  an  account  of American Microscopes, their modifications and
accessories.  This portion of the work is illustrated with nearly one hundred wood-cuts,  and, it is
hoped, will adapt the volume more particularly to the use of  the American student.
  Every care has been taken in the mechanical execution of the work, which is  confidently  pre-
 sented as in no respect inferior to the choicest productions of the London press.
   The mode in which the author has executed his intentions may be gathered from the following
 condensed synopsis of the
                                      CONTENTS.

 Introduction—History of the  Microscope.   Chap. I.  Optical Principles of the  Microscope.
   Chap. II. Construction of the Microscope.  Chap. III.  Accessory Apparatus.   Chap. IV".
   Management of the Microscope  Chap. V. Preparation,  Mounting, and Collection of Objects.
   Chap. VI. Microscopic Forms of Vegetable Life—Protophytes.  Chap. VII. Higher Cryptoga-
   mia.  Chap. VIII. Phanerogamic Plants.  Chap.  IX. Microscopic Forms of Animal Life—Pro-
   tozoa—Animalcules.   Chap. X. Foraminifera, Polycystina, and Sponges.  Chap. XI. Zoophytes.
   Chap. XII.  Echinodermata.   Chap. XIII. Polyzoa and Compound Tunicata.  Chap.  XIV.
   Molluscous Animals Generally. Chap. XV. Annulosa.  Chap. XVI. Crustacea.  Chap. XVII.
   Insects and Arachnida.  Chap. XVIII. Vertebrated Animals.  Chap. XIX. Applications of the
   Microscope to Geology.  Chap. XX.  Inorgauic or Mineral Kingdom—Polarization.  Appendix.
   Microscope as a means of Diagnosis—Injections—Microscopes of American Manufacture.

   Those who are acquainted with  Dr. Carpenter's medical work, the additions by Prof. Smith give it
  frevious writings on Animal and Vegetable Physio- a positive claim upon the profession, for  which we
  ogy, willfully understand how vast a store of know- doubt not he will receive their sincere thanks.  In-
  ledge he is able to bring to bear upon so comprehen-  deed, we know not where the student of medicine
  sive a subject as the revelations of the microscope;  will find such a complete and satisfactory collection
  and even those who have no previous acquaintance of microscopic facts bearing upon physiology and
  with the construction or uses of  this instrument, | practical medicine as is contained in  Prof Smith's
  will find abundance of information,conveyed in clear appendix;  and this of itself, it seems to us, is fully
  and  simple  language.—Med.  Times and Gazette, i worth the cost of the volume.—Louisville Medical
   Although  originally not  intended as a strictly | Review, Nov. 1856.

                                  BY THE  SAME AUTHOR.

  ELEMENTS  (OR  MANUAL)  OF  PHYSIOLOGY,  INCLUDING  PHYSIO-
   LOGICAL ANATOMY.   Second American, from  a new and revised London edition.  With
   one hundred and ninety illustrations.  In one very handsome octavo volume, leather,   pp. 566.
   $3 00.
   In publishing the first edition of this work, its title was altered from that of the  London volume,
  by the substitution of the word " Elements" for that of " Manual," and with the author's sanction
  the title of " Elements" is still retained as being more expressive of the scope of the treatise.

   To say that it is the best manual of Physiology   Those who have occasion for an elementary trea-
  now before the public, would not do sufficient justice tise on Physiology, cannot do better than  to possess
  to the author.__Buffalo Medical Journal.          themselves ofthe manual of Dr. Carpenter.—Medical
   In his former works it would seem that he had  Examiner.
  exhausted the subjectof Physiology. In the present,   The best and  most complete expose of modern
  he gives the essence, as it were, of the whole.—N. Y. Physiology,  in one volume, extant in the English
  Journal of Medicine.                          language.—St. Louis Medical Journal.
                            BY the same author.  (Preparing.)

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

  A  PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN  HEALTH
   AND DISEASE.  New edition, with a Preface by D. F. Condie, M. D., and explanations of
   scientiho words.  In one neat 12mo. volume, extra cloth,   pp. 178.  50 cents. 
BLANCHARD  &  LEA'S MEDICAL
                            CONDIE (D. F.),  M. D., fitc.

 A PRACTICAL  TREATISE ON THE DISEASES OF CHILDREN.   Fourth
   edition, revised and augmented. In one large volume, 8vo., leather, of nearly 750 pages. $3 00.

                               From the Author's Preface.
   The demand for another edition has afforded the author an opportunity of again subjecting the
 entire treatise to a careful revision, and of incorporating in it every important observation recorded
 since the appearance of the last edition, in reference to the pathology and therapeutics of the several
 diseases of which it treats.
   In the preparation of the present edition, as in those which have preceded, while the author has
 appropriated to his use every important fact that he has  found recorded in the works of others,
 having a direct bearing upon either of the subjects of which he treats, and the numerous valuable
 observations—pathological as well as  practical—dispersed  throughout the  pages  of the medical
 journals of Europe and America, he has, nevertheless, relied chiefly upon his own observations and
 experience, acquired during a long and somewhat extensive practice, and under circumstances pe-
 culiarly well adapted for the clinical study of the diseases of early life.
   Every species of hypothetical reasoning has, as much as possible, been avoided. The author has
 endeavored throughout the work to confine himself to a simple statement of well-ascertained patho-
 logical facts, and plain therapeutical directions—his  chief desire being to render it what its title
 imports it to be, a practical treatise on the diseases of children.

  Dr. Condie's scholarship, acumen; industry, and
 practical sense are manifested in this, as in all his
 numerous contributions to science.—Dr. Holmes's
 Report to the American Medical Association.
  Taken as a whole, in our judgment, Dr. Condie's
 Treatise is the one from the perusal of which the
 practitioner in this country will rise with the great-
 est satisfaction.—Western Journal of Medicine and
 Surgery.
  One of the best works upon the Diseases of Chil-
dren in the English language.—Western Lancet.
  Perhaps the most full and complete work now be-
 fore the profession of the United States; indeed, we
 may say in the English language. It is vastly supe-
rior to most of its predecessors.—Transylvania Med.
Journal.
  We feel assured from actual experience that no
physician's library can be complete without a copy
of this work.—N. Y. Journal of Medicine.

  A veritable pediatric encyclopaedia, and an honor
to American medical literature.—Ohio Medical and
Surgical Journal.

  We feel persuaded that the American medical pro-
fession will soon regard it not only as a very good,
but as the vkby bkst  "Practical Treatise on the
Diseases of Children."—American Medical Journal.

  We pronounced the first edition to be the best
work on the diseases  of children in the English
language, and,  notwithstanding all that has been
published, we still regard it in that light.—Medical
Examiner.
            CHRISTISON (ROBERT), M. D., V. P. R. S. E., &.C.

A DISPENSATORY; or, Commentary  on  the Pharmacopoeias of Great Britain
  and the United States;  comprising the Natural History, Description, Chemistry, Pharmacy, Ac-
  tions, Uses, and Doses  of the Articles of the Materia Medica.   Second edition, revised and im-
  proved, with a Supplement containing the most important New Remedies.  With copious Addi-
  tions, and two hundred and thirteen large wood-engravings.  By R. Eglesfeld Griffith, M. D.
  In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50.
  It is not needful that we should compare it with
the other pharmacopoeias extant, which enjoy and
merit the confidence of the profession : it is enough
to say that it appears to us as perfect as a Dispensa-
tory, in the present state of pharmaceutical science,
csuld be made.  If it omits any details pertaining to
this branch of knowledge which the student has a
right to expect in such a work, we confess the omis-
sion has escaped our scrutiny. We cordially recom-
mend this work to such of our readers as are in need
of a Dispensatory. They cannot make choice of a
better.—Western Journ. of Medicine and Surgery.
                        COOPER (BRANSBY B.),  F. R. S.
LECTURES ON  THE  PRINCIPLES  AND  PRACTICE OF  SURGERY.
  In one very large octavo volume, extra cloth, of 750 pages.  $3 00.
COOPER  ON DISLOCATIONS AND  FRAC-
  TURES OF THE JOINTS—Edited by Bransbt
  B. Cooper, F. R. S., &c. With additional Ob-
  servations by Prof. J. C. Warren. A new Ame-
  rican edition.  In one handsome octavo volume,
  extra cloth, of about 500 pages, with numerous
  illustrations on wood. S3 25.
COOPER ON THE ANATOMY AND DISEASES
  OF THE BREAST, with twenty-five Miscellane-
  ous and Surgical Papers.  One large volume, im-
  perial 8vo., extra cloth, with 252 figures, on 36
  plates.  $2 50.
COOPER  ON THE  STRUCTURE AND DIS-
  EASES  OF THE  TESTIS, AND  ON  THE
  THYMUS  GLAND.  One vol. imperial 8vo., ex-
  tra cloth, with 177 figures on 29 plates.  $2 00.
COPLAND ON THE CAUSES, NATURE, AND
  TREATMENT OF PALSY AND APOPLEXY.
  In one volume, royal 12mo., extra cloth, pp. 326.
  80 cents.

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

COLOMBAT DE L'ISERE ON THE DISEASES
  OF FEMALES,  and on the special Hygiene of
  their Sex.  Translated, with many Notes and Ad-
  ditions, by C. D.  Meigs, M. D.  Second edition,
  revised and improved.   In one large volume, oc-
  tavo, leather, with numerous wood-cuts. pp. 720.
  S3 50.
                           CARSON (JOSEPH), M. D.,
           Professor of Materia Medica and Pharmacy in the University of Pennsylvania.
SYNOPSIS OF THE  COURSE  OF LECTURES ON MATERIA  MEDICA
  AND PHARMACY, delivered in the University of Pennsylvania.  Second and  revised edi-
  tion.  In one very neat octavo volume, extra cloth, of 208 pages.  (Now Ready.)  $1 50. 
AND  SCIENTIFIC PUBLICATIONS.                    9
               CHURCHILL  (FLEETWOOD), M. D., M. R. I. A.

ON THE  THEORY AND  PRACTICE  OF  MIDWIFERY.  A new American,
  from the last and improved English edition.  Edited, with Notes and Additions, by D. Francis
  Condie, M. D., author of a "Practical Treatise  on the Diseases of Children," &c.  With 139
  illustrations.  In one very handsome octavo volume, leather,  pp.510.  $3 00.
  To bestow praise on a book that has received such
marked approbation would be superfluous. We need
only say, therefore, that if the first edition was
thought worthy  of a  favorable reception by  the
medical public, we can confidently affirm that this
will be found much  more  bo. The lecturer,  the
practitioner, and the student, may all have recourse
to its pages, and derive from their perusal much in-
terest and instruction in every thing  relating to theo-
retical and practical midwifery.—Dublin Quarterly
Journal of Medical Science.

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

  This is certainly the  most  perfect system extant.
It is the best adapted for the purposes of a text-
book,  and that which he whose necessities confine
him to one book, should select in preference  to all
others.—Southern Medical and Surgical Journal.

  The most popular work on midwifery ever issued
from the American press.—Charleston Med. Journal.

  Were we reduced to the necessity of having but
one work on midwifery, and permitted  to choose,
we  would unhesitatingly take Churchill.—Western
Med. and Surg. Journal.
  It is impossible to  conceive a more useful and
elegant  manual  than  Dr. Churchill's Practice of
Midwifery.—Provincial Medical Journal.

  Certainly, in our opinion,  the very best work on
the subject which exists.—N. Y. Annalist.
  No work holds a higher position, or is more de-
serving of being placed in the hands of the tyro,
the advanced student, or the practitioner.—Medical
Examiner.

  Previous editions, under the editorial supervision
of Prof  R. M. Huston, have  been  received with
marked favor,  and they deserved it; but this, re-
printed from a very late Dublin edition, carefully
revised and brought up by the author to the present
time, does present an unusually accurate and able
exposition of every important particular embraced
in the department of midwifery. * *  The clearness,
directness, and precision of its teachings,  together
with the great amount of statistical research which
its text exhibits, have served to place it already in
the foremost rank of works in this department of re-
medial science.—N. O. Med. and Surg. Journal.

  In our opinion, it forms one of the  best if not the
very best text-book and epitome of obstetric science
which we at  present possess in the English lan-
guage.—Monthly Journal of Medical  Science.

  The clearness and precision of style in which it is
written, and the great amount of statistical research
which it contains, have served to place it in the first
rank of works in this departmentof medical science.
—N. Y. Journal of Medicine.

  Few treatises will be found  better adapted as a
text-book for  the  student, or as a manual for the
frequent consultation of the young  practitioner.—
American Medical Journal.
                         by the same author.  (Now Ready, 1856.)

ON THE  DISEASES OF INFANTS  AND  CHILDREN.   Second American
  Edition, revised and enlarged by the author.  Edited, with Notes, by W. V. Keating, M. D.  In
  one large and handsome volume, extra cloth, of over 700 pages.   $3 00, or in leather, $3 25.
  In preparing this work a second time for the American profession, the author has  spared no
labor in giving it a very thorough revision, introducing several new chapters, and rewriting others,
while every portion of the volume has  been subjected  to a severe scrutiny.  The efforts of the
American editor have been directed to supplying  such information relative to matters peculiar
to this country as might have  escaped the attention of the author, and the whole may, there-
fore, be safely pronounced one of the most complete works on the  subject accessible to the Ame-
rican Profession.   By an alteration in the size of the page, these very extensive additions have
been accommodated without unduly increasing the size of the work.
  A few notices of the former edition are subjoined:—
  We regard this volume as possessing more claims
to completeness than any other of the kind with
which we are acquainted.  Most cordially and ear-
nestly, therefore, do we commend it to our profession-
al brethren, and we  feel assured that the stamp of
their approbation will in due time be impressed upon
it.  After an attentive perusal of its contents, we
hesitate not to say,  that it is one of the most com-
prehensive ever written upon the diseases of chil-
dren, and that,forcopiousnessof reference,extentof
research, and  perspicuity of detail, it is scarcely to
be equalled, and not to be excelled, in any  lan-
guage.—Dublin Quarterly Journal.

  After this meagre, and we  know,  very imperfect
notice of  Dr. Churchill's work, we shall conclude
by saying, that it is one that cannot fail from its co-
piousness, extensive  research, and general accuracy,
to exalt still higher the  reputation of the author in
this country.  The American reader will beparticu-
larly pleased to find that Dr. Churchill has done full
justice throughout his work to the various American
authors on this subject.   The names of Dewees,
Eberle, Condie, and  Stewart, occur on nearly every
page, and these authors are constantly referred to by
the author in terms of the highest praise, and with
the most liberal courtesy.—The Medical Examiner.
  The present volume will sustain the reputation
acquired by the author  from his previous works.
The reader will find in it full and judicious direc-
tions for the management of infants at birth, and a
compendious, but clear account of the diseases to
which children are  liable, and the most successful
mode of treating them.  We must not close this no-
tice without calling attention to the author's style,
which is perspicuous and polished to a degree, we
regret to say, not generally characteristic of medical
works. We recommend the work of Dr.  Churchill
most cordially, both to students and practitioners,
as a valuable and reliable guide in the treatment of
the diseases of children.—Am. Journ. of the Med.
Sciences.

  We know of no work on this department of Prac
tical Medicine which presents so candid and unpre-
judiced a  statement or  posting up of our  actual
knowledge as this.—N. Y. Journal of Medicine.

  Its claims to merit both as a scientific and practi-
cal work, are  of the highest order.  Whilst we
would not elevate it above every other treatise on
the same subject, we certainly believe  that very few
are equal to it, and  none superior.—Southern Med.
and Surgical Journal.
BY THE SAME AUTHOR.
ESSAYS  ON THE PUERPERAL FEVER, AND OTHER DISEASES PE-
  CULIAR TO WOMEN.  Selected from the writings of British Authors previous to the close of
  the Eighteenth Century.   In one neat octavo volume, extra cloth, of about 450 pages.   $2 50. 
10
BLANCHARD  &  LEA'S  MEDICAL
           CHURCHILL (FLEETWOOD),  M.O.,  M.R.I.A.,  8cc.

ON  THE  DISEASES OF WOMEN;  including  those of  Pregnancy and Child-
  bed.  A new American edition, revised by the Author.  With Notes and Additions, by D  Fran-
  cis Condie, M. D., author of "A Practical Treatise on the Diseases of Children." With nume-
  rous illustrations.  Tn one large  and handsome octavo volume, leather, of 768 pages. (Now Ready,
  May, 1857.)  $3 00.
  This edition of Dr. Churchill's very popular treatise  may almost be termed a  new  work, to
thoroughly has he revised it in every portion.   It will be found greatly enlarged, and  thoroughly
brought up to the most recent condition of the subject,  while the very handsome series of illustra-
tions introduced, representing such pathological  conditions as can be accurately portrayed, present
a novel feature, and afford valuable  assistance to the young practitioner.   Such additions as ap-
peared  desirable for the American  student  have  been made by the editor, Dr. Condie, while a
marked improvement in  the mechanical execution keeps pace with the advance in all other respects
which the volume has undergone, while the  price has been kept at the former very  moderate rate.
A few notices of the former edition are subjoined :—
  We now regretfully take leave of Dr. Churchill's
book.  Had our typographical limits permitted, we
should gladly have borrowed more from its richly
stored pages.  In conclusion, wc heartily recom-
mend it to  the profession, and would at the same
time express our firm conviction that it will not only
add to the reputation of its author, but will prove a
work of great and extensive utility to obstetric
practitioners.—Dublin Medical Press.

  Former editions of this work have been noticed in
previous numbers of the Journal. The sentiments of
high commendation expressed in those notices, have
only to be repeated in this; not from the fact that
the profession at large are not aware of the high
merits which this work really possesses, but from a
desire to see the principles  and doctrines therein
contained more generally recognized, and more uni-
versally carried out in  practice.—N. Y. Journal of
Medicine.

  We know of no author who deserves that appro-
bation, on "the  diseases  of females,"  to the same
extent that Dr. Churchill does.  His, indeed, is the
only thorough treatise we know of on the subject;
and it may be commended to practitioners and stu-
dents as a masterpiece in  its particular department.
The former editions of this  work have been com-
mended strongly  in this journal, and they have won
their way to an extended, and a well-deserved popu-
larity.  This fifth edition, before us, is well calcu-
lated to maintain Dr. Churchill's high reputation.
It was  revised and enlarged by the author, for  his
American publishers, and it seems to us that thereis
scarcely any species of desirable information on its
subjects that may not be found in  this work.—Tht
Western Journal of Medicine and Surgery.

  We are gratified  to announce a new and revised
edition of Dr. Churchill's valuable work on the dis-
eases of females   We have ever regarded it as one
of the  very  best works on the  subjects  embraced
within  its scope, in the English  language; and  the
present edition, enlarged and revised by the author,
renders it still more entitled to the confidence of the
profession.  The valuable notes of Prof.  Huston
have been retained, and contribute, in no small de-
gree, to enhance the value of the  work.  It is a
source  of congratulation  that the publishers have
permitted the author to be, in  this  instance,  his
own editor, thus securing all the revision which
an author alone is capable of making.—The Western
Lancet.

  As a comprehensive  manual for  students,  or a
work of reference for practitioners, we only speak
with common justice when we say that it surpasses
any other that has ever issued  on  the same sub-
ject from the British press.—The Dublin  Quarterly
Journal.
                              DICKSON  (S.  H.),  M. D.,
       Professor of Institutes and Practice of Medicine in the Medical College of South Carolina.

