* t
 
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          Bethesda, Maryland
LIBRi
Se(
   Works of this Section cannot be {liken from the Library except by written
permission of the Bureau of Medicine and Surgery.

V 
(S-G 
160
r 
ON THE
THEORY   AND  PRACTICE






            MIDWIFERY.:  £J~&f

                                   So,   \ A
          \               BY    r    ^S   \  j

     FLEETWOOD  CHURCHILL^M. D., M. R.I. A.,

  »ELLOW OF, AND PROFESSOR OF MIDWIFERY AND DISEASES OF WOMEN AND ' «H!.I>msf IN. TnE KINO AND
    QCEEN'S COLLEGE OF PHYSICIANS IN IRELAND J EXAMINER IN MIDWIFERY IN THE QUEEN'S UNIVERSITY
      IN IRELAND; ONE OF THE PRESIDENTS OF THE OBSTETRICAL SOCIETY; ASSOCIATE MEMBER
            OF THE COLLEGE OF PHY8ICIANS, PHILADELPHIA, U. S.. ETC. ETC.
WITH  ADDITIONS
    D. FRANCIS  CONDIE, M.D.,


FEU.OW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; AUTHOR OF "A PRACTICAL

        TREATISE ON THE DISEASES OF CHILDREN,'' ETC ETC.
WITH ONE  HUNDRED AND NINETY-FOUR ILLUSTRATIONS.





             A NEW AMERICAN,


                  FROM THE



 FOURTH CORRECTED AND ENLARGED ENGLISH EDITION.
  PHILADELPHIA:

HENRY  C.  LEA.

         1866. 

SUV)
                   Entered, according to Act of Congress, in the year 1860, by
                             BLANCHARD AND  LEA,
In the Clerk's Office of the District Court of the United States for the Eastern District of Pennsylvania. 
      OHAKLES JOHNSON, Esq., M. D.,







                      THIS VOLUME











                         AS A





TOKEN OF RESPECT FOR HIS HIGH PROFESSIONAL ATTAINMENTS,





                         AND OF





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

               TO

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

                TO

THE  FOURTH  EDITION.
   I trust the reader will see proofs that this Edition has undergone a
careful  revision.   I have  added what I found wanting, pruned what
appeared redundant, and corrected what was vaguely or carelessly ex-
pressed.  I earnestly hope that it has been rendered less imperfect and
more useful.
   Since the last Edition, a controversy has been in some degree forced
upon me, on the operation of craniotomy, but, unlike most controversies,
I do believe it has had no evil effects — has left no ill-feeling after it.
Nay, I  am free to confess that  it has done me good, for, by obliging
me to sift the question thoroughly, it has  enabled me to define more
precisely the grounds of the operation, and to restrict its limits  in a
more definite manner;  and of this the  students of this volume will, I
think, have the benefit. As the subject has not been so fully  ventilated
in any English work, I have  thought  it advisable  to append  the essay
I published on the question.
   I  allude with regret to another controversy both unpleasant and un-
profitable.  Dr. Francis Ramsbotham has accused me  of copying many
of his plates without  acknowledgment, implying that I put them forth
as my own.  Such a  thought never  entered into my head.   I copied
from previous  authors as they had done from their predecessors, men-
tioning  in my preface to the First Edition that I had so availed myself
of their labors.   I regret  that I  did  not specify with  each wood-cut
whence  it was  taken.   I must now be satisfied with apologizing to Dr.
Ramsbotham and all others who think  that I have  done them injustice,
assuring them  that nothing could be further from  my intention than to
claim a  merit not justly my  due.   I am too  old  to wish for quarrels,
and too  busy to have time for controversy,  so that I trust that what I
Have said will be sufficient to  prevent future misunderstanding.
  15, Stephen's Green, April, 1860.
                                                          (ix) 
 
CONTENTS.'
                                                                            PAGE
Preliminary Observations..........33


                                 PART  I.

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


                                PART  II.

            OP THE PHYSIOLOGY OP THE ORGANS OP  GENERATION.

 1.  Menstruation..........         .7?
 2.  Disorders of menstruation........             9]
 3.  Generation — Conception     ........          ,102
 4.  Utero-gestation............m
 5.  Signs of Pregnancy     ••.......            16^
 6.  Duration of pregnancy  .........         .167
 7.  Sterility...........         .171
 8.  Spurious pregnancy     ••.......    ,        174
 9.  Super-foetation...........     .177
1O.  Extra-uterine pregnancy........         ,  180
11.  Pathology of the foetus...........187
12.  Abortion.........•                190


                               PART  III.

                PHYSIOLOGY OF  THE UTERUS — PARTURITION.

 1. Classification—Definitions..........19!,
 2. Mechanism of parturition     •..«.....        203
 8. Natural labor .............222
 4  Convalescence after natural labor.........247
 6  Tedious labor.............237
                                                                   (xij  ' 
Xli                               CONTENTS.

CHAP.                                                                           *A_0B
 6. Powerless labor    .     .     .     .     .     •     •     •     •     •     •    •  -' '
 7. Obstructed labor   .     .     .     .     .     •     •     •     •     •     •    .3/8
 8. Deformed pelvis    ........••••  -•'-
 9. Obstetric operations — 1. Induction of premature labor.....29G
10. Version, or turning.....,          •     .     •     »    •  309
11. The vectis, or lever     ...........  3-3
12. The forceps   .    .     #..........331
13. Craniotomy   ........•••••  361
14. The Caesarian section..........•  383
15. Symphyseotomy    ...........  397
16. Mal-position and mal-presentation of the child      ......  403
17. Plural births—Monsters .     .          ........  428
18. Prolapse of the funis umbilicalis    .........  438
19. Retention of the placenta     ..........  443
20. Flooding.............  449
21. Convulsions.............467
22. Lacerations   ............    .  484
23. Inversion of the uterus  .     .     .     .     .     .     .     .     ...    .515
24. Sudden death............523
25. Puerperal fever    ............  537
26. Phlegmasia dolens ............  590
27. Puerperal mania   ............  599
28. Ephemeral fever or weid     ..........  606
29. Sore nipples............    .  608
30. Inflammation and abscess of the breast  .     .     .     .     .     .     .     .  609


                                APPENDIX.

Obstetric Morality............613
Qualifioat ons and duties of Monthly Nurses  .     .     .     . ■         .     .    .  629 
no
21.
LIST  OF  WOOD  ENGRAVINGS.
                                                                           PAGE
 1.  Os Innominatum, inner surface .......••■  3-'j
 2.        "        outer surface..........37
 3.  Os Sacrum.............38
 4.  Concavity of Sacrum............38
 5.  Skeleton of  trunk    .    .    .   ■  .    .     ,     .    .    .     .    •    .  4l
 6.  Pelvis — front view  .         ..........43
 7.    "     brim............, •    -44
 8.    "     cavity.............43
 9.    "     lower outlet............45
10.    "     canal of............46
11.    "     equable excess of     ...■■•■•••  49
12.    "       "    diminution of .     .    .     .     .    •    •     •    .    .  60
13.    "     distortion of brim...........50
14.    "        "         ".......••••  51
15    (i        ««         "..,....••••  51
16.    "        "         "...........  52
17.    "        "       cavity..........52
18.    "        "         "   exostosis.........53
19.    "        "         "...........53
20.    "        "         "...........54
54
22.    "        "       lower outlet.........55
23.    "        "           "..........55
24.    "     oblique distortion     ..........   55
25.  Calliper for measuring pelvis (Baudelocque's).......58
26.  Measurement of pelvis by the fingers.........59
oj.      »           «           ».........   59
28.  External organs of generation  .     .    .    .......60
29.  Anatomy of external organs of generation.......65
30.
65
31.  Section of pelvis............66
32.  Uterus, tubes and ovaries...........67
33.     "   cavity of............69
34.     "   double............."-
35.     "   bicollis.......•....."'-
36.     "   double.............73
37.            ".............^3
38.  Section of ovary, Graafian vesicles..........74
39.  Ovum of rabbit.............76
40.    "   of man.............76
41.  Ovary at menstrual  period...........84
42.
84
(xiiij 
xiv
LIS1  OF WOOD ENGRAVINGS.
                                                                              PAGE
™-                                                                             104
43.  Spermatozoa.........■
44.  Graafian vesicle after impregnation.........
45.  Ovary after escape of ovum........
46.  Corpus luteum........                             a
47.    "       "   from Montgomery.........1"°
48.  Vessels of gravid uterus...........
49.  Nerves of gravid uterus .     .     .     •     ♦......H^
50.  Cervix uteri at 3d month of gestation........H4
51.       "     at6thmonth.....•.....ui
52.       "     at 8th month..........I14
53.       "     at 9th month..........114
54.  Decidua vera........•    •      •    •     .116
55.  Decidual cotyledons.........•    ■     .116
56.  Decidua reflexa, formation of around ovum.......118
57.     <<      <<        «<      »      "........   118
58.  Human ovum of two weeks..........119
59.        "            "     laid open.......-  119
60.  Placenta and  cord.............122
61.     "     section of............   123
62.  Human ovum at an early period.......    •     .132
63.        "      about 3 weeks..........132
64.       "            "        ..........132
65.        "            2 month's..........133
66.        "               "..........133
67.        "            3 months..........134
68.  Section of a hen's egg...........135
69.  Vitelline  membrane, Blastoderma — T. W.  Jones......185
70.  Changes in the hen's egg during incubation.......136
71,     "               "       "      "........137
72.     "               "       "      "........138
73.  Vesicula  umbilicalis, from  Baer.........139
74.     "         "         "..........141
75.  Diagram  of foetus and membranes about the 4th week, from Carus  .    .     .142
76.     "        "           "         "       6th week   .    .     .         .   142
77.  Position of foetus in utero..........144
78.  Foetal head diameters...........   146
79.  Mode of  examination by ballottement........162
80.  Tubal foetation............182
81. Dewees' wire  crotchet...........195
82. Bond's placental forceps...........196
83. External layer of uterine muscular fibres........203
84. Internal    "        "       "       "........203
85. Planes of the pelvis...........206
86.    "          "............207
87.               "............207
88. Deformed pelvis............208
89.     "     "............208
90. Outlet of the pelvis............209
91. Foetal head, diameters.......    .     .     .    .211
92. Mechanism of parturition — 1st position .    .......  215
93. Vertex presentation — 1st position......     .     .     .215
94.    "       "           "       first step in mechanism of labor  .     .    .215
95. Outlet of pelvis with foetal head passing through in the 1st position    .    .  216
96. First  position of vertex, third step in mechanism of labor     ....  216
97. Mechanism of parturition — 2d position  ........  216
98. Outlet of pelvis — foetal head passing through in the  2d  position   .    .    .  217 
LIST  OF  WOOD  ENGRAVINGS.
XV
no
PAGE
 99.  Mechanism of parturition—3d position........"1<
100.  C-Ulet of pelvis — foetal head in the 3d position    .     .    .    •    •    .218
101.  Mechanism of parturition — 4th position.......-'"
102.  Outlet of the pelvis aud foetal head in the 4th position.....219
103.  Head at lower outlet in the 4th position........2-0
104.  Head at the lower outlet,..........228
105.  Vaginal examination...........^°u
106.  Extraction of placenta...........236
107.  Obstructed labor — polypus uteri.........283
108.      "        "     ovarian tumor.........28o
109.       "        "     vaginal cystocele........-^
110. Version or turning.    .....••••••   0i"
111.
113.  Modern vectis.
127.
320
112.  Roonhuysen's vectis    .....••••••  °-~t
324
114.  Application of vectis...........3-9
115.  Chamberlen's forceps...........383
116.  Short forceps.............334
117.  Long forceps .                        ........°°*
118.  Dr. Radford's forceps...........336
119.  Churchill's forceps............336
120.  Operation with long forceps..........346
121.     "          "     "..........347
122.     "         short forceps..........348
123.  Axes of pelvis............  354
124.  Dr. Huston's forceps...........356
125.  Dr. Hodge's forceps...........35 <
126.  Dr. Bond's forceps............359
359
t-'H     "        "..,...•••■••  359
129.  Hayn's perforator............363
130.  Smellie's perforator...........363
131.  Crotchet.............363
132.  Churchill's crotchet...........364
133.     "        "         ...........364
134.  Mr. Holmes's perforator..........364
135.      "           "...........364
136.  Knife for amputating limbs..........365
137.  Blunt hook.............365
138.  Dr. Davis's bone forceps...........365
139.  Oldham's instrument...........366
140.  Craniotomy forceps...........366
141.  Dr. Meigs's Embryulcia instruments........367
U2.      "       "         "         .........   367
143#      <<       *««         "         ,     ,.......367
144. Craniotomy forceps...........368
145.        '«      "         ...........368
146.  The cephalotribe............369
147. Use of the perforator...........376
148.   "          "         ...........377
149. Application of the Crotchet..........   378
150.     "               "..........379
151. Perforator for cranioclasm    .     .........380
152. The cranioclast............  380
153. Sketch of the head of a child delivered by cranioclasm, showing the change of
         form and amount of diminution caused by the operation  ....  381 
XVI
LIST  OF  WOOD  ENGRAVINGS.
FIO.				PAOB
155.	Face presentations ......			403
156.	Face presentation—1st position			404
157.	Passage of the head through the external parts in face presentation			405
158.	Face presentation — 2d position			405
159.	Forehead under the arch of the pubis			410
160.	Breech presentation— 1st position .			411
161.	" " ♦' ...			412
162.	<< " 2d position .			412
163.	» " extraction of head			416
164.	Presentation of inferior extremities			417
165.	" " " . .		.....	418
166.	Arm presentation—1st position			420
167.	" " 2d position			421
168.	" '• .....			421
169.			.	421
170.	" " . . . . .		■	422
171.				422
172.	Compound presentation — hand, foot, and funis			427
173.	Hydrocephalus .....			436
174.	Prolapse of the funis.....			440
175.	Hour-glass contraction of the womb			447
176.	Removal of adherent placenta			447
177.	Placenta praevia .....		.	456
178.	Duck-billed speculum.....			497
179.	The manner in whfch Sims adjusts and fixes the silver sutures			498
180.	Bozeman's button as it is being passed along the threads down to the wound ■			499
181.	Bozeman's button-suture finally applied . .			499
182.	Bozeman's suture adjusted ..........			500
183.	Tubular needle for passing wire threads through the lips of vesico-vaginal fistulre.			500
184.	Fork or pulley used in drawing through the wire threads ....			500
185.	Blunt hook for directing the point of the needle ......			500
186.	The iron wire splint of Simpson finally adjusted.....			501
187.	Dr. Coghill's instrument for finally tightening and fixing the wires .			501
188.	The iron-wire splint finally adjusted and the ends of the stitches twisted and			
	secured across the lower bar of the splint ......			502
189.	The tenaculum, or sharp hook used for catching up the edge of the mucous			
	membrane of the vagina around the fistula ......			503
190.	Straight knife used for paring the edges of the fistula .....			503
191.	Bent knife used for paring the edges of the fistula ......			503
192.	Lateral view of the bent knife to show the angle at which the blade is bent .			503
193.	Laceration of perineum, Dr. Horner's operation . .			513
194.	a it <t n		. . • •	513
 
ON
THE  THEORY   AND  PRACTICE

                          OF

            MIDWIFERY.
           PRELIMINARY  OBSERVATIONS.

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

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

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

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

   Part I. will include the normal and abnormal anatomy of the pelvis, and
of the external and internal organs of generation.
       3                                                   (33) 
34                PRELIMINARY OBSERVATIONS.

   Part II, the function of menstruation, with its abnormal conditions :  and
of conception, utero-gestation, ovology, etc., with their abnormal deviations,
as sterility, superfoetation, extra-uterine gestation,  fcetal  pathology, abor-
tion, etc.

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

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


THE  ANATOMY OF THE  PELVIS  AND OF THE  ORGANS OF

                         GENERATION.
                          CHAPTER  I.

                 OF  THE  BONES OF THE  PELVIS.

  1. The pelvis  is an  irregular bony cavity,  situated at the  base of the
spinal column, and above the inferior extremities, with  which it is connected
by articulations and muscles, and for which, as well as for the muscles of the
trunk, it constitutes a "point d'appui."
  As it  forms one of the  two  mechanical elements of parturition, it is of
great consequence to  understand rightly its  component parts, their connec
tions, relations, coverings, and abnormal varieties.  These we shall  therefor*
proceed to investigate at once.
  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.  Let us now examine these bones separately.

                                 Fig.  1.
Os Innominatum, inner surface.
  o. Each Os Innominatum (Fig. 1), at an early period of intra-uterine life.
consists of cartilage only, in which, subsequently, numerous spiculae of ossifi
                                                            (35) 
36
BONES  OF  THE PELVIS.
cation are seen, and which at birth have coalesced so as to form three bones,
separated by cartilage.                                        •
  After birth, the process of ossification continues until these separate bonea
meet in the acetabulum, where they are identified with each other, and at the
symphysis pubis, where the opposite ossa pubis are united  by cartilage and
ligaments.   The breadth of each os innominatum, from the anterior-superior
to the posterior-superior spinous process, is  six inches, and the height from
the tuber ischii to the highest part  of the crest of  the  ilium is seven inches.
   The three bones into  which each  os innominatum is  divided at birth have
received different names, and require a distinct notice.
   4. The Os Ilium, Up, or haunch bone  (Fig.  2), is the larger  of  the
three, of a triangular shape, situated  superiorly, and with its fellow forming
what is  called the false pelvis.
  Its external surface  (x), or dorsum,  is convex, irregular,  with  elevations
and depressions which serve for the attachment of the glutaei muscles.   Its
internal surface,  or venter (10), is concave and smooth, affording a bed for
the iliacus internus muscle.  The lower portion, body or base  (5), is  the
thickest  part of the bone, and forms more than one-third of the acetabulum.
Above the body,  the bone spreads out into  its ala or  wing, which  rises  ob-
liquely forwards,  upwards, outwards, and then backwards, terminating in the
crest or crista ilii—a semicircular ridge  of some thickness, which, at its
posterior part, curves downwards and forwards.   Its  borders serve for the
attachment of the abdominal  muscles, and certain  ligaments  to be hereafter
described ; and it terminates anteriorly, in the anterior-superior, and ante-
rior-inferior spinous processes (4,5).   The former afford  attachment to Pou-
part's ligament,  the tensor vagina? femoris, the sartorius, and a portion of
the rectus femoris  muscles.   Between  the  posterior  spinous processes is a
deep arch, — the sciatic notch — which is divided by ligaments into the two
sciatic foramina: through the upper of these, which is the larger, pass the
gluteal,  sciatic, and pudic arteries, the sciatic and pudic nerves, and the pyri-
form muscle ;  whilst, through the  inferior  opening, the pudic  arteries  and
nerve re-enter the pelvis, and the obturator internus muscle passes out.   The
posterior part of the crest of the ilium terminates in an irregularly oval rough
 surface, with numerous  prominences, which occupy corresponding depressions
 in the sacrum, and constitute (with a thin layer of cartilage interposed) the
 sacro iliac synchondrosis of each side.   The body of  the  bone is  divided
 from the ala internally  by a well-marked ridge (12), running from the junction
 of the ilium, with the sacrum, forward ; this is part of the linea ilio-pectinea,
 and defines the boundary of the true pelvis.
    Thus we find that the ilium is connected  posteriorly with the sacrum, and
 identified anteriorly with the ischium and pubis in the acetabulum.
    5. The Os Ischium, os sedentarivm, etc., is the lower of the  three bones
 composing the os innominatum, and the  next in size to the os ilium.   Its
 base or body (2), which forms the  inferior portion of  the acetabulum, is the
 thickest part;  below this we find a narrower portion, from which a spinous
 process juts out backwards and inwards,  and affords insertion to part of the
 sacro-sciatic ligament.   This process varies in length and  direction, and is
 occasionally  of some importance  obstetrically.   From  the  neck, the bone
 descends downwards and forwards,  until, enlarging at  its lower portion, it
 forms the tuber ischii  (u),  the bony seat, a rough, thick protuberance ; and
 turning upwards, at an obtuse  angle, becomes the ascending ramus (15)  of
 the ischium.   Its internal surface is smooth and  even, and forms one of the
 inclined planes of the  pelvic  cavity.  Its external  surface is rough, and
 gives attachment  to the sacro-sciatic ligament, to the semi-membranosus,
 semi-tendinosus, the long head of the biceps flexor cruris, and the quadratus
 femoris muscles. 
BONES  OF  THE PELVIS.                     37
  Thus the ischium is identified with the ilium and pubis in the acetabulum,
with the descending ramus of the pubis, and is connected by ligament with
the sacrum.
  6. The  Os Pubis, pecten or share-bone, is the smaller and most  anterior
of the three bones.  Its base  is  the  thickest part, and forms  the  anterior
and smaller third of the acetabulum, beyond which the bone narrows;  and,
proceeding  forwards, constitutes the horizontal  ramus (16)  of the pubis ;
somewhat triangular in shape,  and about half an inch in breadth.   It meets

                                 Fig. 2.
                         Os Innominatum, outer surface.

its opposite at the symphysis pubis ("), and  completes  the  anterior wall of
the pelvis.   From the inferior part of the symphysis, and at an acute angle
with the horizontal ramus, a thin plate of bone, the descending ramus (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  termination is
a small spinous process, to which  is attached the inner end of Poupart's
ligament, and  near it the pectineus  muscle, whilst the inner and outer edges
of this portion of the bone  afford  insertions to  the  abdominal  muscles.
Although I have stated that the anterior part of the bony pelvis is completed
bv the osa 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.   The shape of these foramina is
stated  by Meckel, Cruvelhier, Cloquet,  etc., to be oval in the  male  and tri-
angular in the female.   Other and  opposite statements have been made, bur
from the  observations of Dr.  John Neill1 there can be little doubt that the
former opinion is the correct one, and this  affords  an additional  distinction
between the male and  female  skeleton.   The os pubis is identified with the

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

                 Fig. 3.                               [Fig. 4.]
               Os Sacrum.

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

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

                 OF  THE  JOINTS OF THE PELVIS.

   9.  Before proceeding to the  consideration of the  pelvis collectively, let
 us briefly examine the joints by which the separate bones are connected, and
 especially as deficient information on this subject has heretofore led to erro-
 neous practical conclusions.   I shall notice, 1, the sacro-iliac synchondroses;
 2, the symphysis pubis; and, 3,  the sacro-coccygeal joint.
   10.  The  Sacro-iliac Synchondrosis, of either side, consists of a rough
 irregular surface on  the posterior  part of  the  ilium  and the side of the
 sacrum,  each of which is covered with a layer of cartilage from one-sixth to
 one-eighth of an inch in thickness; the sacral layer being the thicker, and
 the entire, when  the  bones  are  forcibly separated, adhering to the sacrum.
 At the point of  junction of these  two layers, their substance is  somewhat
 softer, which has led  to the erroneous supposition that it is a joint properly
 so called.   This  union of  the bones is strengthened by strong ligamentous
 bands, which by  some writers are described as the superior, inferior, ante-
 rior,  and posterior sacro-iliac ligaments.   They stretch across  from  one
 bone  to the other in  front and behind, rendering the  joint perfectly immo-
 vable, unless great force be used.  Additional strength also is obtained  by
 the sacro-sciatic ligaments connecting the lower part of the sacrum with the
 ilium.
  11.  The mode  in which the sacrum is inserted between the ossa ilia is    <
 worthy of notice; it  resembles the  position of the keystone of an arch in-
 verted— i. e., its  transverse diameter is greater inside than outside, because
the pressure which it  has to resist is from within.  The interposition of car-
 tilage  is probably for the  purpose  of  diminishing the  effect of shocks, and
so preserving the integrity of the union. 
40
OF  THE JOINTS  OF  THE PELVIS.
  12. The Symphysis Pubis is situated anteriorly, and formed by the junc-
tion of the two  ossa pubis, whose  extremities are covered by cartilage or
fibro-cartilage.   It was formerly supposed that the junction was effected by
the interposition of a single mass of cartilage ; but the researches of Dr.
W. Hunter led him to  the  conclusion that the  end of each bone is covered
with cartilage, and that between each so covered, there is a matter resembling
the intervertebral substance.  With this view M. Baudelocque and Dr. Burns
agree, but M. Tenon thinks that sometimes the one and sometimes the other
mode obtains.
  Occupying two-thirds of the length, and the posterior third of the centre
of this junction, we find a true arthrodial articulation, six lines in length and
two in breadth, in shape like  an almond, lined by synovial membrane, and
containing a small quantity of synovia.   M.  Gardien  defines  this joint as
" an arthrodial articulation in  part, and the remainder a true synevrotic syn-
chondrosis."1
   13. Though the joint be  weak in itself, it is strongly fortified by ligaments.
The capsule is strong, and is connected with, or partly formed by, the ante-
rior and posterior pubic  and sub-pubic ligaments, which  consist  of inter-
lacing fibres  stretched  across the joint on all  sides, and firmly attached to
each os pubis.
   14. Ambrose  Pare,  Severin Pineau, and other ancient  writers,  with  Si-
gault, Chaussier,  Gardien, Matthews Duncan,2 etc.,  among  the moderns,
judging from its occurrence in certain animals, have concluded that the ossa
pubis are separated to a certain extent during labor, and that this joint is a
special  provision for increasing the antero-posterior diameter of the brim of
the pelvis; and  certain post-mortem examinations of females who died near
the full term of  gestation,  have been adduced  in proof of the fact.   On the
other hand this  separation is denied,  and I believe most justly, by Denman,
Baudelocque, Boyer, Burns, Dewees, etc.  M. Baudelocque, and others, have
sought  for it in vain in cases where no violence has been used;  and, from a
fair  examination of the observations on record,  we may  conclude that it
never takes place as a natural process, but that we  occasionally meet it as an
accident.  Dr. Dewees'3 arguments appear to me conclusive :  "1. It is not
stated to  be more frequent in distorted than in well-formed  pelves, which
ought to be the case on account of the greater pressure.  2.  When it does
occur, it is attended with severe inconveniences, which are not observed after
ordinary labor.  3. That such a separation as has been imagined, would not
materially increase the antero-posterior diameter of the brim, as  it would
require  the two  ossa pubis to  be separated one inch from each other to gain
two lines."
   I may add, that this separation can only be effected by the rupture of the
pubic ligaments and sacro-iliac synchondroses,  the structure of which prove,
beyond doubt, that they were  not intended to expand ; and that when this
accident  does occur, it completely incapacitates  the  patient from moving
about, by depriving the lower extremities of a  firm "point oVappui^ which,
as M. Martin has  recently shown,4 can only be restored by a band  passed
firmly around the pelvis, and pressing the sacro-iliac synchondroses strongly
together.
   15. The Sacro-coccygeal joint is of the kind  called ginglymoid, admit-
ting of  extensive motion,  especially backwardc, so as to permit the enlarge-
ment of the lower outlet, in its antero-posterior diameter, at least one inch.
The articulating surfaces  are  covered with cartilage, and between them is a
synovial capsule;  whilst on the  outside, and entirely embracing the joint, is
u fibrous capsular ligament.
  1 Traite" des Accouchemens, vol. i. p. 28.        2 Dublin Journal, vol. xviii. p. 60.
  ' Compendious System of Midwifery, p. 13.     4 Gazette Medicale, Nov. 1851. 
OF  THE PELVIS.
41
  16. Abnormal deviations.  Relaxation, or violent disruption of the pubic
joint  and sacro-iliac synchondroses, has been well described by Dr. Den-
nian1  and others.   The most remarkable symptom is the difficulty or impos-
sibility of sitting erect, of assuming  an upright position without help, of
standing or walking.   There is often pain or uneasiness in the pelvic region,
which may give rise to a suspicion of uterine disease ; and  a sense of weak-
ness and looseness in the bones.  Relief will be immediately  afforded  by  a
binder, which, by its tightness, shall supply the degree of firmness in which
the pelvis is deficient; this and absolute rest are our chief remedies, and the
former should be  worn until a natural union takes place.
  But a  further evil  may occur, as Dr. Denman has pointed out.  Inflamma-
tion may take place in the injured  joints, and matter be  formed on their
loosened surfaces.  "When suppuration," he observes, "has taken place, in
consequence  of the injury sustained at the junction of the ossa  innominata
with the sacrum,  the  abscess has in some cases  been formed near the  part
affected,  and  been cured by common treatment.  But in others, where matter
has been formed and confined at the  symphysis of the  ossa  pubis, the symp-
toms of a hectic fever have been produced, and  the cause has not been dis-
covered till after  the death of the patient.  In others, the  matter has burst
through  the capsular ligament of the symphysis  at the inferior edge,  or per-
haps made its way into the bladder; and in others, it has  insinuated itself
under the periosteum, continuing its  course till it arrived at the acetabulum.
The mischief being thus extended, all the symptoms were aggravated ; and
the matter making its way to the surface, a large abscess  has been  formed
on the inner  and  fore  part of the thigh, or near the  hip, and the patients
being exhausted by the free and proper discharge, have at length yielded to
their fate."1   In  all  such cases, where it  is  possible, the  abscess should be
opened, and the matter evacuated..
  17. The sacro-coccygeal joint may become  anchylosed, and so  offer  a
decided impediment  to the dilatation of the  lower outlet during labor, as
we  shall  see by and bye.
                        CHAPTER  III.

                 OF  THE  PELVIS  COLLECTIVELY.

   18. Having thus examined each bone of the  pelvis separately, and the
joints by which they are united, our next object is the consideration of the
pelvis as a whole, in relation to the rest of the body, its magnitude, axes, etc.
   It is connected with the trunk by the articulation of the sacrum with the
last  lumbar vertebra, effected in the  same  manner  as the junction of the
vertebrae with  each other:  with  the  lower extremities, it is connected by
means of the hip-joints.
   But the position  of the pelvis in situ is very different from what we might
suppose from  examining  it separately.   The brim  of the pelvis  is neither
horizontal  nor perpendicular,  but  oblique.   When the body is erect, the
upper part of the sacrum and the acetabula are nearly in the same descend-
ing line.   The obliquity has been variously estimated ;  that of the brim from
1 Introduction to Midwifery, p. 17.   7th Ed.
8 Ibid. 
42
OF  THE PELVIS.
35° to 60°,  and that of the  outlet from  5£° to 18°.  Naegele states the
obliquity of the brim to be from 50° to 60°, and that of the outlet from
10° to 11°; the point of the coccyx being seven or eight lines above the
summit of the arch of the pubis, and the sacro-vertebral angle three inches
nine lines higher than the pubis.
  19.  The  advantages of  this obliquity are obvious.  As Dr. F. Rams-
botham has truly  observed : " Were the axes of the trunk and pelvic en-
trance in the same line, owing to the upright position of the human female,
the womb, towards the  close of gestation, would  gravitate  low  into the
pelvis, and produce most injurious pressure on the contained viscera; while
Skeleton of Trunk.
in the early months not only would the same distressful inconvenience be
occasioned, but there would be great  danger of its protruding externally,
and  appearing as a tumor between the  thighs, covered by  the  inverted
vagina."1  We  may add, that, when  not pregnant, the patient would be
obnoxious to  prolapse  of the uterus  and the other pelvic viscera,  upon
making very slight expulsive efforts.
   20. Now let us examine the  Pelvis itself.   It is divided by the linea ilio-
pectinea  into the false and true, or upper and lower pelvis.  The Upper or
False Pelvis is formed by the lateral divergence of the alae of the ossa inno-
i Obstetric Med. and Surgery, p. 12.  2d Ed. 
OF  THE PELVIS
48
Fig. 6.
Front view of Pelvis.
 minata.  It is not of much importance obstetrically, except for the general
 relation which its normal size bears to that of the true pelvis, and the infer-
 ence to be drawn therefrom as to the normal or abnormal condition of the
 latter.   Dr. Burns gives the following measurements, which I believe are
 correct: — " From the symphysis pubis to the  commencement of the iliac
 wing  at the inferior spinous process,  is nearly four inches.   From the
 inferior spinous  process to the posterior ridge  of the ilium, a line subtend-
 ing the hollow of the costa, measures  five inches.  The distance  from the
 superior spine is the same.  From  the  top  of  the crest of the ilium to the
 brim of the pelvis, a direct line measures three inches and a half.   The dis-
 tance between the two superior anterior  spinous processes  of the ilium, is
 fully ten inches.   A  line drawn from the top of the crest of the ilium to the
 opposite side,  measures rather more than eleven inches, and touches in its
 course  the  intervertebral  substance between the  fourth  and fifth lumbar
 vertebrae.   A line drawn from the centre of the third lumbar vertebra, count-
 ing from the sacrum to the upper spine of the ilium, measures six inches and
 three quarters.   A line drawn  from the  same vertebra to the top of the
 symphysis, measures seven inches and three quarters :  and when the subject
 is erect, this line is exactly perpendicular."1
   21.  The Lower or True Pelvis is the  part  involved in parturition, and
 which therefore ought to be  known  with great  accuracy.  For the purpose
 of description, it is divided into the brim, cavity, and outlet.
   22. The Brim of  the  Pelvis  is defined by the linea ilio-pectinea •  it is
 of an oval form,  except posteriorly, where the  oval is broken  by the  pro-
 montory of  the sacrum.  Its influence upon labor will be understood, when
 we recollect that it is the  first solid resistance with which the head of the
 foetus meets : that any diminution in its size is more hazardous and less reme-
 diable than in any other part  of  the passages; and lastly, that deviations
 from the normal proportions of the brim most frequently entail similar ones
 in the cavity.
  The three principal diameters are, the antero-posterior (Fig. 71) from the
prominence  of the sacrum  to the  inner and upper edge of the symphysis
pubis;  the transverse (2) across the  widest part  of the brim, at right angles
to the antero-posterior; and the oblique  diameter (s) from  the sacro-iliac
i Principles of Midwifery, p. 23.  9th Ed. 
44
OF  THE PELVIS.
Fig. 7.
Brim of Pelvis.
synchondrosis of one side, to the opposite side  of the brim, just above the
acetabulum.
  Yrolick states that, to exhibit accurately the relations between the head
of the foetus and the brim of the pelvis, their diameters should be so drawn
as to intersect each other in the central  point  of the brim ; and to  do so,
the  anterior extremity of the oblique diameter and  the  transverse diameter
must be rather more forward than they are usually placed.1
  23. The measurements of these diameters are not  exactly the  same in
different  women, though the  variation  is  but  slight.   I  shall place  the
measurements given by some of the chief authorities before the reader.
Antero-post. diameter... Transverse..	Denman.	Burns.	Bamsbo-tbam.	Kigby.	Baude-locque.	Velpeau.	Moreau.
	4 in. & a fraction. 5	4 in. 5	4 in. 5	43 in. 5-4 4-8	4 in. 5	4 in. 5 4*	4 in. 5 4*
  If we take the smallest of these estimates, there will still be space enough
to admit the head of the child ; and if we allow half an inch for variations,
this will give us a pretty correct idea of the diameters of the brim.
  The circumference varies from thirteen to fourteen and a half inches.
  Dr. Burns has given us some other measurements : "From the sacro-iliac
symphysis to the crest of the pubis on the  same side is four inches  and a
half;  from the top of the sacrum to that part of the brim which is directly
above the foramen thyroideum, is three inches and a half; the  line, if drawn
to the acetabulum in place of the foramen, is a quarter of an inch shorter;
a line drawn across the fore part  of the brim, from one acetabulum to the
other, is nearly four inches and a  quarter." 2
  24. The Cavity  of the Pelvis, whose fixed boundaries  are the sacrum,
the ischium, and  the pubis, is  of unequal  depth.   Posteriorly it  measures
five' inches, or six if the  coccyx be  extended; from the brim  to the tuber
ischii, three inches and three-quarters ; and the depth of the symphysis pubis
is from two to two and a half inches.