ELEMENTS  OF  MEDICINE;  a Compendious  View of Pathology  and  Thera-
  peutics, or the History and Treatment of Diseases.   In one large and handsome octavo volume,
  of 750 pages, leather   (Lately Issued.)  $3 75.
  As au American text-book on the Practice of Medicine for the student, and as a condensed work
of reference forthe practitioner, this volume will have strong claims on the attention of the profession.
Few physicians have had wider opportunities than the author for observation  and experience, and
few perhaps have used them better.  As the result of a life of study and practice, therefore, the
present volume will doubtless be received with the welcome it deserves.
  This book is eminently what it professes to be; a I   Prof. Dickson's work supplies, to a great extent,
distinguished merit in  these days.  Designed  fori a desideratum long felt in American medicine.—N.
" Teachers and  Students of Medicine," and admira-  O. Med. and Surg. Journal.
bly suited to their wants, we think it will be received,    Estimating this work according to the purpose for
',!? l}* ow,n'nentr' WIth,a hearty welcome.—Boston | which jt is desiKned) we ,nugt t)link  highly of its
Med. and Surg.  Journal.                         | merjtS! and we have no hesitation in predicting for
  Indited by one of the most accomplished writers | it a favorable reception by both students and teachers.
of our country,  as well as by one who has long held    Not professing to be a complete and comprehensive
 a high position among teachers and practitioners of
 medicine, this work is  entitled  to  patronage and
 careful study. The learned author has endeavored
 to condense in this  volume most of the practical
 matter contained in his former productions, so as to
 adapt it to the use of those who have not time to
 devote to more extensive works.—Southern Med. and
 Surg. Journal.
  We can strongly recommend Dr. Dickson's work
 to our readers as one of interest ana practical utility,
 well deserving of a place in their libraries as a book
 of referenct ; and we especially commend the first
 part as presenting an admirable outline of the princi-
 ples of medicineT—Dublin Quarterly Journal, Feb.
 1856
  This volume, while as its title denotes it is a
 compendious view, is also a comprehensive system
 of practice, perspicuously and pleasantly written,
 and admirably suited to engage the interest, and in-
struct the reader.—Peninsular Journal of Medicine,
Jan. 1656.
treatise, it will not be found full in detail, nor filled
with discussions of theories and opinions, but em-
bracing all that is essential in theory and practice,
it is admirably adapted to the wants of the American
student.  Avoiding all that is uncertain, it presents
more clearly to the mind of the reader that which is
established and verified  by experience.  The varied
and extensive reading of the author is conspicuously
apparent, and all the recent  improvements and dis-
coveries in therapeutics and pathology are  chroni-
cled in its pages.—Charleston Med. Journal.

  In the first part of the work the subject of gene-
ral pathology is presented in outline, giving  a btau-
tiful picture  of  its distinguishing  features, and
throughout the succeeding chapters we find  that he
has kept  scrupulously within the bounds of sound
reasoning  and  legitimate deduction.   Upon the
whole, we do not hesitate  to pronounce it a superior
work  in its  class, and  that Dr. Dickson merits a
place in the first rank of American writers.—Western
Lancet. 
AND  SCIENTIFIC PUBLICATIONS.                    11
                      DRUITT  (ROBERT),  M.R. C. S.,  &.c.

THE  PRINCIPLES  AND PRACTICE  OF  MODERN  SURGERY.   A new
  American, from the improved London edition.  Edited by F. W.  Sargent, M. D., author of
  " Minor Surgery,"  &c.   Illustrated  with one hundred and ninety-three wood-engravings.  Ia
  one very handsomely printed octavo volume, leather, of 576 large pages.   $3 00.
  Dr. Druitt's researches into the literature of his
subject  have  been  not only extensive, but well di-
rected ;  the most discordant authors are fairly and
impartially quoted, and, while due credit  is given
to each, their respective  merits are weighed with
an unprejudiced hand.  The grain of wheat is pre-
served, and the chaff is unmercifully stripped off.
The arrangement is simple  and philosophical, and
the style, though clear and interesting, is so precise,
that the book contains more information condensed
into a few words than any other surgical work with
which ue  are acquainted.—London Medical Times
and Gazette.

  No work, in our opinion, equals it in presenting
so much valuable surgical matter in so small a
eompass.—St. Louis Med. and Surgical Journal.

  Druitt's Surgery is too well known to the Ameri-
can medical profession  to require its announcement
anywhere. Probably no work of the kind has ever
been more cordially received and extensively circu-
lated than this.  The fact that  it comprehends in a
comparatively small compass, all the essential ele-
ments of theoretical and practical Surgery—that it
is found to contain  reliable and authentic  informa-
tion on the nature and treatment of nearly all surgi-
cal affections—is a sufficient reason for the liberal
patronage it  has obtained.  The editor, Dr. F. W.
Sargent.', has contributed much to enhance the value
of the work, by such American improvements as are
calculated more perfectly to adapt it to  our own
views  and practice in this country.  It abounds
everywhere with spirited and life-like illustrations,
which to  the young surgeon, especially, are of no
minor consideration. Every medical man frequently
needs just such a work  as this, for immediate  refer-
ence in  moments of sudden emergency, when he has
not time to consult more elaborate treatises.—The
Ohio Medical and  Surgical Journal.

  The author hag evidently ransacked every stand-
ard treatise of ancient and modern times, and all that
 s really practically useful at the bedside will be
found in a form at once clear, distinct, and interest-
ing.—Edinburgh Monthly Medical Journal.

  Druitt's work, condensed, systematic, lucid, and
practical as it is, beyond most works on  Surgery
accessible  to the American student, has had much
currency in this country, and under its present au-
spices  promises to rise to yet  higher favor.—The
 Western Journal of Medicine and Surgery.

  The most accurate and ample resume of the pre-
sent state of Surgery that we are acquainted with.—
Dublin Medical Journal.

  A  better  book on the principles and practice of
Surgery as now understood in England and America,
has not been given to the profession.—Boston Medi-
cal and Surgical Journal.

  An unsurpassable compendium, not only of Sur-
gical,  but of Medical Practice.—London Medical
Gazette.
  This work merits our warmest commendations,
and we strongly recommend it to young surgeons as
an admirable digest of the principles and practice of
modern Surgery.—Medical Gazette.

  It may be said with truth  that  the work of Mr.
Druitt  affords a complete, though brief and  con-
densed view, of the entire field  of modern surgery.
We know of no work on the same subject having the
appearance of a manual, which includes so many
topics of interest to the surgeon  ; and the terse man-
ner in which each has been treated evinces a most
enviable quality of mind on the part of the author,
who seems to have an innate power of searching
out and grasping the leading facts and features of
the most elaborate productions  of the pen. It is a
useful handbook for the practitioner, and we should
deem a teacher of surgery unpardonable who did not
recommend it to his pupils.  In our own opinion, it
is admirably adapted to the wants of the student.—
Provincial Medical and Surgical Journal.
           DUNGLISON,  FORBES, TWEEDIE, AND  CONOLLY.
THE  CYCLOPEDIA OF PRACTICAL  MEDICINE: comprising Treatises on
  the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women
  and Children, Medical Jurisprudence, &c. &c.   In  four  large super-royal octavo volumes, of
  3254 double-columned pages, strongly and handsomely bound, with raised bands.  $12 00.
  *** This work contains no less than four hundred and eighteen distinct treatises, contributed by
sixty-eight distinguished physicians, rendering it a complete library of reference for the country
practitioner.
  The most complete work on  Practical Medicine ! titioner. This estimate of it has not  been formed
extant-  or, at least, in our  language.— Buffalo from a hasty examination, but after an intimate ac-
Medical and Surgical Journal
  For reference, it is above all price to every prac
titioner.—Western Lancet.
 2uaintance derived from  frequent consultation of it
 uring the past nine or ten years.  The editors are
practitioners of established reputation, and the list
of contributors embraces  many of the most eminent
  One of the most valuable medical publications of professors and teachers of London, Edinburgh, Dub-
the day__as a work of reference it is invaluable.— i lin, and Glasgow.  It is, indeed, the great merit of
Western Journal of Medicine and Surgery.         this work that the principal articles have been fur-
  It has been to us. both as learner and teacher, a I nished by practitioners w/io have not  only devoted
workfor ready and frequent reference, one in which especial attention to the diseases about which they
modern  English medicine is exhibited  in the most have written, but have also enjoyed opportunities
                                               for an extensive practical acquaintance with them,
advantageous light.—Medical Examiner.

  We rejoice that this work is to be placed within
the reach of the profession in this country, it being
unquestionably one of very great value to the prac-
and whose reputation carries the assurance of their
competency  justly to appreciate the opinions of
others, while it stamps their own doctrines with
high and just authority.—American Medical Journ.
DEWEES'S COMPREHENSIVE  SYSTEM OF
  MIDWIFERY.  Illustrated by occasional cases
  and many engravings.  Twelfth edition, with the
  author's last improvements and  corrections  In
  one octavo volume, extra cloth, of 600pages. 8320.
DEWEKS S TREATISE  ON THE PHYSICAL
  AND  MEDICAL TREATMENT  OF  CHILD-
  REN.  Tenth  edition.  In one volume, octavo,
  extra cloth, 548 pages.  82 80.
DEWEES'S TREATISE  ON  THE DISEASES
  OF FKMALES.  Tenth edition.  In one volume,
  octavo, extra cloth, 532 pages, with plates. 83 00.
DANA ON ZOOPHYTES AND CORALS.  In one
  volume, imperial quarto, extra cloth, with wood-
  cuts. 815 00.  Also, AN ATLAS, in one volume,
  imperial folio, with sixty-one magnificent colored
  plates.   Bound in half morocco.  $30 00.
DE LA BECHE'S GEOLOGICAL OBSERVER.
  In one very large and handsome octavo volume, ex-
  tra cloth, of 700 pages, with 300 wood-cuts. $4 00.
FRICK ON  RENAL AFFECTIONS; their Diag-
  nosis and Pathology.  With illustrations.  One
  volume, royal 12mo., extra cloth.  75 cents. 
12
BLANCHARD &  LEA'S MEDICAL
                          DUNGLISON  (ROBLEY),  M.  D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

MEDICAL  LEXICON;  a Dictionary of  Medical  Science,  containing;  a concise
  Explanation of the various Subjects and Terms of Physiology, Pathology, Hygiene, Therapeutics,
  Pharmacology, Obstetrics, Medical Jurisprudence, &c.  With the French and other Synonymes ;
  Notices of Climate and of celebrated Mineral Waters; Formulae for various Officinal, Empirical,
  and Dietetic Preparations, etc. A new edition, revised, is now ready.  In one very thick octavo
  volume, of over nine hundred large  double-columned  pages, strongly bound in  leather, with
  raised bands.  $4 00.
  Every successive edition of this work bears the marks of the industry of the author, and of his
determination to keep it fully on a level with the most advanced  state of medical science.  Thus
nearlv fifteen thousand words have been added to it within the last few years.  As a complete
Medical Dictionary, therefore, embracing over FIFTY THOUSAND  DEFINITIONS, in all the
branches of the science, it  is presented as meriting a continuance of the great favor and popularity
which have carried it, within no very long space of time, through so many editions.
  Every precaution has been taken in the preparation of the present volume, to render its mecha-
nical execution  and typographical accuracy worthy of its extended  reputation and universal use.
The very extensive additions have been accommodated, without materially  increasing the bulk of
the volume, by the employment of a small but exceedingly clear type, cast for this purpose.  The
press has been watched with great care, and every effort used to insure the verbal accuracy so ne-
cessary to a work of this nature.   The whole is printed on fine white paper;  and, while thus exhi-
biting in every respect so  great an improvement over former  issues, it is presented at the original
exceedingly low price.
  We welcome it cordially; it is an admirable work,
and indispensable to all literary medical men.  The
labor which has been bestowed upon it is something
prodigious.  The  work, however,  has  now  been
done, and we are happy in the thought that no hu-
man being will have  again to undertake the same
gigantic task.  Revised and corrected from time to
time, Dr. Dunglison's " Medical Lexicon" will last
for centuries.—British and Foreign  Med.-Chirurg.
Review.
  The fact that this excellent and  learned work has
passed  through eight  editions, and that  a ninth is
rendered necessary by the demands of the public,
affords a sufficient evidence of the general apprecia-
tion of Dr. Dunglison's labors by the medical pro-
fession in England and America.  It  is a book which
will be of  great service to the student, in teaching
readers to  its peculiar  merits; and we  need  do
little more than  state, in reference to the present
reissue, that, notwithstanding  the large additions
previously  made to it, no fewer thnn four  thou-
sand terms, not to  be found  in the preceding edi-
tion, are contained in  the  volume before  us.—
Whilst it is a wonderful  monument of its author's
erudition and industry, it is  also a work of great
practical utility, as we can testify from our own
experience; for we keep it constantly  within our
reach,  and make very frequent reference  to  it,
nearly always finding in it the information we seek.
—British and Foreign Med.-Chirurg. Review.

  It has the rare merit that it certainly has no rival
in the English language for accuracy and extent
of references.  The  terms generally  include  short
physiological and pathological descriptions, so that,
him the meaning of all the technical terms used in , £s'the a*thor jugtf  obse8rves, the reader does not
medicine, and will  be of no less use to the practi- ,     esg  in thig wo/k a mere ,1ictionary but a book,
turner who desires  to keep himself on a level with which  while it instructs him in medical etymo-
the advance of medical science.—London Medical -
Times and Gazette.
  In taking leave of our author, we feel compelled
to confess that his work bears evidence of almost
incredible labor having been bestowed upon its com-
position.—Edinburgh Journal of Med. Science.
  A miracle of labor and industry in one who has
written able and voluminous works on nearly every
branch of medical science.  There could be no more
useful book  to the student or practitioner, in the
present advancing age, than one in which would be
found, in addition to the ordinary meaning and deri-
vation of medical terms—so many of which are of
modem  introduction—concise descriptions of their
explanation and employment; and all this and much
more is contained  in the volume before us.  It is
therefore almost as indispensable to the other learned
professions as to our own.  In fact,  to all who may
have occasion to ascertain the meaning of any word
belonging to the many branches of medicine.  From
a careful examination of the present edition, we can
vouch for its accuracy, and  for its being brought
quite up to thedate of publication ; the author states
in his preface that he has added to it about four thou-
sand terms, which are not to be found in the prece-
ding one. — Dublin Quarterly Journal of Medical
Sciences.
  On the appearance  of the last edition of  this
valuable work, we directed the attention of out
wiiji.u.  Willie  lb iiiob.uv.io iiii.i ill mi.uii.ni v.tj'iiivs-
logy, furnishes him with a large amount of useful
information.  The author's labors have been pro-
perly appreciated by his own countrymen ; ana we
can only confirm their judgment, by recommending
this  most useful volume  to the notice of our cisat-
lantic readers. No medical library will be complete
without it.—London Med. Gazette.

  It  is certainly more complete and comprehensive
than any with which we are acquainted  in  the
English language.  Few,  in fact, could  be  found
better qualified than Dt.  Dunglison for the produc-
tion  of  such  a work.  Learned, industrious, per-
severing, and accurate,  he brings to the task all
the peculiar  talents necessary  for its successful
performance;  while, at  the same time, his  fami-
liarity with the writings  of the ancient and modern
" masters of our art," renders him skilful to note
the exact usage  of  the  Beveral  terms of science,
and the various modifications which medical term-
inology has undergone with the change of theo-
ries  or the  progress of  improvement. — American
Journal of the Medical Sciences.
  One of the most complete nnd copious known to
the cultivators of medical science.—Boston Med.
Journal.

  The most comprehensive and  best English Dic-
tionary of medical terms extant.—Buffalo Medical
Journal.
                                   BT THE  SAME  AUTHOR.

THE PEACTICE  OF  MEDICINE.    A Treatise on Special Pathology and The-
  rapeutics.  Third Edition.   In two large octavo volumes, leather, of 1,500 pages.   $6 25.
  Upon every topic embraced in the work the latest
information  will be  found  carefully  posted up.—
Medical Examiner.

  The  student of medicine will find, in these two
elegant volumes, a mine of facts, a gathering of
precepts and advice from the world of experience,
that will nerve him with courage, and faithfully
direct him in his efforts to relieve the physical suf-
ferings of the race.—Boston Medical and Surgical
Journal.

  It is certainly the most complete treatise of which
we have any knowledge.— We stern Journal of Medi-
cine and Surgery.

  One of the mos lelaborate treatises of the kind
we have.—Southern Med. and Surg. Journal. 
AND SCIENTIFIC  PUBLICATIONS.                    13
                         DUNGLISON  (ROBLEY),  M.D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

HUMAN   PHYSIOLOGY.   Eighth  edition.    Thoroughly revised  and  exten-
  sively modified and enlarged, with five hundred and thirty-two illustrations.  In two laige and
  handsomely printed octavo volumes, leather, of about 1500 pages.   (Just Issued, 1856.)   $7 00.
  In revising this work for its eighth appearance, the author has spared no labor to render it worthy
a continuance of the very great favor which has been extended to it by the profession.  The whole
contents have been rearranged, and to a great extent  remodelled ; the investigations which of late
years have been so numerous and so important, have been carefully examined and incorporated,
and the work in every respect has been brought up to a level with the present state of the subject.
The object of the author has been to render it a concise but comprehensive treatise, containing the
whole body of physiological science, to which the student and man of science can at all times refer
with the certainty of finding whatever they are in search of, fully presented in all its aspects; and
on no former edition has the author bestowed more labor to secure this result.
  A similar improvement will be found in the typographical execution of the volumes, which, in
this  respect, are superior to their predecessors.   A large number of additional wood-cuts have been
introduced, and  the series of illustrations has been greatly modified by the substitution of many
new ones for such as were  not deemed satisfactory.  By an enlargement of the page, these very
considerable additions have been accommodated without increasing  the size of the volumes to an
extent to render them unwieldy.
                                                The best work of the  kind in the  English lan-
                                               guage.—Silliman's Journal.
                                                The present edition the author has made a perfect
                                               mirror of the  science as it is at the present hour.
                                               As a work upon physiology proper, the science of
                                               the functions performed by the body, the student will
                                               find it all he wishes.—Nashville Journ.  of Med.
                                               Sept. 1856.
  We believe that it can truly be said, no more com-
plete repertory of facts upon the subject treated,
can anywhere be found.  The author bus, moreover,
that enviable  tact at description and that facility
and ease of expression which render him peculiarly
acceptable to the  casual, or the studious reader.
This faculty, so requisite in setting forth many
graver and less attractive subjects,  lends additional
eharms to one always fascinating.—Boston  Med.
and Surg. J-ournal, Sept. 1856.
  The most  complete and  satisfactory system of
Physiology in the English  language.—Amer. Med.
Journal.
                                                That he has succeeded, most admirably succeeded
                                               in his purpose, is apparent from the appearance of
                                               an eighth edition.  It is now the great encyclopaedia
                                               on the subject, and worthy of a place in every phy-
                                               sician's library.— Western Lancet, Sept. 1656.
                                   BY THE SAME AUTHOR.