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

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

                                Fig. 10.
Canal of Pelvis.
which I have copied from  one given by M. Danyau in his translation ol
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 obturator foramen oval • the 
OF  THE PELVIS.
11
arch of the pubis is narrower, its angle being about 70° or 80° ;  the tubera
ischii are nearer to each other, and the coccyx less  movable.
  From the  greater width  of the  female  pelvis, the acetabula are further
apart than in the  male, although the  thigh  bones  approach  each other in
their descent, and the knees (in  the erect position) are nearly in contact,
giving a peculiarity to the movements of the female not observable in the
other sex.
  32.  So far, we have considered the  skeleton pelvis only;  but the subject
would be incomplete without a brief notice of the soft parts lining the pelvis,
and covering it  externally.   The former modify the diameters of the pelvis,
and the latter must be taken into account in forming a diagnosis in the living
subject.
  The iliac fossae are each occupied by the iliacus  internus muscle, internal
to which, and slightly overlapping the edge of the brim, is the psoas muscle ;
these pass over  the anterior part of the brim to their insertions.   Near the
inner margin of the psoas muscle we find the iliac  artery and vein, with the
crural nerves and lymphatics.  In  the cavity we find the obturator internus
and the pyramidalis muscles,  with the haemorrhoidal  and sacral vessels, and
the sacral nerves. The rectum passes down nearly in the centre of the sacrum,
and the bladder lies behind  and above the  symphysis pubis.   These parts are
held in situ  by cellular membrane,  superficial and deep  fascia, etc.
   The lower outlet is nearly closed by soft parts, which are capable of great
distension.   On either side of the  sacrum  and coccyx are situated the sacro-
sciatic ligament, the coccygeus muscle, and layers of fascia and cellular sub-
stance ; whilst the termination of  the rectum,  and the  perineum, consisting
of  transverse muscular fibres, fascia and cellular tissue, close the outlet pos-
terior to the orifice of the vagina.
   33. The effect of these additions, in diminishing  the internal measurements
of  the pelvis, is not very great, except at the lower outlet.   The transverse
diameter of  the brim is diminished about half an inch, or rather more when
the psoae muscles are in action, and the conjugate  diameter about a quarter
 of  an inch.   The diameters  of the  cavity are not lessened more  than a
 quarter of an inch.   The lower outlet may be said  to be  almost closed  in
the absence  of any distending force, the orifice of  the vagina being the only
vacancy ; but the elasticity of the  perineum, etc., occasions the soft parts  to
be  little or no permanent diminution of the  antero-posterior diameter.
   34. To the crest of the ilium the abdominal muscles are  attached, and on
the outer surface of the ossa  innominata  there  is a large mass  of muscles,
the glutaei, pyriformis, gemellus superior and inferior, obturator internus and
 externus, and quadratus femoris.   These muscles are separated by fascia,
 and are covered by a thick  layer of adipose tissue, and the  skin.   The ante-
 rior wall of  the pelvis gives origin  to a great number of  muscles, most of
which have  been  already enumerated.
   35. The external measurements of the  pelvis are of considerable import-
 ance in the diagnosis of deformity, as deviations externally appreciable will,
in most cases, though not in all, be found  to accompany internal ones. Un-
fortunately,  the  data  we possess  are but  few; however, the following, I
believe, are correct: —
   The external antero-posterior diameter of the pelvis  is from 7  to 8 inches.
   The external transverse, between  the  crista  ilii of  each side, 13 to 16
     inches.
   From the  anterior superior spine of one oide to the other, 10 to 12 inches.
   From the  great trochanter of one side to  the sacro-iliac  synchondrosis of
     the other, 9 inches.
   The depth of the pelvis, from the top of the sacrum to  the coccyx, from
     4 to 5 inches.
< 
48
OF  THE PELVIS.
  Ir-  order from these measurements to form a sufficiently-correct estimate
of the internal diameters of the pelvis, we must deduct from them the thick-
ness of the parietes; i. e., about  three inches antero-posteriorly, and_tour
inches laterally, according to Baudelocque, Navas, and Yelpeau.   The depth
is easily ascertained externally; posteriorly, by taking the length  of the
sacrum; laterally, by measuring from the anterior superior spine of the ilium,
and dividing by two ; and anteriorly, by taking the depth  of the  symphysis

  It  is  but fair to add, that  doubts  have been  expressed of the utility and
accuracy of these  measurements, by Mesdames Boivin and Lachappelle, on
account of the varying thickness  of the  parietes of the  pelvis : but, even
allowing for this, they appear  to me of  some value as an approximative
estimate.                                                    .
   36. In this  opinion  I am supported  by M.  Naegele, who,  in  his recent
work on Oblique Distortion, has pointed out certain external measurements
as  a  means of  diagnosis, and has given a  careful estimate of forty-two cases.
Hts  French translator, M. Danyau, has  added to these eighty cases mea-
sured by himself, and the average result is as follows:
    1.  From the tuber ischii of one side  to the posterior superior spinous
       process of the opposite side, 6 inches, 6 lines.
    2.  From the anterior superior spine of the ilium of oneside to the poste-
       rior superior spine of the other side, 7 inches, 10 lines.
    3.  From the spinous process of the last lumbar vertebra to the anterior
        superior spine of the ilium of either side, 6 inches, 7 or 8 lines.
    4.  From the great trochanter of one side to the posterior superior spine
        of  the  ilium of the opposite side,  8 inches, 2 lines.
    5. From  the centre of the inferior edge of the  symphysis  pubis to the
        posterior superior spine of  the ilium of either side, 6 inches, 3 or 4
        lines.1
    These measurements are those of ordinary-sized pelves; they will of course
  vary if the pelvis  be unusually large or small; but the utmost variation  in
  No.  1  was 6 lines;  in No.  2 was 11 lines; in  No.  3 was 7 lines ; in No. 4
  was  9 lines;  and  in No. 5 was 9 lines;  and  these were almost all single
  exceptions.
    37.  The next point  relates to the practical application of these facts, or,
  in other words, to the  best mode of ascertaining the size  of the pelvis in the
  living  subject.  A certain amount  of information may be obtained from the
  general and equable contour of  the pelvis, the breadth of the hips  as com-
  pared  with the shoulders, the degree of obliquity of the pelvis, the curve  of
  the  sacrum, etc.;  and in  many cases  we may pronounce, from a cursory
  glance, that the  patient is  well  or ill made.   Should this not  be so appa-
  rent, we must have recourse to external measurement, which is easily effected
  by means of  a pair of curved calipers and a foot measure.   Care  must be
  taken  to place the points of the  instrument  accurately, as a slight deviation
  may produce different and  incorrect  results.    The  measurements  thus
  obtained  we can  reduce to the internal diameters of the pelvis by making the
  deductions already mentioned, although without any pretensions to absolute
  accuracy.
    38.  There  is greater difficulty in ascertaining the magnitude of the pelvis
  internally.   In Great Britain we are  almost limited to the  information
  afforded  by the  "toucher;" and undoubtedly, by  this means alone, a well-
  educated finger may obtain a sufficiently-accurate estimate for practical pur-
  poses.   When making an examination for this purpose, the  finger should

    i  Des Principaux Vices de Conformation du Bassin, par Naegele, translated by M.
  Danyau.
9 
DEFORMITIES.
49
be passed  direct to the promontory of the sacrum, and thence  carried for-
ward  slowly to the symphysis pubis :  we may then pass it across the pelvis,
in the direction of the transverse and oblique diameters, and finally follow
the course of the brim, taking note of any deviation from  the  usual form,
Or of any obstacle.  The  state of the  sacrum and cavity generally, and the
mobility of the  coccyx, can readily be ascertained by the finger, as well as
the dimensions  of the lower  outlet.   Although  deficient in precision, the
information thus obtained may satisfy us of the possibility of the passage of
the child; and of course, if the  patient be pregnant, and  still better if she
be in  labor,  there will be more certainty, as we  shall then  have the child's
head  as a standard of comparison.
  39.  But, in order to arrive  at  greater accuracy, certain instruments have
been invented, chiefly by continental obstetricians, for measuring the internal
as well as the external diameters  of the pelvis.   Thus we have the "compas
d'epaisseur" of Baudelocque, the  "cephalometre" of Stein, the "mecome-
tre" of Chaussier, the pelvimeters of De Creve, Aitken,  Coutouly, Bang,
Traisnel, etc., with various  modifications of modern invention ; but I do not
think it necessary to enter into any minute description of these instruments,
as they are seldom, if ever, used in these countries.  The  natural delicacy
of the sex precludes their employment in  the cases in which they would be
of the greatest value : I mean, before marriage,  or conception.
                          CHAPTER  IV.

  ABNORMAL DEVIATIONS  IN  THE  PELVIb.-  DE*FOR.MITIES

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

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

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

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

                                 Fig. 14.
Distortion of Brim of Pelvis.
to  one of these  situations.   The distortion may also occur in any of the
diameters, though the antero-posterior diameter of the brim, and the trans-
verse of the lower outlet, present them most frequently.
  45.  At the brim we find distortions more common in the antero-posterior
diameter, as I have  said;  next in  the  oblique, and lastly in the transverse
diameter.

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

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

                                 Fig. 17.
Distortion of Cavity of Pelvis. 
DEF0RMITIE8.
53
cacrum is too much or too little curved, when the  other parts of the pelvis
are of normal form.   In some very rare cases the cavity contracts gradually
from the brim to the  outlet, forming what has been called a " funnel-shaped
pelvis."
   The capacity of the cavity may also be diminished by a fibrous or bony
growth from the sacrum, as in the annexed figures.   The first (Fig. 18) is

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

                                 Fig. 19.
Exostosis of Cavity of Pelvis.
  The third is a fibrous growth from the periosteum : the  case  occurred in
the Dublin Lying-in Hospital, and has been described by Dr. Shekelton,1 to
1 Dublin Journal, vol. x. p. 287   New Series. 
54
DEFORMITIES.
whom I am indebted for the cast from which this drawing has been taken.
These  morbid growths from the periosteum or bone  involve the same diffi-
culty as distortions, inasmuch as they are incompressible and immovable;
but, unlike most  distortions, they increase slowly, so that the longer they
continue, the greater the obstacle.
   47.  The lower outlet is comparatively independent of the brim and cavity

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

                                Fig. 21.
Exostosis of Cavity of Pelvis.
the figures annexed; fig.  22 being the lower outlet of fig. 15, and fig. 23 of
fig. 17.   On the other hand, distortions of the  lower outlet may occur with
a normal shape and size of the brim.   They are most frequent in the trans-
verse diameter, owing  to  the  approximation of the tubera ischii, which at
the same time will diminish the span of the arch of the pubis, and so effectu- 
DEFORMITIES.
55
Fig. 22.
Distortion of Lower Outlet of Pelvis.
ally, though  not apparently,  shorten the  antero-posterior  diameter.   The
other way in which the latter diameter  is lessened, is by too great a curve
forward of the lower part of the sacrum and coccyx, and by the anchylosis
of the coccygeal joint.   There is a case related  by  Dr.  Summer, in the
American Journal of Medicine, in which the projection of the coccyx, the
joint being anchylosed, was so great as to cause the death of three infants
successively.   The fourth time Dr. S. endeavored to straighten it, but being
unable, he  broke it, and the child was born alive. The same proceeding was
necessary in  two subsequent  labors.  The spinous process of the  ischium
may offer some obstruction, if it be unusually long, and curved inwards.

                                 Fig. 23.
Distortion of Lower Outlet of Pelvis.
  48. The amount of these distortions varies as much as possible: it may
be so slight as merely to retard delivery;  or it may be so great as to pre-
clude it altogether, as in Mr. Bell's case, where the antero-posterior diameter
was about half an inch, or in that recorded by M.  Naegele, in which it was
even less.
  49. In most cases of pelvic deformity the distortion is somewhat unequal,
one side suffering more  than the other; but there is a class of cases in  which 
5C
DEFORMITIES.
this distortion is almost entirely confined to one side.  An allusion to such
will be found in  several authors ;  but it remained for M. Naegele to add to
his high reputation by a careful and accurate description of this oblique dis-
tortion (" das schrdg verengte becken," or "pelvis oblique ovata").   In
these  cases (fig. 24), the affected side  is flattened, and the sacro-iliac syn-

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

  1 The reader will find an excellent translation of  Nuegele's valuable memoir, by Dr
Christie, of Aberdeen, in the British Record of Obstetric Medicine. 
58
DEF0RMITIE8.
               6 in. 11 lines on the left side, and 5 in. 8 lines on the right
      No. 2,   7 "  9   "    "      "         6 " 10  "     "
      No. 3,   6 "  6   "    "      "         5 "  3  "
      No. 4,   9 "  0   "    "      "         8 "  0  "     "     "
      No. 5,   6 " 11   "    "      "         6 "  1  "     "     "
  Let the reader  compare these with the measurements of a well-formed
pelvis, as  already given, and he will be convinced that either method, or the
two combined, will afford fair grounds for a diagnosis.
  Anchylosis of the sacro-coccygeal joint will be discovered by its immobility
when pressed by the finger during an  external examination.
  The effect of the different kinds and  degrees of deformity upon the mechan-
ism of parturition, and the practical considerations upon which the manage-
ment of such cases must be founded, will be discussed in the Third Part of
this work.
  [In a  great  majority of the cases of reduced or distorted  pelves, the
degree of deviation from the natural  standard, although perhaps sufficient
to cause great difficulty in delivery, is nevertheless too  small to be  readily
detected  by the external measurements  pointed  out by the author.   The
calliper,  or " Le compas d'epaisseur de Baudelocque" (fig.  25), so much

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

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

                Fig. 26.                               Fig. 27.
Measurement of Pelvis by the Fingers.           Measurement of Pelvis by the Fingers.
  " Some little allowance is to be made for the length of the oblique  line
represented  by the finger, which, instead of passing directly to the centre
of the pubis, falls under it.
  " With the finger  we can easily discover  whether the concavity of the
sacrum is augmented or  diminished,  which will  enable us  to  determine
whether the antero-posterior diameter of the excavation is deranged.
  " The antero-posterior  diameter of  the inferior strait may be ascertained 
60
EXTERNAL  ORGANS OF  GENERATION.
in the same manner as the corresponding diameter of the upper strait:  the
end of the forefinger being placed on the extremity of the coccyx, the hand
must be raised until the radial edge of the finger touches beneath the pubis ;
being marked at this point, it can be measured as before described.
  " The finger thus introduced enables us at the  same time to judge of the
flexibility or otherwise of the sacro-coccygeal joint."1  There is indeed very
little difficulty in  ascertaining accurately the diameters of the inferior strait
with the  fingers externally applied.
  During  the labor, the internal examination of the pelvis is greatly  facili-
tated by  the relaxed condition of the  internal parts;  and, if necessary, the
hand may be introduced for the purpose.]
                         CHAPTER  Y.

        OF THE EXTERNAL ORGANS OF GENERATION.

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

                                 Fig. 28.
                         External Organs of Generation.

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

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

   1 It would be inconsistent with the object of a work like the present to enter into details
upon the various diseases to which the parts are subject; I must therefore content my-
self with enumerating them, and refer the reader to my work on Diseases of Women.
   2 M6m. de l'Acad. M£d.  de Paris, vol.  xv. p. 528. 
62
EXTERNAL ORGANS  OF  GENERATION.
the erectores penis, and terminates in  a gland  covered by a prepuce, but
which is imperforate.  The clitoris projects about the eighth of an incK and
is situated just below the point of junction of the nymphae.   It is richly
endowed with nerves, extremely sensitive, capable of erection, and is  said to
be the seat of  sexual gratification.  In  the foetus  it is disproportionately
large, but it does not increase afterwards in proportion  to  the  surrounding
parts.
   65. Abnormal deviations.—The clitoris may vary in  size from congenital
malformation or disease ;  but the researches of M. Parent-Duchatelet1 have
disproved the opinion that it enlarges from frequent sexual indulgence ; and,
according to the  same high  authority, its excessive development  does not
entail extreme  sexual desire.
   This organ  may be attacked by inflammation, or  by malignant disease.
Bartholinus relates the  case  of  a courtezan whose  clitoris  was the seat of
calcareous deposition
   66.  Below the clitoris there is a smooth triangular space,—the Yestibtj-
LTJMj—at the lower part of which we find the Orifice of the Urethra, or
the Meatus TJrinarius, just at the upper edge  of the orifice of the  vagina.
The exact situation of this opening is important, because we are frequently
called upon to  introduce the catheter, and in ordinary cases it should be done
without exposure.   The operation is not difficult:  the  patient  being placed
on her back, and the labia being  separated, the point  of the forefinger of
the left hand should be placed just within the orifice of the vagina, so as to
press slightly its upper edge: the catheter should then be passed  along the
inner surface of the finger, until it reaches the vestibulum, near the edge of
the vaginal opening; when  there, a very slight movement will cause it to
enter the meatus urinarius.  Or the patient may be placed on  her left side,
in the ordinary position for labor,  and  the finger carried  from behind for-
ward to the vestibulum ; the catheter should then be passed along the finger
in the direction of the axis of the outlet, and on reaching  the vestibulum, a
slight movement will detect the  orifice.  The operation is more difficult when
 the parts are  swollen  or distorted, as happens occasionally from  disease.
 during pregnancy or labor, and after delivery;  and if  we cannot detect the
 orifice by the touch, we  must of course use a light; and  then, for  obvious
 reasons, it is better that the patient should be placed on her side.
   The orifice is round, though its sides are usually in contact, and its  edges
 are somewhat  thickened.
   67. The Urethra is a membranous canal about an inch or an inch  and a
 half in length, dilatable,  and directed obliquely from before backwards, and
 from below upwards, running under and  behind the  symphysis pubis, from
 which it is  separated by loose cellular tissue.   Internally it  opens into the
 bladder.   Its  direction  is subject to  variation.  During pregnancy, the
 bladder being  carried upwards with the uterus, the urethra curves under the
 pubic arch,  and then ascends  perpendicularly.  The  same change occurs
 when the uterus is  enlarged from other causes.  In prolapse  of the  pelvic
 viscera its course is reversed.  These changes should be borne  in mind when
 catheterism is  required.
    68. Immediately below the orifice of the urethra we find a much  larger
 opening, of about an inch in diameter,—the Orifice of the Yagina.  Its
 sides are in contact ordinarily, but it is capable of  enormous distension, and
 of again returning to its natural size.   The opening is closed inferiorly in
 infants, by a fold of mucous membrane of a crescentic shape,  the concavity
 looking upwards, and which is called the Hymen.   This membrane  is easily
 destroyed, or it may become so relaxed  as scarcely to  be perceptible, which
1 De la Prostitution de la Yille de Paris.  1836. 
external organs  of  generation.
63
will account for its rarity in adults.   It was formerly held to be peculiar to
the human female, but the researches of MM. Duvernoy, Cuvier, and Steller
have proved  its existence  in many animals.  From very early times  it has
been made the test  of  virginity, its  absence being considered conclusive
proof of sexual intercourse having taken place;  and the fate of the wives
of Henry YIII. is an extreme instance of the injustice to which this opinion
led.  Modern investigations have proved, not only that it may be destroyed
by many causes unconnected with  sexual  indulgence, but that intercourse
may take  place, followed by pregnancy,  without its destruction, as in three
cases which occurred in my own practice.
  It is therefore of no value as a test of virginity.
  69. Abnormal deviations. — The principal ones  are the following:  1, it
may be unusually thick and strong, so as to preclude intromission ; 2, instead
of the single opening superiorly, it maybe pierced with several small holes;
3, instead  of the usual form, the  hymen may consist of a single or double
bridle stretching across  the  orifice of the vagina;  or, 4, it may be imperfo-
rate, and close the vagina completely.  Examples of each kind are recorded
in the different works on midwifery, and in the periodicals.  These abnormal
deviations  are of importance only as they may prevent sexual connexion, or
impede  the natural  discharges or delivery;  and once discovered, they are
easily removed.
   70. The Caruncul^e Myrtiformes are  four or five small tubercles, which
in most females  occupy the situation of the hymen, of which they are  con-
sidered  the remains by most anatomists : others, however, suppose them to
be small duplicatures of the mucous membrane  of the vagina.   They may
possibly facilitate the distension of the orifice of the vagina by unfolding.
  Abnormal deviations.—Occasionally they are greatly hypertrophied.
   71. The parts contained within  the vulva are abundantly supplied  with
nerves,  owing to  which, and to the extreme delicacy of their texture,  they
possess exquisite sensibility.   This  explains the very severe pain which
accompanies even trifling diseases of these parts;  and it is merely a repeti-
tion of the fact observed in  other mucous membranes, viz., that they acquire
their highest degree of  sensibility near their junction with the skin.
   72. The Fourchette is the inner edge of the posterior commissure of the
vulva, and the anterior border of the  perineum,  between which is a space
called  the fossa  navicularis; it is formed by the union posteriorly of the
labia.   It consists of a fold of mucous membrane, meeting externally the
skin of  the perineum, and is frequently, perhaps generally, torn slightly in
first labors.
   73. The Perineum is the name given  to the  space between the posterior
commissure and  the anus.   It is  of a somewhat  triangular shape, and its
medium length, in women  who have not borne children, is from one to two
inches.   It is shorter, of course, in those who  have had  children.   In the
centre a prominent line  may be observed, running antero-posteriorly, called
the  "raphe."  The perineum is composed of various tissues;  externally
there is the  skin, then  adipose and cellular  tissue, fascia, a portion  of the
constrictor vaginae, levator  ani, transverse and sphincter muscles ; besides
which, it contains the superficial and  transverse arteries, veins, nerves, and
lymphatics.'  Yery few hairs grow on this part.
  The use of the perineum  is obvious: it closes the lower outlet posteriorly,
so as to prevent the prolapse of the pelvic viscera; whilst it admits of dis-
tension  when necessary, and  by  its elasticity, speedily resumes its former
condition.
  74. Abnormal deviations. — The perineum is  sometimes unusually long,
increasing  the  risk of its laceration during labor;  or it may be very short,
and so afford inadequate support to the superimposed viscera.   It may be 
64
EXTERNAL ORGANS  OF  GENERATION.
torn in various ways during labor, as we shall see hereafter, and either not
unite or present the cicatrices  of former lacerations.   It is  sometimes the
seat of hernia, according to Smellie, Mery, and Curade.
  75.  The Yagina is a musculo-membranous canal, extending from its 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,  describing  nearly the line
of the canal of the pelvis (§30).  Its form is cylindrical, somewhat flattened
superiorly, but, when quiescent, its parietes  are in contact.   Its dimensions
vary according to age, and other circumstances ; for instance,  it is propor-
tionately longer in the foetus than in the  child.  In. some individuals it  is
very long, in others very short.  Dr. Dewees  mentions a case where  it was
only an inch  and a half long, and I have  met with others nearly as  short.
It  is also longer  and narrower in virgins than  in  those who 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 color, re-
sembling in some degree fibrous tissue, and about a line and a half in thick-
ness anteriorly, though less near the womb.   It is well supplied with vessels,
which are multiplied and interlaced so much towards  its  anterior extremity
as  to  constitute a kind of erectile tissue, which has  received the name  of
plexus retiformis,  Internally, the vagina is lined by mucous membrane of
a pink color, continued from the vulva, and which near the orifice, and there
only, possesses great sensibility, except when it is  the  seat of  inflamma-
tion, and then the whole canal is very tender.    The mucous coat is disposed
in the form of transverse rugae, anteriorly and posteriorly, which, by unfold-
ing, permit the distension of the vagina.
  From the "cut de sac," at the inner extremity of the vagina, the mucous
membrane is reflected down upon  the  projecting cervix uteri,  and exhibits
peculiarities  of which I  shall speak presently.   In  addition to  its proper
tissue aud 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 lym-
phatics, which are very numerous, are derived  from the hypogastric plexus.
The use of the vagina  is twofold; first, for copulation, and,  secondly, for
the transmission of the foetus;  and, to facilitate the latter process, the inner
membrane, which in  its ordinary state secretes  just enough mucus to lubri-
cate its surface, during labor, secretes it most profusely.
  It has  been established by the observations of Whitehead, Tyler Smith,
and others, that the vaginal  mucus is acid, thus differing from that  of the
uterus, which is alkaline.
  76.  Abnormal deviations.—The vagina varies  much in length, as already
stated: its width differs equally in different subjects; it  may be  so  narrow
as  to render intercourse difficult and painful; its  exit may be closed  by the
hymen, or by a membrane higher up ; its sides may be adherent, or the seat
of cicatrices  or callosities; or it may be altogether wanting.
  Of  course, occlusion or absence of this  canal will  prevent the escape of
the menses, and render copulation impossible, constituting one  cause of ste-
rility;  but, though a partial closure  may impede intromission, it does not
render impregnation impossible.  I may add, that the narrowness or width
of  the canal is no proof of virginity, or the contrary;  for M.  Parent-Ducha-
telet states, that in many of the younger prostitutes of Paris it was wide and
dilated ;  whilst in others, who had  followed  their degrading  pursuits  for
twenty years, it might have  been mistaken for the vagina  of virgins.  Dr.
Montgomery has pointed out, what most practitioners must  have observed,
how very quickly,  after delivery, the vagina recovers  its usual size and tone. 
                   EXTERNAL  ORGANS  OF  GENERATION.                65

   The vagina is also very obnoxious to  attacks of acute and chronic  inflam-
mation, and  their consequences;  to lesions  of  nutrition, and to specific and
malignant diseases.
   [The annexed two cuts will assist in presenting to the mind of the  student
a clear idea  of the anatomy of the  external organs  of generation.]

                                         [Fig. 29.]
  Front view of the erectile structures of the external organs of generation in the female. — a. Bultms
vestibuli.  b. Sphincter vaginas muscle,  e, e. Venous plexus, or pars intermedia.  /. Glands of the cli-
toris,  g. Connecting veins,  h. Dorsal vein of the clitoris,  k. Veins going beneath pubes.  I. The obtu-
rator vein.
                                      [Fig. 30.]
  A. view of the muscles of the perineum in the female. — 1. Tuber ischii.  2. Sphincter vaginsB muscie.
8. Its origin from the base of the clitoris.   4. Vaginal ring of the same muscle, which receives a part
of the fibres of the levator ani.  5. Intercrossing of the sphincter ani and sphincter vaginae muscles at
the perineal centre.  6. Erector clitoridis muscle. 7. The clitoris covered by its prepuce.  8. Transversus
ferinei muscle of the female.  9. Sphincter ani. 10.  Levator ani.  11. The gracilis. 12. Adductor mag-
nus. 13.  Posterior part of the gluteus magnus.
      5 
66
INTERNAL ORGANS  OF  GENERATION.
                         C HA PTER  VI.

         OF THE INTERNAL ORGANS  OF  GENERATION.

  77. According to the arrangement I have proposed, our next  subject is
the formative, or internal organs of  generation.   But before we proceed to
take them in detail, it will not be unprofitable to direct the attention of the
student to the relative situation of  the pelvic viscera, as shown in the next
engraving.
Section of Pelvis.
  Proceeding from before, backwards, we  find the urethra running in  an
oblique direction, antero-posteriorly, and from below, upwards,  under the
arch of the pubis, and then merging in the  bladder, which, when distended,
rises about half its height above the symphysis pubis.  Below the urethra,
but with an interval between them,  is the vagina, running its oblique course
to the os uteri, which is a little above the level of the pubes.   The position
of the  uterus is  not vertical, but inclining  a little  forward, with  its fundus
above the level of the bladder.  The peritoneum is reflected from the abdo-
minal parietes, on the fundus and posterior  wall of the bladder down  to the
commencement of the cervix uteri; from whence it passes over the anterior
surface, fundus, and posterior surface of the uterus, and on to the posterior
wall of the vagina, down to  about  an inch below  the level of the os uteri,
from whence  it is reflected upon the rectum.  The  latter organ lies between
the  uterus and the sacrum, and a little to the left  side of the uterus.  I do
not of  course mean that this exact position  of the parts  never varies, but
the  sketch I have given is sufficiently accurate  for practical purposes;  and
it is very important for the practitioner to be acquainted with  the position
and elevation of the pelvic viscera.
  •We  may now pass on to the description of the uterus, fallopian tubes and
ovaries.1
  1 I beg to refer the reader for more minute details than I have space for, to Dr. Farre's
uhle article in Dr. Todd's Cyclopaedia of Anatomy and Physiology, Parts 49, 50. 
INTERNAL ORGANS  OF GENERATION.              67
  78. The Uteris is the receptacle provided for the nutrition, maturation,
and, ultimately, for  the  expulsion  of  the  foetus.   It is the largest of the
generative  organs, and is peculiar to the human female, though there is an
approach to  such an organ  in the  mammalia.   It is a hollow symmetrical
viscus, in shape somewhat triangular  or pyramidal, resembling a flattened
pear, but rounder posteriorly than anteriorly;  situated, as we have just seen,
in the centre of the pelvis, behind the bladder, above the vagina, below the
small intestines, and in front of the rectum.   For the convenience of descrip- .
tion, anatomists ordinarily divide it into trie fundus, or that part above a
line drawn  from the orifice of one  fallopian tube to the other;  the cervix, f
or the narrow and inferior part; and the body, or that part between the ,
fundus and cervix.  Dewees maintains that the cervix differs essentially, in
structure and function, from the rest  of the  uterus.   The microscopic re-
searches of Dr. Tyler Smith have shown certain peculiarities of arrangement,
and  differences of structure, in its internal and external mucous membrane ;
its  general structure is  more dense, less vascular,  and the menses  are not
excreted by this part.   In the  unimpregnated  state it  projects  into the
vagina about half or three-quarters of an inch, the anterior lip being the
lower.
  79. The uterus  gradually  assumes  its  normal  form during fcetal  and
infantile life.   Dr. Rigby remarks, that it is at first  divided into two  cornua,
and usually continues so until the end  of the third month, or even later; the
younger  the  embryo, the  longer are  the  cornua,  and  the more acute the
angle which they form ; but even after  this  angle has disappeared, the cornua
continue for some  time  longer.   The uterus is  at first of an equal width
throughout;  it is perfectly smooth,  and not  distinguished from the vagina,
either internally or externally, by any prominence  whatever.  This  change
is first observed when the cornua disappear, and  leave the uterus with a

                                 Fig. 32.
Uterus, Tubes, and Ovaries.
simple cavity.   The  upper portion m  proportionally smaller, the younger
the embryo is.  The body of the  uterus gradually increases, until, at the
period of puberty, it is  no longer cylindrical, but pyriform.   Even in the
full-grown  fcetus the length of the body is not more than a fourth part ot
the whole uterus;  from the seventh to the fourteenth year it is only a third :
nor does it reach half until puberty has  been fully attained.   The os tincae,
or os uteri externum, first appears as scarcely a perceptible prominence,
projecting  into the vagina.  The parietes  of the  uterus are thin in  propor-
tion to the age of  the embryo.   They are of equal thickness throughout, ai
first;  at the fifth  month, the cervix becomes  thicker than the upper parts; 
68
INTERNAL ORGANS  OF  GENERATION.
  between five and six years of age, the uterine parietes are nearly of an equal
  thickness, and remain so until the period of puberty, when the body becomes
  somewhat thicker than the cervix.1
     80.  The  adult healthy uterus  may vary a  little in  size, but the following
  measurements, given by Dr. Burns,2 are sufficiently accurate.  " The length
  of the uterus, from the margin of the lip to the fundus,  is two inches  and
  three-quarters ;  breadth between the  insertion of the fallopian  tubes, from
  two  inches  and three-eighths to two inches and five-eighths ; the middle of
  the fundus rises  a quarter of an inch above  a line drawn from the insertion
  of one tube to that of the other; the  commencement of the body is an inch
K 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 btreadth an inch and a quarter.   The breadth of the termination
  or lips of the os uteri, an inch  and one-eighth ;  thickness, including both
  lips, three-quarters of an  inch.  The  length of the transverse chink, or os
  uteri, from three-eighths to half an inch ; each lip is three-eights of an inch
  thick, though the posterior is said to be the  thinnest."  "From the margin
  of the lip to the top of the cervix is an inch, but  sometimes  only three-
  quarters, or even less.   From the top  of the triangular cavity of the fundus
  to the end of the narrow cylindrical cavity of the body is an inch and one-
  eighth ;  the extreme breadth of the top of  the cavity stretching from the
  entrance of one tube to that of the other is nearly an inch and a half."
Fig. 33.
Cavity of the Uterus.
  According to the calculations of Levret, its superficies may be reckoned
at sixteen  inches, and its  cavity at eleven-twelfths, or about three-quarters
of a cubic inch.
           1 Library of Practical Medicine, vol. vi. — Midwifery; p. 16.
           2 Principles of Midwifery, p. 50. 
                INTERNAL  ORGANS OF GENERATION.              69

  The weight  of  a virgin uterus, according to Meckel, is from  seven  to
eight drachms ;  but after child-bearing it amounts to an ounce and a half.
  81.  The Os  Uteri, or Os  Tineas, 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 U
enters the cavity  of the uterus,  marking the os uteri internum, as it  has
been.called.  Between the os uteri externum  and internum the mucous mem-
brane is  curiously  disposed in rugae, branching out from a central line ; this
has been called the arbor vitoe.   The internal surface of this canal is thickly
studded  with  mucous  follicles, called glandules Nabothi, and which,  after
impregnation, secrete a thick mucus which blocks up the canal.
  The cavity of the uterus is of a triangular shape, the base being upwards ;
its dimensions have already been given.
  82.  Much difference of opinion has existed, and  many  discussions have
taken place, as to the structures which compose the uterus ; though of late
years the opinions of authors are more harmonious.  It possesses three dis-
tinct tunics: I. We have already seen  (§ 77) that it is covered anteriorly
and  posteriorly by peritoneum, which is reflected laterally to the sides  of
the  pelvis, near the sacro-iliac  synchondroses,  forming the broad ligaments
of the uterus, or the aloe vespertilionis, on each side, containing the fallopian
tubes, ovaries,  and round ligaments.  From  their attachment to the pelvis
they may, perhaps, serve  as supports to the uterus, at least before conception.
This serous covering is identical with the lining of the abdomen.
  83.  II.  The Middle Coat of the  Uterus is  by some asserted, and by others
denied, to be muscular;  but  this really appears to me little  more than a dis-
pute  about the name,  for those who  deny its muscularity admit  that it per-
forms the  functions of a muscle.  Mr. Rainey has examined very minutely
with the microscope the middle coat of the uterus, and finds that it is made
up of "fusiform nucleated fibres, contained in a matrix of exceedingly cohe-
rent granular  matter.   The  average  breadth of one of these fibres, at  its
dilated or nucleated part, is  about  40Vota or>  an incn-  Their length cannot
be ascertained with certainty, as it is impossible to  estimate the degree  of
curtailment which they suffer in  being separated from the  granular matrix
in which they lie embedded."1  The fibres belong to the class of non-striated
or involuntary muscles.   This middle coat differs in  color from  ordinary
muscle, being  yellowish, with a faint tinge of red, like the middle coat  of
arteries,  and it is much more  dense than muscular  tissue.  It  consists  of
fibrous structure,  though it  is not easy to trace the course of the fibres in
the unimpregnated womb; however, when the  uterus is enlarged from im-
pregnation or other causes, it can readily be  done,  aud  they may be divided
into  several sets.   The  superficial set are very irregular,  interlacing  with
each  other  in  every direction, though with  a general tendency from  the
fundus towards the cervix;  but  some regularity is observable in the deeper
sets ;  for instance, there  is a  circular arrangement around the orifice of each
fallopian tube,  and at the os uteri;  a layer diverging from the middle line
anteriorly and  posteriorly, and  perpendicular bands descending to  the  os
uteri.  Among  these more  regular layers there are irregular fibres inter-
spersed.   From the middle coat fibres are sent off to the fallopian tubes aud
rouud ligaments.
  S-i. 111. The Mucous  Coat.—A  considerable number  of distinguished
1 Philosophical Trans.: 1850.  Part ii., p. 519. 
70
INTERNAL ORGANS  OF  GENERATION.
  foreign writers, among whom we find Morgagni, Assoguidi, Chaussier, and
  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, etc., do not question the presence
  of a lining  membrane, but  contend that it is  not mucous ; and apparently
  for the sole reason that one of its functions (menstruation) is not a function
  of mucous membranes.  This objection, however, is refuted by the fact that
  other mucous  membranes do  occasionally secrete a fluid apparently identical
  with the menses (vicarious menstruation); and we may add, that the  uterine
  membrane presents the anatomical and histological characteristics of mucous
  membrane; that it secretes mucus, undistinguishable from that of the vagina.
  Its pathology also is that of mucous membranes.
    For  these reasons I have no doubt that the uterus is lined by mucous
  membrane,  continued from the  mucous  membrane of the vagina after it
  covers  the cervix  uteri.  Dr.  Tyler Smith has recently published some very
  interesting and original microscopic researches on the structure of the mucous
  membrane covering the cervix and lining its canal, of which I shall give a
  brief abstract, especially on  account of  their bearing upon  disease.  The
  external  mucous  membrane  consists of  epithelium,  basement  membrane,
  fibrous tissue, bloodvessels,  and nerves, like other mucous membranes.  The
*  special peculiarities are as follows:  The  epithelial layer is tessellated or
  squamous, and so arranged as to form a membrane of considerable thick-
  ness.   Immediately beneath, the basement membrane  covers  the villi;  each
  villus contains a looped bloodvessel, passing  to the  end  of  the villus, and
  returning to its base, where it inosculates with the bloodvessels of the neigh-
  boring villi.   The villi are everywhere  covered by pavement  epithelium,
  which renders the  external surface smooth.  The points of the villi are  nipple-
  shaped, with  a depression in the centre.   From Dr. Smith's researches, it
  appears doubtful if  the external surface  possesses any mucous or glandular
  follicles.  Just within the os uteri a small extent of smooth surface is found,
  with villi covered by cylinder epithelium, like those of  the intestines; these
  villi being three or four times larger than those of the external surface, and
  containing  one or two looped vessels.   Underneath  the villi of this part,
  and  externally, a dense fibrous  and  vascular tissue  is found,  mixed with
  iuvoluntary muscular fibres and nerve fibres.   Higher up, we find the pecu-
  liar  structure of the cervical canal.   It  exhibits four columns  of oblique,
  curved, or transverse rugas,  with four longitudinal grooves or  ridges.  Under
  the microscope, these  rugae, and the fosse between,  are found to be divided
  and subdivided many  times, and these rugae,  and even the  secondary septa,
  are covered with  mucous follicles so numerously, that Dr. Smith calculates
  that in a well-developed virgin cervix uteri there  must be  10,000 mucous
  follicles.   The villi of this  portion of the canal are numerous, and covered
  with cylinder epithelium.  Thus we have a provision made for a very large
  extent of glandular secreting  surface; in fact, Dr. Smith calls  the cervix "an
  open gland," and he regards this as the principal seat of leucorrhcea.  The
  uorniai mucus  secreted by this portion is very viscid, and almost transparent.
  It adheres to the  crypts and rugas, and fills the canal of the cervix.  It has
  an alkaline reaction, whilst  that from the cervix externally is acid.   It con-
  sists of minute corpuscles, caudate corpuscles, minute oil globules, and occa-
  sionally dentated  epithelium,  in a thick, tenacious plasma; and its use, Dr.
  Smith  thinks,  is to close the canal of the cervix, and probably to afford a
  suitable medium for the passage  of the spermatozoa into the uterine cavity.1
1 Med.-Chir. Trans., vol. xxxv., p. 377. 
INTERNAL ORGANS  OF GENERATION.              71
  85. The Arteries of the uterus are four in number, furnished by the aorta,
the hypogastric, and emulgent arteries.   The two superior — the spermatic
— arise from the aorta or emulgent arteries, and descend along the sides of
the womb in a serpentine course; they  are distributed to the upper part of
the uterus, to the fallopian tubes and ovaries.  The two inferior — the ute-
rine arteries — given off by the hypogastric arteries, run along the sides of
the uterus, to within  a short distance of the lips, then divide,  and  supply
the cervix and upper part of the vagina.   The spermatic and uterine arte-
ries anastomose freely  with each  other.
   86. The Veins are more numerous than the arteries, are capable of greater
distension, and lie superior to their corresponding arterial branches.   They
possess no valves, and, like the  arteries, are  of small size  so long  as  the
genital system  is quiescent, but increase very  greatly during  pregnancy,
when they form what have been called the uterine sinuses.
   87.  Some uncertainty has existed as to the Nerves of the uterus;  but
the researches of Drs.  R. Lee, Robin, Snow Beck, and Hirschfeld, added to
those of their  predecessors, have  rendered our information  more complete.
They arise from the  aortic plexus, and from the  hypogastric  nerves  and
plexus, being  a mixture of spinal  and sympathetic nerves.  I shall take
the liberty of quoting Dr. Lee's  account of a dissection of  these nerves in
the unimpregnated uterus :  " The aortic plexus, the hypogastric nerves  and
plexuses,  were all much smaller than in any of the  gravid uteri I had pre-
viously seen.   From the fore and middle part of the left hypogastric plexus
a small branch passed down on the inside of the ureter, to the trunk of the
uterine artery and veins,  which  was  surrounded by a plexus of  nerves,
as  in  the gravid uteri before  examined.   From  this, branches  passed
upwards to the fundus uteri, and a communication between these and the
spermatic  nerves  was quite evident.   From the left hypogastric plexus,
numerous branches passed also directly  into the uterus, without entering the
ganglia at the cervix,  which ramified on the peritoneum  behind, and on the
muscular  coat.  Branches from the posterior part of the hypogastric plexus
communicated with some branches of the sacral nerves behind the gauglion.
The trunk of the left hypogastric nerve was easily traced through the plexus
to the upper part of the  ganglion, which was remarkably large and distinct,
and consisted  of white  and grey matter.   Into  the posterior  part of the
ganglion the third sacral nerve sent numerous branches.  From the anterior
margin of the ganglion a broad band of white and grey nerves passed round
the outer surface of the ureter, and, after uniting with a similar band  on
the inside, sent branches to the  plexus  surrounding the uterine artery and
vein, and  also branches to the anterior surface of the uterus.  Large flat
nerves were  seen passing off from the  anterior border of the ganglion, to
the bladder and vagina, and from its inferior and posterior borders to the
vagina and rectum.  A great number of nerves likewise passed off from the
inner surface of the ganglion into the cervix uteri.  The nerves sent off from
the ganglion were both larger and more numerous than those which entered
it.  A great web of nerves was  seen under the peritoneum, both on the
anterior and  posterior surface of the uterus,  intimately connected with the
nerves sent off by the  ganglion and hypogastric plexus."1
  88. The Lymphatics are very  numerous, though very small, in the unim-
pregnated uterus.  The  most  numerous set of these vessels runs  from the
upper part of the body and cervix  of the womb along with the spermatic
vessels,  and with those from the ovary, in front  of  the  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 liga-

    1 The  Anatomy of  the Nerves of  the Uterus, by Robert Lee,  M. D, etc., p.  7. 
72              INTERNAL  ORGANS OF  GENERATION.
ment through  the  inguinal ring.   A  third set joins the lymphatics of the
vagina, and enters the hypogastric plexus.
  89. The lower portion of the uterus is within the reach  of a vaginal ex-
amination, so that we can estimate its size, temperature, integrity, mobility,
sensibility, etc. ;  and by the use of the speculum we are able to ascertain its
color; the state  of its surface, and,  if 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 applica-
tion of the stethoscope.   An examination "per rectum" is of value in cer-
tain diseases of the uterus, and especially of  the ovaries.
  90. Abnormal deviations. — 1. The uterus may be  altogether wanting ;
several such cases  are on record.1  2.   The canal of the cervix may be ex-
tremely narrow throughout, or it may be the  seat of stricture.   3. It may
be closed, either by the union of its sides, or by the mucous membrane being
continued over the os uteri.   4. The  uterus  may be malformed ;  and it  is
remarkable that these malformations,  which are owing  to  an  arrest of de-
velopment, appear to reproduce the analogous  organs  of lower  classes of
animals;  for instance, the double uterus, (fig. 34) resembles in some degree
the tubular oviduct of birds, it opens  by two  ora uteri into the vagina ; or
both the  uteri and vagina may be distinct.2

               Fig. 34.                                 Fig. 35.
                                                    Uterus Bicollis.

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

  1 Kussmaul has published a volume devoted to these and analogous deviations • see  also
cases by Dubois, Lancet, Dec. 8, 1855.
  2 Amer. Journ. of Med. Science, p. 331.  Oct. 1852. 
INTERNAL ORGANS OF GENERATION.
73
  The effect of the three first abnormal deviations will be either the absence
of menstruation, and consequent  sterility, or inefficient or painful menstrua-
tion.   The deviations from arrest of development may exert no injurious
36.
Fig. 37.
D6nble Uterus.
Double Uterus.
influence upon menstruation or conception, but they have been adduced to
explain the phenomenon of  superfoetation, as it  is pretty certain that a
double conception may take place ; and, when  it is single, the vacant cavity'
is lined by decidua.   In addition, the uterus is the seat of many forms of
disease.
   [A singular instance of  malformation of the uterus is recorded by  M.
Lecluyse.  The subject of it "was a  small female,  who had previously been
twice confined with an arm  presentation.  The occurrence of the same acci-
dent for the third time caused the accoucheur to make a minute examination,
in order, if possible, to  find an explanation of so  unusual a circumstance.
The result of the  investigation wras, the womb, instead of being of  the
natural pyriform shape, had its greatest diameter in a transverse direction ;
so that  the long axis of the elliptic form which the foetus occupies in utero
was horizontal.   This anomaly was thought by M.  Lecluyee to account for
the three consecutive arm presentations."1]
   91. The Fallopian  Tubes  are two cylindrical canals, about four inches
long,  proceeding from the upper angles of the  uterus.  They are contained
in the superior and lateral  folds of the  broad  ligaments.  Internally, they
open obliquely into the  uterus, at which point the canal is narrow;  it after-
wards expands, and then again contracts towards its external termination,
where it is open to the  abdomen. Externally,  the tubes are of equal thick-
ness for about three inches  and a half, when they expand, and terminate in
a fringed process, called the fimbriae, or  mbrsus dimoli, which is applied to
the ovary during impregnation.  The tubes are covered externally by peri-
toneum, beneath  which  is their proper tissue, with some circular and longi-
tudinal  fibres, derived from  the middle coat of  the uterus.  Internally, they
are lined by mucous membrane, disposed in longitudinal folds, the villi of
which are  highly developed after impregnation.  The tubes share in  the
vessels and nerves by which the ovaries are  supplied.
   Their function is the transmission of spermatozoa to the ovary in the first
instance, and afterwards of  the  impregnated ovum  to the uterus ; in fact,
they are the excretory ducts of  the ovary.
   92.  Abnormal deviations. —The tubes, one  or both, may be impervious,
from disease, or as a congenital malformation.  The closure of both of course
entails sterility.  They are also subject to inflammation and its consequences,
and to malignant diseases.
  1 [Runking's Abstract, p. 240, American edition, from Journal de Chirurgie, Mars, 1845.] 
74              internal  organs of  generation.
   93. I have already stated that the round ligaments are formed by fibres,
derived from the middle  coat  of the uterus.   Mr. G. Rainey asserts, that
they are composed  of striated fibres,  and are of the nature of voluntary
muscular fibre, and  that their function  is in some way connected with the
act of coition.1  M. Rau has also  published  an  interesting paper on this
subject.2   He conceives that for two-thirds of  their course, these fibres are
a  continuation  of the  muscular fibres, both superficial and  middle, of the
uterus.  He admits the correctness of  Rosenberger's description of the
courses of the three bundles of muscular fibres that form part of the  liga-
ment while in the inguinal canal.   Some of the fibres proceed to the hori-
zontal ramus and symphysis pubis.
   M. Rau  thinks that the round ligaments exercise no function during the
^impregnated  state of the womb ;  but, that towards  the end of pregnancy,
they contribute  to give a forward tendency to the fundus uteri, and especially
during the early part of labor.
   94. The  Ovaries are the essential organs of generation  in  the female ;
they are the " analogues" of the testes in the male, and up  to  the time of
Steuo, 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.
   95. When laid open, we find their internal structure to consist of cellular
tissue,  permeated by numerous blood-vessels  derived from the spermatic

                                Fig. 38.
Section of Ovary, Graafian Vwicles.
arteries, running tortuously across the ovaries in nearly parallel  lines •  and
by nerves.   Embedded in the cellular parenchyma of the organ, in the adult,
a number (from 10 to 20) of small vesicles may be observed, which, though
noticed by Fallopius and Vesalius, were more particularly described by De
Graaf, and called after him, Graafian Vesicles.
  They vary somewhat in number; and in size, from that of the head  of a
small pin to that of a small pea.
  96. There is some difference of opinion as to the age at which these vesi-
cles are developed:  some say, about the period of puberty;  others among
whom is Dr. Rigby, state that they make their appearance about the'seventh
              1 Philosophical Transactions.  1850.  Part II. p. 515
              a Zeitschrift fur Geburtshulfe.   July, 1851. 
internal  organs of  generation.
75
year; but according to M. Xegrier, in his "Recherches sur les Ovaires'^
they are  to  be found much earlier.  He states that at birth the texture of
the ovarian parenchyma is homogeneous, but  that in the course of a year,
an uncertain number of miliary granulations may be observed ; after a short
time, these granulations are  surrounded by an opaque zone, and a small
vesicular globule, whose walls are formed  by this zone, is  annexed to the
granule.   This globule contains a vesicle (the Graafian)  formed by  two
membranes, concentric  and in contact.   At the  age 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 vesicles go on increasing more rapidly than the cavity in the
ovarian tissue  in which they are  lodged, which gives  to them a compressed
and slightly corrugated appearance.  The grey pulp of the vesicle is gradu-
ally changed to a yellow color, marking the epoch of puberty.  The vesicles
are connected  to the part in which they are embedded by cellular filaments,
which become  weaker in proportion to  the age  of the child.  During early
life the vesicles occupy the deeper parts of the ovary, but gradually ap-
proach the circumference;  and,  at the time when the pulp becomes yellow,
some of  them are in contact with the  envelope of the  ovary.   I have con-
densed this  account from  M. Negrier, but am  not  able to decide upon its
correctness.
   97- So much for  the development of the  Graafian  vesicles:  upon their
intimate  structure very great light has been thrown of late years by the
labors  of Baer, Rathke, Purkinje, Valentin, Wagner, etc., in Germany ; of
Prevost,  Dumas, Coste, etc., in France ; and of Allan Thompson, Wharton
Jones, and Martin Barry, etc., in England.   From their writings the follow-
ing description has been gathered, which I believe to be correct, with the
exception of a few minor points  not yet settled.
   The Graafian vesicle consists of an external and an  internal  membrane :
the former {tunic  of the  ovisac, Barry) is extremely  vascular; the latter
(ovisac, Barry) is smooth and velvety, deriving its vessels from the former.
The cavity enclosed by these membranes  is far from being filled by the
ovum ; it contains, besides, a whitish  or yellowish albuminous  mass which
consists chiefly of granules, from ^o^th to  a^th part of a line in diameter,
connected together by a tenacious fluid, and forming the tunica granulosa
of Bischoff, Wagner, and Barry.   Its density is  unequal; towards some  part
of the periphery of the vesicle these granules are accumulated in a disk-like
form, making  a slight prominence in which is a depression.
   The disk and prominence are termed by Baer the discus proligerus and
cumulus.  Dr. Barry has also observed certain granular cords, resembling
the chalazae in the egg in appearance and function, and which he has called
the retinacula. In the depression in the cumulus is lodged the ovum (ovulum,
Baer), the discovery of which by Professor v.  Baer explained satisfactorily
the small size  of the ova observed in the fallopian tube by De Graaf, Cruik-
shank, and Haighton, compared  with the Graafian vesicle in the ovary.   The
ovum is surrounded by a thick white ring, which has been called zona pellu-
cida, but which Valentin and Wagner conceive to be a membrane; internal
to which we find a granular layer, the vitellus, the larger granules  of which
are superficial and  compact,  whilst internally it is a clear albuminous  fluid,
almost devoid of granules.
   Embedded in this vitellus, but nearer to its  circumference than centre is
the germinal vesicle, or vesicle  of Purkinje, a very important part of the
ovum.   It was first discovered  in eggs by Purkinje, but  in mammalia by
Wharton Jones, Coste, Valentin, and  Bernhardt.  It  appears  like a cleai
ring of very small size, measuring in man and  mammalia at most 6'0th part
of  a line in  diameter.  Upon the surface of the germinal vesicle a dark spot 
76
internal organs  of  generation.
was discovered by Wagner, and called by him macula germinativa.  " It is
almost always seen as a simple rounded body from 3£oth to 3^otn Part °^ a
Fig. 39.
Fig. 40.
 Ovum of Man, from Bernhardt.—1. Ger-
minal vesicle.   2. Vitellus.  3. Chorion.
(Zona pellucida?) 4. Tunica granulosa.
 Ovum of Rabbit.—aa. Discus proligerus. 66. Pale
oil globules, c. Zona pellucida.  d. Vitelline mem-
brane,  e. Vitellus. f. Germinal vesicle,  g. Ger-
minal spot.
line in diameter;  it is very rarely observed  double or as  an aggregate  of
granules, which, however, is sometimes the case in immature ova."
  It may serve to render this minute description more intelligible to the stu-
dent, if I  give the summary of Valentin  and Barry of the contents of a
Graafian vesicle :
             Valentin.
1.  An external membrane (yolk-bag).
2.  Fluid contents (yolk).
3.  Layer  of  granules which  form the
    disk (blastoderma).
   Ovum or ovulum, in which is to be
    distinguished —
   An outer  membrane.
   A  granular layer, internal to it.
7.  A  transparent half-fluid content.
8.  The germinal vesicle
Barry.
                                      1.  Tunic of the ovisac.
                                      2.  Ovisac.
                                      3.  Membrana granulosa, in which
                                          are found —
                                      4.  Tunica granulosa and retinacula
                                          (disk and cumulus of Baer).
                                      5.  Zona pellucida.
                                      6.  Membrana vitelli.
                                      7.  The yolk.
                                      8.  Germ vesicle, with Wagner's ger-
                                          minal spot.
  Dr. Barry states that the tunic of the ovisac  is not always  present; but
that, when it is, it is furnished by the ovary.  The order of time in which
the parts are formed is thus given by him :—1, the germinal vesicle with its
contents;  2,  an envelope consisting  of peculiar granules and  oil-like glo-
bules ; 3,  the ovisac ; 4, the yolk ;  5, the membrana vitelli; 6, the zona pel-
lucida; and  7, the tunic  of the ovisac,  tunica granulosa, retinacula, and
membrana granulosa.
  98.  Abnormal deviations. — One or both ovaries may be absent, or atro-
phied.  There may be few or no Graafian vesicles, or they may be morbidly
changed.   The ovaries may also be the seat of inflammation, dropsy, ma-
lignant diseases, etc.
  The absence or  disorganization  of both  ovaries, or of  all the Graafian
vesicles, entails sterility ; but conception is not  impossible so long as a por-
tion remains  healthy.
   Having thus minutely investigated the anatomy of the sexual system  in
the female, we may now proceed to  consider its  functions. 
PART  II.
PHYSIOLOGY OF THE ORGANS OF GENERATION.
                          CHAPTER  I.

PHYSIOLOGY OF THE UTERUS AND OVARIES.-1. MENSTRUATION

   99.  The  generative organs of the female are in a state of activity only
during the  prime of life,  embracing  a period  of about thirty years,  and
during this time,  the most remarkable  characteristic of their functions  is
their periodicity.
   It is impossible to separate the functions of the uterus from those of the
ovary, because in each we may discern their combined  influence.  Those
offices which are peculiarly uterine may thus be enumerated : — 1, the secre-
tion of mucus; 2, secretion of the menses;  3, formation of decidua;  4,
reception and nutrition of the foetus ;  and 5, the expulsion  of the foetus.
From  the ovary,  on  the  other  hand, is derived,  1, the effective stimulus to
menstruation, and 2, the fecundated germ ; so that we see that the effective
co-operation of both the organs is  necessary for the  fulfilment of either of
the three great functions of the uterine system, viz., Menstruation,  Concep-
tion, and Parturition.  We shall consider these functions in order.
   100. Menstruation. — In healthy  women  at the period  of puberty  a
certain amount of sanguineous fluid is eliminated by the uterus, and escapes
from the vagina, every month ;  this is termed the catamenia or menses,  and
the function itself, menstruation.
   That it is excreted by the uterus, has been ascertained in cases of prolapse
and inversion of the organ ; and that it is really a  secretion by its lining
membrane, and not blood mechanically filtered through it, is, I believe, now
generally admitted.
   [It  has been shown by the researches of modern  physiologists, that  the
catamenial fluid is ordinary blood mixed  with the mucus of the vagina and
epithelial cells.  Menstruation, therefore, is, strictly  speaking, a  periodical
hemorrhage from the uterus.   The doctrine of the secretion  of the menses
is altogether untenable, and has been given up by nearly all the authoritative
writers of a late date on  the  functions of the female sexual  organs.  Dr.
Dalton, who has examined the subject with great care, remarks that " the
menstrual blood is discharged by a kind of capillary hemorrhage,  similar to
that which  takes  place  from the lungs in cases of haemoptysis, only less
sudden and violent.  The blood does not form any visible coagulum, owing
to its being gradually exuded from many minute  points, and mingled with  a
large  quantity of mucus.  . . . The hemorrhage which  supplies  it comes
                                                            (77) 
78
MENSTRUATION.
from the whole extent of the mucous membrane of the body of the uterus,
and is, at the same time, the consequence and the natural termination of the
periodical congestion of the parts."1  Madame Boivin expresses a similar
opinion.   Dr. W.  Tyler Smith, in his Manual of Obstetrics (page 57),  pro-
nounces the catamenial fluid to be essentially different from the  product of
any secretory  process.  The same view is expressed by Professor Meigs,
Professor H. Miller, of Louisville, and others of equal eminence.]
  A female in whom this discharge recurs at the usual periods, in the usual
quantity, and of the usual quality, is said to be "regular;" and various
conventional phrases are in use to avoid a more direct reference, as " being
regular,"  "unwell,"  etc.
  101.  The occurrence of menstruation  defines the period of puberty, at
which the girl becomes a woman and capable of conception  ; as its cessation
terminates the prolific period of female life.  In Great Britain this generally
happens between  the ages of thirteen  and sixteen, although we meet with
cases of earlier and later puberty, dependent, probably, upon peculiarity of
constitution, habits of life, pursuits, etc.  A case  is recorded by Dr. Wall,
in the second volume of the Med.-Chir. Trans., of a child who menstruated
at nine  months  old, and continued to do  so regularly afterwards.  There is
another instance in the  American Journ. of Med.  Science, for Nov.  1832,
by Dr.  Le Beau, of New Orleans, of a child born with the marks  of puberty,
in whom the catamenia appeared at three years of age, and recurred regu-
larly.   I  find also a case by Mr. Enabling,2 of menstruation at less  than
three years old; one by Dr. Diffenbach3 at nineteen months  old; one by
Dr.  Catals4 at six years old; one by Dr.  Carus5 at two years old ; one by
Mr.  Whitmore6 of a child who menstruated from a few days after birth, till
it died  at  four years of  age; one by Dr. Lenz7 at eighteen months;  aud
one by  M. Gruere8  at one year old.  In  all these  cases menstruation not
only commenced at that  age, but continued to return at the regular periods.
Additional examples  may be found in  the writings  of Lobstein, Meyer,
Plocquet,  etc., etc.
  Mr. Roberton, of Manchester, has stated  the age at which it commenced
in 450 cases.9

           10 menstruated  for the first time  at 11  years of age.
19		u		n	k	12
53		K		it	<<	13
85		d		it	n	14
97		ii		a	it	15
76		it		<<	a	16
57		n			n	17
26		n		<<	it	18
23		tt		tt	it	19
4		n		n	n	20
7hich gives	the	mean	age	15-204	years.	
  Mr. Whitehead, in his work  On  Abortion,  gives the following table,
showing  the  age at  which puberty was  established in 4000 individuals iu
Manchester:—

  1 [Human Physiology, Philadelphia, 1859, page 477.]
  2 Lancet, Jan. 29th, 1848.                 » Meckel's Archiv fur Anat., p. 367.
  4 Journal de M6d. et de Chir., vol. ii., p. 37.  5 Ed. Monthly Journal, 1842, p. 1050.
  6 Northern Journal of  Med., July, 1845.     ' Caspar's Wochenschrift., Oct. 3,  1840.
  8 Journ. de Med. et de Chir. Pratique, May, 1842.
.  9 Physiology and Diseases of Women, and Midwifery, p. 29. 
MENSTRUATION.
79
At  the  age of 10 years  9 first menstruated.
11	tt	26
12	it	136
13	a	332
14	it	638
15	a	761
16	a	967
17	n	499
18	it	393
19	u	148
20	it	71
21	a	9
22	it	6
23	it	2
24	it	1
25	it	1
26	it	1
  These  tables seem to bear  out the  inference of Mr.  Roberton, that the
"natural period of puberty, instead of being the fourteenth or fifteenth year,
occurs in a more  extended  range of ages, and is more equally distributed
throughout that range than  authors have  alleged."   It is influenced, how-
ever, by many causes; for example, it is earlier in towns than in the country,
for M. Brierre de Boismont found the mean  age of  first menstruation to be
fourteen  years six months in Paris, and fourteen years ten  months  in the
country,  and fourteen years nine months in small towns.
  [i)7. Brierre de Boismont, in  his work,  "De la Menstruation consideree
dans ses Rapports Physiologiques et Pathologiques," among a mass of inte-
resting facts, gives the following curious table of ages at which menstruation
commences.   It is the most  extensive table yet published, and includes the
results of 2352 cases: —
	Paris,	Paris, 85	Lyons,	Marseilles, 68	Manchester,	Gottingen, i
Age.	1200 cases by	cases by Marc	432 cases by	cases by Marc	450 cn.«es by	137 cafes by
	Meniere. 1	D'Kspine. 4	Petrequin.	D'Espine.	Roberton.	Osiander. | I
5		0	0		0	1 o 1
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 1
11	93	3	14	6	10	3 !
12	105	14	26	10	19	1 1
13	132	6	47	13	53	o !
14	194	18	50	9	85	20
15	190	14	70	16	97	32- 1
16	141	7	79	8	76	24 |
17	127	6	58 .	4	57	11 1
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 l	8	0	1	0	0	0
23 /	4	0	0	0 .	0	1
24 /	0	0	3	0	0	0
 
80
MENSTRUATION.
      This table demonstrates  that  by far the greater number of women begin
    to menstruate during their 14th or 15th year, and that the proportion dimin-
    ishes both above and under that age.1
      A very interesting  case  by Dr. Carus, of  Dresden, is mentioned in the
    recent medical journals, of a child born in the mountains of Saxony,  in
    whom menstruation began  at two years of age.
      " She was scarcely a year old, when she began to grow rapidly.  At the
    end of her second twelvemonth, the  catamenia appeared,  and have  continued
    ever since to flow regularly once a month.  The Academy of Medicine  of
    Dresden sent for both her and  her mother, and, in  order to examine  more
    particularly into the case, kept them under their observation during several
    weeks.   The infant was 37 inches 3 lines long.   The  mammae were firm,
    like  those of a strong girl of  16.  Her  body was stoutly made, and the
    genital  organs were covered with dark brown hair.   Her physiognomy and.
    tone  of voice were childish, which contrasted singularly with the strength
    of her  body.  Her intellectual functions were equal to those  of a child
    three years  old, and  her head was  covered with  beautiful dark brown
    hair."2]
       Again, the rink of life  and degree of civilization exert  an  influence, for
    the same writer states that he found the mean age in 171 of the poor to  be
    fourteen years ten months; in 135 of the comfortable working-classes to  be
    fourteen years five months ; and in 53 daughters of the rich and noble, thir-
    teen years eight months.
       By most writers, a very great effect is attributed to climate.   Menstrua-
    tion, it is said, commences much earlier than  the  period I have  named  in
    hot climates, and much later in cold ones.  Women are stated to be mothers
    very  commonly at ten or twelve years old  in the East, and to  cease bearing
    at twenty-five  or thirty; and  that in Lapland, and other northern climes,
8   they  do not begin to  menstruate till about twenty or twenty-four, and con-
    tinue until sixty years of age.  Now, without denying the occurrence  of
     such cases, I do not believe that either extreme is very common, and aHhough
     there is a difference according to climate, that difference is far less than has
     been supposed.
       Thus Mr. Roberton, in his valuable researches,  gives  it as the result, that
     in Labrador and Northern Europe, the  period of first menstruation iswery
     nearly the  same as in this country, nor does the discharge continue later;3
     whilst in India, although the average  age, tn his return, is earlier, it is pro-
     bable that puberty does not actually appear earlier there than here.*
       Dr. Tilt, who has published a valuable table on this subject, finds the mean
     age for the first menstruation in hot climates, out of 629 cases, to  be thirteen
     years and sixteen days; out of 5775 cases, in temperate climates, fourteen
     years, four months, and four days;  out of 4018 cases, in  cold climates, fifteen
     years, ten months, and five days.5
       102.  In these countries the discharge continues until the age of forty-five
     or fifty;  in some cases it ceases earlier,  in others it continues  longer; gene-
     rail/ according to the age at which it commenced.  From Mr. Robertou's
     work I extract the periods at which it ceased in 77 individuals :6

       t [Edinb. Med. and Surg. Journ., Jan. 1843.]
       2 [American Journ. Med. Sciences, April, 1843, from Allgemeine Zeit. fur Chirurgie.l
       3 Physiology and Diseases of Women,  etc., p. 56.              * Ibid, p. 127.
       5 Edinburgii Monthly Journal of Med. Science, Oct., 1850, p. 294.
       6 Phys. aud Dis. of Wonie"h, and Mid., p.  185. 
MENSTRUATION.
81
In
1 at the	age of 35	In	26	at the age of 50
4	40		2	51
1	42		7	52
1	43		2	53
3	44		2	54
4	45		1	57
3	47		2	60
0	48		1	" 70
7	49			
  The period of its  cessation is called by women the "time, or turn of
life;" and  is preceded by irregularity and occasional interruption.  It is
looked upon as a  critical period,  from the supposed liability to serious
attacks and the greater mortality; but the researches of MM. Benoiston de
Chateauneuf, Bellefroid, etc., have shown that the mortality at this period
of female life is not greater than amongst males at the same age.
  103. As the name {menses, catamenia) implies, the discharge recurs every'
month; that is, deducting four or six  days for the time of its  flow, every
twenty-seven or twenty-eight days.   Mr. Roberton found that, out of  100
women, 61 menstruated every month, 28 every three weeks, 10 at uncertain
intervals, and one, a healthy woman,  aet. twenty-three, every fortnight.   The
shortening of the interval of twenty-six or twenty-eight days is a deviation
from functional integrity, owing, most likely, to habits of life, impaired con-
stitution, etc.  Dr. Gall made some very curious observations, from a journal
which he kept of the periods of menstruation  in different  women:  " It
resulted" (I quote from Elliotson's Physiology, not having the original at
hand) "that women are divided into two great classes, each  having a dif-
ferent period.  The women of the same class all menstruate within eight
days: after this time an interval of ten or twelve days follows, during which
very few women menstruate.    At the end of the  ten or twelve days begins
the period of the second great class, all the individuals of which also men-
struate within eight days."  Admitting exceptions to the rule, Dr. Gall says
that it applies generally to all parts of Europe.
  104. The duration  of each menstrual  period varies from three to six days,
or even longer.   The quantity which escapes  each time  is  from  four to
eight ounces, varying according to the temperament or constitution of the
individual.  It is not  discharged at once, but slowly and gradually.   As to
the character of the secretion, it greatly resembles venous blood, being of a
dark-red color, thin, and1  either without odor, or with "a very faint one.   It
consists at first  of pure blood, but  in  its passage through the vagina its
fibrine is probably dissolved by the acid secretions  of that part.  It  is found
to redden litmus paper, aud to contain phosphoric and  lactic acids,  with
some phosphate of lime.
  105. The symptoms which precede and accompany the first menstruation
are very slight  in some cases,  well-marked in others.  There is generally  a
degree of languor and lassitude, fatigue after exertion, inequality of spirits,
dark  shade under the eyes, headache, sometimes pain in the thyroid gland,
pain in the back, weight and aching in the pelvis and down the thighs, etc.:
occasionally there is a smart attack of fever.
  If the discharge takes place, most of these  symptoms disappear,  and the
female merely complains of weakness, and exhibits pallor of countenance.
  Or the menstrual secretion may make  its appearance  quite suddenly, with-
out any previous suffering or  any symptom likely to attract attention, and
in such cases it is a cause of considerable alarm, and it may be that steps
uie  taken to suppress  it by the  girl herself, which may be very injurious.
  Or the symptoms enumerated may  occur, and pass off once or twice with-
       6 
82                         MENSTRUATION.
out the appearance of the menses, or with  a white discharge only.   This
may generally be remedied by an improvement in diet and  tonics at the
approach of the next  menstrual period.
  Sometimes the color of the discharge is light at first, growing deeper each
period.   During its flow, the skin  exhales a peculiar odor, the appetite is
diminished, and  often  capricious, and occasionally sympathetic pains are felt
in the breasts.   There is a case1 related of a woman whose breasts secreted
milk after each  menstrual period, and  I have myself seen a similar  case.
The amount of suffering differs, as I have said, in different women, according
to some peculiarity of constitution,  and according to the degree of care and
good management bestowed upon them during the earlier periods.   In  some
it is never attended  by pain or distress, beyond  a slight indisposition to
exertion ; in others, more or less pain and  uneasiness attend each period,
whilst  in some women it  always amounts to  dysmenorrhcea, and is accom-
panied with great suffering,  debility, or  feverishness.  I may add that the
first menstruation is not necessarily a type of the subsequent periods.   The
more perfectly the function is performed the less is the distress.
  106.  The effects of the development of this function upon the body and
mind of a young  girl  are  very striking.   The figure enlarges,  becomes
rounder and more fully formed, the pelvis expands, the mammas enlarge, and
the general bearing becomes graceful and dignified.  The mental change is as
remarkable :  the pursuits of girlhood are exchanged  for more  womanly
interests; and a more  exquisite perception of her position  and relations
results  in iigher  enjoyment, veiled by  a  more delicate modesty.  These
changes are  rapid, and, occurring  at this peculiar period, doubtless fit the
individual for the more perfect fulfilment of the duties about to devolve upon
her.
  107.  From the  importance of this function, a few brief directions  as tc
the  management of young girls at its commencement will not be out of
place.   And first,  I  would  protest against the demand not  unfrequentlj
made upon  us, that at  the usual age we should endeavor to bring on  men-
struation, in  cases in  which it has not appeared.  The intimate dependencs
of this  function on the general development of the body  ensures its estab-
lishment at the proper time in the majority of cases, and  in those where  it
is tardy it most frequently arises from causes over which we have no imme-
diate control,  and to attempt  to  interfere will probably end  in  mischief.
The cases suitable  for our medical interference we shall enumerate bv-and-
bye.                                                             J
   I do  not  think  that  girls should be instructed beforehand  as to the oc-
currence of this discharge, or certainly, if it be done, it  should  be in the
most general manner; but I think we  may safely leave this to the watchful
care of the  mother.
   Warm  clothing  and rest are very necessary.  The  custom of wearing
drawers, which  is becoming general, will, I have no doubt, contribute to
the  more perfect  performance of this function, and to  the health of youn<*
women generally.                                                      °
   During menstrual  periods, especially the earlier ones, the girl should be
much  restricted in her exercise, and be prevented from  violent or  rapid
movements.   And especially she should guard against cold.   Exposure to
cold air, too liberal  use of cold water  in washing, bathing the feet in cold
water if it be summer, may inflict permanent injury.
   During the intervals, the girl may resume her ordinary habits; and  what-
ever is calculated  to  strengthen the constitution, and to improve the general
health, such as  fresh  air,  exercise, bathing, and  good diet, will also tend to
render  complete and  permanent the healthy performance of this function.
                  1 British and Foreign Med. Review, Oct. 1840. 
MENSTRUATION.
83
  This  is scarcely the place to indicate  the  moral management of young
girls, but I may just mention that, as this is the most susceptible age for re-
ceiving impressions, it is desirable  that they should be of a healthy kind ;
that as all such as enervate, all those which appeal  to the imagination —
novels and poetry, which make life a dream of  idle fancy or of affection un-
connected with duty — should be controlled, if not avoided.   As the girl is
becoming a woman she should be treated  as such,  and true views of life and
duty, as  well  as  of pleasure, be laid before her.   Late hours, excitement,
balls, exhibitions, etc., should be made the exception, not the rule, remem-
bering always, that while softness,  and affection, and grace, are the natural
attributes of woman,  it is the province of a wise educator to instil principles,
and strength,  and practical wisdom
  108.  The next very important  question  is the condition of the organs
during menstruation.  By a great number of writers the attention  has been
limited to the uterus, which,  being the seat, was regarded as the chief, if not
the sole organ involved.  Upon careful investigation, we find that the uterus
is congested during  menstruation ;  its vessels are distended with blood, its
substance more flaccid than usual, of a  more decided pink  color, and its
lining  membrane of  a deep red, studded  with bloody points, and covered
with menstrual fluid.   The  cervix,  however, participates but slightly in the
increased vascularity, and its lining membrane is scarcely altered in  color, so
that the os uteri internum is marked by the abrupt termination of  the dark
color of the lining membrane  of the body.  On  making a vaginal exami-
nation,  we find the cervix  softer, more puffy, and slightly swollen, and the
os uteri more open, than at  other times.  The fallopian tubes are also some-
what more vascular than usual.
   A very careful examination  was made by  Dr.  Janser  of the  organs of
generation of a girl who was murdered four days  after menstruation, and he
thus describes the state of  the uterine mucous membrane : " It was much
swollen between the body and neck.  In the uterus itself it formed  a velvety
membrane, glossy and brilliant, easily detached with the handle  of the scalpel,
and presenting a fine network of vessels.   This mucous membrane was evi-
dently thickened : it  was composed of the uterine glands,  ranged perpen-
dicularly alongside each other, and fitted with cylinder epithelium not ciliated.
The structure between the  uterine glands was composed of  a network of
delicate fibres, of some nucleated cellular fibres, and  of amorphous tissues.
The surface of the uterus was covered with a thin layer of mucus, and lined
with cylindrical  epithelium, without cilia.  The  orifices of  the fallopian
tubes were  open.   The vaginal mucous  membrane was pale, but was only
covered with a thin layer of mucus, containing epithelial cells."   The writer
adds, " It results from this  observation  that  the  mucous membrane  of the
uterus presents, during menstruation, characters analogous to those which
exist during gestation, such as the hypertrophy of the uterine follicles, and
the disappearance of vibratile cilia."1
   M.  Pouchet conceives that not only  does this peculiar change in the
mucous membrane take place, but that a deciduous membrane  is formed and
discharged  each  month.  Dr.  Lee believes it to  be a frequent occurrence
with unmarried females; Dr. J. C. Dalton  thinks its  periodical occurrence
very probable.   Professor  Bischoff's examinations  did  not  confirm  this
opinion.  Dr. Tyler Smith and others believe that the mucous membrane is
exfoliated every month.
   These changes rapidly subside when the function ceases, and the parts
return tq their ordinary state.
   109.  A still more essential question, however, is the state of the ovaries,