GENERAL   THERAPEUTICS  AND   MATERIA  MEDICA;  adapted for a
  Medical Text-book.  New edition, much improved.  With one hundred  and eighty-seven  illus-
  trations.   In two large and handsomely printed octavo vols., leather, of about 1100 pages. $6  00.
  In this work of Dr. Dunglison,we recognize the |   As a text-book for students, for whom it is par-
same untiring industry  in the collection and  em-  ticularly designed, we know of none superior to
bodying of facts on the several subjects of which he  it.—St. Louis Medical  and Surgical Journal.
treats,  that has heretofore distinguished him, and   .             .         ....    .   .  .     .
we cheerfully point to these volumes, as two of the   Jt Purports to  be  a new edition,  but it is rather
most interesting that we know of.  fn noticing the  a ne.w book> s0 ST™tlV f" it been improved, both
additions to this, the fourth  edition, there isVery  ln »? ■monnt :and quality of the matter which it
little in the periodical or  annual  literature of the S  contains.-iv. O. Medical and Surgical Journal.
profession,  published in the interval which  has   We bespeak for this  edition, from the profession,
elapsed since the issue of the first, that has escaped  an  increase of patronage over any of its former
the careful  search of the  author.  A* a book for  oneg  on accoUnt of its increased merit.—N. Y.
reference, it is invaluable.—Charleston Med. Jour- , journal of MeMfre.
nal and Review.                                            ^P^
  It may be. said to be tht work now upon the sub-   We consider this work unequalled.—Boston Med.
Jects upon which it treats.—Western Lancet.         and Surg. Journal.      I*j»^_
                         BY the same  author. (.A new Edition.)          i

NEW REMEDIES,  WITH FORMULA FOR THEIR  PREPARATIO^kAND
  ADMINISTRATION.   Seventh edition, with  extensive  Additions.   In  one very" large octavo
  volume,  leather, of 770 pages.  (Just Issued, May, 1856.)  $3 75.
  Another  edition of the  '«New Remedies" having been called for, the author has  endeavored te
add everything of moment that has appeared since the publication of the last edition.
  The chief remedial means which have obtained a place, for the first time, in this volume, either
owing to their having been recently introduced into pharmacology, or to  their having received novel
applications—and which, consequently, belong to the category of " New Remedies"—are the fol-
lowinff *^—
  Apiol, Caffein, Carbazotic acid, Cauterization and catheterism of the larynx and trachea, Cedron,
Cerium', Chloride of bromine, Chloride of iron, Chloride of sodium, Cinchonicine, Cod-liver olein,
Congelation, Eau de Pagliari, Galvanic cautery, Hydriodic ether, Hyposulphite of soda and silver,
Inunction, Iodide of sodium, Nickel, Permanganate of potassa, Phosphate  of lime, Pumpkin, Quinidia,
Rennet, Saccharine carbonate of iron and manganese, Santonin, Tellurium, and Traumaticine.
  The articles treated of in the former editions will be found to have undergone considerable ex-
pansion in  this, in order that the  author might be enabled to introduce, as far as practicable,  the
results of the subsequent experience of others, as well as of his  own  observation  and reflection;
and to make the work still more deserving of the extended circulation with which the preceding
editions have been favored by the profession.  By an enlargement of the page, the numerous  addi-
tions have been incorporated without greatly increasing the bulk of the volume.— Preface.
                                                 The great learning of the author, and his remark-
                                               able industry in  pushing his  researches into  every
                                               source whence information is derivable,have enabled
                                               him  to throw together an  extensive mass of facts
                                               and statements, accompanied by full  reference to
                                               authorities; which last feature renders the  work
                                               practically valuable to investigators who desire to
  One of the most useful of the author's works.—
Southern Medical and Surgical Journal.
  This elaborate  and useful  volume  should  be
fonnd in every medical library, for as a book of re-
ference, for physicians, it is unsurpassed by any
other work in existence, and the double index for
diseases and for remedies, will be found greatly to
enhance its value.—New York Med. Gazette.
examine the original papers.—The American Journal
of Pharmacy. 
14
BLANCHARD <fc  LEA'S
metTTTtal
                                 ERICHSEN  (JOHN),
                     Professor of Surgery in University College, London, See.

THE SCIENCE  AND ART  OF SURGERY; being a Treatise on Surgical
  Injuries, Diseases, and Operations.  Edited bv John H. Brinton, M. D.   Illustrated with
  three hundred and  eleven  engravings on  wood.  In one large and handsome octavo volume, of
  over nine hundred closely printed pages, leather, raised bands.  $4 25.
  It is, in our humble judgment, decidedly the  best
book of the kind in the English language. Strange
that just such books are notofiener produced by pub-
lic teacher" of surgery in this country and Great
Britain  Indeed, it is a matter of great astonishment
rarely encounter cases requiring surgical manage-
ment.—Stethoscope.
  Embracing, as will be perceived, the whole surgi-
cal domain, and each division of itself almost com-
                                               plete and perfect, each chapter full and explicit, each
but no less true than astonishing, that ot the many , subject faithfully exhibited, we can only express our
works on surgery republished in this country w.thin | eg1ima)e of it in the aggregate. We consider it an
the la-t fifteen or twenty years as textbooks  for j excellent contribution to surgery, as probably the
medical students, this is the only one that even ap- I best single voiume now  extant on the subject, and
proximate? to the fulfilment of the peculiar wants of  wjth ereat pleasure  we add it  to our text-books.—
youngmen just entering upon the study of this branch  --
of the profession.— Western Jour, of Med. and Surgery.

  Its value is greatly enhanced  by a very eopious
well-arransred index.  We regard this as one of the
most valuable contributions to modern surgery.  To
one entering his novitiate  of practice, we regard it
the mosi serviceable guide which he can consult.  He
will find a fulness of detail leadinghim through every
step of ihe operation, and not deserting him until the
final issue of the case is decided.   For the same rea-
son wf recommend it to those whose routine of prac-
tice lies in such parts of the country  that they must
NashviHe Journal of Medicine and Surgery.

  Prof. Ericbsen's work, for its size, has not been
surpassed; his nine hundred and eight pages, pro-
fusely illustrated, are rich in physiological, patholo-
gical, and operative suggestions, doctrines, details,
and processes; and will  prove  a reliable resource
for information, both to physician and surgeon, in the
hour of peril.—JV. O. Med. and Surg.  Journal.

  We are acquainted with no other work wherein
so much good sense, sound  principle, and practical
inferences, stamp every page.—Amerira* Lancet.
                             ELLIS  (BENJAMIN),  M.D.

THE  MEDICAL FORMULARY:  being a Collection  of Prescriptions, derived
  from the writings and practice of many of the most eminent physicians of America and Europe.
  Together with the usual Dietetic Preparations and Antidotes for Poisons.   To which is added
  an  Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform.  The
  whole accompanied with a few brief Pharmaceutic and Medical Observations.   Tenth edition,
  revir-ed and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the
  Philadelphia College of Pharmacy.  In one neat octavo volume, extra cloth, of 296 pages. (Lately
  Issued.) $1 75.
  After an examination of the new matter and the
alterations, we believe the reputation of the work
built up by the author, and the late distinguished
editor, will continue to flourish under the auspices
of the present editor, who has the industry and accu-
racy,  and, we would  say, conscientiousness requi-
site for the responsible task.—Am. Jour, of Pharm.
  It will prove particularly useful to students and
young practitioners, as the most important prescrip-
tions employed in modern  practice, which lie scat-
tered through our medical  literature, are here col-
lected and conveniently arranged for  reference.—
Charleston Med. Journal and Review.
                        FOWNES (GEORGE), PH. D., &c

ELEMENTARY  CHEMISTRY;  Theoretical  and Practical.   With numerous
  illustrations.  Edited, with '"Additions,  by Robert Bridges, M. D.  In one large royal 12mo.
  volume, of over 550jjjges, with 181 wood-cuts.   In leather, $1 50; extra cloth, .*! 35.
  We know of no better text-book, especially in the
difficult department of organic chemistry,  upon
which it isjogjPWSrrly full and satisfactory. We
WQulJL rec^Bfend  it  to  preceptors as a capital
^office boolTTor their students who are beginners
in Chemistry.  It is copiously illustrated with ex-
cellent wood-cuts,  and altogether admirably  "got
np."—iV. J. Medical Reporter.
  A standard manual, which has long enjoyed the
reputation of embodying much knowledge in a small
space. The author hasachieved the difficult task of
condensation with masterly tact.  His book is con-
cise without being dry, and brief without being too
dogmatical or general.— Virginia Med. and Surgical
Journal.
  The work of Dr.  Fownes has long been before
the public, and its merits have been fully appreci-
ated  as  the best text-book on chemistry now in
existence.   We do not, of course, place it in a rank
superior to the works of Brande, Graham,  Turner,
Gregory, or Gmelin, but we say that, as a work
for students, it is preferable to any of  them.—Lon-
don Journal of Medicine.
  A work well adapted to the wants of the student.
It is an excellent exposition of the chief doctrinei
and facts of modern chemistry. The size of the work,
and still more the condensed yet perspicuous style
in which it is  written, absolve it from the charges
very properly urged against most manuals termed
popular.—Edinburgh Journal of Medical Science.
                       FERGUSSON  (WILLIAM), F. R. S.,
                      Professor of Surgery  in King's College, London, Ice.

A  SYSTEM  OF  PRACTICAL SURGERY.   Fourth American, from the third
  and enlarged London edition.  In one large and beautifully printed octavo volume, of about 700
  pages, with 393 handsome illustrations, leather.  $3 00.
  The most important subjects in connection with
practical surgery which have been more recently
brought under  the notice of, and discussed by, the
surgeons of Great Britain, are fully and dispassion-
ately considered by Mr. Fergusson, and that which
was before wanting has now been supplied; so that
we can now look upon it as a work on practical sur-
gery instead of  one  on  operative surgery  alone.
Medical Times and Gazette.

  No work was  ever written which more  nearly
comprehended the necessities of  the  student and
practitioner, and was more carefully arranged to
that single purpose than this.—N. Y. Med. Journal.
  The addition of many new pages mnkes this work
more thnn ever indispensable to the student and prac-
titioner.—Ranking's Abstract.
  Among the numerous works upon surgery pub-
lished of late years, we know of none we value
more highly than the one before us.  It is perhaps
the very best we have for a text-book and for ordi-
nary reference, being concise and eminently practi-
cal.—Southern Med. and Surg. Journal. 
AND  SCIENTIFIC  PUBLICATIONS.                   15
                             FLINT  (AUSTIN),  M. D.,
        Professor of the Theory and Practice of Medicine in the University of Louisville, tec.
                                (An Important New Work.)

PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT-
  ING THE RESPIRATORY ORGANS.  In one large and  handsome octavo  volume, extra
  cloth, 636 pages.  (Now Ready.)  $3 00.

l-^YC Can on'y 8tate our general impression of the ! the results of his study and experience. These ex-
high value of this work, and cordially recommend pectations we are confident will not  be disappointed.
it to all. We regard it, in point both of trrangement For our own part, we have been favorably impressed
and of the marked ability of its treatment of the sub- by a perusal of the book, and heartily recommend it
jects, as destined to take the first rank in works of to all who are desirous of acquiring a thorough ac-
this class.  So far as our information extends, it has quaiatance with the means of exploring the condi-
at present no equal.   To the practitioner, as well as i tions of the respiratory organs by means of auscul-
the student, it will be invaluable in clearing  up the Station and  percussion. — Boston Med. and Surg.
diagnosis of doubtful cases, and in shedding light Journal.
upon difficult phenomena—Buffalo Med. Journal.    A work of original observation of thehighestmerit.
  This  is the  most elaborate work devoted  exclu- I We recommend the treatise to every one who wishes
sively to the physical exploration of diseases of the to become a correct auscultator.  Based  to a very
lungs, with which we are acquainted in the English large extent upon cases numerically examined, it
language.  From the high standing of the author as : carries the evidence of careful study and disorimina-
a clinical teacher, and his known devotion,  during tion upon every pa?e.  It does credit to the author,
many years, to the study of thoracic diseases, much and, through him, to the profession  in this country.
was to be expected from the announcement of his It is, what we cannot call every book upon auscul-
determination  to embody in the form of a treatise, I tation, a readable book.—Am. Jour. Med. Sciences.
                          FISKE  FUND PRIZE  ESSAYS.
THE EFFECTS OF CLIMATE ON TUBERCULOUS  DISEASE.   By Edwin
  Lee, M. R. C. S., London.

THE INFLUENCE  OF  PREGNANCY  ON  THE  DEVELOPMENT  OF
  TUBERCLES.  By Edward Warren, M. D., of Edenton, N. C.
  Together in one neat octavo volume, extra cloth.   $1 00.  (Just Ready.)
  These two valuable Essays on Tuberculosis are reprinted by request of the Rhode Island Medi-
cal Society, from the " American Journal oftJie Medical  Sciences" for April and July, 1857.
                         GRAHAM  (THOMAS), F. R. S.,
                   Professor of Chemistry in University College, London, tec.

THE ELEMENTS OF  CHEMISTRY.  Including the application of the Science
  to the Arts.  With numerous illustrations.  With Notes and  Additions, by Robert Bridges,
  M. D., &c. &c.  Second American, from the second and enlarged London edition.
PART I. (Lately Issued) large 8vo., 430 pages, 185 illustrations.  $1 50.
PART II. (Preparing) to match.

                      GRIFFITH  (ROBERT  E.),  M.  D., &c.
A  UNIVERSAL  FORMULARY, containing the methods of  Preparing and Ad-
  ministering Officinal  and other Medicines.  The whole adapted to Physicians and  Pharmaceu-
  tists.  Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas,
  M. D., Profe-sor of Materia Medica in the Philadelphia College of Pharmacy.  In one larpe and
  handsome octavo volume, extra cloth, of 650 pages, double  columns.  (Just Issued.)  $3 00;  or
  bound in sheep, $3 25.
  It was a work requiring much perseverance, and j tioner can possibly have in his possession.—Medical
when published was looked upon as by far the best
work of its kind thai had issued from the American
press.  Prof Thomas has certainly "improved," as
well as added lotliis Formulary, and has rendered it
additionally deserving of the confidence of pharma-
ceutists and physicians.—Am. Journal of Pharmacy.

  We are happy to announce a new and improved
edition of this, one of the most valuable and useful
works that have emanated from an American pen.
It would do credit to any country, and will be found
of daily usefulness to practitioners of medicine; it is
better adapted to their purposes than the dispensato-
ries.— Southern Med. and Surg. Journal.
  A new edition of this well-known work, edited by
R. P. Thomas, M D., affords occasion for renewing
our commendation of so useful  a handbook, which
ought to be universally studied  by  medical men of
every clas*, and made use of by way ofreferenee by
office pupils, as a standard authority.  It has been
much enlarged, and now condenses a vast amount
of needful and necessary knowledge in small com-
pass  The more of such hooks the better for the pro-
fession and the public- N. V. Med. Gazette.

  It is one of the most useful books a country practi-
Chronicle.
  The amount of useful, every-day matter, for a prac-
ticing physician, is  really immense.—Boston Med.
and Surg. Journal.
  This i* a work of six hundred and fifty one  pages,
embracing all on the  subject of preparing and nilmi-
nistering medicines that can be desired by the physi-
cian and pharmaceutist.— Western Lancet.
  In short, it is a full and complete work of the kind,
and should be in the hands of every physician and
apothecary.   O. Med. and Surg. Journal
  We predict a great sale for this work, andwe espe-
cially recommend it  to all medical teachers.—Rich-
mond Stethoscope.
  This edition of Dr. Griffith's work has been ereatly
improved by the revision and ample additions of Dr.
Thomas, and is now, we believe, one of the most
complete works of its kind in any language. The
additions  amount to  about seventy pages, and no
effort has been spared to include in them all the re-
eent  improvements which have  been published in
medical journals, and systematic treatises.  \ work
of this kind appears to us indispensable to the physi-
cian, and ihereis none we can more cordially recom-
mend.—AT. Y. Journal of Medicine.
BY THE SAME AUTHOR.
MEDICAL BOTANY;  or, a Description of all the  more important  Plants used
  in  Medicine and of their Properties, Uses, and Modes of Administration.  In one larpe octavo
  volume, extra doth, of 704 pages, handsomely printed, with nearly 350 illustrations on wood. $3 00. 
Id
BLANCHARD  <k LEA'S  MEDICAL
                          GROSS (SAMUEL D.),  M. D.,
             Professor of Surgery in the Jefferson Medical College of Philadelphia, &c.

                            New Edition (Now Ready.)

ELEMENTS  OF PATHOLOGICAL  ANATOMY.  Third edition, thoroughly
  revised and greatly improved.  In one large and very handsome octavo volume, with about three
  hundred and fifty beautiful illustrations, of which a large  number are from original drawings.
  Price in extra cloth, f 4 75; leather, raised bands, $5  25.
  The length of time which has elapsed since the  appearance of the last edition of this work, and
the energetic labors of the numerous investigators of pathological subjects, have so changed the
details of the science, that very extensive alterations have been found requisite in  its revision, to
bring it thoroughly up to the present state of the subject.  In many respects this edition may there-
fore be regarded as  a new work.  A similar improvement will likewise be found in its mechanical
execution, and in the series of illustrations, which has been greatly altered and improved.  In every
respect it may therefore be expected to fully maintain the very high reputation which it has acquired
as a sound practical text-book on all points relating to its important subject, while a considerable
reduction has been made  in the price.

                                BY THE SAME AUTHOR.

A  PRACTICAL  TREATISE  ON  THE  DISEASES,  INJURIES,  AND
  MALFORMATIONS OF THE  UBINARY  BLADDER, THE PROSTATE GLAND, AND
  THE URETHRA. Second Edition, revised  and much enlarged, with one hundred and eighty-
  four illustrations.   In one large and very handsome octavo volume, of over nine huntbeJ pages.
  (Just Issued.)  In leather, raised bands, $5 25; extra cloth, $4 75.
  A volume replete with truths and principles of the
utmost valne in the investigation of these diseases.—
American Medical Journal.

  On the appearance of the first edition of this work,
*he leading English medical review predicted that it
would have a " permanent place in the literature of
surgery worthy to rank with the best works of the
present age." This prediction has been amply ful-
filled. Dr. Gross's treatise has been fonnd to sup-
ply completely the  want which has  been felt ever
since the elevation of surgery to the rank of a science,
of a good practical treatise on the  diseases of the
bladder and its accessory organs.  Philosophical in
its design, methodical in its arrangement, ample and
sound in its practical details, it may in truth be said
to leave  scarcely anything to be desired on so im-
portant a subject, and with the additions and modi-
fications resulting from future discoveries and im-
provements, it will probably remain one of the most
valuable works on this subject so long as the science
of medicine shall exist.—Boston Med. and Surg.
Journal.
  Dr.  Gross has brought all his learning,  experi-
ence, tact, and judgment to the task, and has pro-
duced a work worthy of his high reputation. We
feel perfectly safe in recommending it  to our read-.
ers as a monograph  unequalled  in interest and
practical value by any other on the subject in our
language.—Western Journal of Med. and  Surg.
  Whoever will peruse the vast amount of valuable
practical information it contains, and which we
have been unable even to notice, will, we think,
agree with us, that there is no work in the English
language which can make any just pretensions t»
be its equal.—N. Y. Journal of Medicine.
                          BY THE SAME author.  (Just Issued).

A PRACTICAL  TREATISE ON FOREIGN BODIES  IN THE  AIR-PAS-
  SAGES.  In one handsome octavo volume, extra cloth, with illustrations,  pp. 468.  $2 75.
  A very elaborate work. It is a complete summary  conclude by recommending it to our readers, fully
of the whole subject, and will be a useful book of
reference.—British and Foreign  Medico-Chirurg.
Review.
  A highly valuablebook of reference on a most im-
portant subject in the practice of medicine.  We
persuaded that its perusal will afford them much
practical information well conveyed, evidently da-
rived from considerable experience and deduced "Vorn
an ample collection of facts. — Dublin Quarterly
Journal, May, 1855.
                           by the same author.  (Preparing.)

A SYSTEM  OF  SURGERY j  Diagnostic, Pathological, Therapeutic, and Opera-
  tive.  With very numerous engravings on wood.
                          GLUGE (GOTTLIEB),  M. D.,
        Professor'•f Physiology and Pathological Anatomy in the University of Brussels, &e.