        i Med. Annals, vol. xiii.  part iv.  Lond. Journal of Med., April, 1850. 
84
MENSTRUATION.
and the influence they exert upon menstruation.   From time to time it has
been suggested that these organs were  of greater importance to this func-
tion than was generally admitted, or even of equal importance to the uterus
itself.  A reference of this kind is made by Dr. Friend, in  his " Emmeno-
logia;" and Dr. Power goes further, and attributes menstruation entirely to
the action of the ovaries : Dr. Vaughan  also regarded the menses as a se-
cretion dependent upon the ovaries ; and other authorities might be adduced.
Indeed, there are certain facts which cannot but lead to an  admission of a
certain influence exerted over menstruation by these  organs : for instance,
it is  well known that they participate in the congestion which is observed in
the uterus at the monthly periods; again, when the ovaries have both been
atrophied or diseased, as noticed  by Morgagni and  Frank; or when one
was congenitally absent and the other disorganized, as in  a  case related to
me by my friend  Dr. Montgomery, the secretion of the  menses has been
prevented  altogether, or it has  ceased prematurely.   Moreover, when  the
uterus is absent but the ovaries present, the menstrual molimen and other
sexual peculiarities are observed.  Lastly, when the  ovaries  have been re-
moved, as in the case mentioned by Mr. Pott, menstruation  ceased entirely.
   These considerations  alone  would,  I  think, be sufficient to  justify  the
opinion that, although the uterus be the seat, and its lining  membrane  the
secreting agent in  the process, yet that the impulse or stimulus upon which
the function depends is in some way or other derived from the ovaries.
   Nor is this inference weakened by the changes which are  observed in the
ovaries during menstruation, which  may throw  some  light also as to  the
nature of the stimulus.   For almost all the accurate information we  possess,
we are indebted to the recent  researches  of Drs. Girdwood, Lee, Ritchie,
Knox, Renaud, Dalton, etc., in this country and  America, and Pouchet,
Negrier, Gendrin, Bishoff, Raciborski,  Chereau,1 etc., on  the Continent,
although the main fact established by their labors was curiously noticed by
Mr.  Cruikshank so long as 1797 : "I have also," he says,  "in my possession
the uterus and ovaria of a young woman,  who died with  the menses upon
her.   The external membranes of the ovary were burst at  one place, from
Fig. 41.                               Fig. 42.
Ovary at Menstrual Period.
whence I suspect an ovum escaped, descended through the tube to the uterus,
and was washed off by the menstrual blood."  several similar observations
have  been  published  by Dr. Lee  in the Cyclop, of Pract. Medicine, and

               1 See Miiller's Physiology:  Supplement, p. 45, et seq. 
MENSTRUATION.
85
 since in the Med.-Chir. Transactions ;  Mr. Girdwood and M. Gendrin have
 each added five cases, and M. Negrier five more, of the same kind.  All the
 observations agree that, in females dying during or soon after menstruation,
 a small irregular rupture or cicatrix was found in  the coats of the ovarium
 (ng. 41), and that this communicated with the remains of one of the Graafian
 vesicles ; from which Dr. Lee concludes that it is "extremely probable that
 all  the phenomena of menstruation depend upon, or are  connected with,
 some peculiar changes in the Graafian vesicles, in consequence of which an
 opening is formed in the peritoneal and proper coats.   Whether an  entire
 vesicle, or  only the fluid it contains,  escapes  through this opening at the
 period  of menstruation, further observations may hereafter determine."
    ine changes which  take place in the vesicle are thus stated by M. "Ne-
 grier:  an afflux of transparent  fluid  occurs in the vesicles, distending and
 ultimately causing its rupture at the least resisting part,  which corresponds
 to the  surface of the ovary.  This opening  is  cicatrised,  at least externally,
 in about eight or ten days, so as to prevent the escape of the blood  which
 proceeds from the  lacerated vessels  of the vesicle, and,  in consequence, a
 clot is  frequently formed in the capsule of the  vesicle (fig. 42).   Sometimes
 it contains a serous fluid, colorless, or tinged with  blood.
   A very valuable prize essay on the subject has lately been published  by
 Dr. J.  0. Dalton/in which he records eleven cases  in which he observed
 these menstrual  corpora lutea, and gives very minutely the changes which
 take place  in them.   He thinks  the exact period  of  the  menstrual flow, at
 which  the vesicles rupture, variable :  sometimes during  the flow, in  other
 cases —as stated by Bischoff, Pouchet, and Raciborski_at the termination.
 Ine appearance of the corpus luteum will  depend upon the extent of the
 rupture, and the amount of  hemorrhage into the  cavity.   " As to the seat
 of the  peculiar growth which characterizes these bodies," he considers it to
 be the  proper membrane of the vesicle hypertrophied, and that the proliger-
 ous disc, and a considerable portion of the membrana granulosa are expelled
 with the  ovum.   " The new growth or deposit of yellow matter,  when
 examined under the microscope,  is seen to consist  of an abundance of pecu-
 liar, irregular-shaped granular cells, varying in size, and sometimes enclos-
 ing minute, opaline, yellowish globules, like oil.   The contour  of the cell
 wall can in most instances  be completely traced throughout;  but in  some
 instances it is indistinct in  certain parts of the circumference.  There are
 also to be seen in the  field  of the microscope a few  oil globules similar to
 those  in the interior of the cells, but for  the most  part  of  larger size."
 Recent researches seem to show that the  development of fatty matter is an
 early step in the death and removal of tissues ;  and it is possible that a simi-
 lar step may thus be observed in these menstrual corpora lutea, for we find
 them attain their maximum in the course of three weeks, then rapidly retro-
 grade  until the yellow matter diminishes in size, becomes softer and more
 friable, and at length merely exhibits  a cicatrix, with a small, faint yellow
 spot.   Dr.  Dalton  agrees with those  already  mentioned, who regard the
 discharge of ova as an essential part of menstruation.
   I may add here the examination of the ovary in the case related by Dr.
 Janser, to which I have already referred.   " The  surface  of the left ovary
 presented a deep red spot, surrounded by finely injected vessels.  This spot
 was formed by a small globular mass,  embedded in the ovary, and of an in-
tense red through its whole  thickness.   The mass in question was separated
from the tissue of the ovary by a thin yellow envelope, and was  composed
of fibres like those of areolar tissue, arranged in superimposed layers.  The

  1 On the Corpus Luteum of Menstruation and Pregnancy,  p. 45.   [See also Treatise on
Human Physiology, by the same author, pp. 478, et seq.] 
86
MENSTRUATION.
 yellow envelope was formed by the same kind of fibres, among which there
 was a pretty considerable quantity of fat, not contained in cells.  Near this
 body, there was  seen  a  small yellow, spherical, nodulated mass, composed
 of areolar tissue  and fat.   The right ovary contained  two yellow bodies."1
 No ovule was found ;  but  the examination was four or five days after men-
 struation.
   M. Bischoff has  published the  minute examination of thirteen cases, in
 which the clot was found in the place  of the discharged ovum, the rent in
 the coats, cicatrices,  and marks  of former ova,  congestion  of the  uterine
 mucous  membrane, but neither decidua nor ovule.   There are but  two or
 three cases  (by Hyrtl  and  Letheby) in  which the ovum has been found.
   If  the reader  will carefully  compare the cases  here quoted, and those
 recorded by the authors  mentioned, but which it would be out of place to
 detail more fully here, he  will  agree with me, I think, that they justify the
 following conclusions : —
   1.  That ovarian influence is necessary to menstruation : a.  because when
 the ovaries  are  congenitally absent, or have been removed, or have become
 disorganized, menstruation is absent or ceases,  b. Because when the uterus
 is absent or has been removed, the ovaries being  present, the menstrual
 mohmen may still recur periodically,   c. Because coincident with  the com-
 mencement  and cessation  of menstruation  we find  corresponding organic
 changes  in the ovaries.
   2.  We find that the ovaries do  not contain a definite and limited number
 of Graafian vesicles, as Haller and others  have thought, but  a vast assem-
 blage, according  to the researches of Dr. Martin Barry, and the number of
 which vesicles may be increased, according to Dr. Ritchie.
   3.  In  the ovaries of women who menstruate regularly,  there may be  ob-
 served a number of the Graafian  vesicles, in different degrees of develop-
 ment, from the size of a millet seed to that of a cherry stone.
   4.  There are  cases on  record  of women who  died  just before menstru-
 ating, in one of  whose ovaries a  vesicle was observed in  a state of great
 maturity, enlarged and prominent, with its  outer coverings much thinned
 semi-transparent, and  in  one point apparently about  to burst.
   5.  In  a considerable number of cases of death during menstruation  one
 ovary presented a cavity recently emptied,  or partially filled by a clot from
 which a  duct-like canal passed through the  coats of the ovary.   That this
 cavity contained a Graafian vesicle cannot reasonably be doubted.
   6.  On examining the ovaries, a number of  cicatrices may be'observed
 some  more, some less recent; and in several  cases  these have been ascer-
 tained to correspond  exactly with the number of the menstrual periods
 According to Mr. Girdwood's researches, this is always the case.
   7. These  cicatrices,  when cut open, exhibit the yellow spots, which result
 from an hypertrophied condition of  the proper membrane of  the Graafian
 vesicle.   These menstrual  corpora lutea  have given rise to,  much contro-
 versy as  to their difference  from, or relation to, the corpora lutea of vrea-
 nancy, of which I shall have more to say presently.
   8  Cases  are on record in which (according to Dr. Ritchie)  menstruation
 has taken place without the escape of  a vesicle, and others, also  in  which
 there was evidence of the escape of a vesicle  previous to menstruation  This
latter case has occurred  more frequently than the former (and answers to
those  cases  in which conception  has preceded menstruation  or occurred
during lactation), but  both are so rare as scarcely,  if at all'to  nflWt  +i^
question.                                                  '       eci  Iae
   9.  This view is further supported by the analogy of other mammalia, as

                   1 London Journal of Med., April, 1850. 
MENSTRUATION.
87
 both Bischoff and Raciborski have shown in the case of the bitch ; so much
 so that the former accurate observer lays down the law as equally applicable,
 that " the ova formed in the  ovaries of  females of the human species and of
 mammiferous animals, undergo  a periodical maturation quite independent of
 the influence of the male seminal fluid."1
   The conclusions which have been so  ably put forth by M. Pouchet are as
 follows: " 1. That in all classes  of mammalia ova are produced spontane-
 ously in the ovaries.   2.  That they are expelled spontaneously at regular
 intervals, independently of coition.  3.  That in the human female they are
 so expelled at each menstrual period, this  period corresponding to the rut-
 ting season of animals.  4.  That  the  ova are, and can be, fecundated only
 after their expulsion from the ovary;  the various solid membranes by which
 they are protected previous  to this expulsion opposing a complete obstacle
 to the access  of the spermatic corpuscles, the actual contact  of which is
 indispensable to the  impregnation of the ovum.   5. That  in all probability
 the part where fecundation usually takes place, is the cavity of the  uterus,
 or the lower part of the fallopian tube."2  With these views Bischoff, Raci-
 borski, and others agree ; but although there is a great body of evidence in
 support  of this view, it may be doubted whether it is as  yet sufficient to
 warrant such positive deductions.
   Professor Miiller's opinion, which is more cautiously expressed, is perhaps
 more strictly in accordance with the present state of our  knowledge.   He
 observes that "the number of  facts at  present collected are insufficient to
 establish it as a law, that an ovum is discharged from the ovary of the human
 female at every normally developed period of menstruation.   Yet it must
 be observed, that although the diseases causing death  must, in the majority
 of instances, disturb the function of the ovaries, and prevent the extrusion
 of the ovum, yet to  each of those  inquirers who have been  on the watch for
 such cases, several instances of  ruptured  follicles in  menstruating  women
 have occurred within a short space of  time.   And the fact that the ovaries
 of the human female become turgid and vascular  at the menstrual periods,
 as those of animals  do at the time of heat, strongly favors the opinion that
 the generative system of the  human female is subject to the almost universal
 law  of the periodical discharge of ova."3
   110. The final cause of menstruation is said  to be, 1, To get rid of the
 surplus blood employed during gestation in the  nutrition of the foetus,  but
 which  in the unimpregnated  state might be injurious ; and, 2,  To prepare
 the uterus for impregnation and conception.   The first is a mere hypothesis
 grounded on an assumption,  for it is  not proved that there is any surplus
 blood  when the  female is not pregnant;  I need, therefore,  say  no more
 about it.
  As to the second theory, it is based upon the observation, that conception
 seldom or never takes place before the  period  of the first  menstruation, or
 puberty;  that it does not  occur in those who do not menstruate, or after
 the cessation  of menstruation ; and  that  calculations  show that it takes
 place more readily soon after a menstrual period.   This latter is a very old
 observation, and is held by most modern obstetricians. Naegele, for instance,
 calculates the duration  of pregnancy at nine months and  eight days from
 the last menstrual period, and in normal cases he says he has  never been
 wrong.   The popular mode of calculation is pretty much the same.
  [As regards the coincidence of menstruation and  conception  we have
conflicting testimony.   The  late  Dr. Dewees, whose experience was very
extensive, wrote as follows:  " The final cause of the menses is perhaps  en-

  1 Miiller's Physiology: Supplement, p. 45.    2 The'orie Positive de la F6condation.
  8 Physiology: Supplement, p. 50. 
88
MENSTRUATION.
veloped in some obscurity; but of this we know at least one incontrovertible
fact, namely, that the healthy performance of this  function is  in  some way
or other connected with the capacity for impregnation ;  as no well-attested
instance is upon record,  where this has taken place in a female who never
had had this discharge, or  even when it was not of a healthy character, and
with a greater or less  degree of regularity."   In these remarks we must
understand Dr. Dewees as merely asserting  his own  experience, for the ex-
perience of numerous equally competent observers is in direct opposition.
The regular and healthy  performance of the menstrual function is certainly
indicative of a  natural condition  of the female  genital organs, and  of the
consequent aptitude  of the individual for impregnation ; yet it is not always
so ;  every healthy menstruating female  is not fruitful;  and I have known
many instances  where women bore children regularly, although the men-
strual  office was neither regularly nor healthfully  performed.   Professor
Dunglison  well observes: "As a general rule, the appearance of the menses
denotes the capability of being impregnated, and their cessation the loss of
such capability.  Yet, females  have become mothers  without  ever having
menstruated.   Fodere  attended a woman who had menstruated but once —
in her seventeenth year, although thirty-five years  of age, healthy, and the
mother  of five  children.   Morgagni instances a mother and daughter, both
of whom were  mothers before they menstruated.  Sir  E. Home  mentions
the case of a young woman, who was married before she  was seventeen, and
having never menstruated, became pregnant; four months after her delivery,
she became pregnant again ; and four months after the second delivery, she
was a third time pregnant,  but miscarried.   After this she menstruated for
the first time, and continued to do so for several  periods, when  she again
became pregnant;  and  Mr. Harrison, at a meeting of the Westminster
Medical Society, remarked, that he knew an instance in which the mother
of a large  family had never menstruated.1   Such instances  prove that ova
are maturated without the  ordinary recurrence of a sanguineous exhalation
from the lining membrane of the womb."
   " The menstrual flow,"  remarks Dr. Dalton,2 "is, in fact, only the external
sign and accompaniment of a  more important process taking place within.
It is habitually scanty in  some  individuals, and abundant in others.   Such
variations depend upon the condition of vascular activity of the  system at
large, or of the uterine organs in particular; and though  the bloody dis-
charge is usually an index of the general aptitude  of these  organs for suc-
cessful impregnation, it is not an absolute or necessary requisite.  Provided
a mature egg be discharged from the  ovary at  the appointed period, men-
struation, properly speaking, exists, and pregnancy is possible."
   The modern ovular doctrine of menstruation is unquestionably encompassed
with some difficulties: these have caused it by a few to be considered rather
as " a plausible and ingenious hypothesis, than as a well-established theory."
Mr. Kester3 thinks that  "the actual state of our knowledge of the  nature
of menstruation may be expressed in the following propositions :__
   " 1 Menstruation is a periodical function of the  uterus.
   " 2.  Ovulation is the constant function of  the ovaries.
   " 3.  Ova are matured in the ovaries at all ages,  but more rapidly during
menstrual life.
   "4.  Ova are discharged at all periods of female life, in the intervals of,
as well as at the time of,  menstruation.
   " 5.  Ovulation and menstruation being often concurrent, indicate that they

  1 [Human Physiology, 4th edition, vol. ii. p.  357.     2 Human Physiology  t) 476 1
  8 [London Medical Gazette, Nov. 1849.]                                  'J 
MENSTRUATION.
89
are both the result of the attainment of a certain point in the development
of the female economy.
   " 6. The law of periodicity in the one not obtaining in the other, leaves still
wanting the inseparable link in the chain of causation whereby menstruation
can be shown  to be the effect of ovulation.
   " 7.  At the menstrual period, the ovaries experience an extension  of the
uterine  congestion, and become, equally with the uterus, the seat of increased
functional activity.
   " 8.  The menstrual flow is a  true haemorrhage, as shown by chemical
analysis, and by the phenomena of disease."]
   jM. Bischoff thus expresses himself: "At certain periods, known as those
of ' heat' or 'the rut' in animals, and 'menstruation' in the  human female,
the  ova which have become mature disengage  themselves from the  ovary,
and  are extruded.   Sexual desire manifests  itself in the human female with
greater intensity at these periods, and in the females of mammiferous animals
it no other time.  If the union of the sexes takes place, the ovum is fecun-
dated by the direct action of the semen upon it.  If no union of the sexes
occur, the ovum is  nevertheless extruded from the ovary, and  enters the
fallopian tubes, but there perishes."
   I  may here remark, 1, That if this view be strictly correct,  conception
could scarcely occur previous to the  appearance of the menses,  or without
their reappearance; and yet  both cases do occur, and the latter not very
rarely.   2, That the discharge of the ovum must necessarily be about the
termination of menstruation,  or  it would escape with that excretion.   3,
That conception must take place within a few days of that period,  or the
ovum would escape, and only during that short space, because  afterwards
there would be no vesicle to be fecundated.   How long this period may be
it is difficult to say ; but it would be difficult to reconcile this view with the
cases which occur, of impregnation taking place ten, twelve, or twenty days
after the cessation of  the  menstrual  period,1 which  are not  uncommon.
Jewish  females are required to abstain from intercourse for five days before
and seven days  after menstruation,  and yet they are very fruitful;  and
Hirscher mentions a case of conception, where he ascertained that impreg-
nation occurred twenty-two days after healthy menstruation.  If we calculate
the  period of pregnancy according  to  Naegele, or allow a few days more
(reckoning from the mid-period,  in the popular mode), my own experience,
and that of others,  would show that more women overrun than anticipate
the nine months. I cannot think that the period for conception is so limited
as these opinions, if  correct, would require ; neither am I sure that there is
an increase of sexual desire at the menstrual period.
   111.  Dr. F. H. Ramsbotham has lately put forth his views  of the final
cause of menstruation, which I think it right to lay before the reader.  He
conceives that the function  of menstrution is " identical with the nutrition
of the young ovum, and that the menstrual discharge  indeed is nothing less
than the rudiments of the deciduous membrane itself; or rather that it would
have become the deciduous  membrane, provided conception had  occurred :"
and  he  explains  the process more fully thus,—"An ovule ripe for impregna-
tion parts from the  nest in which it had been elaborated, being conveyed by
the grasp of the fallopian fimbriae.  At the same time Nature establishes an
action for the  purpose of preserving it, provided an opportunity of becoming
impregnated by  contact with the  male semen  is  afforded  it.   Should that
contact  take place, and conception follow, the fluid formed is retained within
the uterus, and is gradually converted into the deciduous membrane, which
becomes the  first medium of communication  between the newly animated
» Oldham: Med. Gaz., July 13th, 1849. 
90
MENSTRUATION.
ovum and  the  maternal vessels.  If, on  the  contrary, conception does not
happen, the ovule perishes, and the fluid secreted for its advantage not being
required, is allowed to exude  externally, as a superabundant and useless
excretion."1
  The first difficulty involved by this view is the limitation  of  the  period
of impregnation, which hardly corresponds with the latitude allowed, so far
as we can infer from the period  of delivery.   This,  Dr.  R. thinks, maybe
explained by the impregnation taking place either in the  ovary or fallopian
tube, and the additional time required for the descent of  the ovum.
  In a subsequent communication, Dr.  Ramsbotham widens  his theory a
little, by supposing that the ovum may "part from its previous connections
some days before  the  menstrual fluid is secreted," and so be liable  to im-
pregnation ;  and, on the other hand,  that the ovum may be retained after
the escape of the catamenia;  and that if  within a certain  period it be im-
pregnated, the  uterus may then take on new action, and form a fresh secre-
tion, which is converted into decidua.
  This extension of the period of conception, to a certain extent removes a
second objection, viz., that we  can hardly suppose impregnation to occur
after the commencement of  the  menstrual  secretion, because of the  impedi-
ment |,hat would be to the ascent of the spermatozoa, and  because separation
of the sexes is almost universal during these periods, unless we suppose also
that the menses are retained in utero  after secretion, of  which we have  no
evidence.
  I  must add,  as a third objection, that I cannot  think that we have any
adequate proof that the menstrual secretions can be  converted into the
decidua, considering the difference in their  elementary constituents.  That
the  same  condition of the organ may, under a different  stimulus,  secrete
either the one or the other, according to the peculiar stimulus, I can easily
understand, but that does not seem to be Dr. Ramsbotham's view.
  Lastly, this theory seems hardly consistent with the laws of  menstruation,
when  the fallopian tubes  are  impervious, or with  cases  of extra-uterine
foetation in which a deciduous membrane is found.
  Having noticed  these different theories, I think it will be the wiser plan
to put forward no theory of  my own.  Our knowledge  is at present very
deficient, but the inquiries recently set on foot may perhaps result in a more
perfect acquaintance with these important processes and their various relations.

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

                 DISORDERS  OF  MENSTRUATION.