AN ATLAS  OF  PATHOLOGICAL  HISTOLOGY.   Translated, with Notes
  and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva-
  nia.  In one volume, very large imperial quarto, extra cloth, with 320 figures, plain and colo*ed,
  on twelve copperplates.  $5 00.
GARDNER'S MEDICAL CHEMISTRY, for the
  use of Students and the Profession. In one royal
  12mo. vol., ex. cloth, pp. 396, with illustrations.
  SI 00.
HARRISON'S ESSAY TOWARDS A CORRECT
  THEORY OF THE NERVOUS SYSTEM.  In
  one octavo volume, leather, 292 pages.   SI 50.
HUGHES'  CLINICAL  INTRODUCTION TO
  THE PRACTICE OF AUSCULTATION AND
  OTHER MODES OF PHYSICAL DIAGNOSIS,
  IN DISEASES OF THE LUN GS AND HEART.
  Second American, from the second London edition.
  I vol. royal 12mo., ex. cloth, pp. 304.  SI  00.
                       HAMILTON  (FRANK H.),  M.  D.,
                     Professor of Surgery, in Buffalo Medical College, tee.
A TREATISE  ON  FRACTURES AND DISLOCATIONS.
  octavo volume, with numerous illustrations.   (Preparing.)
In one handsome 
AND  SCIENTIFIC  PUBLICATIONS.
17
                         HOBLYN (RICHARD  D.), M. D.

A DICTIONARY OF  THE  TERMS  USED  IN  MEDICINE  AND THE
  COLLATERAL  SCIENCES.  By Richard D.  Hoblyn, A. M, &c.  A new American from
  the last London edition.  Revised, with numerous Additions, by Isaac Hays, M. D., editor of
  the "American Journal of the Medical Sciences."  In  one large royal 12mo. volume, leather,
  of over 500 double columned pages.  (Just Issued, 1856.)  SI 50.
  *f the frequency with which we have referred to ] nor desire to  procure a larger work. — American
tins volume since its reception from the publisher,  Lancet.
two or  three weeks ago, be  any criterion for the
future, the binding will soon have to be renewed, even
With careful handling.  We find that Dr. Hays has
done the profession great service bv his careful and
industrious labors. The Dictionary has thus become
eminently  suited  to our medical  brethren in  this
eountry.  The additions by Dr. Hays are in brackets,
and we believe there is not a  single page but bears
Oiese insignia; in every instance which we have thus
far  noticed, the additions are really needed and ex-
ceedingly valuable.  We heartily commend the work
to all who wish to be au courant in medical termi-
nology.— Boston Med. and Surg. Journal.

  To both practitioner and student, we recommend
this dictionary as being convenient in size, accurate
in definition, and  sufficiently  full and complete for
ordinary consultation.—Charleston Med. Journ. and
Review.

  Admirably calculated to meet the wants of the
practitioner or student, who has neither  the means
  Hoblyn has always been a favorite dictionary, and
in its present enlarged and improved form will  give
greater satisfaction than ever.  The American editor,
Dr. Hays, has made many very valuable additions.
—N.J. Med. Reporter.
  To supply the want of the medical reader arising
from this cause, we know of no dictionary better
arranged and adapted than the one bearing the above
title.  It is not encumbered with the obsolete terms
of a bygone age, but it contains all that are now in
use ; embracing every department of medical science
down to the very latest date.  The volume is  of a
convenient size to be used by the medical student,
and yet large enough to make a respectable appear-
ance in the library of a physician.—Western Lancet.
  Hoblyn's Dictionary has long been a favorite with
us.   It is the best book of definitions we have, and
ought always to be upon the  student's table.—
Southern Med. and Surg. Journal.
             HOLLAND  (SIR  HENRY),  BART.,  M.D..F. R. S.,
                      Physician in Ordinary to the Queen of England, &c.
MEDICAL  NOTES  AND REFLECTIONS.   From the  third London edition.
  In one handsome octavo volume, extra cloth.  (Now Ready.)  $3 00.
  As the work of a thoughtful and observant physician, embodying the results of forty years' ac-
tive professional experience,  on topics of the  highest interest, this volume is commended to the
American practitioner as well worthy his  attention.  Few will rise from its perusal without  feel-
ing their convictions strengthened, and armed  with new weapons for the daily struggle with
disease.
                                  HUNTER (JOHN).

TREATISE ON  THE  VENEREAL DISEASE.
  Dr. Ph. Ricord, Surgeon to the Venereal Hospital of Paris.
  F. J. Bumstead, M. D.   In one octavo volume, with plates.
Al$so, HUNTER'S COMPLETE WORKS, with Memoir, Notes, &c. &c.
  volumes, leather, with plates.   $10 0C.
 With copious Additions, hy
Edited, with additional Notes, by
$3 25.  I3F* See Ricord.

             In four neat octavo
                        HORNER (WILLIAM  E.),  M. D.,
                    Professor of Anatomy in the University of  Pennsylvania.

SPECIAL  ANATOMY  AND   HISTOLOGY.   Eighth edition.   Extensively
  revised  and modified.  In two large octavo volumes, extra cloth, of more than one thousand
  pages,  handsomely printed, with over three hundred illustrations.  $6 00.
  This edition enjoyed a thorough and laborious revision on the part of the author shortly before
his death, with the view of bringing it fully up to the existing state of knowledge on the subject of
general and special anatomy.  To adapt it more perfectly to the wants of the student, he introduced
a large number of additional wood-engravings, illustrative of the objects described, while the pub-
lishers have endeavored to render the mechanical execution  of the work worthy of its extended
reputation.
                        JONES  (T.  WHARTON),  F. R. S.,
         Professor of Ophthalmic Medicine and Surgery in University College, London, &c.

THE  PRINCIPLES AND  PRACTICE OF  OPHTHALMIC   MEDICINE
  AND SURGERY.  With one hundred and ten illustrations.  Second American from the second
  and revised London edition, with additions by Edward Hartshorne, M.D., Surgeon to Wills'
  Hospital, &c.  In one large, handsome royal  12mo. volume, extra cloth, of 500 pages.  (Now
       ' .)  $1 50.
                                             ly wrought up, and digested in the author's mind,
                                             as to come forth with the freshnens and  impressive-
                                             ness of an original production.  We entertain little
                                             doubt that this book will become  what its author
                                             hoped it might become, a manual for daily reference
                                             and consultation by the student and  the general prac-
                                             titioner.  The work is marked by  that correctness,
                                             clearness, and precision of  style which distinguish
                                             all the productions of the learned author.—British
                                             and For. Med. Review.
  We are confident that the reader will find, on
perusal, that the execution of the work amply fulfils
the promise of the preface, and sustains, in every
point, the already high reputation  of the author ns
au ophthalmic surgeon as well as a physiologist
and pathologist.  The book is evidently the result
of much labor and research, and has been written
with the  greatest care and attention;  it possesses
that best  quality which a general work, like a sys-
tem or manual can show, viz : the quality of having
•31 thematerials whencesoever derived, so thorough- 
18
BLANCHARD &  LEA'S MEDICAL
JONES (C. HANDFIELD), F. R. S., &.  EDWARD H. SIEVEKING, M.D.,
                Assistant Physicians and Lecturers in St. Mary's Hospital, London.

A  MANUAL  OF  PATHOLOGICAL   ANATOMY.   First American Edition,
  Revised.  With three hundred and ninety-seven handsome wood engravings.   In one large and
  beautiful octavo volume of nearly 750 pages, leather.  (Lately Issued.) $3 75.
  As a concise text-book, containing, in a condensed I present condition of pathological anatomy.  In thig
torin, a complete outline of what is known in the  they have been completely successful.  The work is
domain of Pathological  Anatomy, it is perhaps the  one of the best compilations which  we have ever
best work in the English language.  Its great merit I perused.—Charleston Medical Journal and Review.
consists in its completeness and brevity, and in this    We urge upon our readers and the profession gene-
respect it supplies  a great desideratum in our lite- | rally the importance of informing themselves in re-
ra*ure-  Heretofore the student of pathology was  gard to modern views of pathology, and recommend
  l/'u  tog'ean fromagreat number of monographs,  to them to procure the work before  us as the bes
and the field was so extensive that but few cultivated ; means of obtaining this information.—Stethoscop e.
nf^etO?/  d?i?reer0f 8UCC.ess-  As a 8imP,e W0Jk    From  the casual examination we have given we
IK  ',?.  ?^  ll ls of ffreaJt v?,u?Jtl.> the  are inclined to regard it as  a text-book, plain, ra-
bI»,?, Ii   Path°lo£'cal anatomy, and should be in , tional and intelligible, such a book as the practical
every physician's library.—Western Lancet.        | m!ln  neetU for dal)y reference.  For this reason it
  In offering the above titled work to the public, the  will be likely to be largely useful, as  it suits itself
authors have not attempted to intrude new views on  to those busy men who have little time for minute
their professional brethren, but simply to lay before  investigation, and prefer a summary to an elaborate
them, what has long been wanted, an outline of the  tieatise.—Buffalo Medical Journal.
                    KIRKES  (WILLIAM  SENHOUSE),  M.D.,
               Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c.

A  MANUAL  OF   PHYSIOLOGY.   A now  American,  from  the  third and
  improved London edition.  With two hundred illustrations.  In one large and handsome royal
  12mo. volume,  leather,   pp. 586.  $2 00.  (Now Ready, 1857.)
  In again passing this work through his hands, the  author has endeavored to render it a correct
exposition of the  present condition of the science, making such alterations and additions  as have
been dictated by further experience, or as the progress of investigation has rendered desirable.   In
every point of mechanical execution the publishers have sought to make it superior to former edi-
tions, and at the very low price at which it is offered, it will be found one of the handsomest and
cheapest volumes before the profession.
  In making these improvements, care has been exercised not unduly to inerease its size, thus
maintaining its distinctive characteristic of presenting within a  moderate compass a clear and con-
nected view of its subjects, sufficient for the wants of the student.
                                                One of the very best handbooks  of Physiology we
                                               possess—presenting just such an outline of the sci-
  This is a new and very much improved edition of
Dr. Kirkes' well-known Handbook of Physiology.
Oiiginally constructed on the basis of the admirable
treatise of Miller, it has in successive editions  de-
veloped itself into an almost original work, though
no change has been made in the plan or arrangement.
It combines conciseness with completeness, and is,
therefore, admirably adapted for consultation by the
busy practitioner.—Dublin Quarterly Journal, Feb.
1857.
  Its excellence is in its compactness, its clearness,
and its carefully cited authorities.   It is the most
convenient of text-books. These gentlemen, Messrs
Kirkesami Paget, have really an immense talent for
silence, which is not so common or so cheap as prat-
ence, comprising an account of its leading facts and
generally admitted principles, as the student requires
during his attendance upon a course of lectures, or
for reference whilst preparing for  examination.—
Am. Medical Journal.
  We need only say, that, without entering into dis-
cussions of unsettled questions, it contains all the
recent improvements in this department of medical
science. For the student beginning this study, and
the practitioner who has but leisure to refresh his
memory, this book is invaluable,  as it contains all
that it is important to know, without special details,
which  are read  with interest  only by  those who
ing people fancy.  They have the gift of telling us I would makea specialty, or desire to possessa criti-
wnat we want to know, without thinking it neces- | cal knowledge of the subject.—Charleston Medical
sary to  tell us all they know.—Boston Med  and . Journal.
Surg. Journal, May 14, 1857.                     I
KNAPP'S TECHNOLOGY; or,Chemistry applied
  to the Arts and to Manufactures.  Edited, with
  numerous Notes and Additions, by Dr. Edmund
  Ronalds and Dr.  Thomas Richardson.  First
  American edition,  with Notes and Additions, by
  Prof. Walter R. Johnson.  In two handsome
  octavo volumes, extra cloth, with about 500 wood-
  engravings.  $6 00.
L.ALLEMAND ON SPERMATORRHOEA. Trans-
  lated and edited by Henry J. McDougal. In one
  volume, octavo, extra cloth, 320 pages.  Second
  American edition.  $1 75.
                               LUDLOW (J.  L.), M.  D.
A  MANUAL  OF  EXAMINATIONS  upon  Anatomy,  Physiology,  Surgery,
  Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics.  To
  which is added a Medical Formulary.  Designed for Students of Medicine throughout the United
  States.   Third edition, thoroughly  revised and greatly extended  and enlarged.   With three
  hundred and seventy illustrations.  In one large and  handsome royal 12mo. volume,  leather, of
  over 800 closely printed pages   (Now Ready.)  $2 50.
  The great popularity of this volume, and the numerous demands for it during the two years in which
it has been out of print, have induced the author in its  revision to  spare no pains to render it  a
correct and accurate digest of the most recent condition of all the branches of medical science.  In
many respects it may, therefore, be regarded rather as a new book than a new*edition, an entire
section on Physiology having been added, as also one  on Organic Chemistry, and many portions
having been rewritten.  A very complete series of illustrations has been introduced, and every
care has been  taken in the mechanical execution to render it a convenient and satisfactory book for
study or reference.
  The arrangement of the volume in the form of question and answer renders it especially suited
for the office examination of students and for those preparing for graduation.
  We know if  no better companion for the student I crammed into his head by the various professors to
during the hours spent in the lecture room, or to re-   whom he is  compelled   listen.— We stern Lancet,
fresh, at a glance, his memory of the various topics | May, 1857. 
AND SCIENTIFIC  PUBLICATIONS.                    19
                                LEHMANN (C. G.)

PHYSIOLOGICAL  CHEMISTRY.   Translated  from  the  second  edition  by
  George E. Day, M. D., F. R. S., fee , edited by R. E. Rogers, M. D., Profe»or of Chemistry
  ui the  Medical Department of the  University of Pennsylvania, with illustrations selected from
  tunke's Atlas of Physiological Chemistry, and an Appendix of plates.  Complete in two large
  and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus-
  trations.   (Just Issued.)  $6 00.
  This great work, universally acknowledged as the most complete and authoritative exposition of
the principles and details of Zoochemistry, in its passage through the press, has  received from
Professor Rogers such care as was necessary to present it in a correct and reliable form   To such
a work additions were deemed superfluous, but several years having  elapsed between the appear-
ance in Germany of the first and last volume, the latter contained a supplement, embodying nume-
rous corrections and additions resulting from  the advance of the science.  These have all been incor-
porated in the text in their appropriate places,  while the subjects have been still further elucidated by
the insertion of illustrations from the Atlas of Dr. Otto Funke.  With the view of supplying the student
with the  means of convenient comparison, a  large number of wood-cuts, from works on kindred
subjects,  have also been added in the form of  an Appendix of Plates.  The work is, therefore, pre-
sented as in every way worthy the attention  of all who desire to be familiar with the modern facts
and doctrines of Physiological Science.

  The most important contribution as yet  made to ! it treats.—Edinburgh Monthly Journal of Medical
Physiological Chemistry—Am. Journal Med. Sci- j Science.
tnces, Jan. 1856.                                  .,  .     ...        ,       . , ,.   .,
     '                                          Already well known and appreciated by the scien-
  The present volumes belong to  the small class of | tific world, Professor  Lehmann's great  work re-
medical literature which comprises elaborate works  quires no laudatory sentences, as, under a new garb,
of the highest order of merit.—Montreal Med. Chron-  it is now presented to us.  The  little space at our
tele, Jan. 1856.                                  command would ill suffice to set forth even a small
  The work of Lehmann  stands unrivalled as  the  portion of  its excellences.—Boston Med. and Surg.
most comprehensive book of reference and informa-  Journal, Dec. 1855.
tion extant on every branch of the subject on which

                         BY THE SAME AUTHOR.  (Just Issued, 1856.)

MANUAL  OF  CHEMICAL  PHYSIOLOGY.    Translated from the  German,
  with Notes and Additions, by J. Cheston  Morris, M. D., with an Introductory  Essay on Vital
  Force, by Samuel Jackson, M. D., Professor of the Institutes of Medicine  in  the University of
  Pennsylvania.  With illustrations on wood.  In one very handsome octavo volume, extra c!oth,
  of 336 pages.  $2 25.

                         From Prof. Jackson''s Introductory Essay.

  In adopting the handbook  of Dr. Lehmann as a manual  of Organic Chemistry for the use of the
students  of the University, and in recommending his original work of Physiological Chemistry
for their more mature studies,  the high value of his researches, and the great weight of his autho-
rity in that important department of medical  science are fully recognized.

  The present volume will be a very convenient  one I densed form, the positive  facts of Physiological
for students, as offering a brief epitome of the more  Chemistry.—Am. Journal Med. Sciences, April, 1856.
elaborate work, and as containing, in a very con- [
                         LAWRENCE (W.), F. R. S., Etc.

A TREATISE  ON  DISEASES   OF  THE  EYE.   A  new  edition,  edited,
  with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi-
  tal, &c.  In one very large and handsome octavo volume, of 950 pages, strongly bound in leather
  with raised bands.  $5 00.
  This work is so universally  recognized  as the standard authority on the subject, that the pub-
lishers in presenting this new edition have  only to remark that in  its preparation the editor has
carefully revised every portion, introducing additions and illustrations wherever the advance of
science has rendered them necessary or  desirable, constituting  it  a complete  and thorough
exponent of the most advanced state of the subject.
  This admirable treatise—the safest guide and most | octavo pnges—has enabled both author and editor to
comprehensive work of reference, wnich is within  do justice to all the details of this subject, and con-
the reach of the profession.—Stethoscope.          | dense in this single  volume the  present state of our
                                              knowledge of the whole science in this department,
  This  standard  text-book  on the  department of  whereby its practical value cannot be excelled. We
which it treats, has not been superseded, by any or  heartily commend it, especially as a book of refer-
all of the numerous publications on the  subject  ence, indispensable  in  every medical library.  The
heretofore issued. Nor with the multiplied improve- i additions of the American editor very greatly  en-
mentsof Dr. Hays, the American editor,  is  it at all  hance the value of the work, exhibiting the learning
likely that this great work will  cease to merit the | and experience of Dr. Hays, in the light in which he
confidence and preference of students or practition-  ought to  be held, as a standard authority on all sub-
ers.  Its ample extent—nearly one thousand large, jects appertaining to this specialty.—N.Y. Med. Gaz.
                    LARDNER  (DION YSI US),  D. C.  L., &.c.
HANDBOOKS   OF   NATURAL   PHILOSOPHY   AND  ASTRONOMY.
  Revised, with numerous Additions, by the American editor.  First Course, containing Mecha-
  nics  Hydrostatics, Hydraulics, Pneumatics,  Sound,  and Optics.  In  one large royal  12mo.
  volume, of 750 pages, with 424 wood-cuts. $1 75. Second Course, containing Heat, Electricity,
  Magnetism, and Galvanism, one volume, large royal 12mo., of 450 pages, with 250 illustrations.
  91 25.  Third Course (now ready), containing Meteorology and Astronomy, in one large volume,
  royal 12mo. of nearly 800 pages, with 37 plates and 200 wood-cuts.  $2 00. 
80
BLANCHARD  & LEA'S MEDICAL
vvmr\r*r                LA  R0CHE  (R->,  M. D., &c.
YELLOW  FEVER, considered  in its Historical,  Pathological, Etiological, and
  Therapeutical Relations.  Including a Sketch of the Disease as it has occurred in  Philadelphia
  trom lby9to 1854, with an examination of the connections between it and the fevers known under
  the same name in other parts of temperate  as  well as in tropical regions.  In  two large  and
  handsome octavo volumes of nearly 1500 pages, extra cloth.   (Just Issued.)  $7 00.
 From Professor S. IT. Dickson, Charleston, S. C,
              September 18, 1855.
  A monument of intelligent and well applied re-
search, almost without example.  It is, indeed, in
itself, a large  library, and is destined to constitute
the special resort as  a book of reference, in  the
subject of which it treats, to all future time.
  We have not time at present, engaged as we are,
by da# and by night, in the work of combating this
very disease, now prevailing in our city, to do more
than give  this cursory notice of what we consider
as undoubtedly the most able and  erudite  medical
publication our country has yet produced   But in
view of the startling fact, that this, the most malig-
nant and unmanageable disease of modern times,
has for several years been prevailing in our country
to a greater extent than ever before; that it is no
longer confined to either large or small  cities, but
penetrates country villages, plantations, and farm-
houses;  that it is treated with scarcely better suc-
cess now than thirty or forty years ago;  that there
is vast mischief done by ignorant pretenders to know-
ledge in regard to the disease, and in view of the pro-
bability that a majority of southern physicians will
be called upon to treat the disease, we trust that this
able and comprehensive treatise will be very gene-
rally read  in the south.—Memphis Med. Recorder.
  This is decidedly the great Americnn medical work
of the day—a full, complete, and systematic treatise,
unequalled by any other upon the all-important sub-
ject of Yellow Fever.  The laborious, indefatigable,
and learned author has devoted to it many years of
                                    BY THE SAME AUTHOR.