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

  i For fuller details concerning these disorders, I beg to refer my readers to  my volume
on Diseases of Women. 
92
DISORDERS OP MENSTRUATION.
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, accom-
panied by rigors,  pain in the back and loins, weight at the lower part of the
abdomen, aching along the thighs, general lassitude and uneasiness, etc.,
etc., without any discharge.  But, though these symptoms pass away, ano-
ther series arises : the  patient complains of frequent headache, sometimes
with intolerance of light and sound, throbbing, and a sense of fulness in the
head, pain in the  side or back; the stomach and bowels become irregular,
the countenance pale, and  the strength  reduced.   Paroxysms of dyspnoea
and hysteria may also occur, and the patient acquires the appearance  of
confirmed ill-health.   Of course these symptoms will differ in different con-
stitutions ; and cases  occur occasionally in  which a long  continuance  of
amenorrhcea has but slightly disturbed the general health.
   A vaginal examination with the finger or bougie affords no information
in these  cases.
   The causes of  this variety, says Dr. Locock, " are  generally to be found
in the previous habits of the patient; for it is most frequently met with in
those who have led sedentary and indolent lives, who have indulged in luxu-
rious and gross diet, and been accustomed to hot rooms, soft beds, and too
much sleep."
   The proximate cause is probably some peculiar condition of the ovary in
the majority of cases.
   The diagnosis must  be formed upon the fact of there being a menstrual
effort or not;  and, if  there  be, upon the existence  or non-existence  of
obstructions.   If  the  menstrual molimen  occur, and  there  be  neither
obstruction nor discharge, we  may conclude the case to be  one of simple
amenorrhcea.
   117. The treatment  must depend  upon the  constitution of the patient,
and will vary, as it is  administered  during an  interval, or at a menstrual
period.   In patients of a full habit, venesection will often afford relief.  This
must be followed during an interval  by  a diminution in the quantity of the
food, absence of  stimulants, exercise,  and occasional purgatives.  When the
patient  is of a weak, nervous, or leuco-phlegmatic constitution, the system
 should be strengthened by generous diet and the moderate use of wine, with
 gentle exercise.   Preparations of iron  will  be  found very useful.  By the
 older writers a long list of  emmenagogues is given ; but modern experience
 has reduced the number.   Iodine, strychnine, electricity, and iron, certainly
 seem to  have  a  direct power over the uterus,  and may be used advan-
 tageously.   Stimulating injections   into the vagina or uterus  have been
 recommended, but they are very questionable.    M. Carron  du  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  tincse, Soult  with aconite,  Hannay  with the  ammoniated  tincture of
 guaiacum, and Schonlein by enemata  of aloes.  Stimulating the neighboring
 organs (the rectum and bladder) is often beneficial.
    [The  author has shown less than his wonted  clearness  on this  subject.
 He has  fallen into the common error  of regarding amenorrhcea as a disease ;
 whereas it is only an occasional symptom — merely the non-performance of
 a function, the exercise  of  which is  not always  necessary for the health of
 the female, during  the period of her life when it usually occurs.   It  has
 been  shown (page 90) that women  may even  bear  children without men-
 struating.  I know a maiden lady, now  nearly fifty years old, who has gene-
 rally enjoyed very good health, although she never menstruated more than
 twice a  year, and sometimes only once in twelve or fifteen months.  Amen-
 orrhcea,  therefore, is not properly a disease, but a  consequence of  either 
AMENORRHEA.
93
individual  organization, disorder of the uterus or ovaries, or of some other
organ  or  organs, of sufficient importance for the disturbance of their func-
tions to affect materially the  patient's constitution.   When it is the conse-
quence of peculiar organization, of course all attempts to excite or produce
the discharge will  be vain,  and  most likely pernicious ;  when  it depends
upon disorder of any one or more organs, it is obvious that the pathological
condition  of these must be sought out and removed before we can hope that
the menstrual flow can be restored.   In such cases, all the  means adapted
to restore health to the system,  medicinal  or  hygienic, may be regarded as
emmenagogue ; but that we possess  any article  having the direct power of
causing or restoring the regular monthly discharge of blood from the  uterus,
apart from its property of overcoming some morbid condition of the uterus
or ovaries, or of some other organ by which the general health  of the indi-
vidual is  impaired,  has not yet been proved, nor is it probable that  any
such exists.   Nothing can be more opposite and heterogeneous than the
articles commonly  prescribed as  emmenagogues;  and it is  therefore  with
justice that they are  classed by  Dr. Ferguson  as "nostrums."   The little
confidence reposed in such agents has induced some practitioners to attempt
the restoration or establishment of the discharge by means of a more direct
nature.   In  some instances of  mere torpor, electricity has  been useful in
exciting the capillaries to greater activity by its direct impression  on the
nerves of the uterus ; but it is a means which is adapted to a very  limited
class  of cases.   " Stimulating injections into the vagina and uterus," are
indeed questionable — into the latter organ, imminently dangerous.   This is
the declaration  of Bretonneau, Ricord, and several other respectable autho-
rities.   " M.  Hourmann  relates a case where violent abdominal pain, fol-
lowed by metro-peritonitis, was caused by the injection  of  a decoctkn of
walnut leaves into the uterus, for the cure of an obstinate  leucorrhceal dis-
charge, which had been traced  to the cavity of that organ.  Wishing to
ascertain  whether these dangerous symptoms  could be produced from a por-
tion of the fluid having passed through the  fallopian tubes into the oavity
of the abdomen, he found, on injecting fluid into the uterus after death, that
such was actually the case."  If the opinion  now generally admitted by
physiologists shall be fully established, that menstruation is intimately con-
nected with, or dependent on, the maturation and shedding of Graafian vesi-
cles, it is  manifest that little good can be expected from articles that  are not
calculated to impress favorably the ovaries.]
   118. Amenorrhcea,  with vicarious Uterine  Leucorrhcea, differs essentially
from the  preceding varieties, inasmuch  as  uterine secretion exists, whereas
in them the uterus was quiescent.  The product  is a white or colorless fluid,
and so far, not the  menses; but  the symptoms  of menstruation occur, and
the patient does not  require medicine  acting directly upon  the uterus.  I
have already alluded  (§ 105) to the  leucorrhcea which occurs at the com-
mencement of menstruation, and which is generally superseded by the  menses
after one or two periods.   It is only when this  change does  not take place
that we  need interfere.   The white  discharge may continue  periodically to
usurp  the place of the catamenia;  but, in addition, it  often continues during
the interval.
   119. Treatment.—When the white discharge is persistent, the case is one
of uterine leucorrhcea, and requires the appropriate treatment; but when it
occurs only at intervals, as vicarious of the menses, our object should be to
strengthen  the constitution by generous  diet, exercise,  bathing, etc.,  and
tonic medicines.  I have found great benefit in such cases from the carbonate
of iron.
   120. Suppressio Mensium. — A suppression  of the menstrual discharge 
94
DISORDERS  OF  MENSTRUATION.
may occur suddenly, or more gradually;  in other words, it may be acute or
chronic.
  121. Among the causes of Acute Suppression of the Menses maybe men-
tioned cold caught during their flow, by wet feet, etc.; sudden mental emo-
tion, or a bodily shock, fear, disease, etc.
  The amount of disturbance consequent upon the sudden arrest, varies a
good deal.   Most frequently a  degree of fever results, with headache, hot
skin,  thirst, quick pulse,  etc.;  or the patient may be  attacked  by local
inflammation of the brain, lungs,  intestinal  canal,  or of the uterus itself.
Sometimes, instead of inflammation, we  see  attacks of hysteria  simulating
inflammation, or of neuralgia of  different parts.    Occasionally derange-
ments of the senses, aphonia, imperfect vision, etc., or paralysis and apo-
plexy, follow.
   The sudden suppression, from a definite cause, will distinguish this form
of  amenorrhcea from all others.
   122.  Treatment.—The  first object  is  to recall the discharge, if possible.
For this purpose the patient should take hip-baths or pediluvia, and swallow
some warm drinks.  Mild diaphoretics and gentle  purgatives will also be
useful.   Should all our attempts fail,  we may content ourselves with miti-
gating the severer symptoms, until the approach of the next menstrual period,
when the diligent use  of the ordinary remedies will probably be followed by
the proper secretion or by a colorless discharge.  If neither take  place, then
we must have recourse to some of those  remedies, already mentioned, which
act directly upon the uterus.
   123. Chronic Suppression of the Menses may be the issue of an  acute
attack, or  it may arise from the gradual supervention of delicate health, or
from disease of the ovaries, uterus, etc.; or it may occur as the termination
of  menstruation.   The quantity of the discharge  may  diminish,  and the
periods  become  irregular, until at length the function  ceases.   But very
often the menses are  superseded by leucorrhcea, at first  periodic, but ulti-
mately persistent.
   The symptoms which develope themselves are headache, loss of appetite,
pain in the side and back, debility, and general deterioration of health.
   The most  important point for diagnosis is to distinguish this form of sup-
pression from pregnancy, and which will  mainly depend upon the  absence of
the usual signs of pregnancy, at a  period when they ought to be present.
    124. Treatment.—When the  suppression has been the result  of disease,
upon its removal the catamenia will return ; and, if it have  been caused by
leucorrhcea, the proper treatment  of  that disease will generally  end  in  the
restoration of the menstrual discharge.  When the suppression is uncompli-
 cated, the remedies for simple  amenorrhcea may be  tried; but caution will
 be necessary, and a careful estimate of the general condition of the patient,
 together with a vaginal  examination, in order to make sure that there is
 neither organic disease, nor obstruction of the womb, and that the case be
 not one of premature  but normal cessation of the menses.
    125.  Vicarious  Menstruation. — This is  a very curious  deviation from
 normal menstruation,  and seems a provision for, in some  degree, mitigating
 the constitutional effects of suppressed menstruation, by substituting a simi-
 lar discharge from some  other part. It is recorded to have taken place from
 the nostrils,  eyes, ears, gums, lungs, stomach, anus, bladder, nipples, the ends
 of the fingers and toes, from different joints, from the axilla, from the stump
 of an amputated limb, from ulcers, from varicose tumors, and from the sur-
 face of the  skin generally.  The  more extensive mucous membranes are,
 however, most frequently the seat of* the discharge.   It appears to be some-
 times blood ;  in others it has the characters of catamenial fluid, beino- dark-
foiored, thin,  and  not coagulable.  The  repetition of this discharge may 
DYSMENORRHEA.
*95
occur at the regular period, or it may intermit; and it does* not appear that
any serious result follows, even when delicate organs  are  the seat  of it.
Sooner or later the uterus resumes its functions, and the attack ceases.
  [The cases of the so-called " vicarious menstruation," are nothing more
nor less than cases' of simple capillary hemorrhage, resulting from the general
disturbance of the circulation which occurs during amenorrhcea.  The hemor-
rhage may take  place  at  nearly the natural periods of menstruation, but
generally  it appears «at irregular  periods.   Although  in every  case it is
dependent on an  arrest  of the  menstrual discharge from the  uterus, yet it
cannot properly be said to take or supply the place of the latter.]
   126. Treatment.—After this discharge has once occurred, it will be proper
to take measures to relieve the  system in a less questionable manner, by vene-
section, cupping, or leeches ; and a careful watch will be necessary.   If the
evacuation take place from the lungs or stomach,  opium combined with lead
or bismuth, and the  mineral acids, will  be found beneficial.   During an in-
terval, the patient may  be treated much in the same way as for amenorrhcea,
and occasionally we may try some of the direct remedies.
   127. II. Dysmenorrhea, difficult or painful menstruation.—This form
of  abnormal menstruation consists of severe pain in the secretion or emis-
sion  of the discharge,  which  may be scanty,  profuse,  or  about the usual
amount.   The attack  is occasionally confined to one  or two periods, but
more frequently lasts  for a longer  time,  and sometimes for  many  years.
From the different  character  of the pain  and constitutional symptoms, I
have divided the disorder into  three species,—neuralgic, inflammatory, and
mechanical dysmenorrhcea.
   128. Neuralgic Dysmenorrhcea.—This variety may occur at any age, but
is more frequent after the  thirtieth year than before ; in unmarried than in
married women,  and, if married, in those who have not borne children.   It
is almost confined to those of a nervous temperament, and of a thin delicate
 habit.  The monthly paroxysms present all the characteristics of neuralgia:
 and  I am very much inclined to agree  with  Dr. Tyler Smith, that the chief
 seat  is in the ovaries.   For a short time previously,  there is a sense  of
 general uneasiness, a deep-seated  feeling of cold, and headache, sometimes
 alternating with pain in the back.   The latter commences in the region of
 the sacrum, and extends round to the lower part of the abdomen, and down
 the thighs.  The amount of suffering varies; but it is sometimes  very great.
 After a longer or shorter period, the  catamenia appear, sometimes  slowly
 and  scantily, in  others, in slight  gushes.   The  quantity differs  in different
 persons,  and in the  same person at  different times.   The quality of the dis-
 charge may be unchanged, but we frequently find it paler, and occasionally
 mixed with small clots.
   In some cases, there is a  membrane,  composed of plastic lymph, dis-
 charged  either in shreds,  or in the form of the uterine cavity which  it has
 lined.  It seldom occurs regularly, contrary to the opinion  of  Dr. Denman.
 It was first, I believe, described by Morgagni; and since by  Denman, Burns,
 and  other obstetric  writers.  Dr. Simpson has recently expressed an opinion
 that these productions " are not the results,  as is generally  supposed, of
 fibrinous  or plastic exudations upon the free surface  of the uterus,  but that
 they consist of exfoliations of that  membrane itself."  At present I confess
 I am not prepared to agree with the able and learned Professor. Denman
 states that he never knew a woman conceive  by whom this membrane was
 secreted;  but this conclusion appears to be too general. Conception is rare
 under such circumstances;  but I have known it occasionally take place.
   The symptoms enumerated  are  not always mitigated on the appearance
of the menses; the pulse is scarcely quickened, nor is there any feverishness.
The  duration of a period is variable.  In some cases there is  comparatively 
96 ,
DISORDERS OF MENSTRUATION.
little constitutional injury sustained, but in others the patient's health is
much deteriorated.
  The  cervix uteri undergoes the change usually observed  during menstrua-
tion, but nothing else is detected by an internal examination.
  From an attentive examination of these cases, I have been led to the con-
clusion that the disease is generally of a simple  neuralgic character.   Pro-
bably in  those cases where the  membrane is  discharged  there  may be, as
Dr. Locock thinks, a degree of inflammation of the nrhcous membrane, of a
peculiar kind.
  The causes are cold, sudden  shocks, mental emotions,  etc.,  acting  upon
an irritable condition of the womb.
  129.  Treatment.—The indications are twofold ; first, to reduce the pain
during  an  attack;  and, secondly, to prevent  its return, by appropriate
remedies  during  an interval.   The first indication  is  best  answered  by
sedatives; opium  or some of its preparations;  hyoscyamus,  conium, etc.,
which  may be given alone or in combination with camphor.   Should the
stomach be irritable, they may be exhibited in an enema.   I have remarked
that the discharge increases when the pain is relieved.  Other remedies have
been tried with success ; as, the acetate of ammonia by Massuyer, Cloquet,
and Patin ; ergot of rye by Dewees and Gooch, etc. etc.
   [In a few instances, I have derived advantage  from the administration of
ten  grains of ergot, morning, noon, and night, commencing three or four
days before  the expected attack, and continuing it daily until the period
arrived.   As soon as the attack commences, I have always found it advisable
to moderate its  violence by sending the patient to bed, applying warmth to
the  feet and to the vulva, and  administering some of the preparations of
opium.  Three grains of opium as a suppository, or sixty drops  of laudanum,
suspended in a  tablespoonful of mucilage,  as an enema,  is a prescription
that has  always afforded great relief at the time, and, apparently, lessened
the  disposition  to a return at  the next period.   In severe cases, it may be
proper to repeat the anodyne every day until the pain ceases.]
   During the intervals, every effort should be made to strengthen the patient,
and to diminish general and local irritability.   The diet should be nourish-
ing, and  plenty of exercise  in  the  open air should be taken by the patient.
 Chalybeate waters or  some preparation of iron may be given.   Dr. Locock
 speaks highly of a mixture  of equal parts  of vinum ferri and the spirit.
 aether, sulph. co., of which from half a drachm to a drachm may be taken two
 or three  times a day.   Dr. Dewees has tried the tinct. cantharid., and  Dr.
 Chapman the senega root, with  success. A blister to the sacrum, or  a caustic
 issue,  is  often of great use;  and I have seen much benefit derived from the
 daily use of vaginal injections  of tepid or cold water, during the  interval.
 On  the approach of the next period, warm water should be substituted,  and
 the patient should use a hip-bath or pediluvium for two or three nights in
 succession, antecedent to the eruption of the menses.  I  have succeeded in
 curing a case  in which the  false membrane  in sheds  was discharged every
 month, by repeated applications of the strong tincture of iodine to the cervix
 uteri.   This is by far  the most  obstinate variety of the disorder.
   [Dr.  Dewees found advantage from the  administration of the volatile
 tincture of guiacum during the intervals of menstruation.   When the patient
 was of  a robust habit, with a firm  and bounding pulse, he directed the use
 of the remedy to be preceded  by bleeding, smart  purging, and a  low diet.
 To  obtain benefit from the guiacum, perseverance in its use for several
 months is often necessary.  The dose directed  by Dr. Dewees was a teaspoon-
 ful  three times a day, in a  glass of sweetened milk, or,  when not counter-
 indicated, in a glass of some light wine.   The tincture used  by the Doctor
 was made of four ounces gum guiacum, one drachm and a half of carbonate 
DYSMENORRHEA.
97
of soda, and an  ounce of allspice;  these were digested in  a pint of proof-
ppirits for a few  days, when the volatile spirits of ammonia was added in the
proportion of one or two drachms to every four  ounces of the tincture.]
  130.  Inflammatory Dysmenorrhcea. — The  subjects of  this form differ
as widely from those of the former as its symptoms.  It occurs in females of
a full habit and  of a sanguine temperament, in the married as well as in the
unmarried, and  in those who  have  borne children.  Few precursory symp-
toms^ announce the attack ; a degree of restlessness and feverishness, rigors.
flushing, and headache, generally precede the severer svmptoms.  For some
time before and  after  the catamenia appear, the  suffering is very great;  the
patient  complains of pain  across the back, aching of the limbs, weariness,
and  intolerance  of light and  sound ; the face is  flushed, the skin hot, and
the  pulse  full,  quick, and  bounding.  Delirium  occasionally  supervenes.
Most frequently the symptoms are mitigated when  menstruation takes place,
and  by  degrees  subside.   The discharge is generally sufficient,  and in some
cases is accompanied by the  secretion  of the plastic  membrane spoken of
above.
  During the intervals, the health of the patient is little affected ; she may
be subject to headaches, and pain  in the side, but  these are  generally trans'
sient, and do not interrupt the functions of  the different organs.   Uterine
leucorrhcea  is not unfrequently present during  the  interval.   An  internal
examination  during the  attack affords  evidence of some  congestion of the
uterus ;  the  cervix is swollen, and the heat of the  parts increased.  Dr.
Dewees has noticed pain and swelling of the breasts as an occasional accom-
paniment of  this form of dysmenorrhcea.
  [In a recent very interesting treatise on the Diseases of Menstruation, etc.,
Dr.  E.  J. Tilt has endeavored to show:  That dysmenorrhcea  is often pro-
duced by subacute ovaritis ;  and sometimes of the uterine engorgement which
it determines.   That it  is often the result, also,  of morbid  ovulation, and
frequently  a symptom of ovarian peritonitis.   That subacute  ovaritis, by
determining the  inflammatory swelling of the neck of the womb, is a common
mediate cause of dysmenorrhcea;  the  painful  symptoms  being, in  many
instances, produced by the partial  closure of the neck of the womb, and the
consequent effusion of menstrual secretion into the peritoneum.]
  A severe attack of either variety has the effect of precluding conception;
but I have repeatedly known  conception to take place in  spite  of, and with
benefit to slighter cases.
  [Dr.  Ryan relates  two cases in which the dysmenorrhcea was aggravated
by marriage;  we have seen many such.   According to Dr. Dewees, concep-
tion  very rarely, if  ever, occurs, when there has been discharged during
menstruation a membranaform substance.  Dr. Ashwell (Diseases of Females)
states, "that when  pregnancy occurs during  the continuance of dysmenor-
rhcea, the female is exposed  to the risk of abortion.]
  131.  Treatment. — The  success of remedies in this variety of dysmenor-
rhea affords a  confirmation  of its character.  Yenesection, cupping the
loins, leeches, or scarifications to the cervix  uteri,  afford the quickest relief.
They should  be  followed  by saline  purgatives, with febrifuge medicines, and
cooling  drinks.   When  by  these  means  the inflammatory symptoms are
subdued, a dose  of calomel and opium at bed-time  is often  very useful.
  During the interval great benefit may be derived from judicious manage-
ment.   The patient should take active exercise,  and be as much as possible
(if the weather be fine) in the open  air.   Walking  is preferable  to riding or
driving.   Brisk  purgatives, and the aloetic are the best, should be regularly
administered ; and  on the approach of the next  monthly period, if  much
excitement arise, it may  be  well to abstract blood by cupping before the
regular  attack comes on. 
98
DISORDERS  OF  MENSTRUATION.
  132. Mechanical Dysmenorrhcea.—I have applied this title to a difficulty
in  the emission of the menses, caused by a narrowing  or  stricture in some
part of the canal of  the cervix.   What may be the cause of this diminution
of calibre, whether it be congenital or the result of inflammation, is not easy
to determine;  but  there  can be  no  doubt  of its  existence.   Capuron
enumerates it among the causes of dysmenorrhcea ;  and the late Dr.  Macin-
tosh,  of Edinburgh, states that he repeatedly detected it.   Professor Simp-
son considers it a very frequent  cause.  I found it remarkably evident in a
case I attended with Dr. Charles O'Reilly, of this city.   It  may occur at
any part of  the  canal, and the degree of obstruction may vary up to com-
plete  closure.  I apprehend that there can be little doubt that dysmenorrhcea
may result from 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  several cases,
although I have cured the stricture,  the dysmenorrhcea has continued.  Nor,
even in Dr.  Macintosh's case, is there sufficient evidence to prove his point;
for he does not show that there was  any retention of the menses, but merely,
that at subsequent periods  menstruation was easier and  more abundant:
this might have  arisen from the direct stimulus to the uterus afforded by the
introduction of bougies.
   133. Treatment.—The fact that such a stricture of the canal of the cervix
has been observed, should lead us to  make an examination with a small-sized
bougie, in all cases of very obstinate dysmenorrhcea.   Such an examination
is neither difficult,  painful, nor  injurious, if  proper caution be observed.
Should stricture be  detected, the remedy is the repeated introduction  of
bougies about  every second or third day, and increasing in  size, until the
obstacle be  overcome.   No force must be used ; and, if any irritation mani-
fest itself, it must be allowed to subside before the operation be repeated.
   Dr. Simpson has invented an instrument  for the division of the cervix in
these cases; but I rather think the  Object can  be  more safely attained  by
dilatation, and quite as satisfactorily.                         v
   134.  III.  Menorrhagia. — I  shall  follow  Dr.  Locock's  example,  and
apply this term to an increase in the monthly evacuations, whether accom-
panied by blood or not.  Excessive menstruation may occur in various ways:
the menses may return too frequently, or too copiously, or  at  unusual inter-
vals,  as during gestation and suckling.  Some allowance also must be made
for differences of constitution, and perhaps of climate.
   I have observed three distinct forms of the disease.  In the first,  the dis-
charge is of the natural quality, but the quantity or frequency of recurrence
is greatly increased.   In the second, the discharge is large, and occasionally
mixed with  blood;  but no change in the condition of  the body or  neck of
the womb can be detected by an  internal examination.  In the third, there
is a considerable loss of  blood, with  a marked  change in the  size and posi-
tion of the uterus.   Let us examine each of these varieties in detail.
   135.  The first  variety of  Menorrhagia  occasionally commences with  a
sudden and  violent gush from the vagina, after which it stops for some hours,
and then recurs; and this alternation may continue during the usual period
of menstruation.  Sometimes, on the  other hand, the discharge  goes on
regularly, but lasts for ten days or a fortnight, or even  three weeks ; or, the
quantity each time not being  excessive, it  may return every two  or three
weeks ; and, although this latter case is most frequently met with in women
who  have borne many children,  I have seen it occasionally in unmarried
females.   It is  also,  more than the others, connected with  that state of the
lining membrane which gives rise to  uterine  leucorrhcea.
   The symptoms are exactly those we  might anticipate from the long con-
tinuance of  a debilitating discharge.   Exhaustion, languor, indisposition  to 
MENORRHAGIA.
99
exertion, weakness across the loins and hips, pallor of countenance, head-
ache, throbbing of the temples, tinnitus aurium, and giddiness, occur more
or less in  these cases.   If relief be not obtained, and especially if uterine
leucorrhcea be present, all these symptoms will be aggravated.  The ex-
haustion and languor increase, the face becomes sallow, an aching pain is
felt across the loins and round the lower part of the  abdomen, pain in the
left side, repeated and  severe headaches, derangements of the stomach and
bowels follow, and, in short, all the secondary symptoms and disturbance of
the general health which result from anaemia, no matter how produced.   In
some extreme, but rare cases, we have diarrhoea and anasarca, with nervous
symptoms, melancholy,  and  even  epilepsy,  resulting  from the  disease.
Nothing is discovered  by a vaginal examination : there is neither swelling
nor increase of heat  about the uterus ; the os uteri is  slightly open, as usual
during menstruation, but there is no tenderness.
   Among the causes we may enumerate repeated child-bearing, over-suck-
ling, excessive coition, cold, mental emotion, etc.
   136.  Treatment.—The first indication is to remove the  cause :  if it pro-
ceed from over-suckling, the child should be weaned, and the patient should
live "absque marito."
   In persons of a full habit  of 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 succeeded with
ergot of rye, in five-grain doses, three  times a day.  Dr. Locock recommends
cold to the vulva, hips, and abdomen, with vaginal injections of cold water;
and Dr. Dewees has used a vaginal injection of sugar  of lead and laudanum,
with rest on a hard bed, twenty drops of elixir of  vitriol, and gentle purga-
tives, with success.   I should altogether deprecate injections into the womb,
recently advised by French writers, as a very hazardous practice, and which
even their own experience does not justify. A far safer, and as I have found
it, a very effectual practice, is to employ enemata of cold water.   Plugging
the vagina has  also been  recommended, and as a " dernier ressort" may be
tried,  though it is  not a very  scientific  remedy.  Dr. Macintosh  speaks
highly of an enema  containing a scruple of the acetate of lead.   The  tinc-
ture of Indian hemp has a powerful effect upon  this form of the disease.  It
was first  tried by my friend,  Dr.  Maguire of Chapelizod, and on his recom-
mendation, by Dr. Hunt and myself, with extraordinary success, both in the
number relieved and the rapidity of cure.  From five to ten drops three
times a day in some suitable  menstruum will be found sufficient.
   During the intervals, a blister  may be applied to the  sacrum, and either
kept open or repeated.  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-phlegmatic
constitution, who have been debilitated by disease or frequent child-bearing.
The progress of the disorder is gradual; one or two small clots  appearing
at first, then an  intermission, and a more copious recurrence.   After  some
time, the  discharge  of blood may be  considerable, so as  in some cases to
produce fainting.  It is of course impossible to ascertain whether the cata-
menia  themselves are  altered in quantity or quality.   A vaginal  examina-
tion throws no light upon the nature of the disease, the uterus being in its
usual state during menstruation.   The constitutional effects are similar to 
100
DISORDERS  OF  MENSTRUATION.
those noticed under the first form (§ 135), but more  severe, and produced
more rapidly.
   138.  Treatment.—The remedies recommended for the former variety are
equally available  here.   Opium, alone or  in  combination with lead, and
ergot,  or  Indian hemp,  during the attack ; with counter-irritation  to the
sacrum, the douche to the loins, or  cold sponging, vaginal injections or ene-
mata, daring the interval, are our chief resources.
   [The juice of the common lesser  nettle  {Urtica urens) is strongly recom-
mended by M. Ginestet,  in doses of fifteen to thirty drachms.   In preparing
the juice, a quantity  of  the  green  herb is bruised,  with  the addition  of a
.ktle water, and the fluid portion then strained off by pressing the mass in
a  linen bag.   One  dose is said  to be  generally sufficient  to  check  the
discharge.1]
   139.  The  third variety  of Menorrhagia differs considerably from  the
other two ; the discharge is more profuse, and  its effects more severe ;  it is
accompanied by marked alterations  in the condition  and  relations  of the
uterus, occurs at a later period of  life, and is  more difficult to cure.   The
attack is  not confined to any one kind of constitution or temperament; it
occurs in  the plethoric  and in the debilitated,  in the melancholic as well as
in the sanguine.  I have never seen it in a patient under forty years of age,
nor after the cessation of the catamenia.
   Theattack is preceded for some  time by irregularity of the menses, both
as to time, quantity, and the duration of  each  period, with occasional ute-
rine  leucorrhcea during the intervals.  It is not  until the menses have flowed
naturally for about twenty-four hours, that the sanguineous discharge appears.
Large clots  are then expelled, in addition to  a great  increase in the fluid
discharge.   At first, the attack lasts  seven or ten days only, but in cases of
longer standing I have  occasionally known it  to continue throughout  the
interval, and terminate  after the next period either gradually or suddenly.
The  quantity lost varies, of course : it is  sometimes very large ;  it was suf-
ficient in one case to excite  fears of a fatal result.
   The recumbent posture appears to have  no effect upon the discharge, there
being as much observed  during the  night as the day.  Any exertion or long
standing never fails to increase the  amount.
   During the attack, the patient  complains of excessive  exhaustion,  of a
sense of weight in the pelvis, of a dull pain there occasionally, and of weak-
ness  in the loins. In all the cases I have seen there was considerable dysuria,
especially  after long  standing: several, indeed,  were  obliged to lie down
before they were able to  evacuate the contents  of the bladder completely.
   1 he general  health, of course, suffers considerably;  the appetite dimin-
ishes, the  tongue is clean, though pale, the bowels become  constipated, the
surface blanched, and the strength much reduced.
   The pulse is  occasionally quickened, but more generallv quiet,  and  en-
feebled in proportion to the loss of  blood.
   An internal examination will detect the os uteri  somewhat lower in  the
pelvis, and directed more towards the sacrum than usual.   It is rather more
patulous than ordinary,  and the cervix is more or less  swollen, especially
anteriorly where it expands  into the body.  It appears to  be tilted forward
by its increased weight,  so  as  to press upon the bladder, thus affording- a
satisfactory explanation of the dysuria which I have noticed in every well-
marked case.   No increase of heat is observed in the vaginal canal or about
the cervix.  The cervix  and lower part of the  body of the  uterus are gene-
rally  but  not always, slightly tender  on  piessure.   Of course, the amount
ot these alterations will vary in different cases.

   [' Rankings Hatf-i'eai-'y Abst.-fr.m Ency:lop. Med. de M. Lartigue, Oct. 1844.] 
/
                           MENORRHAGIA.                        101

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





                        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 forma-
tion of a new being, possessed of individual or independent life.  The first
step in this process is called Generation, Fecundation, Conception, etc.  The
period of  fecundity in the human female lasts about thirty years, i. e., from
the fifteenth to the forty-fifth year, or thereabouts ;  in other words, it is  con-
temporaneous with menstruation.
  142. From the hidden nature of the process  and the stupendous results,
the subject has always possessed the deepest interest for phvsiologists, and
at the same time given rise to a multitude of theories, most of them,  to say
the least, mere  hypotheses.  Dr. Allen Thompson, in  his valuable paper^1
thus classifies them :  "The greater number of the older theories of genera-
tion may be brought under one or other of these divisions ; viz., the theory
of the ovists, of the spermatists, or of that  of combination,  evolution, or
epigenesis.   According to the first-mentioned  of these hvpotheses, or that
of the ovists, the female parent is held to afford all the materials necessary
for the formation of  the  offspring, the  male doing no more than awakening
the formative powers, possessed by and lying dormant in the female product
This was the theory of Pythagoras, adopted in a modified form by Aristotle •
and we  shall afterwards  see that it resembles  most closely the prevailing
opinion of more modern times.   The terms, however, in which some of the
older  authors expressed this theory  are very vague ; as, for example  in the
notion that the  embryo or new product is formed from  the  menstrual blood
of the lemale, assisted by a sort of moisture descending from the brain during
sexual union.                                                         °
  "According to the second theory, or that of the spermatists, amoim- the
earlier supporters of which Galen  may be reckoned,  it was supposed°that
the male  semen alone  furnished all the vital parts of the new animal the
female organs merely affording the offspring a fit place and suitable materials
for its nourishment.  Immediately upon the discovery of the seminal animal-
cules,  these minute moving particles  were regarded by some as the rudiments
of the new animal.  They were said to  be miniature representations of men,
and were styled homunculi; one author going  so far  as to delineate in the
seminal animalcule the body, limbs,  features, and all the parts  of the grown
human body.  The microscopic  animalcules were held by others to  be of
different sexes, to copulate, and thus to  engender male and female offspring:
and the celebrated Lieuwenhoek, who was among the first to observe these
animalcules, described minutely the manner in which they gained the interior
of the egg, and held that after their entrance they were retained by a valvular
apparatus.                                                 J
  " The theory of syngenesis or combination seems to have been auolied
principally to the explanation of the reproduction of quadrupeds and man
the existence and nature of the ova  of  which were involved in doubt   This
hypothesis consists in the supposition, that male and female  parents both
furnish simultaneously some semen  or  product; that  these products  after
1 Cyclopaedia of Anatomy and Physiology.  Art. — Generati 
GENERATION.—CONCEPTION.
103
sexual union, combine with one  another in the uterus, and thus give rise to
the egg or structure from which the foetus is formed.  In connection with this
theory, we may also mention that of metamorphosis, according to which, a
formative substance is held  to  exist, but is allowed to  change its form in
order k) be converted into the new being;  as also the notion of Buffon, that
organic molecules universally pervade plants and animals, that these are  all
endowed with productive powers, that a certain number are employed in the
construction of the textures of organized bodies, and that in the process of
generation, the superabundant quantity of them  proceeds to  the sexual
organs, and there constitutes the rudiments of the offspring."
   It would be mere waste of time to enumerate the modifications of these
theories, which have  been promulgated  in profusion from time to time ;  of
which  "groundless  hypotheses"  Drelincourt reckoned  two  hundred and
sixty-two, and in  addition to which, as  Blumenbach remarks, "nothing is
more certain  than that Drelincourt's own theory formed the  two hundred
and sixty-third."
   143. The best plan will be to state briefly such facts as we possess, which
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 secrete a peculiar fluid called
semen, which in the  act of intercourse  is projected into  the vagina, and
arrives by a process we  cannot as yet explain in the uterus of the female,
and is supposed to  exert a peculiar  influence upon the Graafian vesicles;
but the difficulty has  been to explain how that influence is communicated 01
carried to the ovary,  or whether impregnation takes place in the ovary, fal-
lopian tubes,  or uterus.   Various theories have been propounded (that of
an aura seminalis, for  example), but none were consistent with the obser-
vations made upon other orders of animals;  from which it appeared  that
contact of the semen  with the ova was necessary.   This obstacle  seemed to
be removed by the  observations of Dr.  Bischoff  of Heidelberg, Dr. M.
Barry, and  Professor Wagner  of Berlin, who believed themselves  to have
detected spermatozoa in the fallopian tubes, especially at their ovarian ex-
tremity.  It appears doubtful whether spermatozoa have really been detected
in the  ovary or at the upper extremity of  the fallopian tubes, but Bischoff
still holds the opinion that impregnation takes place generally in the uppei
part of the fallopian  tubes :  Prevost, Dumas, and Barry, that spermatozoa
enter bodily into the  ovum.   The latter view is  not supported by recent
researches, and Pouchet opposes  both that and Bischoff's, maintaining that
fecundation takes  place  only  in  the lower part of the fallopian  tubes  or
uterus.  A very strong argument in favor of ovarian or tubal impregnation
i» the occurrence of extra-uterine — ovarian or fcetal — gestation.   In such
cases the  spermatozoa must have reached  both  tube and ovary.  What I
think clear enough is,  that the contact of the spermatozoa with the liberated
ovum is necessary to fecundation; and this is confirmed both by the obser-
vations of comparative  anatomy and by  the experiments of Cruikshank,
Haighton, and Blundell, who found that if  the fallopian tubes were rendered
impermeable, impregnation was prevented  ; but  this does  not prove where
impregnation is effected ;  whether in the tubes or in the uterus,  or, as  may
be probable, sometimes in one and sometimes in the  other.  The experiments
of Spallanzani and others have proved that a very small quantity of semen
is sufficient for fecundation.
  [The semen as it is discharged from the urethra, is  an exceedingly mixed
fluid, consisting of spermatozoa derived  from  the  testicles, with the secre- 
104
GENERATION.—CONCEPTION.
t'ons of the epididymus and vas deferens, the prostate or Cowper's glands,
and the mucous follicles  of the urethra.   It is now almost  universally ad-
mitted that it is the spermatozoa alone which contribute  the essential  or
fecundating portion of the seminal fluid.   These bodies are  developed within
certain cells found  in the secretion of the testes before this leaves the gland.
Within the cells the spermatozoa are in the form  of filaments arranged in
bundles, but in the passage of the semen through the  efferent vessels, the
cells rupture and set free the spermatozoa.   Each  spermatozoon consists of
an oval and  flattened body, and a filamentous  portion  or  tail.   The width
of the body is about the  one six-thousandth part of an inch, and the entire
length of  the  spermatozoon is from the fourth to  the sixth-hundredth part
of an inch.  These bodies  present no evidences  of organization, consisting
apparently of a homogeneous, tolerably firm, albumenoid substance.   They
have an almost  constant  vibratory or wriggling motion, precisely similar to
that of a  ciliated epithelium cell, which at one time caused them  to be  con-
sidered as distinct animalcules.   They are, strictly  speaking, " organic forms
which are  produced  in the testicles, and constitute a part of their tissue ;
just as the eggs, which are produced in  the ovaries, naturally form a part
of those organs, .  .  . and  like the egg, also, the  spermatozoon  is destined
to be discharged from the organ where  it grew, and to retain, for a certain
length of  time afterward, its vital properties."1

                                  Fig. 43.
           Spermatozoa from man, and their development.  (Wagner). — a. Spermatozoa from the semen of the
         vas deferens. 1 to 4. Show their variety of character. 5. Seminal granules.—b. Contents of the semen
         of the testis. 1. Large round corpuscle or cell. 2. A cell containing three roundish granular hodies,
         from which the spermatozoa are developed. 3. A fasciculus of spermatozoa, as they are seen grouped
         together in the testis.

          The question as to how the sperm arrives  at  the ovarium, has  not yet
        been settled.   Professor Wagner, who is high authority,  considers  that  the
        sperm  reaches the  ovary partly by the ciliary motions, which begin in the
        cervix uteri, partly by the contractions of the tubes, and  partly by the  mo-
        tility  of  the  spermatozoa.2  Dr.  Carpenter, however, seems to thinkx  the
,        latter is the sole means 1   " That the spermatozoa make their way towards
        the ovarium,  and fecundate the, ovum either  before it  entirely  quits  the
        ovisac, or very shortly afterwards, appears to be the general  rule  in regard
        to  mammalia;  and the question naturally arises, — by what  means do they
        arrive there ?   It has been supposed that the action of the cilia, which line
        the fallopian tubes, might account for their transit; but the direction of this
        is from the ovaria towards the  uterus, and would therefore be opposed to it.
        A  peristaltic  action  of  the fallopian  tubes themselves  may generally b«

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

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

                                  Fig. 44
  Graafian Vesicle after
Impregnation.—1. Tunica
granulosa.  2. Chorion.
3. Zona pellucida. 4. Thick
transparent  membrane.
5. Yelk ball. 6. Germinal
vesicle. 7. Germinal spot
yelk is  now immediately surrounded by  the thick  transparent  membrane
{zona pellucida)  of the ovarian ovum.   3.  In the centre of the yelk there
arise several very large and exceedingly transparent vesicles.  These disap-
pear,  and are succeeded by a smaller and  more numerous set.   Several sets
:hus successively  come into view, the vesicles of each succeeding set being
more  numerous and smaller than the last, until a mulberry-like structure has
oeen produced, which occupies the centre of the ovum.  Each of these vesi-
3les contains a colorless and  pellucid nucleus, and each nucleus presents a
•nucleolus.
  " In the uterus, a  layer of  vesicles, of the same kind as those of  the last
and smallest here mentioned, makes its appearance on the whole of the inner
surface  of the membrane which now invests the yelk.   The  mulberry-like
structure then passes from the centre of the yelk to a certain part of that
layer  (the vesicle of the latter coalescing with those of the former, where the
two  sets are in contact, to form a membrane, the future  amnion), and the
interior of the mulberry-like structure is now seen to be occupied by a large
vesicle, containing a fluid and dark granules.  In the centre of the  fluid of
this vesicle  is a spherical body, composed  of a  substance  having  a  finely
granulous appearance, and containing a  cavity filled with  a colorless and
pellucid fluid.  This hollow and spherical body seems to be the true germ.
The vesicle  containing it disappears, and in its  place is seen ^,n elliptical
depression,  filled  with  a pellucid fluid.   In  the centre of this depression is
the germ, still presenting the  appearance of a hollow sphere."
  It is  unnecessary to apologize for this minute  account of the changes in
the vesicle ; the interest of the question, and the light thrown upon it by the
able and careful  researches of  the distinguished physiologist from  whom I
have  quoted, are  more than  sufficient reason for laying the results before
my readers.
  147.  Let us now retrace  our steps a little;  during the increase of the
vesicle  in the ovary, " the inner coat becomes intensely vascular, and on its
external surface, a soft gelatinous substance, of a yellowish-red color, con-
sisting  apparently in part of blood and in  part of lymph, is poured out be-
tween the two coats of the vesicle, in considerable  quantity all round, except
at the point where it is pressed towards the external surface of the ovary."
Such is Dr. Montgomery's description of the formation of the corpus luteum,
which he conceives  aids in the expulsion  of the  ovum,  after having served
" as a sort  of little temporary uterus" to the contained germ, " lined with a
serous  membrane, covered externally by another, and having interposed be-
Graaflan Vesicle after Impregnation. 
GENERATION.—CONCEPTION.                 107
tween them the fleshy or granular structure of the corpus lute am, through
which blood-vessels ramify, and exhale through the lining membrane a serous
fluid for the support of the early ovum, which as yet lives only by imbibition."
Professor von Baer thought that the corpus luteum was the lining membrane
of the vesicle in a  state of hypertrophy, and Dr. R. Lee believes it to be a
deposit external to the lining.   Drs. Paterson and Renard agree with Dr.
Montgomery ; but Knox, Pouchet, Miiller, and Dalton, regard it as a hyper-
trophy of the outer membrane, and formed after the escape of the ovum.
   148. Shortly  after the evolution of  the ovum, the size of the ovary is
found to be increased, especially at a certain  part which is prominent, and
about  the size of a  nut.   At  an early period after  conception, this  small
tumor is of a bluish-red or purple  color, owing probably to the effusion of
blood  attendant on the rupture of its  coats, and having numerous vessels
filled with the florid  blood ramifying on  its surface.   In some part of this
colored surface of the tumor, a cicatrix, depression, or aperture may be dis-
covered, being the  point at which the ovum escaped from the ovary into the
fallopian  tube.
   149.  These external appearances, however, are inadequate to prove the
presence of a true  corpus luteum ; they require confirmation by the results
of an internal examination.   " Upon slitting open the ovarium at this part,"
says Dr. W. Hunter,  " the corpus luteum appears a round body, of a very dis-
tinct nature from the rest of the ovarium.  Sometimes  it is oblong  or oval,
but more generally round.  Its centre is white, with some degree of trans-
parency,  the  rest  of its  substance has a yellowish  cast, is  very vascular,
tender, and  friable, like glandular flesh.   Its  larger vessels cling round its
circumference, and then send their smaller branches inward through its sub-
stance ;" which substance, according to Dr. Allen Thompson, "has a lobular
structure, the lobules radiating in a somewhat irregular manner from the
centre to the circumference.   The  central part of the  corpus luteum fre-
quently remains hollow for some time after its production, opening exteriorly
by a narrow  passage from the  part where the rupture  of the vesicle origi-
nally took place ; at  other times, this passage is closed more early, and there
remains  nothing but an indication of its place, in a depression in the centre
Fig. 45                            Fig. 46.
Ovary after escape of Ovum.           Corpus Luteum, from Dr. Montgomery.
of the most projecting part of the corpus luteum.   The lobules of the coi-
pus luteum, examined with the microscope, exhibit merely a granular struc-
ture, and are not formed of acini, as some have described them, so that there
is no reason to consider them bodies of a glandular nature." 
108                  GENERATION.—CONCEPTION.

  150.  The following measurements  of  the ovaries  and corpus luteum, at
the third month of pregnancy, are given by Dr. Montgomery :
      The unimpregnated ovary.             Ovary containing a corpus luteum.
Length   ...    1 inch 5 lines.      Length   ...    1 inch  3 lines.
Breadth  ...       "    7£  "       Breadth  .   .   .      "   9  "
Thickness   .   .    "   "    5±  "       Thickness   .   .      "   7£ "j
  Dr. Knox has drawn up the following table of measurements of the corpus
iuteum  at different periods of pregnancy.
No. of days after Impreg-	Name of Reporter.	Long diameter,	Short diameter,	Thickness of the glandu-
nation.				
5		9	6	H
8		9	6	ij
46		9 6		l
62				l
62		n	8	3
70		7	6	
93	Ditto................	7*	6£	2£
108		9	7	2
108		7	6	
155		8J	7	
186		6 6	5 5	3
186				3
186		7* 6	4£	1
201				1
280		7 6	4 5	
280				
280		• 6 4	5 2£	
285				1*
L
  151.  For a short time after the escape of the ovum, the corpus luteum i°
said to  increase in size, then to remain stationary, and afterwards to diminish
slowly.   After the third or fourth month the central  cavity contracts, and
its sides coming  in contact, gives it the appearance  of  an irregular white
line, somewhat radiated.   After delivery, the corpus luteum shrinks, absorp-
tion takes place, and it disappears, though at what time is not quite certain.
Dr. 'Montgomery has observed it five months after delivery;  but Dr. Pater-
son's investigations would lead  to the conclusion, that  it  seldom remains so
long.
                                    [Fig. 47.]
 Successive stages of the formation of the Corpus Luteum, in the Graafian follicle of the Sow, as seen
in vertical section;—at a is shown the state of the follicle immediately after the expulsion of the ovum
its cavity being filled with  blood, and no ostensible increase of its epithelial lining having yet taken
place; at 6, a thickening of this lining has become apparent; at c, it begins to present folds which arc
deepened at d, and the clot of blood is absorbed pari passu, and at the same time decolorized • a con-
tinuance of the same process as shown at e,f, g, h, forms the Corpus Luteum, with its stellate  cicatrix.
Diameter of
the Central
  Cavity.
6
3
    3
4£ and 1\

4\ and \\
    2
    2
    4
    3
1* 
GENERATION.—CONCEPTION.
109
   Dr. Dalton gives it as the result of his observation, that the corpora lutea
 of menstruation and  pregnancy follow the  same course of development  in
 the first period.   " Together with the rupture of the vesicle, the same effu-
 sion of blood takes place  in  either  case, followed  by a gradual absorption
 of the coloring matter of  the clot, and hypertrophy and  folding up  of the
 membrane of the vesicle.   When, however, the ovum becomes impregnated,
 and continues its  growth in the uterus, the  corpus luteum, instead of  reach-
 ing its maximum  of development at the end of three weeks, and afterwards
 undergoing  a  rapid  process of atrophy, continues to  develop itself for a
 considerable period, and does not, in fact, become very  decidedly retrograde
 until after the  termination of pregnancy."  "The difference in the progress
 of the corpus luteum, however, relates not only to' its  size, but also to its
 general characters and aspect.  The external wall  becomes much thicker  in
 proportion to the central coagulum, and at the same time acquires a firmer
 and more highly organized structure.   Moreover, the color both of the con-
 voluted wall and  of the central coagulum  constitutes an important  means
 of distinction.  It has been shown that the corpus luteum  of menstruation
 retains the bright color of its walls till the whole body has become  much
 reduced  in size, and that the  coagulum in its  interior also remains  more  or
 less stained with  red till a late period.   On  the other hand, if pregnancy
 occur, the circumstances are reversed.   The color,  both  of the wall and
 the coagulum,  fades rapidly after the first two months,  while  the substance
 of the yellow body continues to increase ;  consequently, during the greater
 part of gestation, the corpus luteum of pregnancy will be distinguished from
 that of menstruation  by the dull hue of  its convoluted  wall, and by the
 absence of color in the central coagulum."1
   The number of corpora  lutea corresponds exactly to  the  number of chil-
 dren ;  as Dr. W.  Hunter remarked,  " Where  there is  only one  child,  there
 is only one corpus luteum,  and two in the case of twins."  Meckel examined
 two hundred females of the class mammalia,and found this correspondence exact.
   [Dr. Carpenter denies that there is a correspondence  between the number
 of corpora lutea found in the ovaries of a woman,  or of cicatrices on  their
 surface, and  the number of children  she may  have borne.    The number  of
 corpora lutea must always  be less, he remarks, when there  have been many
 conceptions ;  but the number of cicatrices  may be greater;  for several
 causes, such  as the escape  of unimpregnated  ova, or the bursting of little
 abscesses, may give rise to such appearances.2]
   152. Two very  important questions here  demand notice :  1. Are corpora
 lutea the result of pregnancy only, and does their presence indicate previous
 impregnation ?  And, 2. If  not  the  result  solely of  pregnancy,  can the
 corpora lutea of pregnancy be distinguished accurately  from those  of  men-
 struation ?
   Various opposite opinions have been held upon the first of these points.
   Haller, Meckel, Haighton, Yelpeau, Montgomery,  Miiller, etc., believe
 that corpora lutea are the  result  of impregnation only ; others, as Cruik-
 shank, Gross, Seymour, Gooch, Blundelh Renaud, etc., believe that whilst,
 as  a general rule, corpora  lutea result from  conception, yet that they are
 occasionally  met with in virgins, the one being true, the other false corpora
lutea.
   [" The true corpus  luteum," says Carpenter, " is distinguished by its capa-
bility of being injected from the vessels of  the ovary ; which is not the case
with tubercular deposits, or other substances which may simulate it."3]

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

  1 Theorle Positive de l'Ovulation Spontanea, etc. p. 185.       2 Prize Essay,  p. 73. 
UTERO GESTATION.
Ill
in the extent of its development and the duration of its existence.  While the
former passes through all the important phases of its growth and decline in
the period of two months, the  latter lasts for from nine to ten months, and
presents, during a great portion of the time, a larger size and a more solid
organization.   It will be  observed  that,  even with the corpus luteum  of
pregnancy, the bright yellow color, which is so important a characteristic, is
only temporary in its duration, not making its appearance till about the  end
of the fourth week, and disappearing after the sixth month."]
  Thus, if due care be taken, the corpus luteum of pregnancy can be distin-
guished  from the  changes  which follow ordinary  ovulation, by whatever
name they are called, and therefore the presence of such a corpus luteum is
as sure an evidence of  pregnancy as it has ever been considered.
                          CHAPTER  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 fcetus.

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

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

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

  i Philosophical Trans.,  1850, part  ii. p. 519.
  2 Researches on the Conduct of  the Human Uterus after  Delivery,  translated by Dr.  R,
M'Donnell.
  » E.lin. Monthly Journal.  Aug.,  1852, p. 127, note.
  * American  Journal of  -Med. Science, April,  1858
       8 
114
UTERO-GESTATION.
the umbilicus and the ensiform cartilage ;  at the  end of the  eighth month,
it reaches the ensiform cartilage and fills the abdomen, having the intestines
above and behind it.
  During the ninth month, although it somewhat increases in size, yet, from
the yielding of the abdominal parietes, it does not  ascend, but on  the  con-
trary is  somewhat  lower than  previously.  Its  capacity is immensely in-
creased :  according to the calculations  of Levret, its  superficies  may be
estimated at 339 inches, and its  cavity will contain 408 inches ; its length
being from 12 to 14 inches;  its breadth from 9 to 10, and its depth, antero-
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 cervix,
during the early months, is closed by the  glutinous  secretion of the follicles,
and these glands are themselves enlarged, so as occasionally to be felt rolling
under the finger.
  During the first three months, the os uteri is lower than usual in the pelvis,
owing to the increased weight of the uterus, and  directed a little more for-

            Fig. 50.                                  Fig. 51.
     Cervix Uteri at three months.                    Cervix Uteri at six months.

wards;  as the uterus rises above the brim of the pelvis, it is directed back-
wards, and after the fifth  month, the cervix is said to be drawn out by the
expanding uterus, and shortened.  At the sixth month it is said to lose one-
fourth of its length  (fig. 51) ;  at the seventh  it is  only  half its  original
length ; at the eighth it loses another quarter (fig. 52); and at  the ninth the
neck is obliterated (fig. 53) : so that upon making an examination, we find

              Fig. 52.                                Fig. 53.
       Cervix Uteri at eight months.                  Cervix Uteri at nine months.

the vagina closed superiorly by the rounded  lower end of the uterus, but no
protruding cervix.   It would appear, however, that this shortening  of the
cervix is  more apparent than real.   Examined  by the finger, it  certainly
protrudes less into the vagina, and its length is  really somewhat less;  but
499 
UTERO-GESTATION.
115
this, according to the researches of Stolz, Cazeaux,1 and Matthews Duncan,
is not by distension of its cavity, but by approximation of its two extremities.
The latter author2 hjas given sectional outlines of the cervix uteri at different
periods, made from  dissection, and which appear to justify his conclusions.
At the same time he states that the capacity of the  canal becomes greater
as pregnancy  advances by an  increase  of breadth ;  that the  length of the
vaginal projection of the cervix diminishes as the uterus rises, as represented
in the plates, and that the substance of  the cervix becomes  more soft and
bulky.   In these views Dr. Farre  seems  to coincide.
   159.  The figure of the uterus  at the full term is oviform (fig. 48), the
larger end being uppermost, and rounder in proportion than the lower end.
Some variations in  shape are observed from the pressure  of neighboring
parts, the position of the patient  or of the 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 labor.
   The axis of the  uterus, at the end of gestation, is commonly more perpen-
dicular  than that of the  brim of the pelvis ;  but this want of agreement  is
rectified at the time of labor by the uterine contractions which tilt the fundus
forwards.
   160.  The lining membrane of the uterus participates in the general con-
gestion of the uterus at the  time of conception.   It becomes turgid with
blood;  its villi, according to Yon Baer,  elongate,  and  over and between
them is spread a thin layer  of pulpy, semi-fluid  matter,  secreted by the
mucous membrane :  this  is the decidua (fig. 54).  It was noticed by Burton,
but described particularly by W.  Hunter, and called after him the decidua
of Hunter.   The  pulpy matter,  after  a short time, acquires consistence,
and, in its appearance and connection with the  subjacent membrane, resem-
bles the coagulable  lymph thrown off  by mucous membranes in a state  of
disease.  It lines the entire  cavity of  the uterus, closes it inferiorly, and,
according to John Hunter and Breschet, sends off a short process into the
fallopian tube, through which, they conceive, the ovum descends.
   Dr.  Sharpey, of  London,  whose  microscopical  researches are so well
 known, on investigating the membrana decidua  of a bitch, came to the con-
clusion that  it was  not  a secretion from the lining membrane of  the uterus,
 but that membrane itself altered and  modified.3   It appears that W. Hunter
 regarded the decidua as the mucous membrane modified, and this view has
 also been put forth  by Bischoff.   Having had the opportunity of examining
 the uterus of a woman supposed to have  been impregnated about three  weeks
 before  death,  he  was enaoled to  demonstrate  quite satisfactorily that the
 membrana decidua  in the human  female, as in the bitch, is merely the ordi-
 nary mucous  membrane  of the uterus  considerably developed, and that it
 consists essentially of enlarged uterine follicles and their blood-vessels, toge-
 ther with an unusually large quantity of secretion which these follicles have
 poured out.   The  internal surface of the uterus presented an appearance
 quite different from its ordinary one, being finely villous ; and this was espe-
cially evident  on  placing it  in water, or examining perpendicular sections
 of it.   The surface  itself, when looked upon from above, appeared as  if per-
 forated by a number of  small apertures,  or covered  with  numerous  white
points, and  these,  when examined by  the  microscope, were found  to  be
openings of cylindrical  glandules.  These glandules or follicles were' from
 H to 2 Paris lines  in length, were held together by a transparent material,
and terminated each by a blind extremity which rested on the fibrous  tissue

    » Midwifery, p. 108, Amer. Trans.          2 Edin. Med. Journ., March, 1859.
    s Miiller's Physiology, by Baly, part iv. p.  1578. 
116                       UTERO-GESTATION.
of the uterus.  They ran a somewhat wavy course, but never  branched or
anastomosed.  Previous to impregnation it seems to be exceedingly difficult
to discover these glands in the mucous membrane of the uterus.   Probably
they then exist in  a very undeveloped state, but immediately on the  occur-
rence of conception increase rapidly, and exude an abundant secretion.   Of
these glands and their secretions (together with blood-vessels) the membrana
decidua and, later on, the placenta essentially consist.  The statement that
a membrana decidua exists in the fallopian tube as well as  in the uterus, in
cases of fallopian  impregnation, 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 ordinary
nrtiinbrana decidua could be effected.
Fig. 54.                                 Fig. 55.
Decidua Vera.                          Decidual Cotyledons.
  A similar view to the above, with regard to the membrana decidua, was
advocated  also by  M. Coste1 some years  ago,  and since by M.  Cazeaux,
and  recently repeated before the Academie des Sciences, Paris ;  and it is
held, with  some modifications,  by those who, with  Cruveilhier, Fergusson,2
T. Smith, believe that, after delivery, the muscular structure of the uterus is
denuded  of mucous membrane.  It has always appeared to me that this
point is  far from being  proved, and I see,  by Dr. J.  Matthews  Duncan's
paper,3 that his investigations have led him to the conclusion that the mucous
membrane  is not thrown off, except at the  part  to which the placenta is
attached.
  The decidua is rough externally at an early period, and smooth internally;
and  so far resembles serous membranes, that it is a shut sac, and contains a
small quantity of fluid.   Its color is reddish or whitish* grey.   Its thickness
varies in different places;  it is thicker near the placenta, and thinner near
the cervix uteri; it  also becomes thinner after the third month, in proportion
as pregnancy advances.  It adheres but loosely to the mucous membrane at
an early period, but firmly during the latter months, so much so that Yon
Baer states that it cannot be separated without  bringing away the lining
membrane  also ;  this, however, is not always the case.   The medium  of its
connection with the uterus is chiefly the small vessels which are supplied to

  1 Archives Ge"n. d'Anatomie Ge"n.  et de Physiologie, Sept. 1846.  London Med  Gaz .
Nov.  1850.
  2 On Puerperal Fever, p. 76. et seq.
  3 British and Foreign Med.-Chir. Review, Oct. 1853. p. 506. 
UTERO-GESTATION
117
it by that organ, and which are arranged in loops round  its villi; they are
very numerous near the placenta, but more scanty at the cervix.
  161. A very important observation on the  structure of the decidua vera
has been  made by Dr. Montgomery, in  his valuable wrork On  the Signs of
Pregnancy.   " Repeated examinations," he remarks,  "have shown me that
there are on the external  surface of the decidua vera  (fig.  55) a great
'lumber of small cup-like elevations, having  the  appearance of little bags,
the bottoms of which are attached to, or imbedded in, its  substance; they
then expand or belly out a little, and again grow smaller towards their outer
or uterine end, which in by far the greater number of them is an open mouth
when separated  from the uterus;  how it may be while  they are adherent I
cannot at present say.  Some of them, which I have found  more deeply
imbedded in  the decidua, were completely closed sacs.   Their form is cir-
cular, or nearly  so ; they vary in diameter, from  the twelfth to the sixth of
an inch, and  project about the twelfth  of an inch from  the surface of the
decidua."  In a note, Dr. Montgomery  suggests that these "decidual coty-
ledons " serve " as reservoirs  for nutrient fluids separated from the maternal
blood, to be thence  absorbed, for the support and  development of the
ovum."
   162. Those who  hold  the  membrana decidua to be a distinct secretion,
suppose that when the ovum  arrives at the uterine extremity of the fallopian
tube, it must either push the membrana decidua before it, or pierce it, in
order to  enter the  cavity of the uterus.   Opinions have been much divided
as to which of these two operations takes place: Dr. W. Hunter, Dr.  R. Lee,
and M. Breschet say that the  ovum passes into the sack of the decidua ; but
Lobstein, Burdach, Yelpeau, and others,  conceive  that the  sac  remains
entire, but that  the ovum  passes  behind it  to  the  situation where it fixes
itself,  and that  its free  surface (that part I mean which is not in  contact
with the uterus) is  covered by the displaced  decidua, to which  the name of
decidua  reflexa has  been  given, to distinguish  it from  the decidua  vera,
and which was first observed  by Dr. W.  Hunter.   As the  ovum expands, so
does  the decidua reflexa, until at  the  end of  gestation its inner surface is in
contact with the inner surface of the decidua vera, just like (if I may be
pardoned a very homely simile) the layers of a  double night-cap when put
on the head.  That  space of the uterine parieties from which the decidua
was detached by the ovum,  increases with  the  enlargement  of the uterus,
and is occupied  subsequently by the placenta;  but between this organ and
the uterus anew layer of membrane — the decidua  serotina — is deposited,
resembling the decidua vera, to which  it is  united  at the  circumference of
the placenta.
   A third view is held by those  who, like Dr.  Sharpey, MM. Bischoff and
Coste, regard the membrana decidua  as nothing but the  hypertrophied mu-
cous membrane of the uterus.  They consider that the fallopian tubes open
freely into the  uterine cavity, and that the  ovum, on entering the uterus,
becomes buried  in  the mucous membrane by which it is covered.  As the
ovum increases,  the hypertrophied membrane is distended, and  forms what is
termed the decidua reflexa.  As  far as I understand, they seem to  say that
the ovum divides the mucous membrane into two layers — an outer and an
i,mer—answering to the decidua reflexa and the placenta  decidua, whilst the
remainder answers to the decidua vera.
   The decidua reflexa becomes thinner as pregnancy advances, and is ulti-
mately expelled,, more or less entire,  with the 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 exists before the descent  of the  ovum, and
is therefore  independent of it; and it is stated  by most  authorities, that in 
118
UTERO-GESTATION.
cases of double uterus, both  contain decidua, and in extra uterine foetation
the uterus is lined by decidua.   There are, however, exceptions to the lat-
ter ;  for in the cases published by Dr. R. Lee1 the decidua surrounded the
ovum in the tube, and was not present in the uterus.
   [We shall endeavor to render the formation of the decidua reflexa, accord-
ing to the views entertained by modern physiologists, somewhat clearer than
does the description given of it by the author.
   When the impregnated ovum is  about to descend into the cavity 'Of the
uterus, the mucous membrane of the  entire body of the latter takes  on an
increased activity of growth and a special development.   It becomes  tume-
fied and more vascular ; and as it increases in thickness, its surface is formed
into rounded, projecting eminences or convolutions.   When the fecundated
ovum passes through the lower orifice of the fallopian tube, it insinuates
itself between the opposed  surfaces of the lining membrane of the  uterus,
and soon  afterwards becomes lodged in  one of  the furrows or depressions
between the above-described projecting  convolutions of the internal thick,
rich, soft,  vascular, velvety lining of the  uterus, which is the decidua vera.
It is at this situation that an adhesion is  subsequently to take place between
the external membranes  of  the ovum on the  one hand, and  the uterine
mucous surface, or decidua, on the other.  At the  point where the ovum
becomes  thus arrested and  entangled, a still more  rapid development than
before takes place in the uterine mucous membrane.   Its projecting folds
begin to grow up around the ovum in such a manner as  partially to enclose
it in a kind of circumvallation of the  uterine membrane, and to shut it off,
more or less completely, from the general cavity of the uterus.   It is thus

           ■ Fig. 56.                                 Fig. 57.
   First stage of the formation of the Decidua          More advanced stage of Decidua reflexa.
 reflexa around the Ovum.

soon contained in a special cavity of its own, which still communicates for
a time with the  general  cavity of the  uterus, by a small  opening,  situated
over its  most prominent portion.   As the growth of the mucous  membrane
around  the ovum  goes  on, this opening becomes gradually smaller, until,
finally, the projecting folds of mucous membrane touch each other and unite,
forming a kind of  cicatrix,  which remains  for a certain time to mark the
situation of the  original  opening.  The ovum has now become completely
enclosed in a distinct cavity of its own, being  everywhere covered with a
decidual layer — an outgrowth of the altered mucous  membrane of the ute-
rus, and by which  it is concealed from view when  the  uterine cavity is laid
open.   This  newly-formed  layer of  decidua, enveloping, as just described,
the projecting portion of the ovum, is called the decidua reflexa, because it
is  reflected over  the ovum by a continuous  growth from the general surface
of the uterine mucous membrane.  It gradually grows larger and larger,  as

1

||PP||
mm?-
1 Med. Gazette, June 5th, 1840. 
UTERO-GESTATION.
119
the ovum becomes developed in size, until, finally, it conies in contact at its
external  surface with the entire mucous coat lining the cavity of the uterus.
   The decidua vera, agreeably to the views  here set  forth, is the  original
mucous membrane lining the surface of the uterus ; while the decidua reflexa
is  a new  formation, which has grown up around the ovum and enclosed it in
a distinct cavity.   For a full exposition of this  subject, we would refer the
reader to Dalton's Human Physiology, page  516 et seq.]
   164. Abnormal deviations.—The decidua occasionally exhibits the effects
of inflammation;  it may be hypertrophied or increased  iu thickness by layers
of adventitious membrane, and pus  has been found on its surface.  In its
substance calcareous depositions and  spiculae of bone may  sometimes be
detected.  It may adhere  firmly to the lining membrane of the uterus, and
persisting after delivery, may constitute the nucleus of a mole, etc.
   165. We have  seen that, on  leaving the ovary, the ovum is received into
the fallopian tube ; that  its  further  transmission is  effected by muscular
motion and  the  ciliary movements of the villi  of the mucous membrane;
and that there is reason to believe (judging from the ovum  of the rabbit)
that in its passage through the tube,  an additional covering is developed.
   It is difficult to determine the period (even if it be regular) at which the
ovum arrives in the uterus.  One thing  appears certain ; that several days
elapse from  the  moment  of  impregnation.   One of  the earliest ova on
record is that described  by M. Yelpeau (fig. 58, natural size ;  fig. 59, opened
and magnified),  which could not have been more than fourteen days old,
unless the midwife who gave  it to him, and who was herself the subject of
the  miscarriage, deceived him ;  and she appears to have had no reason for
so doing.1

               Fig. 58.                              Fig. 59.
        Human Ovum of two weeks.            Human Ovum of two weeks, laid open.

   166.  When the ovum arrives at the uterus,  it consists of two membranes,
the chorion and amnion ; in the interspace between which is contained the
vesicida alba or umbilicalis, and a gelatinous substance — the tunica media
of Bischoff.  Internal to the amnion, we find  the  liquor amnii,  and the
embri/o.  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 extremities.  The
interspaces are larger and more smooth.   About the beginning of the second
month the villi divide into branches,  which  arise from  short thin stems, and
terminate either in thin filiform  or vesicular enlargements.   The process of

  1 Dr. Allen Thompson has given an excellent notice of early ova, observed by himself
and others, in the Ediu. Med.  and Surg. Journal, vol. lii. p. 119, to which I beg to refer
the reader.
 
120
UTERO-GESTATION.
obliteration thus commenced, continues until no villi remain, except  at that
part of the chorion  which is in contact with the uterus ; the other part pre-
senting the appearance of a thin, colorless, transparent membrane.
  The umbilical cord is inserted into some part of  the  inner surface of the
chorion, and the part of the outer surface which corresponds to this inser-
tion, is always that which  comes in contact with the uterine parietes, and
upon which the placenta is formed.
  The chorion may be  divided into two lamina?, especially where it covers
the placenta;  the outer is called the exochorion,  the inner the endochorion,
by Burdach, who believed  the latter to be  the vascular layer of the allan-
tois.  From the endochorion, according to Bischoff, are derived  the vessels
which run to the villi.   The chorion itself appears to  be destitute of  ves-
sels, unless, as Dr. \V. Hunter suggested, we regard  as such the white  fila-
ments observed near the  edge  of the placenta.   The intimate structure of
the membrane is cellular, and in many places bears a strong resemblance to
that of vegetables,  each cell containing a distinct nucleus ; the villi  partici-
pate in the same texture, but their cells are filled  with a granular matter.
   The strength of the  membrane is  greatest in  early ova; at the termina-
tion of pregnancy it is considerably weaker than the amnion : at an early
period it is equally strong in  all parts, but afterwards it is  stronger near
the placenta.   It is covered externally by the decidua reflexa, and internally
it is separated from the amnion by a layer of gelatinous matter,  which is
afterwards condensed  into a thin membrane, called tunica media by Bischoff,
who first described  it.
   168. Abnormal  deviations.—Inflammation  may attack  the  membrane,
giving rise to vascularity, opacity, thickening,1 or  the  effusion  of fluid be-
tween it, and the amnion.   Occasionally false membranes are deposited upon
it, and the villi may be the seat of hydatids.  Dr. Montgomery has a prepa-
ration in his  museum, in which the cord  is inserted into the part of the
chorion covered by the decidua reflexa, instead of into  that attached to the
uterus.   The  foetus, of course, perished for want of nourishment.  Hemor-
rhage sometimes occurs into the space between the chorion and amnion.
   169.  I have already mentioned that during the first months  of gestation,
an albuminous or gelatinous mass  of  varying consistency is found  between
the  chorion and amnion.   It  is often mixed with flocculi, or threads, and
occasionally presents  a reticulated appearance.  " When put into spirits,"
Wagner observes, " this mass assumes the appearance of the cellular tissue
that is found between the muscles, and seems, in fact, to bear the same rela-
tion to the amnion  and the chorion as the intermuscular  cellular membrane
does to  the fasciculi between  which it lies."  The space it occupies is, in
early ova, considerable, but it  gradually diminishes  as  the  two  membranes
approximate,  and  in  proportion the interposed matter  is condensed into an
extremely delicate  membrane,  like the arachnoid, termed by Bischoff and
Wagner the tunica media.  By Yelpeau it is called the "corps reticulare,"
and he considers it to be the allantois; but this opinion is rejected by other
physiologists.
   170.  The Yesicula Alba, or umbilical vesicle (fig. 63), is also contained
in  the interspace  between  the amnion and chorion.  According to modern
investigations, it is constantly present as a normal formation in the earlier
months of gestation, and is connected  with the intestinal canal of the foetus.
It is, in fact, the vitellus,  surrounded by the blastoderma, upon which the
embryo is 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
1 Dr. Montgomery, Dub. Hosp. Gaz., March 15, 1857. 
UTERO-GESTATION.
121
form, and lying upon the intestine, with which it communicates.  In a short
time, however, the  inner end becomes narrow, and forms a pervious canal,
or duct, through  which its contents may be transmitted.  M Yelpeau found
it pervious in almost every  ovum of six weeks old that he  examined ; and
he states that he not only saw vitellary matter in the intestine, but that he
could push  the fluid from the vesicle through the duct into the intestine.
The length of the duct varies in different ova, and its calibre diminishes  as
gestation advances,  until, in the second month, it is impervious and thread-
like, but may still be traced to the  loop of intestine contained in the sheath
of the umbilical cord.   The vesicle contains a yellowish-white or yelk-colored
fluid, in which numerous  globules  are  suspended.   Its parietes consist  of
two lamina?, an  external vascular,  and  an internal mucous layer.   It  pos-
sesses two  vessels, the omphalo-mesenteric  artery and vein,  which ramify
upon its  surface and on the duct.  As  gestation advances, the vesicle is
emptied,  shrinks, and remains flat  and  collapsed  to the  termination  of
pregnancy.
   Its use is evidently to contain nutriment for the foetus, before the develop-
ment of the placenta.
   171.  The Amnion (fig. 63). — In  the  quotation from Dr. Barry's paper
(§ 146) descriptive of the changes which take place in the ovum after im-
pregnation, it will be remembered that the amnion was stated to be formed
by the  coalescing of the layer of small vesicles formed on the inner surface
of the membrane which invests the yelk, with the "mulberry-like structure
formed in the centre of the yelk, but passing to its circumference." M. Coste
calls the  amnion a  "true epidermis of the blastoderma," and states that it
is detached from the external surface of the embryonic spot.  The membrane
thus  formed envelopes the  embryo very  closely at an early period, and is
continuous with the common integument of the foetus, at the open abdominal
parietes.   At a  later period, it is distended with fluid,  and so separated
from the foetus;  and after being reflected upon the funis, of which it forms
the outer coat, it terminates at the  umbilicus.  In the progress of gestation,
the amnion approaches the  chorion, until, at last, it is in  contact with  it or
rather  with the  tunica media.  It is thin and transparent, but of a firm
texture, resisting laceration much  more  than the other  membranes.   Its
external surface  is somewhat flocculent, but internally it is quite  smooth,
like serous membrane, and  like it, secretes  a bland fluid.   Neither vessels
nor nerves can be demonstrated in the  amnion in  a state  of health, though
it may be presumed to possess  them.
   172.  Abnormal deviations. — The researches of M. Mercier have estab-
lished the fact that this  membrane may be  the seat of inflammation, and
that in such  cases  it becomes vascular, and secretes a  disproportionate
quantity of fluid.  It is not quite certain whether its quality is changed
from  diseased action.  The membrane may also  become  thickened  and
opaque.
   173.  The  Placenta. —Let us  now consider the  chorion at a more ad
vanced  period of gestation, and we shall find that a new organ has  been
developed  on that  part of  it  which  is in contact with the uterus.   This
organ was first called the placenta, I believe, by Fallopius ; it is a spongy
vascular mass, existing in some form  in all mammalia, as an appendage  of
the chorion.  It  is of considerable size at the termination of utero-gesta-
tion, its diameter being six  or eight inches, its circumference eighteen  or
twenty-four, and  its thickness from  one  inch to one and a half.   In general
it is of a  rounded  or oval form.   Internally, its surface  is smooth  and
shining, from  its  being covered by the  chorion and amnion, beneath which
the radiations of the  umbilical vessels may  be discovered.  The chorion,
which covers its inner surface immediately, is  firmly attached to it, and sends 
122
UTERO-GESTATION.
processes between its lobes  and lobules, whilst the amnion, lying over the
chorion,  is  but loosely attached.   The outer  or uterine surface,  if the
placenta be "in situ"  or  removed carefully, is  uniform and  level, though
not  exactly smooth, being covered  by the  decidua serotina;  if this be
peeled off, the lobes and  lobules  into  which the placenta is divided, are
evident, and we find  processes of  the decidua  serotina, entering these di-
visions.  The vessels  of one lobe have very rarely any direct communication
with those of another.
                                 Fig. 60.
Placenta and Cord.
   174. As to the formation of the placenta, we  observed that the villi of
 the  chorion diminish  gradually in number, and finally disappear from every
 part of its surface, except where it is in contact with the uterus  at which
 part they become, as it were, concentrated, and grow with great luxuriance
 in consequence of the development within them of vessels derived  from the
 inner layer of the chorion  (the endochorion), or from between the two layers
 lhese vessels go on enlarging and multiplying, interlacing and anastomosing
 wjtb *ach °thf > until they> with their connecting (or separating) sheaths
 of villi or decidua serotina, form the mass of the placenta.  The vessels are
 divided into arterial and venous  branches.   The  two umbilical arteries at
 their insertion into the internal surface of the placenta, divide and subdiv'ide
 ^V^    ^.bra,ncheS'  Which' Plun£ing ^to 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  mav
 be doubted whether the placenta is supplied with nerves, but it  is pretty
 certain that it possesses lymphatics.                                 v   y

rS-7*Q -\vmatT °f+the placenta commerices 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."1]

  i [Carpenter's Human Physiology, p. 603.  For a very clear account of the  formation
oW^^l           ^^ * ^ Dalt°n'S " ^^ °D H-an Sysl- 
UTERO-GESTATION.                       123

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

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

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

  1 Edin.  Med. and Surg. Journal, vol. xlv. p. 265.          «Ibid., vol. Ixxii. p. 50.
  3 Prov.  Med. and Surg. Journal, May 30th, ] 849.
  * On Fatty Degeneration of the Placenta, etc., Med.-Chir. Ti-ans., vols, xxxiv. and xxxvi.
  5 Microscopical Anatomy.       6 Med. Times and Gazette, Oct. 30th, 1852, p. 432.
  * Med.-Chir. Trans., vol. xxxvi. p. 99. 
UTERO-GESTATION.
127
eration, just as the small vessels of the  lungs or other parts.   Dr. Hassall
observes that " in the placenta affected with fatty degeneration, certain of
the lobes,  in place of presenting  the red spongy texture of healthy tissue,
exhibit a  fatty appearance, and are of a yellow color, glistening,  firm,  and
exsanguine, while the remaining lobes present their ordinary characters, at
least  to the unaided  eye."  The minute  alterations  which he  has detected
are as follows : " 1.  We observe that the villi are thickly studded with innu-
merable  spherules of oil.  2.  The chorion is much  altered, it is  thickened
and destitute of nuclaei.  3. The walls of the vessel no longer contain nuclei;
these having, in  all  probability, become degenerated into spherules of oil.
4. The spherules of oil are contained, some in the chorion, some in the walls
of  the  blood-vessels, and many in the intervals or spaces between  them.
5. The cavities of the vessels  are  almost invariably free  from fatty deposi-
tion.   6.  The vessels are destitute of blood."   No  doubt that so far as  it
extends, this change is destructive to the functions of the organ; but it does
not follow that the remaining healthy portion may not be  adequate to the
complete nutrition of the foetus.  Mr. Barlow remarks very justly,  that pla-
cental apoplexy may  be owing to this fatty degeneration of the vessels.   Dr.
Druitt and others  regard this change  as "a natural rather than  a morbid
process; that it  is in fact the mode of death of  a temporary  organ, whose
functions are about to terminate.
   5.  It may be the seat of cartilaginous or calcareous degeneration, or of
other morbid products.
   6.  It may give rise to hydatids.
   181.  The Umbilical Curd, funis or navel-string, is the connecting link
between the foetus  and placenta (fig. 60), terminating with the functions of
the latter  at birth.   It is visible at the earliest period of pregnancy.   It
arises from the centre of the placenta most frequently, but occasionally from
its edge (battledore placenta), and  is formed by  the umbilical arteries and
vein,  embedded in  (the Whartonian) gelatine, and enclosed within a sheath
of the chorion internally, and  of the amnion externally.   Besides the vessels,
it contains the  duct of the umbilical vesicle  and the urachus,  the omphalo-
mesenteric vessels, and, at an  early period, the fcetal intestines at its fcetal
extremity.   At first,  the cord  is thin and cylindrical, the vessels  running a
straight course through it; from the third to the ninth week, it appears to
be divided by two  or three vesicular swellings, which ultimately disappear.
After this  time, the  vessels  run in a spiral  form, the arteries around  the
vein,  from left to right, and form in their course  a number of small loops or
knots.  The vein has no valves, and its calibre is equal to that of both the
arteries.   The cord is also supplied with lymphatics, as has been proved by
the injections of Fohmann and Montgomery.   It is probable, though not as
yet demonstrated, that it may possess nerves also.
   The length of the cord varies much ;  it is  very rarely less than eight
inches, though  such cases are  on record, and it is  sometimes five  or six feet
long.   Out of 500 cases, selected from the writings of Osiander, Adelmann,
and Henne, with some additional measurements  of my own, I  find the most
common length to be eighteen inches; none  were under twelve, nor above
fifty-four inches.  Dr. Storer  has  found the most common length to be two
feet;  next, twenty-six inches ; next, twenty-three inches ; the shortest was
four and a half inches, and the  longest forty-three.   Dr.  G. Thompson,  of
Boston,1 mentions one of five feet nine inches; Mr.  Rouse one of fifty-one
and a half inches, which was  coiled six  times round the  neck;2  and Dr.
Tyler Smith, one of fifty-nine and a half inches.