PNEUMONIA;  its Supposed Connection, Pathological  and Etiological, with Au-
  tumnal Fevers, including an Inquiry into the Existence and  Morbid Agency of Malaria.  In one
  handsome octavo volume, extra cloth, of 500 pages.  $3 00.
  A more simple, clear, and forcible exposition ofl   This work should be carefully studied hy Southern
the groundless nature and dangerous tendency of |  physicians, embodying as  it does the reflections of
certain pathological  and  etiological  heresies, has l  an original thinker and close observer on a subject
seldom been presented to our notice.—N. Y. Journal  peculiarly their own.—Virginia Med. and Surgical
of Medicine and Collateral Science.              \  Journal.

                    LAYCOCK (THOMAS),  M. D.,  F. R. S. E.,
          Professor of Practical and Clinical Medicine in the University of Edinburgh, tec.

LECTURES   ON  THE  PRINCIPLES  AND  METHODS   OF  MEDICAL
  OBSERVATION  AND  RESEARCH.  For the Use of Advanced Students and Junior Prac-
  titioners. In one very neat royal 12mo. volume, extra cloth.  Price $1 00.  (Just Published, 1857.)
  A review of the book cannot now be attempted ;
and our desire is simply to recommend it to all—not
arduous research and careful study, and the result
is such as will  reflect the highest honor upon the
author and our country.—Southern Med. and Surg.
Journal.
  The genius and scholarship of this great physician
could not have  been better employed than in the
erection of this towering monument to his own fame,
and to the glory of the medical literature of his own
country.  It is destined to remain the great autho-
rity upon the subject of Yellow Fever.  The student
and physician will find in these volumes a risumi
of the sum total of the knowledge of the world upon
the awful scourge which they so elaborately discuss.
The style is so soft and so pure as to refresh and in-
vigorate the mind while absorbing the thoughts of
the gifted author, while the publishers have sue-
ceeded in bringing the externals into a most felicitous
harmony with  the inspiration  that dwells within.
Take it all in all, it is a book we have often dreamed
of, but dreamed not that it would ever meet  our
waking eye as a tangible reality.—Nashville Journal
of Medicine.
  We deem  it fortunate that the splendid worb of
Dr. La Roche should have been issued from the press
at this particular time.  The want of a reliable di-
gest of all that is known in relation to this frightful
malady has long been felt—a want very satisfactorily
met in the work before us.  We deem it but faint
praise to say that Dr. La Roche has succeeded in
presenting the profession with an able and complete
monograph, one. which will find its way into every
well ordered library.—Va. Stethoscope.
merely the class for which it was designed; since
there are many senior practitioners in full and (pe-
cuniarily)  successful practice who would be very
much benefited by a close study of its precepts and
principles.—Va. Med. Journal, March, 1857.
  To the medical investigator, who would be philo-
sophical, and who would accustom himself  to ob-
serve  and  to  think, the work  before us will  be
scarcely less than a cyclopaedia—a treasury of logi-
cal professional thought and reasoning.  Appropri-
ated ton heretofore unoccupied field of research, and
designed to fill an obvious hiatus, in medical litera-
ture, it may in truth, from its discussiveness of rea-
soning, and its  copiousness  us regards number and
variety of topics, with great propriety be denomi-
nated multum inparvo.—Medical Independent, De-
troit, April, 1857.
  This is a most interesting  and suggestive little
work.—iV. J. Med. Reporter, March, 1857.
MULLER'S PRINCIPLES OF PHYSICS AND  METEOROLOGY.   Edited,
  with Additions, by R. Eglesfeld Griffith, M. D.  In one large and handsome octavo volume,
  extra cloth, with 550 wood-cuts, and two colored plates,  pp. 636.  f 3 50.

                             MILLER (HENRYl, M.  D.,
     Professor of Obstetrics and Diseases of Women and Children in the University of Louisville.
PRINCIPLES  AND PRACTICE OF OBSTETRICS, &c; including the  Treat-
  ment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent
  cause of Abortion.  With illustrations on wood.  In one very handsome octavo volume,  of over
  600 pages.  (In Press.)
  The very favorable reception accorded by the profession to the " Treatise on Hftman Parturition,"
published some years since by Prof. Miller, is an earnest that the present work will fulfil the author's
purpose of providing within  moderate compass an accurate and trustworthy text-book for the stu-
dent, and work  of reference  for the Obstetric practitioner.   Based upon  the former work,  but en-
larged to more than double its size, and almost entirely rewritten, it presents the matured experience
gained in long and extensive practice, while the author's position as a teacher for  so many years
has given him  a familiarity with  the  wants of students, and  a facility of conveying instruction,
which cannot fail to render the volume eminently adapted to its purposes. 
AND  SCIENTIFIC  PUBLICATIONS.                   21
                          MEIGS (CHARLES D.),  M. D.,
             Professor of Obstetrics, tec. in the Jefferson Medical College, Philadelphia.

OBSTETRICS:  THE  SCIENCE  AND  THE  ART.   Third  edition, revised
  and improved.  With one hundred and twenty-nine illustrations In one beautifully printed octavo
  volume, leather, of seven hundred and fifty-two large pages.  $3 75.
  The rapid demand for  another edition of this work is a  sufficient expression of the favorable
verdict of the profession.  In thus preparing it a third time for the press, the author has endeavored
to render it in every  respect worthy of the favor which  it has received.  To accomplish this he
has thoroughly revised it in every part.  Some portions have been rewritten,  others added, new
illustrations have been in many instances substituted for such  as were not  deemed satisfactory,
while, by an alteration in the typographical arrangement, the size of the work has not been  increased,
and the price remains unaltered.  In its present improved form, it is, therefore, hoped that the work
will continue to meet the wants of the American profession as a  sound, practical, and extended
System of Midwifery.
  Though the work has received only five  pages of
enlargement, its chapters throughout wear the im-
press of careful revision. Expunging and rewriting,
remodelling its sentences, with occasional new ma-
terial, aU <"ince a lively desire that it shall deserve
to be regarded as improved in manner as well as
matter.  In the matter, every stroke of the pen has
increased the value of the book, both in expungings
and additions —Western Lancet, Jan. 1857.

                          by  the same author.  (Lately Issued.)

WOMAN:  HER DISEASES AND  THEIR REMEDIES.   A Series of Lec-
  tures to his Class.  Third  and Improved edition.  In one large and beautifully printed  octavo
  volume, leather.    pp. 672.  $3  60.
  The gratifying appreciation of his labors, as evinced by the exhaustion of two large impressions
of this work within a few years, has not been lost upon the  author, who has endeavored in every
way to render it worthy of the favor with which it has been  received.   The opportunity thus
afforded for a second revision has been improved, and the work  is now presented as in every way
superior to its predecessors, additions and alterations having been made whenever the advance of
Bcience has rendered them desirable.  The typographical execution of the work will also be found
to have undergone a similar improvement, and the work is  now confidently presented as in every
way worthy the position it has acquired as the  standard American  text-book on the Diseases of
Females.
  The best American work on Midwifery that is
accessible  to the student and practitioner—N. W.
Med. and Surg. Journal, Jan. 1857.
  This is a standard work by a great American Ob-
stetrician.   It is the third and last edition, and, in
the language of the preface, the author has "brought
the subject up to the latest dates  of real improve-
ment in our art and Science."—Nashville Journ. of
Med. and Surg., May, 1857.
  It contains u vast amount of practical knowledge.
by one who has accurately observed and retained
the experience of many years, and who tells the re-
sult in a free, familiar, and pleasant manner.—Dub-
lin Quarterly Journal.
  There is an off-hand fervor, a glow, and a warm-
heartedness infecting the efT)rt of Dr. Meigs, which
is entirely captivating, and which  absolutely hur-
ries the reader through from beginning to end.  Be-
sides, the  book teems with solid instruction,  and
it shows the very highest evidence  of ability, viz.,
the clearness with which the information  is pre-
sented.  We know of no better test of one's under-
standing a subject than the evidence of the power
of lucidly explaining it.  The most elementary, as
well  as the obscurest subjects, under the pencil of
Prof. Meigs, are isolated and made to stand out in
such bold relief, as to produce distinct impressions
upon the mind and  memory of the reader.— The
Charleston Med. Journal.
  Professor Meigs has enlarged and amended this
great work, for such it  unquestionably is,  having
passed the ordeal of criticism at home and abroad,
but been improved thereby ;  for in this new edition
the author has introduced real improvements, and
increased the value  and utility of  the book im-
measurably.  It presents so many novel,  bright,
and sparkling thoughts; such an exuberance of new
ideas on almost every page, that we confess our-
selves to have become  enamored  with the book
and its author; and cannot withhold our congratu-
lations from our Philadelphia confreres, that such a
teacher is in  their service.—N.  Y. Med. Gazette.
          by the same author.  (Lately Published.)
NATURE,   SIGNS,   AND   TREATMENT   OF  CHILDBED
ON   THE
  FEVER.  In  a Series of Letters addressed  to  the Students of his Class.
  octavo volume, extra cloth, of 365 pages.  $2 50.
In one handsome
  The instructive and interesting author  of  this
work, whose previous labors in the department of
medicine which he so sedulously cultivates, have
placed his countrymen under deep and abiding obli-
gations, again  challenges their admiration in the
fresh and vigorous, attractive and racy pages before
as.  It is a delectable book. * *  *  This treatise
upon child-bed  fevers will have an extensive sale,
being destined,  as it deserves, to find a place in the
library of every practitioner who scorns to lag in the
rear of his  brethren.—Nashville Journal of Medi-
cine and Surgery.
                       BY THE SAME AUTHOR J  WITH COLORED PLATES.

A  TREATISE  ON ACUTE AND  CHRONIC DISEASES  OF  THE  NECK
  OF THE UTERUS.  With numerous plates, drawn and colored from nature in the highest
  style of art.   In.one handsome octavo volume, extra cloth.  $4 50.
MAYNE'S DISPENSATORY
  This book will add more to his fame than either
of those which bear his  name.  Indeed we doubt
whether any material improvement will be made on
the teachings of this volume  for a century to come,
since it is so eminently practical, and based on  pro-
found knowledge of the  science and  consummate
skill  in the art of healing, and ratified by an ample
and extensive experience, such as few men have the
industry or good  fortune to acquire.—N. Y. Med.
Gazette.
                            AND   THERA-
PEUTICAL REMEMBRANCER.  Comprising
the entire lists of Materia Medica, with every
Practical Formula contained in the three British
Pharmacopreins   Edited, with the addition of the
Formula? of the U. S. Pharmacopoeia, by R. E.
Griffith,M.D.  1 12mo. vol. ex.cl.,300pp. 75 c.
MALGAIGNE'S OPERATIVE SURGERY, based
  on Normal and Pathological Anatomy.  Trans-
  lated from the French  by Frederick Brittan,
  A. B.,M.D. With numerous illustrations on wood
  In one handsome octavo volume, extra cloth, of
  nearly six hundred pages.  $2 35. 
22
BLANCHARD &  LEA'S  MEDICAL
„T                     MACLISE (JOSEPH),  SURGEON.
  ■ur k         ANATOMY.   Forming  one volume,  very  large  imperial  quarto.
  With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored.  Con-
  taining one hundred and  ninety Figures, many of them the size of life.  Together with copious
  and explanatory letter-press.   Strongly  and handsomely  bound  in extra cloth, being one  of the
  cheapest and best executed Surgical works as yet issued  in this country.  $11 00.
  , * ,^ne s'ze OI"this work prevents its transmission through the post-office as a whole, but those
who desire to have copies  forwarded  by  mail, can receive  them in  five parts, done up in stout
wrappers.  Price $9  00.

  One of the greatest artistic  triumphs of the  age
m Surgical Anatomy.—British American Medical
Journal.
  Too  much cannot be said in its praise; indeed,
we have not language to doit justice.—Ohio Medi-
cal and Surgical Journal.
  The most admirable surgical atlas we have seen.
To the practitioner deprived of demonstrative dis-
sections upon the human subject, it is an invaluable
companion.—N. J. Medical Reporter.
  The  most accurately engraved  and beautifully
colored  plates  we have ever seen in an American
book—one of the best and cheapest surgical works
ever published.—Buffalo Medical Journal.
  It is  very rare that so elegantly printed, so well
illustrated, and so useful  a work, is  offered at so
moderate a price.—Charleston Medical Journal.
  Its plates can boast a superiority which places
them almost beyond the reach of competition.—Medi-
cal Examiner.
  Every practitioner, we think, should have a work
of this kind within reach.—Southern  Medical and
Surgical Journal.
  No such lithographic illustrations of surgical re-
gions have hitherto, we think, been given.—Boston
Medical and Surgical Journal.

  As a surgical  anatomist, Mr. Maclise has  proba-
bly no superior.—British and Foreign Medico-Chi-
rurgical Review.

  Of great value to the student engaged in dissect-
ing, and to the surgeon at a distance from the means
                                               of keeping up his anatomical knowledge.—Medical
                                               Times.
                                                 The  mechanical execution cannot be excelled.—
                                               Transylvania Medical Journal.

                                                 A work which has no parallel in point of accu-
                                               racy and cheapness in the English language.—N. Y
                                               Journal of Medicine.
                                                 To all engaged in  the study or practice of their
                                               profession, such  a work is almost  indispensable.—
                                               Dublin Quarterly Medical Journal.

                                                 No practitioner whose means will admit should
                                               fail to possess it__Ranking's Abstract.

                                                 Country practitioners will find these plates of im-
                                               mense value__N. Y. Medical Gazette.
                                                 We  are extremely gratified to announce to the
                                               profession the completion of this truly magnificent
                                               work,  which, as a  whole,  certainly  stands unri-
                                               valled,  both for accuracy of drawing,  beauty of
                                               coloring, and all the requisite explanations of the
                                               subject in hand.—The New Orleans  Medical and
                                               Surgical Journal.

                                                 This is by far the  ablest work on Surgical Ana-
                                               tomy that has come under our observation.  We
                                               know of no  other work that would justify a stu-
                                               dent, in any degree, for  neglect of actual dissec-
                                               tion.  In those  sudden emergencies that so often
                                               arise, and which require the instantaneous command
                                               of minute anatomical knowledge, a work of this kind
                                               keeps the details of the dissecting-room perpetually
                                               fresh in the memory.—The  Western Journal of Medi-
                                               cine and Surgery.

        The very low price at which this work is furnished, and  the beauty of its execution,
require an extended sale to compensate the publishers for  the heavy expenses incurred.
      MOHR (FRANCIS), PH. D., AND REDWOOD (TH EOPH I LUS).
PRACTICAL  PHARMACY.    Comprising the Arrangements,  Apparatus, and
  Manipulations of the  Pharmaceutical Shop  and Laboratory.  Edited, with extensive Additions,
  by  Prof. William Procter, of the Philadelphia  College  of Pharmacy.  In one handsomely
  printed octavo volume, extra cloth, of 570 pages, with over 500 engravings on wood.   $2 75.
                             MACKENZIE  (W.),  M.D.,
                  Surgeon Oculist in Scotland in ordinary to Her Majesty, &c. &c.

A  PRACTICAL  TREATISE ON  DISEASES   AND INJURIES  OF  THE
  EYE.   To which is prefixed an Anatomical Introduction explanatory of  a Horizontal Section ol
  the Human Eyeball, by Thomas Wharton Jones, F. R. S.  From the Fourth Revised and En-
  larged  London Edition.  With Notes and Additions by Addinell Hewson, M. D., Surgeon to
  Wills Hospital, &c. &c. In one very large and handsome octavo volume, leather, raised bands, with
  plates  and numerous wood-cuts.   $5 25.
  The treatise of Dr. Mackenzie indisputably holds i accordance with the advances in the science which
the first place, and forms, in respect of learning and  have been made of  late years.   Nothing worthy of
research, an Encyclopaedia unequalled in extent by  repetition upon any  branch of the subject appears to
any other work of the kind, either English or foreign,  have escaped the author's notice  We consider it
—Dixon on Diseases of the Eye.

  Few modern books on any department of medicine
or surgery have met with  such extended circulation,
or have procured for their authors a like amount of
European celebrity.  The immense research which
it displayed,  the thorough acquaintance with  the
subject, practically as well as theoretically, and the
able manner in which the author's stores of learning
and experience were rendered available for general
use, at once procured for  the first edition, as well on
the  continent  as in this country, that high position
as a standard work which each  successive edition
has more firmly established, in spite of the attrac-
tions of several rivals of no mean ability.  This, the
fourth edition, has been in a great measure re-writ-
ten ; new matter, to the extent of one hundred and
fifty pages, has been added, and in several instances
formerly expressed opinions have been modified in
the duty of every one who has the love of his profes-
sion and the welfare of his patient at heart, to make
himself familiar with this the most complete work
in the English language upon the diseases of the eye.
—Med. Times and Gazette.
  The  fourth edition of this standard work will  no
doubt be as fully appreciated as the three former edi-
tions.  It is unnecessary to say a word in its praise,
for the verdict has already been passed upon it by
the most competent judges, and " Mackenzie on the
Eye" has  justly obtained a reputation which it is
no figure of speech to call world-wide.—British and
Foreign Medico-Chirurgical Review.
  This new edition of Dr.  Mackenzie's celebrated
treatise on diseases of the eye, is truly a miracle of
industry and learning.  We need scarcely say that
he has entirely exhausted the subject of his specialty.
—Dublin Quarterly Journal. 
AND  SCIENTIFIC  PUBLICATIONS.                  23
                           MILLER (JAMES), F.  R. S.  E.,
                     Professor of Surgery in the University of Edinburgh, tec.

PRINCIPLES  OF  SURGERY.   Fourth  American, from the third  and revised
  Edinburgh edition. In  one large and very beautiful  volume, leather, of 700 pages, with two
  hundred and forty exquisite illustrations on wood.  (Just Issued, 1856.)    $3 75.
  The extended reputation enjoyed by this work will be fully maintained by the present edition.
Thoroughly revised by the author, it will be found a clear and compendious exposition of surgical
science in its most  advanced condition.
  In connection with the recently  issued third edition of the author's "Practice of Surgery," it
forms a very complete system of Surgery in all its branches.

  The work of Mr. Miller is too well and too favor-  I putation, or seeks the interests of his  clients, can
ably known among us, as one of our best text-books,  | acquit himself before his God and the world without
to render any further notice of it necessary than the  , making himself familiar with the sound and philo-
sophical views developed in the foregoing book.—
New Orleans Med. and Surg. Journal.
  Without doubt the ablest exposition of the prin-
ciples of that branch of the healing art in any lan-
guage. This  opinion, deliberately formed after a
careful study of the first edition, we have had no
cause to change on examining  the second.  This
edition has undergone thorough revision  by the au-
thor; many expressions have  been  modified, and a
mass of new matter introduced.   The book is got up
in the finest style, and is an evidence of the progress
of typography in  our country.—Charleston Medical
Journal and Review.
announcement of a new edition, the fourth in our
country, a proof of its extensive circulation among
us. As a concise and reliable exposition of the sci-
ence of modern surgery, it stnnds deservedly high—
we know not its superior__Boston Med. and Surg.
Journal.
  It presents the most satisfactory exposition of the
modern doctrines of the principles of surgery to be
found in any volume in any language.—N. Y. Journal
of Medicine.
  The work takes rank with Watson's Practice of
Physic; it certainly does not fall  behind that  great
work in soundness of principle or depth of reason-
ing and research-  No physician who values his re-

                          by the same author.  (Lately Published.)

THE  PRACTICE  OF  SURGERY.    A  new  American  from the last  Edin-
   burgh edition.  Illustrated by three hundred  and nineteen engravings on wood.  In one large
   octavo  volume, leather, of over 700 pages.  $3 75.
  No encomium of ours could add to the popularity I his works, both on the principles  and practice of
of Miller's Surgery.  Its reputation in this country i surgery have been assigned the highest rank.  Ifwe
is unsurpassed by that of any other work, and, when | were limited to but one work on surgery, that one
taken in connection with the author's Principles of\ should be Miller's, as we regard it as superior to all
Surgery, constitutes  a whole, without reference to I others.—St. Louis Med. and Surg. Journal.
which  no conscientious surgeon would be willing    „,.         ,. ..    ...  ...            ...... _
to practice his art. The additions, by  Dr. Sargent,    The author, distinguished alike as a practitioner
have materially enhanced the value of the work.-  and w,rlteV has 'n lhis Hnl1  h'8.   Principles.-'  pre-
Southern  Medical and Surgical Journal.           rented to the profession one of the most co.npleteand
   ,  .                   ,                        reliable  systems of Surgery extant.  His style of
   It is seldom that two volumes have ever made so  wrjtjng is original, impressive, and engaging, ener-
profound  an  impression in  so short a time  as the  getic  concise, and lucid. Few have the faculty of
" Principles" and  the  " Praetice" of Surgery by
Mr. Miller—or so richly merited the reputation they
have acquired.  The author is an  eminently sensi-
ble, practical, and well-informed man, who knows
exactly what he is talking about and exactly how to
talk it.—Kentucky Medical Recorder.
  By the almost unanimous voice of the profession,
condensing so much in small space, and at the same
time so persistently holding the attention: indeed,
he appears to make the very process of condensation
a means of eliminating attractions.  Whether as a
text-book for  students or a book of reference for
practitioners,  it cannot be too strongly recommend-
ed.— Southern Journal of Med. and Phys. Sciences.
               MONTGOMERY (W. F.),  M.  D.,  M. R.  I. A., fee.,
        Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c.

AN  EXPOSITION OF THE SIGNS  AND  SYMPTOMS OP  PREGNANCY.
  With some other Papers on Subjects connected with Midwifery.  From the second and enlarged
  English edition.  With two exquisite colored plates, and numerous wood-cuts.  In one very
  handsome octavo volume, extra cloth,  of nearly 600 pages.  (Now  Ready, 1807.)  S3 75.
  The present edition of this classical volume is fairly entitled to be regarded as anew work, every
sentence having been carefully rewritten, and the whole increased to  more than double the  original
size.   The title of the work scarcely does justice  to the  extent and importance of the topics
brought under consideration, embracing,  with the exception of the operative procedures  of mid-
wifery, almost everything connected with obstetries, either directly or incidentally ; and there are
few physicians who will not  find in its pages much that will prove of great interest and value in
their daily practice.  The special Essays on the Period of'Human Gestation, the Signs of Delivery,
and the Spontaneous Amputation and other Lesions of the Foetus in Utero present topics of the
highest interest  fully treated and beautifully illustrated.
  In every point of mechanical execution the work will be found one  of the handsomest yet issued
from the American press.
  A book unusually rich in practical suggestions.—
Am Journal Med. Sciences, Jan. 1857.
  These several subjects so interesting in  them-
selves, and so important, every one of them,  to the
most delicate and precious of social relations, con-
trolling often the honor and domestic peace of a
family! the legitimacy of offspring, or the life of its
parent, are all treated with an elegance  of diction,
tulness of illustrations, acuteness and justice of rea-
soning, unparalleled in obstetrics, and unsurpassed in
medicine.  The reader's  interest can never flag, so
fresh, nnd vigorous, and classical is our author's
st>le;  and one forgets,  in the renewed charm of
every page, that it, and every line, and every word
has been weighed and reweighed through years of
preparation ; that this is of all others the book of
Obstetric Liw, on each of its several topics; on all
points conn, cted with pregnancy, to be everywhere
received as a manual of special jurisprudence, at
once announcing fact, afforJing argument, establish-
ing precedent, and governing alike the juryman, ad-
vocate, and judge.  It is not merely in its legal re-
lations that we find this work so interesting.  Hardly
a page but that has its hints or facts important to
the general practitioner;  and not a chapter without
especial matter for the  anatomist,  physiologist, or
pathologist. —N. A. Mtd.-Chir. Review,  March,
1857. 
24
BLANCHARD  &  LEA'S  MEDICAL
                               NEILL (JOHN), M. D.,
                         Surgeon to the Pennsylvania Hospital, &c; and

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

AN  ANALYTICAL  COMPENDIUM  OF  THE  VARIOUS   BRANCHES
  OF MEDICAL SCIENCE; for the Use and Examination of Students.  A new edition, revised
  and improved.  In one very large and  handsomely printed royal  12mo. volume, of about one
  thousand pages, with 374 wood-cuts.  Strongly bound in leather, with raised  bands.  $3 00.
  The very flattering reception which has been accorded to this work, and the high estimate placed
upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex-
hausted two large editions, have stimulated the authors to render the volume in its present revision
more worthy of the success which has attended it.  It  has accordingly been thoroughly examined,
and such errors as had on former occasions escaped observation have been corrected, and whatever
additions were necessary to maintain it on a level with the advance of science have been introduced.
The extended series of illustrations has been  still further increased and much improved, while, by
a slight enlargement of the page, these various additions have been incorporated without increasing
the bulk of the volume.
  The work is, therefore, again presented as eminently worthy of the favor with which it has hitherto
been received.  As a book for daily reference by the student requiring a guide to his more elaborate
text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate
examination,  or as a source from which the practitioners of older date may easily and cheaply acquire
a knowledge of the changes and improvement in professional science, its reputation is permanently
established.
  The best -work of the kind with which we are
acquainted.—Med. Examiner.
  Having made free use of this volume in our ex-
aminations of  pupils, we can speak from experi-
ence in recommending it as an admirable compend
for students, and as especially useful to preceptors
who examine their pupils.  It will save the teacher
much  labor by enabling him  readily to recall all of
the  points upon which  his  pupils  should  be ex-
amined.  A work of this sort should be in the hands
the students is heavy, and review necessary for an
examination, a compend is not only valuable, but
it is almost a sine qua non.  The one before us is,
in most of  the divisions, the most unexceptionable
of all books of the  kind that  we know of.   The
newest and soundest doctrines and the latest im-
provements and discoveries  are explicitly, though
concisely, laid before the student.  There is a clasf
to whom we very sincerely commend this cheap book
as worth its weight in silver—that class is the gradu-
of every one who takes pupils into his office with a  atf8 ln medicine of more than ten years' standing,
view of examining them; and this is unquestionably  wno hav,e not studied medicine since.   They will
the bestofits class.—Transylvania Med. Journal.   ! perhaps find out from it that tlie science isn<>t exactly
                                             | now what it was when they left it off.—The Stetho-
  In  the rapid  course of lectures, where work for I scope
                              NEILL (JOHN),  M. D.,
                  Professor of Surgery in the Pennsylvania Medical College, &c.
OUTLINES OF THE VEINS AND LYMPHATICS.   With handsome colored
  plates.  1 vol., cloth. $1 25.
OUTLINES OF THE  NERVES.   With handsome plates.   1  vol., cloth. $1  25.
               NELIGAN (J.  MOORE), M. D., M. R.  I. A., &.c.
                             (A splendid work.  Just Issued.)

ATLAS OF CUTANEOUS DISEASES.   In one beautiful quarto volume, extra
  cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of
  disease.  $4 50.
  This beautiful volume is intended as a complete and accurate representation of all the varieties
of Diseases of the Skin.  While it can be consulted in conjunction with any work on Practice, it has
especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the
profession some years since.  The publishers feel justified in saying that few more beautifully exe-
cuted plates have ever been presented  to the profession of this, country.
  The diagnosis of eruptive disease, however, under I placed within its reach and at a moderate cost a most
sril circumstances, is very difficult.  Nevertheless  accurate and well delineated series of plates illus-
Dr. Neligan  has certainly, "as far as  possible," | trating the eruptive disorders.  Tliese plates are all
given a faithful and accurate representation  of this j drawn from the life, and in many of them thedaguer-
cJass of diseases, and there can be no doubt that  reotype has been employed with great success.  Such
these plates will be of great use to the student and i works as these are especially useful to country prae-
practitioner in drawing a diagnosis as to the class, j titioners, who have not an opportunity of seeing the
order, and species to which the particular case may
belong.  While looking over the " Atlas" we have
been induced to examine also the " Practical Trea-
tise," and we  are inclined to consider it a very su-
perior work, combining accurate verbal description,
rarer forms of cutaneous disease, and hence need th«
aid of illustrations to give them the requisite infor-
mation on the subject.  With these plates at hand,
the inexperienced practitioner is enabled to discri-
minate with much accuracy, and  he is thus, com-
with sound views of the pathology and treatment of j paratively speaking, put on an equal footing with
eruptive diseases.—Glasgow Med. Journal.        i those who have had the opportunity of visiting the
  The profession owes its thanks to the publishers of  larKe hospitals of Europe and America.—Va. Med.
Neligan's Atlas of Cutaneous Diseases, for they have I Journal, June, 1656.
                                   BY THE SAME AUTHOR.

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

        The  two volumes will  be sent by mail on receipt of  Five Dollars.
OWEN  ON THE DIFFERENT FORMS OF I  One vol. royal 12mo., extra cloth, with numerous
  THE SKELETON,  AND OF  THE TEETH. |  illustrations.  (Just Issued.)  81 25. 
AND SCIENTIFIC  PUBLICATIONS.                   25
                                     (Now Complete.)
             PEREIRA (JONATHAN), M. D.,  F. R. S.,  AND L. S.

THE  ELEMENTS  OF  MATERIA  MEDICA  AND   THERAPEUTICS.
  Third American edition, enlarged and improved by the author; including Notices of most of the
  Medicinal Substances in use in the civilized world, and forming an Encyclopaedia of Materia
  Medica.  Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and
  Pharmacy in the University of Pennsylvania.  In two very large octavo volumes of 2100 pages,
  on small type, with about 500 illustrations on stone and wood, strongly bound in leather, with
  raised bands.  $9 00.
  Gentlemen who have the first volume are recommended to complete their copies without delay.
The first volume will no longer be sold separate.  Price of Vol. II. $5 00.
  When we remember that Philology, Natural His-
tory, Botany, Chemistry, Physics, and the Micro-
scope, are all brought forward to elucidate the sub-
ject, on<- cannot fail to see that the reader  has here
a work worthy of the name of an encyclopaedia of
Materia Medica.  Our own opinion of its merits is
that of its editors, and also that of the whole profes-
sion, both of this and foreign countries—namely,
" that  in copiousness of details, in extent, variety,
and accuracy of information, and in lucid explana-
tion of difficult and recondite subjects, it surpasses
all other works on Materia Medica hitherto pub-
lished." We cannot close this notice without allud-
ing to the special additions of the American editor,
which  pertain  to the prominent vegetable produc-
tions of this country, and to the directions  of the
United States Pharmacopoeia, in connection with all
the articles contained in the volume which are re-
ferred toby it. The illustrations have been increased,
and this edition by Dr.  Carson cannot well  be re-
garded in  any other light than that of a treasure
which should be found in the library of every  physi-
cian.—New York Journal of Medical and Collateral
Science.
  The third edition of his "Elements of Materia
Medica, although completed under the supervision of
others, is by far the most elaborate treatise in the
English language, and will, while medical literature
is cherished, continue a monument alike honorable
to his  genius, as to his  learning and industry.—
American Journal of Pharmacy.
  The work, in its  present  shape, forms the most
comprehensive  and  complete  treatise on  materia
medica  extant in  the  English  language. — Dr.
Pereira has been at great pains  to introduce into
his work, not only all  the  information  on the
natural, chemical, and commercial history of medi-
cines, which might be serviceable to the physician
and surgeon, but whatever  might enable his read-
ers to  understand thoroughly  the mode of prepar-
ing and manufacturing various articles employed
either for preparing medicines, or for certain pur-
poses in the arts connected with materia medica
and the practice of medicine.  The accounts of the
physiological and therapeutic effects of remedies are
given with great clearness  and accuracy, and in a
manner calculated to interest as well as instruct the
reader.—Edinburgh Medical and Surgical Journal.
                              PEASLEE  (E. R.),  M.  D.,
         Professor of Physiology and General Pathology in the New York Medical College.

HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology;
  for the use of Medical Students.  With over four hundred illustrations.  In one handsome octavo
  volume.   (Nearly Ready.)
  The author's object  in this work has been to  give a connected view of the simple chemical ele-
ments, of the immediate principles, of the simple structural elements, and of the  proper  tissues
entering into the composition of the  fluids and the solids of the human body;  and also, to associate
with the structural elements and tissues their functions while  in health, and  the changes they un-
dergo in disease.  It  will, therefore, be  seen that the subject of the volume is one, the growing
importance  of which, as the basis of all  true medical science, demands for it a separate volume.
The book will therefore supply an acknowledged deficiency in  medical text-books, while the name
of the author, and  his experience as a teacher for the last thirteen years, is a guarantee that it will
be thoroughly adapted to the use of the student.
                         PIRRIE (WILLIAM), F.  R. S. E.,
                       Professor of Surgery in the University of Aberdeen.

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.   Edited  by John
  Neill M D  Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania
  Hospital, &c.' In one very handsome octavo volume, leather, of 780 pages, with 316 illustrations.
  $3 75.
  We know of no other  surgical work of a reason-
able size, wherein there is bo much theory and prac-
tice, or where subjects are more Boundly or clearly
taug'ht.—The Stethoscope.
  There is  scarcely a disease of the bones or soft
narts  fracture, ordislocation, that is not illustrated
Cv accurate wood-engravings.  Then, again, every
instrument  employed %7 the surgeon is thus repre-
sented.  These engravings are not only correct, but
Sy beautiful, .Rowing the astonishing degreof
perfection to which the art of wood-engraving  has
arrived.  Prof. Pirrie, in the woTk before us, has
elaborately discussed the principles of surgery, and
a safe and effectual practice predicated upon them.
Perhaps no work upon this subject heretofore issued
is so full upon the science of the art of surgery.—
Nashville Journal of Medicine and Surgery.
  One of the best treatises on surgery in the English
language.—Canada Med. Journal.
  Our impression is, that, as a manual for students.
Pirrie's is the best work extant.—Western Med. and
Surg. Journal.
                              PARKER (LANGSTON),
                         Surgeon to the Queen's Hospital, Birmingham.

TVtv MODERN TREATMENT  OF SYPHILITIC DISEASES, BOTH  PRI-
  Miuv aNH SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi-
  MAKY ajnu     gUCCessful method.   With numerous Cases, Formulae, and  Clinical Observa-
  lis, by  a_ sate a       ,    , entjreiy rewritten  London edition.  In one neat octavo volume,
  tions.  from tne imru ««*        >
  extra cloth, of 316 pages.  «1 70. 
26
BLANCHARD  &  LEA'S MEDICAL
                               PARRISH  (EDWARD),
  Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, tec.

AN INTRODUCTION  TO  PRACTICAL PHARMACY.   Designed as a  Text-
  Book for the Student, and as a Guide for  the Physician and Pharmaceutist.   With many For-
  mulae and Prescriptions.  In one handsome octavo volume, extra cloth, of 550 pages, with 243
  Illustrations. $2 75.
  A careful examination of this work enables us to, Medica; it familiarizes him with the compounding
speak of it in the highest terms, as being the best  of drugs, and supplies those minutiae which but few
                                              practitioners can impart.  The junior practitioner
                                              will, also, find this volume replete with instruction.
                                              —Charleston Med. Journal and Review, Mar. 1856.
                                                There is no useful information in the details of the
                                              apothecary's or country physician's office conducted
                                              according to science that is omitted.  The young
                                              physician will find ilfen encyclopedia of indispensa-
                                              ble medical knowledge, from the purchase of a spa-
                                              tula to the compounding  of the most learned  pre-
                                              scriptions. The woik is by the ablest pharmaceutist
treatise on practical pharmacy with which we are
acquainted, and an invaluable vade-mecum, not. only
to the apothecary and to those practitioners who are
accustomed to prepare their own medicines, but  to
every medical man and medical student.  Through-
out the work are interspersed valuable tables, useful
formula, and practical hints, and the whole is illus-
trated by a large number of excellent wood-engrav-
ings.—Boston Med. and Surg. Journal.
  This is altogether one of the most useful books we
have seen. It is just what we have long felt to  be j in the United States, and' must meet with an im
needed by apothecaries, students, and practitioners
of medicine, most of whom in this country have to
put up their own prescriptions.  It bears, upon every
page, the impress of practical knowledge, conveyed
in a plain common sense manner, and adapted to the
comprehension  of all who may read it. No detail
has been omitted, however trivial  it may seem, al-
though really important to the dispenser of medicine.
—Southern Med. and Surg. Journal.
  To both the country practitioner and the city apo-
thecary this work of Mr. Parrish is a godsend.  A
careful study of its contents will give the young
graduate a familiarity with the value and  mode of
administering his prescriptions, which will be of as
much use to his patient as  to himself.— Va. Med.
Journal.
  Mr. Parrish has rendered a very acceptable service
to the  practitioner and student, by furnishing this
book, which contains the leading facts and principles
of the  science  of Pharmacy, conveniently arranged
for study, and with special reference to those features
of the subject which possess an especial practical in-
terest to the physician.  It furnishes the student, at
the commencement  of his studies, with that infor-
mation which is of the greatest importance in ini-
tiating him into the domain of Chemistry  and Materia
mense sale.—Nashville Journal of Medicine, April,
1856.
  We are glad to receive this excellent work.  It
will supply a want long felt by the profession, and
especially by the student  of  Pharmacy.  A large
majority  of physicians are obliged  to  compound
their own medicines, and  to  them n work of this
kind is indispensable.—N. O. Medical and Surgical
Journal.
  We cannot say but that this volume is  one of the
most welcome and appropriate which has for a long
time been issued from the press.  It is a work which
we doubt not will at once secure  an extensive cir-
culation, as it is designed not only for  the  druggist
and pharmaceutist, but also for the great body of
practitioners throughout the country, who  not only
have to prescribe medicines, but in the majority of
instances have to rely upon their own resources—
whatever these may be—not only to compound, but
also to manufacture the remedies they  are called
upon to administer.  The author  has not mistaken
the idea in writing this volume, as it is alike useful
and invaluable to those engaged in the active pur-
suits of the profession, and to those preparing to en-
ter upon the field of professional labors.—American
Lancet, March 24, 1856.
                                RICORD <
A TREATISE ON THE VENEREAL
  With copious Additions, by Ph. Ricord, M. D
  M. D.  In one handsome octavo volume, extra
  Every one will recognize the attractiveness and
value which this work derives from thus presenting
the opinions of these two masters side by side.  But,
it must be admitted, what has made the fortune of
the book, is the fact that it contains the "most com-
plete embodiment of the veritable doctrines of the
Hopital du Midi," which has ever been made public.
The doctrinal ideas of M. Ricord, ideas which, if not
universally adopted,aie incontesiably dominant, have
heretofore only been interpreted by more or less skilful
P.), M. D.,
DISEASE.   By John Hunter, F. R. S.
  Edited, with Notes, by Freeman J. Bumstead,
cloth, of 520 pages, with plates.  $3 25.
 secretaries, sometimes accredited and sometimes not.
   In the notes to Hunter, the master substitutes him-
 self for his interpreters, and gives his original thoughts
 to the world in a lucid and perfectly intelligible man-
 ner.  In conclusion we can say that this is incon-
 testably the  best treatise on syphilis with which we
 are acquainted, and, as we do  not often employ the
 phrase, we may be excused for expressing the hope
 that it may find a place in the  library of every phy-
 sician.— Virginia Med. and Surg Journal.
BY THE SAME AUTHOR.
ILLUSTRATIONS OF SYPHILITIC DISEASE.
  Translated by Thomas F. Betton, M.D.  With
  fifty large quarto colored  plates.  In one large
  quarto volume, extra cloth.  $15 00.
LETTERS ON SYPHILIS, addressed to the Chiet
  Editor of the Union Medicale.  Translated by W.
  P.  Lattimore, M.D.  In one neat octavo  vol-
  ume, of 270 pages, extra cloth.  $2 00.
                            RIGBY (EDWARD), M.D.,
                     Senior Physician to the General Lying-in Hospital, tec.