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

  1 [London Lancet, June 4,  1842.      « Provincial Medical Journal, Aug  6 1852 1
  3 Med. Times and Gazette,  July 18, 1857.                             '    "J
  * Lee's Lectures on Midwifery, p. 121. 
UTERO-GESTATION.
129
 of the  mucous layer which is closing to form the intestine, as a growth  of
 the intestine, which proceeds very rapidly.   It  passes out where the ventral
 laminae are still unclosed, in the region of the  umbilicus, and in birds and
 mammalia  reaches  either  mediately or immediately the inner surface of the
 exochorion.  By the constriction of the navel  it is separated into two por-
 tions, which communicate ; that within the body of the embryo is the saccu-
 lated urinary bladder, with  the urachus or tube  of  communication.   It
 receives its vessels from the hypogastric, which  are spread out as a vascular
 layer, especially upon that portion of its surface which faces the exochorion.
 According  to Burdach (as we  have seen) the  vessels form a distinct layer,
 the endochorion."  I have preferred quoting this concise description from an
 article in the Brit, and For. Med. Review, as giving a good account of the
 opinions held by most recent physiologists, to  embarrassing the reader by
 a detail of the different hypotheses which have been  broached upon  the
 subject.
    184.  The Liquor Amnii is the name given  to the  fluid  secreted by the
 amnion, and contained in its cavity.  At first, it is  small  in quantity, clear
 and  transparent;   but  afterwards it increases in  quantity, and becomes
 slightly opaline.  Dr. G. 0. Rees has published in No. 6  of Guy's Hospital
 Reports,' an analysis  of some  amniotic fluid which  he obtained in  a case
 where premature labor was induced.  He found its specific  gravity 10086,
.and in  1000 parts it contained
        Of water.........983-4
        Of albumen, with traces of fatty matter   .    .    .     5 9
        Albuminate  of soda, chloride of sodium   ...     6*1
        Animal extractive, soluble in water and  alcohol, urea,
          chloride of sodium     ......     4-6
        With traces  of alkaline  sulphate.
 Towards the end of gestation the albumen diminishes.
   Professor Scherer  has  published an analysis of liquor amnii at the fifth
 month  of gestation, and at the  full time as follows : —
                           At five months.                 At nine months.
        Water    .     .     .   97584    ....  991-474
        Solids    .     .     .    24-16    ....    8526
       Albumen .    • .    .     7 67    .    .     .     .     0-82
       Extractive     .    .     7 24         .     .     .     0-60
       Salts     .     .    .     9-25    .    .     .     .     7- 061
  The amount at the full time varies from half a pint to several quarts; but
the average quantity is  about  a pound.   The fluid is usually stated, and I
believe truly,  to be a secretion from the inner surface of the amnion : but
Meckel attributes it to the maternal vessels, especially in the earlier months.
  The uses of the  liquor amnii are very intelligible and important: 1, it is
probable that it serves for nutriment to the foetus,  at least during the early
months : 2, it preserves an equable  temperature  for it,  during its intra-
uterine life ; 3, it diminishes the impression from sudden movements, shocks,
etc., and thereby prevents injury: 4,  during labor it protrudes the mem-
branes, and is the primary agent in dilating the os uteri.
  185.  Abnormal deviations—It  maybe very scanty, or, in the opposite
extreme, excessive.   The latter deviation from its natural state is probably
the result  of  inflammation, and occasions some mechanical inconveniences
to the  mother, and  risk to the child during gestation, whilst at the time of
labor it seems to enfeeble the uterus during the first stage.  The quality of
     1 Medical Times, Aug.  7th, 1351, from Schmidt's Jahrbucher, vol. lxvii. p. 7.
       9 
130
UTERO-GESTAT.ON.
the fluid may be changed, though it rarely decomposes.   Its color is some^
times yellow or brown.
   186.  The Embryo.1 — If the reader will take the trouble to turn back to
§ 146, he will  find that, in the quotation from  Dr. Barry,  the last change
there described as occurring after impregnation, was the disappearance of
the germ vesicle.  When the  vesicle bursts in the  hen's egg,  the formation
of the germ-membrane, or blasloderma commences, according to  Purkinje,
and it is completed by the fifth day, according to Yon Baer.   In mammalia,
however, it appears  to exist previous to the bursting or disappearance of
the vesicle: at least it is visible immediately the vitellus becomes transpa-
rent after that occurrence.  Between this membrane and the chorion there
is  a thin layer of albumen, and at some point we find  an  aggregation of
granules, forming the  cumulus of the blastoderma.   It  is at this part  that
the embryo is developed, lying as it were upon the membrane.   The form of
the germinal membrane gradually changes, becoming more oval. It consists
of three superimposed laminae or layers,  at least at the central point or
cumulus;  and upon  this separation into  layers rests the modern theory of
development,  as  first  proposed by Dollinger and  Pander,  and afterwards
illustrated by Yon Baer, Rathke, Burdach, etc.  etc.  "Above, and most ex-
tended," says the author of the very able  article in the Brit, and For. Med.
Review, from whom I have already quoted, "is  the serous layer ; below and
least extended is-the mucous: between the two, and later in its appearance,-
is  the vascular layer.  In one or other of these, as distinct  primitive forms,
there lies concealed  that which is essential, in  the different organs and tis-
sues of which the body is composed, and in virtue of which they admit of
being referred to distinct  original groups.   On the serous layer,  arise the
organs  of  animal life — the brain and  spinal cord, organs of sense, skin,
muscle,  tendons, ligaments, cartilage,  bone ; on the mucous, the organs of
vegetative life, the intestinal canal, lungs, liver, spleen, pancreas, and other
glands.   The heart and vascular system arise from  the vascular layer, if this
is  to be considered  as a separate one.   To which division the generative
system is to be primarily referred,  is  still  undetermined."  This is the view
generally accredited, but Dr. Barry seems to think it doubtful.   He has not
observed this  "splitting of the germinal membrane," nor does he conceive
that the membranous layers originate  the embryo, but the reverse : that the
" previously-existing germ, by means of a hollow process, originates a struc-
ture having the appearance of a membrane."
   In the centre of the blastoderma, where it is supposed to divide into the
serous and mucous layers, there is observed a clear space, the area proligera
or pellucida, in the centre of which and in the transverse axis of the vitellus,
there is a mass of globules, loosely connected together,  forming the primi-
tive streak or trace of Yon Baer, and around this the area vasculosa is
developed.  I  may mention that  these changes have been observed  in the
ova of  different mammalia, as well as in  the egg ;  and there is every  pro-
bability that the human ovum  undergoes  identical mutations.
   The  appearance of the  primitive  trace is observed in eggs  at  about the
fourteenth  hour of incubation, and in the  human ovum may probably be
referred to the second or third week.
   To proceed with the next changes: " The globules of the  primitive streak
seem next to be resolved, and  then there  is a change of appearances.  On
the sides of the streak are two laminae dorsales, which bound a median fur-
row ; and below  this furrow is the chorda dorsalis, which is the axis of the

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

              [Fig. 62.]
 Diagram of an early Human Ovum, showing the
Amnion in process of formation, and the Allantois be-
ginning to appear:—a, chorion ; b, vitelline mass sur-
rounded by the blastodermic vesicle; c, embryo; d,e,
and /, external and internal folds of the serous layer,
forming the amnion; g, incipient allantois.
5%uIu5&>3S>"
for opportunities of observation ; but there is no doubt that the same pro-
cess takes place in the human  ovum.   Professor Wagner has  given a de-
scription of a  human ovum of about three weeks old, part of which I shall
take the liberty of  quoting : " Such ova, still surrounded by decidua, mea-
sure about seven  lines in length ;  in the  naked chorion, they are  about
five  lines  long.  The chorion  at  this time is  beset externally with small
cylindrical hollow villi.  The embryo itself  is two lines long.   It is plainly
surrounded by  an amnion,  which lies loosely, but still pretty closely about it,
and obviously proceeds from the  abdominal laminae.  The embryo is curved,
and presents anterior cerebral vesicles or hemispheres, pretty well developed
(figured rather large in figs. 63, 64J, and considerable corpora quadrigemina
Fig. 63.
Fig. 64.
                        Human Ovum of about three weeks.

immediately behind them ;  there is the distinct appearance of an eye, and a
rounded offset from  the  medulla oblongata indicates the  acoustic  vesicle;
several branchial arteries and fissures are also conspicuous, the last of them,
however  not completely formed.   The  oral aperture is just above the upper
branchial fissure.   The anterior and  posterior extremities  are curved leaf-
like processes, still of very small dimensions."  The abdomen is yet an open
cleft, in which, but projecting beyond it, is the heart, " of very laro-e  relative
dimensions,  and consisting  of  a simple atrium, or  auricle,  and  ventricle;
behind the  heart is  the  liver,  and  under the liver the intestine, which  is
attached  by means of  a  distinct mesentery."  Where the large and small
intestines meet, the canal makes a sweep in  the umbilical vesicle.   On either
side of the  mesenteric  lamina, we find the primordial kidney, composed of
short caeca.   The  allantois  is  seen  extending from the lower part  of the
intestine.                                                      x 
UTER<\  GESTATION.                      133
  190. During the second month, we find the extremities  larger and more
projecting;  the body curved, the  head disproportionately large, and  bent
downwards,  indications of the nostrils, and a gaping  oral aperture.   The
abdomen is  closed  about the  fifth week, except at the  umbilical aperture.
through which a loop of intestine  still escapes.   The os coccygis resembles
a tail, bent forward, and of considerable size.
Fig. 65.                                 Fig. 66.
Human Ovum of about two months.
   The forehead is more vaulted, because of the development of the  hemi-
spheres of the brain ; the spinal cord is cylindrical, of nearly uniform  thick-
ness, and  terminating in a blunt extremity ; posteriorly it is open.   " The
medulla oblongata makes a bend  forwards at the top of the neck, and then
ascends perpendicularly into the capacious  cranium,  where the  corpora
quadrigemina present themselves, as two large semi-globular masses, having
behind  them a  pair of narrow lateral  laminae,  the  rudiments of the cere-
bellum.   The medullary stem, or crus  cerebri, passes under the corpora
quadrigemina, and again bending downwards, the corpora striata and optic
thalami are evolved upon it."
   The first points of ossification  appear about the seventh week, in the cla-
vicle and  lower jaw ;  the vertebral arches are not yet closed in, and the ribs
appear like little streaks.  The only trace of muscular fibre is  in the dia-
phragm.   The heart at this time begins to change  its  form, and the inter-
ventricular septum to form.   The  liver is very  large and  granular.   The
stomach is assuming somewhat of its normal form;  the urinary bladder is
enclosed, but the anus is imperforate.
   After this period, the different parts are developed with tolerable rapidity:
the separate  portions  of the brain are evolved, and the  organs of sense
acquire their external characters ;  the  eyelids,  nose, and ears are formed.
About the seventh  month,  the membrana  pupillaris is ruptured,  and  the
pupil becomes visible.   The cranium continues  cartilaginous for some time,
then points of ossification are seen,  which radiate until each bone is  nearly
complete.
   The  upper and lower extremities  increase, the hands  and feet are deve-
loped ; the fingers  and toes  separate, and the nails become distinct  about
the sixth or seventh month.
   In front of the coccyx »ve  find the  anus, which  at first is imperforate ; and 
134
UTERO-GESTATION
anterior to it, the organs of generation, in form at first of a conicle tubercle,
which is subsequently developed  into the penis or clitoris, while the skin at

                                Fig. 67.
                       Human Ovum of about three raonths.

the sides is prolonged into the scrotum or labia.   The testes are originally
placed on each side of the vertebral column, but afterwards descend  along
the iliac vessels to the inguinal ring, through which they pass, carrying with
them a portion of the peritoneum to form their tunica vaginalis.
   The liver and kidneys are completed before the termination of pregnancy,
and soon commence the performance of their functions ; for the meconium is
found to  be colored by the bile even in premature children, and urine is fre-
quently voided during delivery.
   [The formation of the ovum, and the development of the  embryo, are
among the  most incomprehensible  subjects  to a student;  at the risk, there-
fore, of some repetition of what is said  upon these points by the author, I
here introduce the following quotation, with the accompanying, illustrations,
from Dr.Rigby's work on Midwifery, in which  the subjects are very clearly
and concisely treated :
   "Embryo. — There  is,  perhaps, no department of physiology which has
been so remarkably enriched by recent discoveries, as that which relates to
the primitive development of the ovum and  its  embryo.  The  researches of
Baer, Rathke, Purkinje, Yalentin,  etc., in  Germany;  of Dutrochet, Paevost,
Dumas, and Coste, etc., in France ;  and of Owen, Sharpey, Allen Thompson,
Jones, and Martin Barry, in England, but more especially those of the cele-
brated Baer, have greatly advanced our  knowledge of these  subjects, and
led us deeply into those mysterious processes of nature which  relate to our
first origin and formation.
   "These  researches  have all tended to establish  one  great law, connected
with the  early development of the human embryo, and that of other mammi-
ferous animals, viz., that it at first possesses a structure and  arrangement
analogous to that of animals in a much lower scale of formation ;  this obser-
vation also  applies of course to the  ovum itself, since a variety of changes
take place  in it after impregnation, before a trace  of the embryo can^be
detected.
   "At the earliest periods, the human ovum bears a perfect analoffv to the
eggs  of  fishes, amphibia, and birds : and it is only by carefully examining 
UTERO-GESTATION.                      135
 the changes  produced by impregnation in the ova of these lower classes of
 animals, that we have been enabled to discover them in the mammalia  and
 human subject.
    "As  the bird's  egg, from its  size, best affords  us the  means of investi-
 gating these  changes, and as in all essential respects they are the same in the
 human  ovum, it will be  necessary for us  to  lay before  our readers a short
. account of its  structure and contents, and also of the  changes which they
 undergo, after impregnation.  In doing this we  shall  merely confine our-
 selves to the description of what is applicable to the human ovum.
    " The egg is  known to  consist of two distinct  parts, the vitellus or yelk
 surrounded by its albumen or white; to the former of these we  now more

                 Fig- 68.                              Fig. 69.
 Section of a Hen's Egg within the Ovary.—
a. The granulary membrane forming the peri-
phery of the yelk. b. Vesicle of Purkinje em-
bedded in the cumulus,  c. Vitellary membrane.
d. Inner and outer layers of the capsule of ovum.
e. Indusium of the ovary.
 particularly refer.   The yelk is a granular albuminous fluid, contained in a
 granular membranous sac (the blastodermic membrane), which is covered by
 an investing  membrane called the vitelline membrane or yelk-bag.   The
 impregnated vitellus is  retained in its capsule  in the ovary precisely as the
 ovum of the mammifera is in the Graafian vesicle.   The whole ovary in this
 case has a clustered appearance, like a bunch of grapes, each capsule being
 suspended by a short pedicle of indusium.
   " In those ova which  are considerably developed before  impregnation, the
 granular blastodermic membrane is observed to be thicker, and the granules
 more aggregated at that part which corresponds to the pedicle, forming a
 slight  elevation with a depression  in its centre, like the cumulus in the  pro-
 ligerous disc of a Graafian  vesicle.   This little disc is the blastoderma,  ger-
 minal membrane, or cicatricula; in the  central  depression  just mentioned is
 an exceedingly minute vesicle, first noticed by Professor Purkinje of Breslau,
 and named after him : in more correct language it is the germinal vesicle.
   "According to Wagner,  the germinal vesicle is not  surrounded by a  disc
 before impregnation ; and  it is only after this process that the above-men-
 tioned disc of granules is formed.   By  the time the ovum is about  to  quit
 the ovary the vesicle itself has disappeared, so that an  ovum has never been
 found in the oviduct containing a germinal  vesicle, nothing remaining of it
 beyond the little depression in the  cumulus of the cicatricula.
   " The rupture of the  Purkinjean or germinal vesicle has been supposed
by Mr.  T.  W.  Jones to  take place before impregnation ;  but the observa-
tions of  Professor Yalentin seem to lead to the inference that it is a result
o'  that process, and must be therefore  looked  upon as one of the  earliest 
J3G
UTERO-GESTATION.
changes  which take  place in the  ovum  or yelk-bag  upon quitting the
ovary.1
  " During its passing through the oviduct (what in mammalia is called the
fallopian tube), the ovum  receives a thick covering of albumen, and  as  it
descends still farther along the canal the membrane of the shell is formed.
  " On examining the appearance of the ovum in mammiferous animals, and
especially  the human ovum, it will be found that  it presents a form and
structure very analogous to the ova just described, more especially 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 Yalentin, who considered that 'the enormous swelling of the ova, and
their passage through the fallopian tubes,' tended to prove the circumstance.2
It has since been demonstrated by Mr. T. W. Jones in a rabbit seven days
after  impregnation.   The  vitellary membrane seems, at this time, to give
way, leaving the vitellus of the ovum merely covered by its spherical blasto-
derma, and encased by the layer of albuminous  matter which surrounds it.
  " From what we have now stated, a  close analogy will appear between the
ova of the mammalia and those of the lower classes, more especially birds,
which from their size  affords us the best opportunities  of investigating this
difficult subject.
  "In birds,  the covering of the  vitellus  is called  yelk-bag;  whereas, in
mammalia and nfan 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 be-
comes covered with  a complete down  of little absorbing  fibrillae,  which
rapidly increase in size as development advances, until it presents that tufted
vascular appearance,  which we have already mentioned when describing this
membrane.
  " The first or primitive .Jrace of the embryo is  in the  cicatricula or ger-
minal membrane, which contained the  germinal  vesicle before its disappear-

               Fig. 70.
a rice.   In the centre  of this, upon its upper surface, may be discovered a
small  dark line :3 ' this line or primitive trace is swollen at one extremity, and
is placed in the direction of the transverse axis of the egg.'

  1 [We said, "one of the earliest changes."  Mr. Jones considers that "the breaking
np of the surface of the yelk into crystalline forms," is the first change which he has
observed ]
  2 [Edin. Med. and Surg. Journ., April, 1836.]
  3 [Allen Thompson on the Development of the Vascular System in the Foetus of Ver-
tebmted Animals.  (Edin. New Philosoph. Journ., Oct.  1830.)]
 Changes in the Hen's Egg during
Incubation. — a. Transparent  area.
6. Primitive trace. 
UTERO-GESTATION.
137
  " As development advances, the cicatricula expands.   'We are indebted
to Pander,'1 says Dr. Allen Thompson in his admirable essay above quoted,
' for the important discovery, that towards the twelfth  or  fourteenth hour,
in the hen's egg the germinal membrane becomes divided into two layers of
granules, the serous and mucous layers of the cicatricula ; and that the rudi-
mentary trace  of the  embryo, which  has  at this  time become  evident,  is
placed in  the subtance  of the uppermost or serous layer.'   'According to
this observer, and according to Baer,  the part of this layer which surrounds
the primitive trace soon becomes thicker;  and on examining this part  with
care, towards the eighteenth hour, we  observe that a furrow has been formed
in it, in the bottom of which  the  primitive trace  is  situated ; about the
twentieth hour this furrow is converted into  a canal open  at both  ends, by
the junction of its margins (the plica? primitives of Pander, the laminae
dorsales of Baer) : the canal soon becomes closed at the cephalic or swollen
extremity of the primitive trace,  at which part it  is  of a pyriform  shape,
being wider here than at any other  part.   According to Baer and Serres,

                                 Fig. 71.
   Changes in the Hen's Egg during Incubation.—a. Transparent area.  b. Lamina? 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.

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

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

                 Fig. 72.

                    ____   a
 Changes in the Hen's Egg during Incu-
bation.—a. Serous layer,  b, c. Vascular
layer, d. Mucous layer, e. Heart.
because in it the development of the principal parts  of the vascular system
appears to  take  place.  The third, called the mucous  layer, situated next
the substance of the yelk, is generally in intimate connection with the vascu-
lar layer, and it is to the changes which these combined layers undergo, that
the intestinal, the respiratory, and probably also the glandular systems, owe
their origin.'1
   " The embryo is therefore formed in the layers of the germinal membrane,
and becomes,  as  it were, spread out  upon  the surface of the  ovum ;  the
changes which the ovum of mammalia undergoes appear, from actual obser-
vation,  to be precisely analogous to those in  the inferior animals.   {Baer,
Prevost, and Dumas.)  From the primitive trace, which was at first merely
a line crossing the cicatricula, and which now begins rapidly to  exhibit the
characters  of the spinal column, the parietes  of the head and trunk gradually
approach farther and farther towards  the anterior surface  of the abdomen
and head until they unite ;  in this wTay the  sides of the jaws  close  in the
median line of the face, occasionally leaving the union incomplete, and thus
appearing  to produce in some cases the  congenital defects  of  hair-lip and
cleft palate.  In  some way the ribs  meet  at the sternum ; and it may be sup-
posed that sometimes this bone is left deficient, and thus may become one of
the causes  of  those  rare cases of malformation, where the child has been
born with the heart external to the parietes of the thorax.   In like manner
the parietes of the abdomen and pelvis close in the linea alba and symphysis
pubis,  occasionally leaving the  integuments  of the navel deficient, or, in
other words, producing congenital  umbilical hernia, or at the pubes a non-
union of its symphysis with a species  of inversion of the bladder, the ante-
rior wall of that  viscus being nearly or entirely  wanting.
   " The cavity of the abdomen is therefore  at first open to the vesicula um-
bilicalis or yelk, but this changes as the abdominal parietes begin  to close
in ;  in  man and the mammalia merely  a part of it,  as above mentioned,
forms the intestinal canal, whereas, in oviparous animals, the whole of the
yelk-bag enters the abdominal cavity,  and serves for an early nutriment to
the young  animal.   Another change connected with  the serous  or outer
layer of the germinal membrane  is the formation of the amnion.   The fcetal
rudiment, which  from its shape has been called  carina, now begins to be
enveloped  by a membrane  of exceeding  tenuity, forming a double  covering
upon it; the one which immediately invests  the fcetus is considered to form
1 [A. Thompson, op. cit., 298.] 
UTERO-GESTATION.
139
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, etc.,
are forming on the anterior surface of the  embryo,  which is turned towards
the ovum,  by means of the inner or mucous layer, equally important changes
are now observed in the middle or vascular layer.   'In forming this fold,'
says Dr. A. Thompson, ' the mucous layer is reflected farthest inwards ; the
serous layer advances least, and the  space between them, occupied  by the
vascular layer, is  filled up by a dilated part of this layer, the rudiment  of
the heart.'1

                                                          Fig. 73.


 Vesicula Umbilicalis, from Baer.—6. Is a portion of the convexity of the
amnion, upon which at a, is the fundus of the diminutive human allantois.
 c. The duct of the vesicula umbilicalis, dividing into two intestinal portions;
and besides this duct are two vessels which are distributed upon the vesicula
umbilicalis, and form a reticular anastomosis with each other.
    " Whilst this rudimentary trace of the vascular system  is making its ap-
  pearance, minute  vessels are seen ramifying over the vesicula umbilicalis,
  forming, according to  Baer's  observations, a reticular anastomosis, which
  unites into two vessels the vasa omphalo-meseraica.2   These may be demon-
  strated with great ease in the chick : the cicatricula  increases in extent;  it
  becomes vascular, and  at  length  forms a heart-shaped network of delicate
  vessels,  which unite into two trunks, terminating  one on  each side  of the
  abdomen.
    " The umbilical vesicle now begins to separate itself more and more from
  the abdomen of the foetus, 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 urachus; from its sausage-like shape, it has received
  the name of allantois.
    " The existence of an allantois in the human embryo  has been long in-
  ferred from the presence of a ligamentous cord  extending from the fundus
  of the bladder to the umbilicus, like the urachus in animals.   But from the
v  extreme delicacy of the allantois, and  from its  function ceasing at  a very
  early period,  it had defied all research,  until lately, when it has been satis-
  factorily demonstrated in the human embryo by Baer and Rathke.   It oc-
  cupies the space between the chorion and amnion, and gives  rise  occasion-
  ally to a collection of  fluid between these  membranes, familiarly known by
  the  name of the liquor amnii spurius, which, strictly  speaking, is the liquor
  allantoidis.
1 [Op. cit., p. 301.
8 F titish and Foreign Med. Rev. No. 1.] 
140
UTERO-GESTATION.
  " The function of the allantois is  still in a great measure unknown.   In
animals it evidently acts as a species of receptaculum urinae during the latter
periods of gestation;  but it is very doubtful if this be its  u#e 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 tht
albuminous contents of the vitellus, or vesicula umbilicalis, and afterwards
by the absorbing radicles of  the chorion ; but, from, analogy with the struc-
ture of the  lower classes of animals, it  would appear  that it is  intended to
produce certain  changes  in  the rudimentary circulation of  the  embryo,
similar to those which, at a later period of pregnancy, are effected by means
of the  placenta, and after birth, by the lungs, constituting the great functions
of respiration.
  " In many of the lower classes of animals,  respiration (or at  least the
functions  analogous to it) is  performed  by organs  situated at the inferior or
caudal extremity of the animal:  thus, for instance, certain insect tribes, as
in hymenoptera, or insects with a sting, as wasps,  bees, etc.; in diptera, or
insects with two wings, as the common fly;  and also  the spider-tribe, have
their respiratory organs  situated in the lower part  of the abdomen.  In
some of the Crustacea, as, for instance, the shrimp,  the organs of respiration
lie under  the tail, between the fins, and  floating loosely in the water.  Again,
some of the mollusca, viz., the cuttle-fish, have the  respiratory organs in the
abdomen.   We also  know that many  animals, during  the  first periods of
their lives, respire by a different set of organs to what they do in the  adult
state ; the most familiar illustration of this is the frog, which, during its tad-
pole state, lives entirely in the water.
  "As the growth of the embryo advances, other organs, whose function is
as temporary as that of the allantois, make their appearance : these also cor-
respond to the respiratory organs of a lower class of animals, although higher
than those to which we have just alluded, — we mean branchial processes or
gills.  It is to Professor Rathke1 that  wre are indebted for pointing out the
interesting fact, that several transverse slit-like apertures may be detected
on  each side of the neck of the embryo, at a very early stage of development.
In  the chick,  in which he first observed it, it takes place about the fourth
day of incubation: at this period the neck is remarkably thick, and contains
a cavity  which communicates inferiorly with the  oesophagus and stomach,
and opens externally on each  side by means of the above-mentioned  aper-
tures,  precisely as is observed in fishes, more especially the shark tribe; these
apertures are  separated  from each other by  lobular  septa, of exceedingly
soft and  delicate structure.   Rathke  observed the  same structure in the
embryo of the pig and other mammalia; and  Baer has since  shown it
distinctly in the human  embryo.   It  is curious  to  see  how  the  vascular
system corresponds to the grade of development then present: the heart is
single, consisting of one auricle  and one ventricle  ; the aorta gives off four
delicate,  but perfectly simple  branches, two of which go to the right, and
two to the left side ;  each of these little arteries passes to one of the lobules
or  septa  at the side of the neck, which  correspond to gills, and having
again united with  three  others, close to what is  the  first rudiment of the
vertebral  column, they form  a  single trunk, which afterwards becomes the
abdominal aorta.  In a short time  these slit-like  openings begin to close;
the branchial  processes or septa become obliterated, and indistinguishable
from the  adjacent parts ; the heart  loses the form  of  a single heart; a cres-
centic fold begins to mark the future division  into two  ventricles, and
 gradually extends until the  septum between them  is completed.  It is also
 continued along the bulb  of the aorta,  dividing it into two trunks, the aorta
1 [Acta Naturoe Curios., vol. xiv.] 
UTERO-GESTATION.
141
proper and  pulmonary artery;  at the upper part the division is left incom-
plete, so that there is an opening from  one vessel to the other, which forms
the ductus arteriosus.1   A similar process takes place in  the auricles, the
foramen  ovale  being apparently formed in the same manner as the ductus
arteriosus ;  these changes commence in the human embryo about the fourth
week, and are completed about the seventh.

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

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

     Fig. 75.

                       Diagram of the foetus and membranes about the fourth week. From Carus.
                     __a. Vesicula umbilicalis, already passing into the ventricular and rectum
                     intestine at g.  b. Vtna and arteria omphalo-meseraica. C. Allantois springing
                     from the pelvis with the umbilical arteries, d. Embryo, e. Amnion  /. Cho-
                     rion.
period, the duct of communication between the  intestinal canal and vesicula
umbilicalis, the  foetal extremity of  which, according to  Professor Oken's
views, forms the processus vermiformis.
   " The  hands  seemed  to be fixed to the shoulders without arms and the

                                    Fig. 76.
   Diagram of the Foetus and Membranes about the sixth week. From Carus.—a. Chorion, b. The larger
  absorbent extremities, the site of the placenta, c. Allantois. d. Amnion, e. Urachus. e. Bladder /. Ve-
  Bicula umbilicalis.  g. Communicating canal between the vesicula umbilicalis  and intestine,  h. Vena
  umbilicalis.  i, i. Arteriae umbilicalis.  I. Vena  omphalo-meseraica.  k. Arteria  omphalo-meseraica.
  n. Heart, o. Rudiment of superior extremity, p. Rudiment of lower extremity.

feet to adhere  to the ossa ilii; the liver seems to fill the whole abdomen;
the ossa innominata,  the ribs,  and scapulae, are cartilaginous.
   " In  a short time  the  little  stump-like prominences  of  the extremities
become longer, and  are now divided into two parts, the superior  into the
hand and  the fore-arm, the  inferior into the foot  and leg ; in one or two
weeks  later,  the arms and  thighs are  visible.   These parts of the extremities
which  are  formed later than the others,  are at first smaller, but as they are
gradually developed they become larger.   When the limbs begin to  separate
into an upper and lower part, their extremities become rounder and broader,
and divided  into  the fingers and toes, which at first are  disproportionately
thick,  and until the end of the third  month are connected by a membranous
substance  analogous to the webbed feet of water-birds;   this  membrane
 
UTERO-GESTATION.
143
gradually disappears, beginning at the extremities of the  fingers and toes,
and continuing the division up to their insertion.   The external parts of
generation, the nose, ears, and mouth, appear after  the development of the
extremities.   The insertion of the umbilical cord changes  its situation to a
certain degree ; instead of being nearly at the extremity of the foetus, 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 nervorem
opticorum, the corpora striata, and  tubercula quadrigemina, are seen in the
second  month ;  in the  third, the lateral and longitudinal sinuses can be
traced,  and contain  blood.   In the  fifth we can distinguish the corpus cal-
losum; but the  cerebral mass has yet acquired very little  solidity, for  until
the sixth month it is ajniost semi-fluid.1
   "About the end of the third, during the  fourth, and the beginning of the
fifth months,  the mother begins  to be sensible of  the movements  of the
foetus.   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 foetus.
   " The secretion of bile, like that of the  fat, seems to begin towards the
middle  of pregnancy, and tinges  the meconium, a mucous secretion of the
intestinal tube, which had hitherto been colorless, of a yellow color.  Shortly
after this the hair begins to grow, and the nails are formed about the  sixth
or seventh month.   A  very delicate membrane  (membrana  pupillaris), by
which the pupil  has "been  hitherto closed,  now ruptures, and the  pupil
becomes visible.   The  kidneys, which  at first were composed of numerous
glandular lobules (seventeen or eighteen in number), now unite, and form  a
separate  viscus on  each side of the spine; sometimes they unite  into otve
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 lumbar
vertebrae, near the origin of  the spermatic vessels,  now descend along the
iliac vessels towards the inguinal rings, directed by a cellular cord, which
Hunter has called Gubernaculum testis: they then  pass through the  open-
ings, carrying before them that portion of  the peritoneum which is to form
their tunica vaginalis.
   " The length of a full-grown foetus is generally about eighteen or nineteen
inches : its weight between  six  and seven  pounds.   The different  parts are
well developed and rounded; the body is generally covered  with the vernix
caseosa ;  the nails  are horny, and  project beyond  the tips  of the fingers,
1 [Campbell'.- System of Midwifery.] 
144
UTERO-OE STATION.
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.1
   " Thus then, in the space of forty weeks, or ten lunar months, from an
inappreciable point,  the foetus attains a medium length of about eighteen or
nineteen inches, and  a medium weight of between six and seven pounds."]
   191. It was formerly asserted that the position of the child in utero during
the early months was sedentary, facing anteriorly ;  and that towards the
end of gestation, owing to the greater weight of the head, and to its volun-
tarv efforts, it made  a revolution,  so  as to present with the  head.  This,

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

                                 Fig. 78.
Foetal Head Diameters.
In general, it may be observed, that all  the measurements are less in female
than in male children.
  [Dr. Meigs1 makes the  occipito-frontal diameter four inches and ten-
twelfths of an inch in width.   " I  speak," he remarks, " with  great  confi-
dence as to the above estimate, for I have correctly measured and recorded
the size of three hundred crania of  mature children  that  I received in the
course of  my obstetric practice."
  The bi-parietal diameter, being the mean derived from the  measurement'
of one hundred  and fifty crania, he makes three inches and eleven-twelfths
of an inch.
  The occipito-mental diameter, being the mean derived from the measure-
ment of  one hundred and twenty-six crania, he  makes  five inches and  a
half.]
  The weight of a full-grown child at  birth  varies in the same and in dif-
ferent sexes.   Rcederer found the weight in  Germany to be from  seven to
eight pounds.   Dr. Joseph Clarke, in the Lying-in Hospital, Dublin, ascer-
tained the weight of the majority to be about  seven pounds, but that  it
varied from four to eleven pounds.  In  France, the average weight is less;
according  to Camus, it is six pounds and a quarter, and  observations at La
Maternite have confirmed this estimate.   In  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.
   Dr. Elsbaesser, of Wurtemburg,  has published  some extensive researches
on  this subject: he found in 1000 children at birth, that 13 weighed from 4
to 5 pounds;  58 from 5 to 6 ; IT from 6 to T ;  318 from T to 8";  83 from 8
to  9;  and 11  from 9  to  10 pounds,  giving an  average of  4 pounds 14
ounces.  (The Wurtemburg pound is rather more, and the inch rather less
than the English.)
                 1 [Obstetrics:  the Science and the Art, p. 63.]
3£   to 4
        5
4    to 4£
3£   to 4
        3
        3*
4|   to 5£
4    to 5 
UTERO-GESTATION.
147
    The maximum length of males in 1000 children was 19 in. 17 lines.
                            females    "      "        19 "    1   "
    The minimum length of males     "      "        14 "15   "
                            females    "      "        14 "    9   "]
  Dr. Storer, of Boston, found that in 222  males the average weight was
7| pounds, and in  184 females the average weight was 7£ pounds.2
  [The variations in the weight of new-born  infants are very considerable
in all countries : but it is highly probable that the average in this respect,
if it could be correctly ascertained, would not be found to vary much in dif-
ferent countries.   In the United States, it is by no means customary in pri-
vate practice either to measure or weigh the infant  at the time of birth,
except when the  size is strikingly above  or  below the usual standard :
hence all general statements as to  the medium weight of new-born infants in
this country are derived chiefly from births in alms-houses and hospitals, and
can hardly be considered to represent  fairly what obtains among the mass
of the people.]
  194.  The umbilicus changes  its relative position as the development of
the foetus proceeds, until at birth it is near the middle of the entire length
of the child.   According to  Chaussier, Bigeschi, and others, this  relative
position of the umbilicus is a test of its  maturity, being distant from the
central point in proportion to its immaturity.   But it seems doubtful whether
its  position is so exactly central  in mature children as these authors state ;
for  M. Moreau has recently measured 500 children, born at the full  term in
La Maternite,  Paris, and of this  number he found only four in whom the
umbilicus was  exactly central.   In the remainder, the point of insertion
of the funis fell on an average from eight to ten lines below the middle.  In
a few  children born  about the sixth or  eighth month, the umbilicus was
central.
  Dr. Elsbaesser examined  200 children, and found that the length of the
supra-umbilical portion was—