A  SYSTEM  OF  MIDWIFERY.   With  Notes and  Additional  Illustrations.
  Second American Edition.  One volume octavo, extra cloth, 422 pages.   $2 50.

                         by the same author.  (Now Ready, 1857.)

ON  THE  CONSTITUTIONAL  TREATMENT OF  FEMALE  DISEASES.
  In one neat royal 12mo. volume, extra cloth, of about 250 pages.  $1  00.
  The aim of the author has been throughout to present sound practical views of the important
subjects under consideration ; and without entering into theoretical disputations and disquisitions to
embody the results of his  long  and  extended experience in such a  condensed form as would be
easily accessible to the practitioner.
ROYLE'S   MATERIA  MEDICA  AND  THERAPEUTICS:  including the
  Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United  State*.
  With many new medicines.  Edited by Joseph Carson, M. D.  With ninety-eight illustrations.
  In one large octavo volume, extra cloth, of about 700 pages.  $3 00. 
AND SCIENTIFIC  PUBLICATIONS.                   27
                      RAMSBOTHAM  (FRANCIS H.),  M.D.
THE PRINCIPLES  AND PRACTICE OF OBSTETRIC  MEDICINE AND
  SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly
  revised by the Author.   With Additions by W. V. Keating, M. D.  In one large and handsome
  imperial octavo volume, of 650 pages, strongly bound in leather, with raised bands; with sixty-
  four beautiful Plates, and numerous Wood-cuts in the text, containing in all nearly two hundred
  large and beautiful figures. (Lately Issued,  1856.) $5 00.
  In calling the attention of the profession to the new edition of this standard work, the publishers
would remark that no efforts have been spared to secure for it a continuance and extension  of the
remarkable favor with which it has been received.  The last London issue, which was considera-
bly enlarged, has received  a further revision from the author, especially for this country.  Its pas-
sage through the press here has been supervised by Dr. Keating, who has made numerous addi-
tions with a view  of presenting more fully  whatever was necessary to adapt it thoroughly to
American modes of practice.  In its mechanical execution, n like superiority over former editions
will be found.
                            From Prof. Hodge, of the University of Pa.
  To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being
the best authorized exponent of British Midwifery.  Its circulation will, I trust, be extensive throughout
our country.
  The publishers have shown their appreciation of' cine and  Surgery  to our library, and confidently
the merits of this work nnd secured its success by
the truly elegant style in which they have brought
it out, excelling themselves in its production, espe-
cially in its plates.   It is dedicated to Prof. Meigs,
and has the emphatic endorsement of Prof. Hodge,
as the  best  exponent of British Midwifery.  We
recommend it to our  readers, with  the assurance
that it will not disappoint their most sanguine ex-
pectations.—Western Lancet.
  It is unnecessary to  say anything in regard to the
utility of this work. It is already appreciated in our
country for the value of the matter, the clearness of
know of no text-book which deserves in all respects ■ jtB styie, and the fulness of its illustrations.  To the
to be more highly recommended to students, and we
could wish to see it in the handsof every practitioner,
for they will find it invaluable for reference.—Med.
Gazette.
  But once in a long time some brilliant genius rears
his head above the horizon of science, and illumi-
nates and purifies every department that he investi-
gates ;  and his works become types, by which innu-
merable imitators model their feeble  productions.
Such a genius we find in the younger Ramsbotham,
and such a type we find in the work now before us.
The binding, paper, type, the engravings and wood-
cuts are alfso excellent as to make this book one of
the finest specimens of the art of printing that have
given such a world-wide reputation to its enter-
prising and liberal publishers.  We welcome Rams-
botham'B Principles and Practice of Obstetric Medi-
physician's library it is indispensable, while to the
student as a text-book,  from which to extract the
material for laying the foundation of an education on
obstetrical science, it has no superior.—Ohio Med.
and Surg. Journal.

  We will only add that the student will learn from
it all he need to know, and the practitioner will find
it, as a book of reference, surpassed by none other.—
Stethoscope.
  The character and merits of Dr. Ramsbotham's
work are so well known and thoroughly established,
that comment is unnecessary and praise superfluous.
The illustrations, which are numerous and accurate,
are executed in the highest style of art.  We cannot
too highly recommend the work to our readers.—St.
Louis Med and Surg. Journal.
                          ROKITANSKY (CARL),  M.D.,
    Curator of the Imperial Pathological Museum, and Professor at the University of Vienna, &c.

A  MANUAL  OF  PATHOLOGICAL  ANATOMY.   Four  volumes,  octavo,
  bound in two, extra cloth, of about 1200 pages.  Translated by W. E. Swaine, Edward Sieve-
  king, C. H. Moore, and G. E. Day.  (Just Issued.)  $5 50
To render this large and important work more easy of reference, and at the same time less cum-
  brous and costly, the four volumes have been arranged in two, retaining, however, the separate
  paging, &c.
  The publishers feel much pleasure in presenting to the profession of the United States the great
work of Prof Rokitansky, which is universally referred to as the standard of authority by the pa-
thologists of all nations.  Under the auspices of the  Sydenham Society of London, the combined
laborof four translators  has at length overcome the almost insuperable difficulties which have so
Ions prevented the appearance of the work in an English dress.  To a work so widely known,
eulLv is unnecessary, and the publishers would merely state that it is said to contain the results
of not less than thirty thousand post-mortem examinations made by the author, diligently com-
pared, generalized, and wrought into one complete and harmonious system.
                                  ■   *L "-—  so charged his  text with valuable truths, that any
                                               attempt of a reviewer to epitomize is at once para-
                                               lyzed, and must end in a failure.—Western Lancet
  The profession is too well acquainted with the re-
putation of Rokitansky's work to need our assur-
ance that this is one of the most profound, thorough.
and valuable books  ever issued from the  medical
press  It is sui generis, and has no standard of com-
parison.  It is only necessary to announce that it is
  As this is the highest source of knowledge upon
the important subject of which it  treats, no real
student can afford to be without it.  The American
barison.  It is only necessary to announce muni i»  student can aoord to be witnout it.  ine American
issued iii a form as cheap as is compatible with its | publishers have entitled themselves to the thanks of
    ___■  _____...„i;«n  nnri  iln Mile  follows as a  >k. nmfootinn nf thoir onuntrv fnr this timeOUS and
ISSUcu 111 a n>i"» «*» *...«—v — :------.-
size and  preservation, and  its sale  follows as a
matter of  course. No library can be called com-
plete without it.—Buffalo Med. Journal.

  An attempt to give our readers any adequate idea
of the vast amount of instruction accumulated in
?hese volumes, would be feeble and hopeless.  The
effort  of the distinguished author to concentrat
|>UUUI3IICI a IIOVC i.UblllVU tni,mcn,i»vu ««■ n..w ...—— — — —-
the profession of their country, for this timeous and
beautiful edition.—Nashville Journal of Medicine.
  As a book of reference, therefore, this work must
prove of inestimable value, and we cannot too highly
recommend  it to the  profession.—Charleston Med.
Journal and Review, Jan. 1856.
  This  book is a necessity to every practitioner.—
?nff°artsmallspue"Thu greaTfund of knowledge, has i Am. Med. Monthly

                       SCHOEDLER (FRIEDRICH), PH.D.,
                         Professor of the Natural Sciences at Worms. &c.

THE  BOOK  OF  NATURE;   an  Elementary  Introduction  to  the  Sciences  of
  Phvsios Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoology, and  Physiology.  First
  American edition, with a Glossary and other Additions and  Improvements; from  the second
  S„'l ;h Priition   Translated from the sixth German edition, by Henry Medlock, F. C. S., &c.
  fn one volume%mall octavo, extra cloth, pp. 692, with 679 illustrations.   $1 80. 
28
BLANCHARD &  LEA'S  MEDICAL
                           SMITH  (HENRY  H.),  M.D.,
                    Professor of Surgery in the University of Pennsylvania, tec.

MINOR  SURGERY; or, Hints on the Every-day Duties of the Surgeon.  Illus-
  trated by two hundred and forty-seven illustrations.  Third and enlarged edition.   In one hand-
  some royal 12mo. volume,  pp. 456.  In leather, $2 25; extra cloth, $2 00.
  And a capital little book it is.  . .  Minor Surgery,
we repeat, is really Major Surgery, and  anything
which teaches it is worth having.  So we cordially
recommend  this little book of Dr. Smith's.—Med.-
Chir. Review.
  A work such as the present is therefore highly
useful to the student, and we commend  this one
to their attention.—American Journal of Medical
Sciences.
  No operator, however eminent, need hesitate to
consult this unpretending yet excellent book Those
who are young in the business would find Dr. Smith's
treatise a necessary companion, after once under-
standing its true character.—Boston Med. and Surg.
Journal.
  No young practitioner should be without this little
volume; and we venture  to assert, that it may be
consulted by the senior members of the profession
with more real benefit, than the more voluminous
works.—Western Lancet.
  This beautiful little work has been compiled with
a view to the wants of the profession in the matter
of bandaging, tec., and well and ably has the author
performed his  labors.  Well adapted to  give  the
requisite  information on  the subjects of  which it
treats.—Medical Examiner.
  The directions are plain, and illustrated through-
out with clear engravings.—London Lancet.
  One of the best works they can consult on  the
subject of which it treats.—Southern Journal of
Medicine and Pharmacy.
                               BY THE SAME AUTHOR, AND

                         HORNER (WILLIAM  E.),  M. D.,
                  Late Professor of Anatomy in the University of Pennsylvania.

AN  ANATOMICAL  ATLAS,  illustrative of the Structure of  the Human Body.
  In one volume, large imperial octavo, extra cloth, with about six hundred  and fifty beautiful
  figures.  $3 00.
                                              late the student upon the completion of this Atlas,
                                              as it is the most convenient work of the kind that
                                              has yet appeared ; and we must add, the very beau-
                                              tiful manner in which it is " got up" is so creditable
                                              to the country as to be flattering  to our national
                                              pride.—American Medical Journal.
  These figures are well  selected, and present a
complete and accurate representation of that won-
derful fabric, the human body.  The plan of this
Atlas, which  renders it so peculiarly convenient
for the student, and its superb artistical execution,
have been already pointed out.  We must congratu-
                             SARGENT  (F. W.),  M.  D.
ON BANDAGING  AND OTHER OPERATIONS OF  MINOR SURGERY.
  Second edition, enlarged.  One handsome royal 12mo. vol., of nearly 400 pages, with 182 wood-
  cuts.  Extra cloth, $1 40; leather, $1 50.
  This very useful little work has long been a favor-
ite with practitioners and students. The recent call
for a new edition has induced its author to make
numerous important additions.  A slight alteration
in the size of the page has enabled him to introduce
the new matter, to the extent of some fifty pages of
the former edition, at the same time that his volume
is rendered still more compact than its less compre-
hensive predecessor.  A double gain in thus effected.
which, in a vade-mecum of this kind, is a material
improvement.—Am. Medical Journal.

  Sargent's Minor Surgery has always been popular,
and deservedly so. It furnishes that knowledge of the
most frequently requisite performances of surgical
art which cannot be entirely understood by attend-
ing clinical lectures.  The art of bandaging, which
is regularly taught in Europe, is very frequently
overlooked by teachers in this country; the student
and junior practitioner, therefore, may often require
that knowledge which this little volume so tersely
aad happily supplies.  It is neatly printed and copi-
ously illustrated by the enterprising publishers, and
should be possessed by all who desire to be thorough-
ly conversant with the details of this branch of our
art.—Charleston Med. Journ. and Review, Maich,
1856.
  A work that has been so long and favorably known
to the profession as Dr. Sargent's Minor Surgery,
needs no commendation from us. We would remark,
however, in this connection, that minor surgery sel-
dom gets that attention in our schools that its im-
portance deserves.  Our larger works are also very
defective in their teaching on these small practical
points.  This little book will supply the void which
all must feel who have not studied its pages.—West-
ern Lancet, March, 1856.
  We confess our indebtedness to  this little volume
on many occasions, and can warmly  recommend it
to our readers, as it is not above  the consideration
of the oldest and most experienced.—American Lan-
cet, March, 1856.
SKEY'S OPERATIVE SURGERY.  In one very
  handsome octavo volume, extra cloth, of over 650
  pages, with about one hundred wood-cuts. $3 25.
STANLEY'S TREATISE  ON  DISEASES OF
  THE BONES. In one volume, octavo, extra cloth,
  286 pages.  $1 50.
SOLLY ON THE HUMAN BRAIN; its Structure,
  Physiology, and Diseases.   From the Second and
  much enlarged  London edition. In one octavo
  volume, extra cloth, of 500 pages, with 120 wood-
  cuts. $2 00.

SIMON'S  GENERAL PATHOLOGY, as condus-
  ive to the Establishment of Rational  Principles
  for the prevention and Cure of Disease. In one
  neat octavo volume, extra  cloth,  of 212 pages.
  81 25.
                             STILLE (ALFRED),  M.  D.
PRINCIPLES   OF  GENERAL  AND  SPECIAL  THERAPEUTICS    In
  handsome octavo. (Preparing.)

                            SIBSON  (FRANCIS),  M.D.,
                               Physician to St. Mary's Hospital.
MEDICAL ANATOMY.   Illustrating  the Form, Structure, and Position of  the
  Internal Organs in Health and Disease.  In large imperial quarto, with splendid colored plates.
  To match "Maclise's Surgical Anatomy."  Parti.  (Preparing.) 
AND  SCIENTIFIC  PUBLICATIONS.
29
       SHARPEY  (WILLIAM),  M. D.,  JONES  QUAIN,  M. D.,  AND
                        RICHARD  QUAIN,  F. R.  S.,  &c.
HUMAN  ANATOMY.   Revised, with Notes and Additions, hy Joseph  Leidy,
  M. D., Professor of Anatomy in the University of Pennsylvania.  Complete in two large octavo
  volumes, leather, of about thirteen hundred pages.  Beautifully illustrated with over five hundred
  engravings on wood.  $6 00.
  It is indeed a work calculated to make an era in
anatomical study,  by placing before  the student
every department of his science,  with a view  to
the relative importance of each;  and so skilfully
have the different parts been interwoven, that no
one who makes this work the basis of his studies,
will  hereafter have any excuse for  neglecting  or
undervaluing any important particulars connected
with  the  structure of the human  frame;  and
whether the bias of his mind lead him in  a more
especial manner to surgery, physic, or physiology,
he will find here a work at once so comprehensive
and practical as to defend him from exclusiveness
on the one  hand, and  pedantry on the other.—
Journal  and Retrospect of the Medical Sciences.
  We have no hesitation in recommending this trea-
tise on anatomy as the most complete on that sub-
ject in the English language; and the  only one,
perhaps, in  any language, which  brings the state
of knowledge forward  to the most recent disco-
veries.—The Edinburgh Med. and Surg. Journal.
                           SMITH  (W. TYLER), M. D.,
                       Physician Accoucheur to St. Mary's Hospital, &c.

ON  PARTURITION,  AND  THE  PRINCIPLES  AND  PRACTICE  OF
  OBSTETRICS.  In one royal 12mo. volume, extra cloth, of 400 pages.   $125.

                                  BY THE SAME AUTHOR.

A PRACTICAL  TREATISE  ON  THE  PATHOLOGY AND TREATMENT
  OF LEUCORRHCEA.   "With numerous  illustrations.  In  one very handsome octavo volume,
  extra cloth, of about 250 pages.  $1 50.
  We hail the appearance of this practical and invaluable work, therefore, as a real  acquisition to our
medical literature.—Medical Gazette.
                    TAYLOR (ALFRED S.), M. D.,  F. R. S.,
               Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital.

MEDICAL JURISPRUDENCE.  Fourth American, from the fifth improved and
  enlarged English Edition.  With Notes and  References  to American Decisions, by Edward
  Hartshornk, M. D.   In one large octavo volume, leather, of over seven hundred pages.  (Just
  Issued, 1856.)   $3  00.
  This standard work has lately received a very thorough revision at the hands of the author, who
has introduced whatever was necessary to render it complete and satisfactory ift carrying out the
objects in view.   Tne editor has likewise used every exertion to make it equally thorough with
regard to all matters relating to the practice of  this country.  In doing this, he has carefully ex-
amined all that has appeared on the subject since the publication of the last edition, and has incorpo-
rated all  the new  information  thus presented.  The work has thus been considerably increased m
size, notwithstanding which, it has been kept at its former very moderate price, and in every respect
it will be found worthy of a continuance of the remarkable favor which has carried it  through so
many editions on  both sides of the Atlantic.  A  few notices of the former editions are appended.
most attractive books that we have met with; sup-
plying so much both to interest and instruct, that
we do not hesitate to affirm that after having once
commenced its perusal, few could be prevailed upon
to desist before completing  it.  In the last London
edition, all the newly observed and accurately re-
corded facts have been inserted, including much that
is recent of Chemical, Microscopical, and Patholo-
gical research, besides papers on numerous subjects
never before published.-Charleston Medical Journal
and Review.
  We know of no work on Medical Jurisprudence
Which contains in the same space anything like the
same amount of valuable matter.—N. Y. Journal of
Medicine.
  No work upon the subject can be put into the
hands of students either of law or medicine which
will  engage them more closely or profitably;  and
none could be offered to the busy practitioner of
either callina, for the purpose of casual or hasty
reference, that would be more likely to afford the aid
desired. We therefore recommend it as the best and
safest manual  for daily use.—American Journal of
Medical Sciences.
  So well is this work known to the members both
of the  medical and legal professions, and so highly
is it appreciated by them, that it cannot be necessary
for us to say a word in its commendation; its having
already reached a fourth edition being the best pos-
sible testimony  in its favor.  The author has ob-
viously subjected the entire work to a very careful
revision.—Brit, and Foreign Med. Chirurg. Review.
  This work of Dr.  Taylor's is generally acknow-
ledged to be one of the ablest extant on the subject
otpiedical jurisprudence.  It is certainly one of the
                                  BY THE SAME AUTHOR.

ON  POISONS,  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND
  MEDICINE.  Edited, with Notes and Additions, by R. E. Griffith, M. D. In one large octavo
  volume, leather, of 688 pages.  ?3 00

                       TODD (R.  B.),  M.  D., F.  R. S.,  &.C.

CLINICAL  LECTURES ON CERTAIN  DISEASES  OF THE  URINARY
   ORGANS  AND ON DROPSIES. In one octavo  volume. (Now Ready, IS/7.)  $1 50
   The valuable practical nature of Dr. Todd's writings  have deservedly rendered them favorites
with the pro  es«ion and the present volume, embodying the medical aspects of a class of diseases
not elsewhere to be found similarly treated, can hardly fail to supply a want long felt by the prac-
 titioner.
  It is not excess of praise to say that the volume
before us is the very best treatise extant on Medical
Jurisprudence.  In  saying this, we do not wish K)
be understood  as detracting from  the merits of the
excellent works of Beck, Ryan,  Traill, Guy, and
others; but in interest and value we think  it must
be conceded that Taylor is superior to anything that
has preceded it. The author is already well known
to the profession by his valuable treatise on Poisons;
and the present volume will add materially to his
high reputation for accurate and extensive know-
ledge and discriminating judgment.—N. W. Medical
ana Surgical Journal. 
30
BLANCHARD &  LEA'S  MEDICAL
                            Now Complete (April, 1857.)
                 TODD (ROBERT BENTLEY), M.  D., F.  R. S.,
                     Professor of Physiology in King's College, London; and
                         WILLIAM  BOWMAN, F. R. S.,
                      Demonstrator of Anatomy in King's College, London.

THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN.   With
  about three hundred large and beautiful  illustrations on wood.   Complete in one large  octavo
  volume, of 950 pages, leather.  Price $4 50.
  The very great delay which has occurred in the completion of this work has arisen from  the de-
sire of the authors to verify by their own examination the various questions and statements pre-
sented, thus rendering the work one of peculiar value and authority.  By the wideness of its scope
and the accuracy of its facts  it thus occupies a position of its own, and becomes necessary to all
physiological students.
  ISP Gentlemen who have received portions of this work, as published in the " Medical News
and LrBRARY," can now complete their copies, if immediate application be made. It will be fur-
nished as follows, free by mail, in paper covers, with cloth backs.
  Parts I., II., III. (pp. 25 to 552), $2 50.
  Part IV. (pp. 553 to end, with Title, Preface, Contents, &c), $2 00.
  Or, Part IV., Section II. (pp. 725 to end, with Title, Preface, Contents, &c), $1 25.
                                             cannot conclude without strongly recommending the
                                             present work to all classes of our readers, recogniz-
                                             ing talent and depth of research in every page, and
                                             believing, as we do, that the diffusion of such know-
                                             ledge will certainly tend to elevate the sciences of
                                             Medicine and Surgery.—Dublin Quarterly Journal
                                             of Medical Sciences.
  In the present part (third) some of the most diffi-
cult subjects in Anatomy and Physiology are handled
in the  most  masterly manner.  Its authors have
stated that this work was intended " for the use of
the student and practitioner in  medicine and sur-
gery," and we can recommend it to both, confident
that it is  the most perfect work of its  kind.   We
                             TANNER  (T.  H.),  M.  D.,
                          Physician to the Hospital for Women, &c.

A MANUAL  OF CLINICAL  MEDICINE  AND PHYSICAL DIAGNOSIS.
  To which  is added The Code of Ethics  of  the American  Medical Association.   Second
  American Edition.  In  one  neat volume, small 12mo.  Price in extra cloth, 87j cents; flexible
  style, for the pocket, 80 cents.
  Dr. Tanner has, in a happy and successful manner, | Suited alike  to the wants of students and practi-
indicated the leading particulars to which, in the  tioners, it has only  to be seen, to win for itself a
clinical study of a case of disease, the attention of | place  upon the shelves of every medical library.
the physician is to be directed, the value and import ', Nor will it be " shelved" long at a time; if we mis-
of the various abnormal phenomena detected, and the ! take not, it will be  fonnd, in the best sense of the
several instrumental and  accessory means which  homely but expressive word, " handy.*'  The style
maybe called into requisition to facilitate diagnosis ' is admirably clear, while it is so sententious as not
and increase its certainty.—Am. Journal of Med.  to burden the memory.  The  arrangement is, to our
Sciences.
  The work is an honor to its writer, and must ob-
tain a wide circulation by its  intrinsic merit alone.
mind, unexceptionable.  The work, in short, de-
serves the heartiest commendation.—Boston Med.
and Surg. Journal.
                       WATSON  (THOMAS),  M.D.,  &.c.

LECTURES  ON  THE  PRINCIPLES  AND  PRACTICE  OF  PHYSIC.
  Third American edition, revised, with Additions, by D. Francis Condie, M.D., author of a
  " Treatise on the Diseases of Children," &c.   In one octavo volume, of nearly eleven hundred
  large pages, strongly bound with raised bands.  $3 25.
                                               Confessedly one  of the very best works on the
                                             principles and practice of physic in the English or
                                             any other language.—Med. Examiner.
                                               Asa text- book it has no equal; as a compendium
                                             of pathology  and practice no superior.—New York
                                             Annalist.
                                               We know of no work better  calculated for being
                                             placed in the hands of the student, and for a text-
  By universal consent the work ranks among the, book. on every important point the autnor Beem(J
very  best text-books in our language.—Illinois and  to have posted  up hig knowiedge to the  day
Indiana Med. Journal.

  Regarded on all hands as  one of the very best, if
not tne very best, systematic treatise on practical
medicine extant.—St. Louis  Med. Journal.
  To say that it is the very best work on the sub-
ject now extant, is but to echo the sentiment of the
medical  press  throughout the country. — N. O.
Medical Journal.

  Of the text-books recently republished Watson is
very justly the principal favorite.—Holmes's Rep.
to Nat.-Med. Asloc.
Amer. Med. Journal.
  One of the  most  practically useful books  that
ever was presented  to the student. — N. Y. Med.
Journal.
WHITEHEAD ON THE CAUSES AND TREAT-
  MENT OF AISORTION  AND STERILITY.
  Second American Edition.  In one volume, octa-
  vo, extra cloth, pp. 308.  $1  75.
WALSHE ON DISEASES OF THE HEART,
  LUNGS, AND  APPENDAGES; their  Symp-
  toms and Treatment.  In one handsome volume,
  extra cloth, large royal 12mo., 512 pages.  $1 50.
                               WHAT  TO  OBSERVE
AT  THE  BEDSIDE  AND  AFTER  DEATH,  IN   MEDICAL  CASES.
  Published under the authority of the London Society for Medical Observation.  A new American,
  from the second and revised London edition.   In one very handsome volume, royal 12mo., extra
  cloth.  $1 00.
  To the observer who prefers accuracy to blunders I   One of the finest aids to a young practitioner we
and precision to carelessness, this little book is in-  have ever seen.—Peninsular Journal of Medicine.
valuable.—N. H. Journal of Medicine.            \ 
AND  SCIENTIFIC  PUBLICATIONS.
31
                     WILSON (ERASMUS),  M. DM  F. R. S.,
                                Lecturer on Anatomy, London.

A SYSTEM  OF  HUMAN ANATOMY, General and Special.   Fourth Ameri-
  can, from the last English edition.   Edited by Paul B. Goddard, A. M., M. D.  With two hun-
  dred and fifty illustrations.  Beautifully printed, in  one large octavo volume, leather, of nearly
  six hundred pages.  $3 00.
  In many, if not all the Colleges of the Union, it
has become a standard text-book.   This, of itself,
is sufficiently expressive of its value. A work very
                                               It offers to the student all the assistance that can
                                             be expected from such a work.—Medical Examiner.

desirable to the student;  one. the possession of .JJ'JT* ^l*' *?* co.nven>ent m*nu?lJiOT*he,
which will greatly facilitate \iis  progress in the \ '£&£ We P°**™*—A™rican Journal of Medical

                                               In every respect, this work as an anatomical
                                             guide for the student and practitioner, merits our
study of Practical Anatomy.—New York Journal of
Medicine.

  Its author ranks with the highest on Anatomy.
Southern Medical and Surgical Journal.
                                             warmest and most decided praise.—London Medical
                                             Gazette.
                           BY THE SAME AUTHOR.  (Just Issued.)

THE  DISSECTOR'S  MANUAL;  or, Practical and  Surgical Anatomy.  Third
  American,  from the last revised and enlarged English edition.  Modified and rearranged, by
  William Hunt, M. D., Demonstrator of Anatomy in the  University of Pennsylvania.  In one
  large and handsome royal 12mo. volume, leather, of 582 pages, with 154 illustrations. $2  00.
  The modifications and additions which this work has received  in  passing recently through the
author's hands, is sufficiently indicated  by the fact that it is enlarged  by more than one  hundred
pages, notwithstanding that it is printed in smaller type, and with a greatly enlarged page.
  It remains only to add, that after a careful exami-
nation, we have no hesitation in recommending this
work  to the notice of those for whom it  has been
ing very superior claims, well calculated to facilitate
their studies, and render their labor less irksome, by
constantly keeping before them definite objects of
interest.—The Lancet.
expressly written—the students—as a guide possess-
                   by the same author.  (Now Ready, May, 1857.)

ON DISEASES  OF THE SKIN.  Fourth and enlarged American, from the last
  and improved London edition.  In one large octavo volume, of 650 pages, extra cloth, $2 75.
  This volume in passing for the fourth time through the hands of the. author, has received a care-
ful revision, and has been greatly enlarged and improved. About one hundred and fifty pages have
been added, including new  chapters on Classification, on General Pathology, on  General Thera-
peutics, on Furuncular Eruptions, and on Diseases of the Nails, besides extensive additions through-
out the text, wherever they have seemed desirable, either from former omissions or from the pro-
gress of science and the increased experience of the author.   Appended to the volume will also
now be found a collection of Selected Formula, consisting for the most part of prescriptions of
which the author has tested the value.
  In the present edition Mr. Wilson presents us with  I the mere manifestations of derangement of internal
the results of his matured experience gained after an  .organs, is brought under notice, and the book in-
extensive acquaintance with the pathology and treat-  eludes a mass of information which is spread over a
ment of cutaneous affections; and we have now be-  , great  part of the domain of Medical and Surgical
fore us not  merely a reprint of his former publica-  I Pathology.   We  can  safely  recommend  it to the
tions, but an  entirely new and rewritten volume,  profession ns the  best work on  the subject now in
Thus, the whole history of the diseases affecting the  existence in  the English language.—London Med.
Bkin, whether they originate in that structure or are  I Times and Gazette, March 28, 1857.
                                    ALSO,  JUST READY,

A  SERIES OF PLATES  ILLUSTRATING WILSON  ON DISEASES  OF
  THE SKIN ; consisting of nineteen beautifully executed plates, of which  twelve are exquisitely
  colored, presenting the Normal Anatomy and Pathology of" the Skin, and containing accurate re-
  presentations of about one hundred varieties of disease, most of them the size of nature.   Price
  in cloth $4 25.
  In beauty of drawing and accuracy and finish of coloring these plates will be found superior to
anything of the kind as yet  issued in this country.
  The plates by which this editition is accompanied  The representations of the various forms of cutane-
leave nothing to be desired, so far as excellence of  ; ous disease are singularly accurate, and the coloring
delineation and perfect accuracy of illustration are  ; exceeds almost anything wetiave met with in point
concerned.—Medico-Chirurgical Review.          ' of delicacy and finish.—British and Foreign Medical
  Of these plates it is impossible to speak too highly.  | Reviev>-
                                  BY THE  SAME AUTHOR.

ON   CONSTITUTIONAL  AND  HEREDITARY   SYPHILIS,  AND   ON
  SYPHILITIC ERUPTIONS.  In one small octavo volume, extra cloth, beautifully printed, with
  four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. $2 25.
                           by  the same author.  (Just Issued.)

HEALTHY SKIN; A Popular Treatise on  the Skin and  Hair, their Preserva-
  tion and  Management.  Second American,  from the fourth London edition.   One neat volume,
  royal 12mo., extra cloth, of about 300 pages, with numerous illustrations.   $1  00;  paper cover,
  75 cents.                          _________________

                                   WILDE (W.  R.),
                  Surgeon to St. Mark's Ophthalmic  and Aural Hospital, Dublin.

AURAL SURGERY,  AND THE NATURE AND TREATMENT OF  DIS-
  EASES OF THE EAR.  In one handsome  octavo  volume,  extra cloth, of 476 pages, with
  illustrations.  $~ 80.
                                             the author for his manful effort to rescue this depart
                                             mentof surgery from the hands of the empirics who
  This work certainly contains more information on
the  subject to which it is devoted  than any other
with which we are acquainted.  We feel grateful to
nearly monopolize it.— Va. Med. and Surg. Journal. 
32
BLANCHARD & LEAS  MEDICAL  PUBLICATIONS.
                           WEST  (CHARLES),  M.  D.,
Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for
                                   Sick Children, &c.

LECTURES   ON  THE  DISEASES  OF INFANCY  AND  CHILDHOOD.
  Second American, from the Second and Enlarged London  edition.   In one volume,  octavo,
  extra cloth, of nearly five  hundred pages.  $2 00.
  We take leave of Dr. West  with great respect for
his attornments, a due appreciation of his acute
powers of observation, and a  deep sense of obliga-
tion for this valuable contribution to  our profes-
sional literature.  His book is undoubtedly in many
ligation by this able, thorough, and finished work
upon a subject which almost daily taxes to the ut-
most the skill of the general practitioner.  He has
with singular felicity threaded his way through all
the tortuous labyrinths of the difficult subject he has
undertaken to elucidate, and has in  many  of the
darkest corners left a light, which will never be
extinguished.—Nashville Medical Journal.
 respects the best we possess on diseases of children
 Dublin Quarterly Journal of Medical Science.
  Dr. West has placed the profession under deep ob-
                        by  the same  author.  (Nearly Ready.)
             Publishing in the "Medical News and Library," for 1856 and 1857.

 LECTURES  ON  THE DISEASES OF WOMEN.   In two parts.
  Part I. 8vo. of about 300  pages, comprising the Diseases of the Uterus.
  Part II. (Preparing), will contain Diseases of the Ovaries, and of all the parts jonnected
    with the Uterus ; of the Bladder, Vagina, and External Organs.
  The obf _-ct of the author in this work is to present a complete but succinct treatise on Female
 Diseases, embodying the results of  his experience during the last ten years at St. Bartholomew's
 and the Midwifery Hospitals, as well as in private practice.  The characteristics which have se-
 cured to his former works so favorable a reception, cannot fail to render the present volume a
 standard authority on its important subject.  To show the general scope of the work, an outline of
 the Contents of Part I. is subjoined.
 Lectures I, II.—Introductory—Symptoms—Examination  of Symptoms—Modes cf Examina-
  tions.  Lectures III., IV., V—Disorders of Menstruation, Amenorrhoea, Menorrhagia, Dys-
  menorrhoea.  Lectures VI, VII., VIII.—Inflammation of the Uterus, Hypertrophy, Acute
  Inflammation, Chronic Inflammation, Ulceration of the Os Uteri, Cervical Leucorrhcea.  Lectures
  IX., X., XL, XII, XIII.—Misplacement of the Uterus, Prolapsus, Anteversion, Retrover-
  sion, Inversion.  Lectures XIV., XV., XVI, XVII.—Uterine Tumors and Outgrowths,
  Mucous, Fibro-cellular, and Glandular Polypi, Mucous Cysts, Fibrinous Polypi, Fibrous Tumors,
  Fibrous Polypi, Fatty Tumors, Tubercular Diseases. Lectures XVIII., XIX., XX.—Cancer
  of the Uterus.
 Part II. will receive an equally extended  treatment, rendering the whole an admirable text-book
  for the student, and a reliable work for reference by the practitioner.
                          by the same author.  (Just Issued)

AN  ENQUIRY INTO THE  PATHOLOGICAL IMPORTANCE OF ULCER-
  ATION CF THE OS UTERI.  In one neat octavo volume, extra cloth.  $1 CO.
                    WILLIAMS  (C. J.  B.),  M. D.,  F. R. S.,
                Professor of Clinical Medicine in University College, London, tec.

PRINCIPLES OF  MEDICINE.   An  Elementaiy View  of  the Causes, Nature,
  Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the pre-
  servation of health.  A new American, from the third and revised London edition.  In one octavo
  volume, leather, of about 500 pages.  $2 50.  (Now Ready, May, 1857.)
  The very recent and thorough revision which this work has enjoyed at the  hands of the author
has brougt' it so completely up to the present state of the subject that in reproducing it no udditions
have been found necessary.  The success which the work has heretofore  met shows that 's  im-
portance has been appreciated, and in its present form it will be found eminently worthy a continu-
ance of the ^ame favor,  possessing as it does the strongest claims to the attention of the medical
student and practitioner, from the admirable manner in which the various inquiries in the  different
branches of pathology are investigated, combined and generalized by an experienced practical phy-
sician, and directly applied to the investigation and treatment of disease.
  We find  that the deeply-interesting matter and
style of this book have so  far fascinated us, that we
have unconsciously hung upon its pages, not too
long, indeed, for our own profit, but longer than re
viewers can be permitted to indulge.  We leave the
further analysis to the student and practitioner.  Our
judgment of the work has already been sufficiently
expressed.  It is a judgment of almost unqualified
praise. The work is not of a controversial, but of
a didactic character; and as such we hail  it, and
recommend it for a text-book, guide, and constant
companion to every practitioner and every student
who wishes to extricate himself from the well-worn
ruts of empiricism, and to base his practice of medi-
cine upon principles__London Lancet, Dec. 27,1856.

  A text-book to which no other in our  language is
comparable.—Charleston Medical Journal.
  No work has ever achieved or  maintained a more
deserved reputation,— Va. Med. and Surg. Journal.
                          YOUATT  (WILLIAM),  V. S.
THE   HORSE.   A  new edition,  with  numerous  illustrations;  together with a
  general history of the Horse; a Dissertation on the American Trotting Horse; how Trained and
  Jockeyed; an Account of his Remarkable Performances; and an Essay on the Ass and theMulc.
  By J. S. Skinner, formerly Assistant Postmaster-General, and Editor  of  the Turf Register!
  One large octavo volume, extra cloth. $1 50.
  The attention of all who keep horses is requested to this handsome and  complete  edition  of a
work which is recognized  as the standard authority on all matters connected with veterinary medi-
cine.  The very low price at which it is now offered, free by mail, places it within the reach of
every one.
                                BY THE SAME AUTHOR.

THE  DOG.   Edited  by  E. J. Lewis,  M. D.  With  numerous and  beautiful
  illustrations. In one very handsome volume, crown Svo., crimson cloth, gilt. $1 25. 
I
r 
 
 
 
 
m§

>*^w?*j;
- r*i
'>*>4l
::^.
:JB^?*:
S&
5$
i
i
- >TJT 71
s^
■ : .,.■•■-V'. •.-• 7;f\^H  • ^\
■'■'.'-•** ■V.-'»-'»V
«
i**. .':■ *>',
.•'i#9
!*# <j«
**&
-U

$$i
^ j*"
r.*s;
&;^
^.7,7. '.a?'.
2-^vV.5^


%
^■r/r-v*
&
^**;-
l^S.
U#T: J.i Li*:' i «Ji&*JbV