     In the males......9 in. 2^ lines.
     In the females......9 "   "   "
The infra-umbilical portion  was —
     In the males.......7 in. 9 lines.
     In the females......7 "   7   "
 So that the difference in the length was —
     In the males......1 in. 3 40 lines.
     In the females......1 "  3 57   "
  Dr. Storer found the average length of males was eighteen, and of females
twenty inches.
  195.  The characteristics  of the maturity and perfection of a child  at
birth, according to  Fodere and Capuron,  are, its ability to cry  as  soon  as
it reaches the atmospheric air, or shortly  after;  to  move its  limbs with
facility  and more or less strength, its body being of a clear red color; the
mouth,  nostrils, eyelids, and ears,  perfectly open; the bones of the cranium
possessing some solidity, and the edges  of the fontanelles not far apart; the
hair,  eyebrows, and  nails, perfectly developed ; the  free discharge of the
meconium  a few hours after birth, and finally, the power of swallowing and
digesting, indicated by its  seizing the nipple  or  finger placed within its
mouth.
  The  child may be considered immature when its length  and volume are

    i Edin. Monthly Journal of  Med. Science, vol. iv.  p. 803.
    2 Report of the Boston Lying-in Hospital, Amer. Journal of Med., Oct., 1850. 
148
UTERO-GESTATION.
much less than those of an infant at the full term; when it does not move
its limbs, or makes any ;*eeble motions ; when it seems  unable  to suck, and
has to be fed artificially ; when the skin  is of an intensely red color, and
traversed by numerous bluish vessels ;  when the head is covered with down,
and the nails are not formed; when the bones of the head are soft, and the
fontanelles  widely separated; the eyelids, mouth, and nostrils closed;  when
it sleeps continually, and an artificial heat is  necessary to preserve it; and
when it discharges its urine and meconium imperfectly.
  There are cases on record of children prematurely born at  the  fifth and
sixth month of gestation attaining maturity;  but ordinarily  we do not con-
sider a child "viable" until about the seventh month of utero-gestation.
   196.  The proportion of the sexes in Europe, according to the learned
M. Quetelet, is about 106 males to  100 females, nor does it  appear that  in
this part of the world  climate has  much influence.   At the Cape  of  Good
Hope female births predominate among the free inhabitants,  and male births
among  the slaves.   A country life seems to favor the production  of male
progeny; and the  relative  ages of husband and wife exert  a  decided in-
fluence ; for  in proportion  as the  husband is younger than the wife, girls
predominate, and within certain  limits, a disproportion  the other way has
the opposite effects ;  or, as Mr. Sadler has expressed it,  upon a mean num-
ber  of  births, the  sex of the child is that of the parent whose age is  in
excess.
   The season of the year seems to influence to  some degree both the num-
ber of births and the  greater proportion of female children.  In Philadel-
phia the greatest number of conceptions  occur  in the spring months, and
the greatest excess of  male conceptions in the winter season.1
   [Dr.  G.  Emerson,  of  Philadelphia, has  carefully  investigated  the in-
fluences operating to change the number of births, and  also the relative pro-
portion of the sexes at birth ; he includes them under two heads : —
   1st. The Seasons. — The following general results relative to this point
were obtained  from estimates based  upon 65,542 births in  Philadelphia.
The greatest number of conceptions occurred during  the winter and  spring
months ; the maximum being 17,645  in the spring months.   The  smallest
number occurred in the autumn and summer months, the minimum  being
15,200  in the summer quarter.
   The greatest  excess of male  conceptions  is  shown  to be  in the winter
season, when, the total being 17,184,  the males were 9,007,  and  the females
8,IT7.  The excess of male conceptions for the other three quarters or sea-
sons, varies but little from the minimum excess, which  occurs in spring.        •
   2d. The plenty or deficiency of food, purity or impurity of the  air, over-
working, and whatever tends to exalt or to impair the  vital  energies  of the
people.  In many parts of Europe, where the general population  is over-
worked  and under-fed,  the excess  of  male births is  very  small;  being
throughout France and  Prussia under 6 per cent., and in  England about
5  per cent.  In Philadelphia, where the general condition of the population
is very favorable, the male births exceed  the female about  7  per cent.   In
the rural districts of the "United States, and  especially in the  newest  settle-
ments,  the preponderance of boys at birth is believed to  be not less than 10
per cent.   An opposite result is found when  fatal epidemics alarm and de-
press the public mind.  Thus, among  the children born in  Philadelphia,
whose conception occurred  during  the prevalence of the cholera  in 1832,
there was a preponderance of females.  The same  result was shown in the
births which took place in  Paris, nine  months after the cholera  prevailed
there in 1832.   The births, at a somewhat later period  after the visitation
Trans, of American Med. Association, vol. iii. p. 93. 
UTERO-GESTATION.
149
of thfc epidemic, exhibit an increase in the amount of males, in consequence,
it is presumed, of the parents being  endowed with vital energies above the
average, as is shown by their exemption or recovery from the disease.1]
  The number of twin cases at La Maternite was 444 in 37,441  cases, or  1
in 84 ; in the Dublin Lying-in Hospital 2101 cases in 134,908,  or about 1
in 64 ; in the same number  29 triplet cases occurred, or 1 in 4652 ; aud  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 1T5T to
1836, there occurred 8021 still-born children in 134,908 cases, or about  1 in
IT.  [In New York, from 1854 to 185T, there were 48,323 births, and 5931
still-births, at the full time and prematurely; that is  to say, 1 to every  8-l.
In  Philadelphia, the premature  and  still-births were, in 1858, as 1 to every
14-8 births.]
   The number of still-born males is greater than that of females : in West
Flanders and at Berlin in the proportion of 14 to 10.   [The excess of still-
born females is in Philadelphia even  greater.]
   197.  The Physiology of Fcetal  Life is simply that  of organic nutri-
tion ;  at  first by superficial imbibition, afterwards  probably by absorption
by  the villi of the chorion,  and ultimately by the changes made  in or addi-
tions to the fcetal blood in the placenta.
   The sources of nutriment during  the earliest periods of embryonic  life
are the vitellus, or the fluid in the umbilical vesicle, and  possibly the gela-
tinous matter (tunica media) between the amnion  and chorion.   After the
formation  of  the amnion, its fluid may possibly contribute to this end.   Dr.
Montgomery, as we have seen,  suggests that the  milky fluid contained in
the decidual cotyledons may also be available for this purpose.
   There is no doubt of the functions  of the placenta: there the blood of
the  foetus  is  renovated  from that of the mother, in the same  way as the
blood of fishes is aerated by the water passing through the gills.
   Whether, in the earlier  months, absorption is carried on by  the surface
alone,  or whether, as Yelpeau suggests,  a portion of the liquor  amnii finds
its  way into  the stomach, may be  difficult to  decide, but that a certain
amount of digestion is carried on, is  impossible to doubt.
   [A distinguished physiologist observes on this subject  that, " The most
plausible opinion he can form on  this intricate subject is, that the mother
secretes the substances, which are placed in contact with the foetus, in a con-
dition  best adapted for its nutrition ;  that in  this  state  they are received
into the system, by absorption, as the chyle or the lymph is received into the
adult, undergoing modifications in their  passage through the fcetal 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 in-
testines, which is probably the excrementitious matter arising from the diges-
tion of the mucous secretions of the alimentary canal."2
  The sources from which the nutrition  of the foetus is derived  during  the
first four months of intra-uterine life, are involved in no little obscurity.  Sub-

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

  [] Human Physiology, p. 550.        2 Physiological Chemistry, Histology, p. 97.] 
UTERO-GESTATION.
151
tremities, returns by the superior cava to the right auricle, and passes thence
into the right ventricle and pulmonary artery.   A small part of this blood
goes to the lungs by right and left branches;  but the rest, conveyed by the
ductus arteriosus, joins the blood that we left descending through the thoracic
and abdominal  aorta, and all that is not employed in the  nutrition of the
body and lower  extremities, is  returned by the hypogastric arteries to the
placenta."   The object of this theory is to show that the head and superior
extremities receive a supply of purer blood, which they  are supposed to
need for their development; but there  are great  objections in the way: —
1. Even supposing the pure blood were conveyed in the manner stated, it
is too small in quantity to  answer the  purpose, being only one-fifth of the
whole : 2.  Supposing it to be  sufficient, the  presumed effects are not pro-
duced, the intestines, ribs, etc., being just as perfectly formed at birth as the
brain ;  and  3.  No such  transmission of pure  blood across the  auricle,
through the foramen ovale, can take place, because of the effects  of gravity,
the descending current from the superior cava, and above all, because of the
active  contraction  of  the right auricle.   In Winslow's  explanation, it  is
assumed that the heart is virtually single and the blood mixed.   According
to him, "The blood of the system generally passes from the superior and
inferior cava  into the right auricle.  One part of this is transmitted through
the right ventricle and pulmonary artery, and thence (except a supply for
the nourishment of the lungs) through the ductus arteriosus into  the de-
scending aorta ;  a second and  larger part  passes through the foramen  ovale
into the left auricle, then into the left ventricle and arch of the aorta, the
branches of which supply the head and upper extremities.   The continued
stream passes into the descending aorta, mixing with that already described ;
and all of it  that is not employed in the nutrition of the  body and lower
extremities, is reconveyed by the umbilical arteries to the placenta."
   Dr.  Carpenter, the most recent, as he is certainly one of the ablest, of
our physiologists, thus describes the circulation :—" The fluid brought from
the placenta  by the  umbilical  vein is partly conveyed at once to the ascend-
ing cava by me^ns of the ductus venosus, and partly flows through the vena
portae  into the  liver, whence it reaches the ascending cava by the  hepatic
vein.  Having  been thus  transmitted through  the two great depurating
organs, the placenta and the foetal liver,  it is in  the condition of  arterial
blood ; but being mixed in the vessels with that which has been returned
from the trunk and  lower extremities, it loses this character in some degree
by the time it arrives at the heart. In the right auricle which it then enters,
it would be also mixed with  the venous blood brought thither  by the de-
scending cava, were it not that a very curious provision exists to  prevent
(in a great degree, if not entirely) any such further dilution.  The Eusta-
chian valve has  been found, by the experiments of  Dr. John Reid,1 to  serve
the purpose of  directing the  arterial blood which  flows upward from the
ascending cava, through the foramen ovale, into  the left auricle, whence it
passes into the left  ventricle ;  whilst it also directs the venous blood, that
has been returned by the descending cava, into the right ventricle.  When
the ventricles contract, the arterial blood which the left contains is propelled
into the ascending aorta, and supplies the branches that proceed to the head
and upper extremities before it undergoes any admixture : whilst the venous
blood contained in the right ventricle is forced through the pulmonary artery
and ductus arteriosus into the descending  aorta, mingling with the  arterial
current which that vessel previously conveyed, and passing thus to the trunk
and lower extremities."2

                 1 Anal. Phys. and Path. Researches, chapter ix.
                 2 Principles of Human Physiology, p.  1035. 
152
UTERO-GESTATION.
  [" It will be found,"  remarks Dr. Dalton,1 whose  account of the fcetal
circulation is  particularly  clear  and  accurate,  "it  will  be found upon
examination, that  the  two venae cavae, superior and  inferior, do not open
into the auricular  sac on the same plane or in the  same direction, for while
the superior vena cava is situated  anteriorly, and is directed downward  and
forward, the inferior is situated quite posteriorly, and passes into the auricle
iu a direction from  right to left, and nearly transverse  to  the  axis of the
heart.   A nearly vertical curtain or valve at the same  time hangs downward
behind the orifice  of the  superior vena cava and in front of the orifice of the
inferior.  This curtain is  formed by the  lower edge of the septum of the
auricles, which, as we have before  stated, is incomplete at this age,  and
which  terminates  interiorly, and toward  the  right in a crescentic  border,
leaving at that part an oval opening, the foramen ovale.  The stream of
blood, coming from the superior vena cava, falls accordingly in front of this
curtain,  and passes directly  downward,  through the  auriculo-ventricular
orifice,  into the right ventricle.   But the  inferior vena cava, being  situated
further back and  directed transversely, opens,  properly  speaking, not  into
the right auricle,  but  into the  left; for its stream of blood, falling behind
the  curtain  above-mentioned,  passes  across through   the  foramen ovale
directly into the  cavity of the  left  auricle.   This direction of  the  current
of blood coming from  the inferior vena cava, is further secured by a peculiar
membranous valve, which exists at this period, termed the Eustachian valve.
This valve, which is very thin and  transparent, is attached to the  anterior
border of the orifice  of the inferior vena cava,  and  terminates by a  cres-
centic edge, directed toward the left, the valve, in this way, standing as an
incomplete membranous partition between the  cavity of the inferior  vena
cava and that of  the  right auricle.   A bougie, accordingly, placed in the
inferior vena  cava, lies naturally quite behind  the Eustachian  valve,  and
passes directly through  the foramen, ovale into  the left auricle.  The  two
streams of blood, therefore,  coming from the superior and inferior venae
cavae,  cross each other upon  entering  the  heart.   This  crossing of the
streams does not take place, however, as it  is sometimes described, in the
cavity of the right auricle, but,  owing to the  peculiar position and direction
of the two veins at this  period, with regard  to  the septum of the  auricles,
the stream coming from  the superior vena cava enters the right auricle
exclusively, while that from the inferior passes  almost directly into  the left
auricle.
   " It will also be seen, by examining the positions of the aorta, pulmonary
artery  and ductus  arteriosus,  at this time,  that  the  arteria  innominata,
together with the left carotid,  and left subclavian, are  given off from the
arch  of the aorta,  before its junction with  the ductus  arteriosus,  and this
arrangement causes the blood of the two venae cava?, not only  to enter the
heart  in  different directions, but also to be distributed, after  leaving the
 ventricles, to different parts of the  body.  For the  blood  of the  superior
 vena cava passes through the right auricle  downward  into the right  ven-
tricle, thence, through the pulmonary artery  and ductus arteriosus,  into the
thoracic aorta, while the blood of the inferior cava, entering the left auricle,
 passes into the left ventricle, thence into the arch of the aorta, and is dis-
tributed to the head and upper extremities, before reaching the  situation  of
the arterial duct.  The  two streams, therefore, in passing through the heart,
cross  each other  both behind  and  in  front.   The venous  blood, returning
 from  the  head  and upper  extremities  by  the superior vena  cava, passes
through the abdominal aorta and the umbilical arteries to the lower part of
 the body,  and to  the placenta;  while that returning  from  the  placenta,  by
1 [Human Physiology, p. 581.] 
UTERO-GESTATION.
153
the inferior vena cava, is distributed to the head and  upper extremities,
through the vessels given off from the arch of the aorta."]
   199. The circulation of the foetus  is independent of that of the mother,
though it may be sympathetically affected.   By  applying the stethoscope to
the abdomen of the mother, we can hear the fcetal heart, which beats from
120 to 140 times in a minute ; sometimes, but rarely, it is 150 or  160.   The
sounds audible, however,  are double  this amount, inasmuch  as the  beat  is
double ; the first sound is short, feeble, and obscure, the second comparatively
loud and distinct; the first is inaudible a little distance from the fcetal heart;
the second is audible  over a great part of the abdomen,  and it is  the second
which  is generally counted ; in fact, it is  impossible to count both, fron
their  extreme  rapidity.  The  rhythm  of these sounds in  utero  is  quit*
different from what it is in the adult; i. e., the first is quick and  the seconc
prolonged, and then an interval nearly equal to the  two sounds.  Shortly
after birth a remarkable change in rhythm  takes place; the first sound be-
comes  longer and is about equal in strength and loudness to the second, and
the two divide the period of pulsation equally : e. g., if in utero, we divide
this period into 1 . 2—3. 4 parts ; the first and  second sound occupy 1. and
2, leaving 3 and  4 for the interval.   After birth, the two sounds  occur as
12  3  4.   As the child advances in  age,  the rhythm is again changed to
that of the  adult.1  Dr. M'Clintock  has proved, by extensive  observations,
that the frequency of  the heart's action diminishes after birth until it attains
the usual standard of infancy.
   200. After birth remarkable changes take place.   From the painful im-
pressions on the  surface and senses, efforts are made by the child, which
cause inspiration and end in crying, by which means the lungs are  more or
less  inflated, and space  is afforded  for the pulmonary circulation, which
supersedes the use of the foramen ovale and ductus  arteriosus: the blood
from the lower extremities cannot pass through the umbilical arteries, and
does pass through the ascending cava into the  right auricle and ventricle,
and thence  into the lungs, where it undergoes analogous but  more perfect
changes  to those effected in  the placenta, and is distributed to the body
generally.   By degrees, the foramen  ovale closes, and the ductus arteriosus,
ductus venosus, and umbilical arteries are  obliterated ;  the adult circulation
is then established.
   Digestion takes place on the reception  of food, the liver becomes more
active, and the usual  excretions of the kidneys and intestinal canal occur.
   Before birth, the only sense in exercise was that of touch, but immediately
afterwards those of sight and hearing are called into  activity, and at  a later
period those of taste  and smell.  A considerable time elapses  before the
sensuous impressions  are  correctly appreciated, yet every day adds its quota
of instruction,  and Hourly experience at length produces accuracy.
   The brain, which wTas perfectly quiescent during gestation, is now the
focus for the impressions  produced upon the senses, and the seat  of such in-
tellectual operations as can take place at so early a period ; and the nervous
system generally is the centre to which all  organic operations are referrible.
   201. In conclusion, I shall briefly notice the so-called laws of development.
   The first of these is the law of unity of organization, in virtue of which
"the progressive  phases  of the  embryo correspond  to the  abiding  forms,
which are preserved in  the total organism  of animated nature as typical of
its  gradative evolution ;  and that as the embryo of each higher animal
passes  rapidly through the forms of the animals inferior  to it,  in order to
attain its maturity and  specific rank of being, that of man is transitively the
1 Dublin Quarterly Journal, May, 1855. 
154
UTERO-GESTATION.
compendium of all;  not, indeed, without a difference, since in each instance
the changing form of the  embryo bears the impress of the transitional and
incomplete character, while it ever preserves the promise and  prophecy of
the being into which it is  to be finally evolved."   This law of transitive de-
velopment, so eloquently  described by Mr.  Green in the  extract I have
quoted  from  his  Hunterian oration, has been established by the researches
of AVolff, Otto, Meckel, and other German physiologists ; but it is only just
to state that the idea was familiar  to  our  great natural philosopher, John
Hunter, who  remarks: " If we were capable of following the progress of
increase  of the number of the parts of the most perfect  animal, as they are
formed  in succession, from the very first, to its  state of full perfection, we
should probably be able to compare it with some one of the incomplete animals
themselves, of every order of animals  in the creation,  being at  no stage
different from some of those  inferior orders ;  or, in other words, if we were
to take a series of animals from the more imperfect to the perfect, we should
probably find an imperfect animal corresponding with  some  stage of the
more perfect."
   In accordance with this  law, we find the foetal nervous system at the earliest
period resembling that of the annelides, then that of the invertebrata, and
afterwards that of fishes, reptiles,  birds,  etc.  The same  may be said of
other organs, and we have  already  given an example  in  the case of the
uterus (§ 90).
   More striking illustrations may be derived from certain abnormal devia-
tions, of which Mr.  Green remarks,  "and it  did  not escape  Hunter, as  a
consequence of the same law, that congenital defects, hitherto comprehended
under the vague  designation  of monstrosity,  are to be explained by the
development of the embryo being interrupted  at some early stage of its
regular  evolution, and that the defective form which is the  result, is analo-
gous to the form and structure of an inferior class."
   Thus  we have the law exhibited  in the successive transitions of  the foetus
until its arrival  at its perfect  state ;  and, if possible, more  strikingly illus-
trated by those exceptions where it fails to attain  this perfection.
   202. The  other law I shall notice  has also received its  most impressive
elucidation from certain exceptions :  it is called the law of symmetry, con-
jugation, or  affinity, founded upon the general observation that all formations
proceed from the circumference to  the centre.  According to  M. Serres, the
body generally, and each organ,  whether single or double at birth, is origi-
nally divisible into two parts, that  each half  grows towards the mesial line,
where it meets its opposite and is joined to it, as we  saw in the case of the
dorsal and ventral laminae.   If the law of progression be equally observed
 by both halves, the organ resulting from their union will be perfect; if the
 growth  be unequal, deficient,  or excessive, the result will  be deformity by
 defect or excess.  Again, connected with this law of symmetry, and perhaps
 causing its deviations, is  the fact, that development of each part of the body
 is to a certain extent dependent upon its vascular  supply ; if this be deficient
 or in excess, so most probably will be the other.
   203.  We are now able to  classify to a certain  extent the deviations from
 the normal formation of  the foetus, viz., into those whose  deformity results
 from an arrest of the transitive development, those arising  from irregularity
 of symmetrical growth,  and those dependent upon vascular  irregularities.
 Others still remain, however, the larger class probably depending upon dis-
 eased action in the organs or structures of the foetus or of  its dependencies,
 aud some of which it is very difficult to explain at present.
    [One of the most remarkable of these  congenital defects is the " sponta-
 neous  amputation of the foetal limbs in  utero," so well described by Dr.
 Montgomery of Drblin.   Since the  publication  of his paper in the year 
SIGNS OF PREGNANCY.
155
1832,1 the subject  has attracted a good deal  of attention in Europe, and
also in this country, and several very interesting  cases have been detailed :
in some, it seems to have been caused by the umbilical cord encircling the
limbs  and acting as a ligature; in other cases the origin of the ligature has
been  ascribed by Dr. Montgomery to organized  lymph.   Professor Gurlt,
of the Royal School of Medicine at Berlin, in a  paper published by him in
1833,  regards " these threads  as  prolongations of the egg membrane from
which the 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 pro-
longations of the membrane," Gurlt thinks,  "are afterwards, by the con-
stant  motions of the foetus, twisted into slight  but firm cords, or  threads,
which may involve  different portions of the  foetal limbs, (as we sometimes
find the umbilical cord several times  round the neck, or other  parts of the
child's body,) so as to stricture them, and cause their separation  ; in this
way he explains the presence  of  the  ligatures concerned in the production
of spontaneous amputation."2]
                         CHAPTER V.

                      SIGNS  OF PREGNANCY.

   204.  Having  now minutely described the process of utero-gestation, lei
us examine the signs and symptoms to which it gives  rise, and by which it
may be  detected.  I need say but little as to the importance  of such  an in-
quiry, or of the  responsibility whioh  is incurred by a physician,  when  his
opinion is demanded.  The honor, and therefore the happiness of a female,
may depend upon his decision ;  the peace of families may rest upon it;  and
the inheritance  of property be  controlled  by it.  The limits of this work
oblige me to treat the rjuestion rather as a physiological than a medico-
legal one ; but  although much is omitted which  might be available  in the
latter point of view, all that  is adduced  applies equally to both.   In all
such cases, the reader is to remember that he  may not merely  be requested
to investigate a  case of doubtful pregnancy, where no shame is involved, but
that he  may be consulted in cases where pregnancy is  concealed by unmar-
ried women,  or  by married women  under  certain circumstances, to  avoid
disgrace ; and on the other hand, where it is pretended, in order to secure
an  inheritance, to extort money, or to delay punishment.  In  considering
each " sign," I shall endeavor to state its value as evidence, as well as to
describe its characters as a symptom.
  205.  The signs of pregnancy have been variously classified, and no  doubt
in a formal treatise a scientific classification  is necessary;  but in a brief
summary like  the present, it  appears to  me that it will be  more useful to
take them rather in the order of time in which they are developed; by which
means the student will find  grouped together  the  early evidences of preg-
nancy, and again, those indicative of more  advanced gestation.
  i  [Dublin Journal of Medicil Science, vol. i., p. 140.]
  2  [For further information on this curious subject the reader is referred to Dr. Mont-
gomery's essay, contained in his invaluable -work on the "Signs and  Symptoms of
Pregnancy."] 
156
SIGNS OF  PREGNANCY.
  206. The general condition of a  pregnant woman is plethoric, the pulse
is quicker and fuller, the quantity of circulating fluid is said to be augmented,
and its quality altered by the increase of fibrine, judging from the prevalence
of the 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 occur-
rence, as well as  caprices  of taste.   The chylopoietic viscera are often de-
ranged, and  the  secretion  from the kidneys altered.   The skin may change
its color, and become sallow or discolored in patches, though in some cases
it becomes more florid, with occasional eruptions on the face.  Some women
become fat during pregnancy, others lose flesh.
  But in some  particulars, the deviations from the ordinary state are more
remarkable, and  constitute  the special signs upon which our diagnosis must
be grounded; these we  shall now notice, premising  that  the diagnosis of
early pregnancy is no  easy task,  but one which requires great care  and
discrimination.
   207.  Cessation of menstruation.—One of the first circumstances which
leads a female to suspect that she  is pregnant,  is the non-appearance of the
catamenia at the proper time, and if at the  second period they are  still
absent,  it is deemed conclusive, or nearly so.
   IS'o doubt this is one of the most unvarying, as it is one of the earliest,
results  of pregnancy.  But, strictly speaking, it is not conclusive, inasmuch
as  the  discharge may recur for  some  months  after conception, or even
monthly during the whole period of utero-gestation.   Such cases have been
recorded by Mauriceau,  Puzos,  Desormeaux, Johnson,  Frank,  Dewees,
Kennedy, Montgomery, etc., and  several such  have occurred to myself.1
   [Dr. Meurer has recorded a remarkable instance of menstruation during
pregnancy  in a  woman,  aetat.  27,  who was pregnant for the  fourth time
when he wrote.   She always had had  her menses regularly during preg-
nancy,  and only  during that time.    They came on without any illness; and
 she  had always borne healthy children, at the full period.   While unmarried,
 and except during pregnancy, she never menstruated,  but she was never un-
 well from it.   Her general appearance  was  rather masculine.2  In very
 many of the cases  of supposed menstruation  during pregnancy, there  is
 nothing more takes place than a,hemorrhage from  about the cervix uteri,
 in consequence of inflammatory ulceration or abrasion of the epithelial cover-
 ing of  this part.  Sometimes these conditions precede pregnancy, but  are
 aggravated  by the afflux  of blood and augmented vascular activity of the
 gravid uterus,  while in other instances they originate during  pregnancy.
 The hemorrhage is often very considerable,  and in   accordance with a law
 which, to a certain extent, governs all the capillary hemorrhages of females,
 it is most liable to occur at or about the catamenial periods.]
   Again, conception  may  take place previous to  menstruation, or immedi-
 ately after ceasing to give suck, before it has had time to occur.  Nay, some
 cases are on record where  women menstruated only during gestation.
   Lastly, the catamenia may be arrested by disease of various kinds, and it
 is even possible  for pregnancy to  occur in such cases.
   If, then, menstruation may be suspended by other causes on the one hand,
 and may continue, notwithstanding pregnancy, on the other hand, it is evi-
 dent, that by itself,  the cessation of menstruation is not a proof of concep-
 tion, although it is of considerable value (inversely as to the frequency of the
 exceptions) as evidence, especially combined with other signs.   I may add,

   1  For an explanation of this occurrence, the reader may consult a paper by Dr. J.
 Matthews Duncan in the Ed. Monthly Journal, April, 1853.
   *  [London Medical Gazette, Nov. 1840, from Med. Correspondenzblatt, Bd. 9, No. 31.] 
SIGNS OF  PREGNANCY.
157
that in cases of concealed pregnancy the woman sometimes stains her linen
with blood, in order to simulate this discharge.
  208. .Morning sickness.—The intimate sympathy between the uterus and
stomach, is shown  by the  irritability of the latter soon  after conception.
Most women  suffer more or less from  nausea and vomiting,  especially on
rising in  the morning; hence it  is termed  "the morning sickness."   The
irritability  may  commence immediately after  conception, as in two  cases
mentioned by  Dr. Montgomery; but more generally it sets in about the fifth
or sixth  week, and  ceases  soon after the third month.   The  daily attack
lasts but  a short time, from ten minutes  to  an hour, after which the patient
completely  recovers, and is able to take food.
  As an evidence  of pregnancy, its occurrence at the  regular time and in
the usual manner, is of  great value when combined with other symptoms,
but the  exceptions and  irregularities are sufficiently frequent to render it
more doubtful if taken alone ; for it may be altogether absent, and yet the
patient be  pregnant, or  if present, it may occur at unusual  times, or with
extraordinary violence ;  with  some women it occurs during the night only,
with others it lasts  during  the entire day, and may continue throughout the
period of gestation.  On the other hand, it may be present as morning sick
ness, from various causes, and yet the patient not be pregnant.
   Dr. Ramsbotham remarks, that when vomiting " is entirely absent, utero-
gestation does not proceed with its usual regularity and activity;" and so
far my experience agrees with his, that irregularities in this  particular are
frequently followed by deviations in  the other symptoms of pregnancy.
   [" This remark does not entirely correspond with my experience," remarks
Dr. Huston, in a note to a former  edition.   "I have known  many women
proceed  regularly through  ttr&r  pregnancy, and be  safely  delivered  of
healthy children,  without experiencing the least degree of morning sickness.
But where  a woman laboring under  this disturbance is suddenly relieved,
before the usual time for  its cessation, there is reason to apprehend some
mischief  to the  ovum, the  more  especially if  she  has been exposed to any
mental or other cause capable of strongly impressing the nervous or vascular
system."
   " There is little doubt," says Dr. Montgomery,1 "that, in general, vomiting
is a useful  concomitant  in pregnancy, and that its sudden cessation is very
often indicative of an unfavorable change in the contents of the womb,  and
of approaching abortion, but I have seen so many instances in which females
have been altogether exempt  from  this affection in several successive preg-
nancies,  through which they have passed most favorably, and  gave birth to
strong and healthy children, that I must decidedly dissent from the opinion
of Dr. Ramsbotham, above quoted, as a general rule, although entertaining
the highest respect for its author."]
   209.  Salivation. — The irritation  caused by  pregnancy may affect the
salivary  glands, and induce salivation,  although it is not of very frequent
occurrence.   It is enumerated by Hippocrates and the earlier writers as one
of the signs of  pregnancy ; but  recent authorities consider it of less value.
Cases, however, are mentioned by Dewees, Montgomery, and others.  Several
such have occurred to myself, in which  it commenced at an early period, was
very profuse,  but unaccompanied by swelling of the  glands or tenderness,
and ceased spontaneously, in one case, about the fourth month, in another
about the  fifth, and in a third about the eighth.  As Dr. Montgomery has
observed, it is " easily distinguished from the pytalism  induced by mercury,
by the absence of sponginess and soreness of the gums, and of the peculiar
foetor, and by the presence of pregnancy."
1 [Signs of Pregnancy, I Liladelphia Edition, page 90.] 
158                    SIGNS  OF  PREGNANCY.
  210. Mammary Sympathies. — About two months after conception, the
attention of the female is attracted to the state of the breasts.   She feels an
uneasy sensation of fulness, with  throbbing and tingling  pain in their sub-
stance and at the nipples.  .They increase in size and firmness, and  have a
peculiar knotty, glandular feel; the areola darkens, and after some time, a
milky fluid is secreted.
  But it must be recollected that the breasts may enlarge from other causes,
this  happens with  some women at each menstrual period : when the cata-
menia are  suspended, or  after they cease ;  and  at such time a milky fluid
may be secreted.   Distension of the uterus from hydatids or other causes, ia
accompanied by a change in the breasts.   On the other hand, Gardien and
Mahon have remarked, that when menstruation takes place during the early
months of gestation,  the  swelling and pain of the  breasts are absent;  and
Dr. Montgomery mentions a  case  in which no  alteration took place until
after delivery, in consequence of the delicate state of the patient's health.
  In the virgin state the color of the nipple and areola differs comparatively
little from that of the  surrounding  skin.   It is generally a few shades darker,
but sometimes scarcely that.
  But after conception a great change is observed in most women, though
less marked in those of very light complexions.   The first alteration  percep-
ceptible is " a soft and moist state of the integument, which appears raised
and  in a  state of turgescence, giving  one the idea, that if touched by the
point of the finger, it would be found  emphysematous; this state appears,
however, to be caused by infiltration of the subjacent cellular tissue, which,
together with  its altered color, gives us the idea of a part in which there  is
going  forward a greater  degree of vital action than is in operation around
it, and we not unfrequently find that the little glandular follicles, or tubercles,
as they are called by Morgagni, are bedewed with a secretion sufficient to
damp and color the  woman's inner dress."  The above is an extract from
Dr. Montgomery's work, to which, and to the plates accompanying it, I beg
to refer the reader.   This first change in the areola takes place at an early
period ; Dr. Montgomery states that he has recognized it at the end of the
second month.   Dr, Houghton of  Dudley has mentioned to me the particu-
lars of a case in which he observed it as early as the fourteenth or fifteenth
day, and the circumstances leave no doubt that the lady could not have been
more advanced in pregnancy.  " During  the progress  of the  next  two
months, the changes  in  the  areola are in general perfected, or nearly so ;
and  then  it presents  the following characters : a  circle  round the nipple,
whose color varies in  intensity according to the particular complexion of the
individual, being usually much darker in persons with black hair, dark eyes,
and  sallow skin, than in those of fair hair, light-colored  eyes, and  delicate
complexion.   The extent of the circle varies in diameter from an inch to an
inch  and  a half, and increases in  most persons  as pregnancy advances,  as
does also  the depth of color."  In  the centre of the colored circle, the nipple
is observed partaking of the altered color of the part, and appearing turgid
and prominent, while the surface  of the areola,  especially that part of it
which lies more immediately around the base  of the nipple, is studded over
and rendered unequal by the prominence of the glandular follicles, which,
varying in number from  twelve to twenty, project from the sixteenth to the
eighth of an  inch ;  and  lastly, the integument covering the part  appears
turgescent, softer  and more moist, than that which  surrounds it, while on
both there  are to be observed at this  period, especially in women of dark
hair and eyes, numerous round spots or small mottled  patches of a whitish
color, scattered over  the  outer part of  the  areola, and for about an inch or
more all  around,  presenting  an  appearance as if the  color had been dis-
charged by a shower of drops falling on  the part.   Dr. Montgomery fixes the 
SIGNS OF PREGNANCY.
15
time of this peculiar appearance at about the fifth month, at which time the
breasts have become full and firm, with large veins ramifying on their surface.
After  the  sixth month, a number of silvery streaks like  cracks  may be
observed, the  result of  over-distension.
   To these well-marked changes in the areola  and nipple  there are many
exceptions ; the color,  which  is in general the most  prominent alteration,
may not deepen so decidedly ; and many cases of women  of light complexion
occur, in whom it scarcely differs  from the surrounding skin.   Besides, as
Dr. Ingleby has well remarked, " when the color of the  integument  around
the nipple has been once modified by pregnancy and nursing, it is no longer,
I think, a conclusive criterion."  Again, in other cases the sebaceous glands
are but slightly developed ; but I have almost invariably observed the puffy
state of the areola in first  pregnancies.  If the foetus die,  the changes are
arrested, and  gradually decline.
   On the other hand, something resembling the deepened color of the areola,
as well as enlargement of the mammary gland, is  said  to be present, when
the uterus is  distended from other causes ;  and I have  repeatedly seen the
follicles developed in  patients neither  pregnant nor nursing.  TJpon the
whole, however, the changes  in the  breasts  and nipples  are certainly the
most unequivocal  of all the early signs of pregnancy.
   211.  Milk in the breasts, although  a popular  evidence much relied upon,
can  scarcely be considered of any value at all.   It is true,  we do often find
it at an early period, and generally at a later;  yet it occurs so frequently
without pregnancy, that no certain conclusions  can be drawn from it.  For
instance, Baudelocque mentions the case of a girl of eight years  old, who
milked  her breasts in presence of the Royal Academy of Surgery,  October
16th, 1783, and Belloc another; in both, the secretion  wfLS. apparently the
result of the  application  of a child to the breasts.  A similar case,  but in a
woman, is  related by Mr.  Semple.1   Milk is also occasionally  secreted at
each return of the catamenia, and  may remain very  long  after weaning.
Fodere mentions that he has  frequently known it secreted at the final cessa-
tion of menstruation.2
   212.  From what has preceded,  the student will have gathered  that the
diagnosis of pregnancy in the early months must be  more  or less doubtful.
No  single sign can be relied on as conclusive ;  it is only when two  or three
are present, and occur in proper sequence, that we can feel pretty certain.
For example : if  a patient  miss one  or two periods, we may have  grounds
for suspicion, and these will  be  strengthened if morning sickness  occur in
the second month; but if to these be added enlargement of the breasts and
darkening  of  the  areola, the case will  be pretty certain.  In  many cases,
too,  we may derive assistance from the  character and circumstances of our
patient.   In  doubtful cases,  it is much better to avoid  giving a positive
diagnosis until time shall have developed more  characteristic signs.   It is
not,  however,  until the latter half of gestation that we  obtain positive evi-
dence, which  can  neither be  simulated  nor  evaded.   This  we shall  now
consider.
   213.  Enlargement  of the Abdomen.—The gradual distension of the
uterus has already been described (§ 157) as  tolerably equable, enabling us
to estimate the period  of pregnancy  by the height to which it has attained
in the abdomen.   During the early  months,  although it be not perceptible
above the pubis, yet the abdomen  increases by  degrees, owing to the intes-
tines being pushed up from  the pelvis.  This enlargement, however, is varia-

  i North of England Med. and Surg. Journal, vol. i.  p.  230.
  2 [For an account of several cases of mammary secretion, in both the male and unim-
pre<:nated female, the reader is referred to Dunglison's Human  Physiology, and Mont'
gomery on the "Signs and Symptoms of  Pregnancy," Philad. ed., p. 110, et seq.] 
160
SIGNS OF PREGNANCY.
ble, owing to the distention of the intestines by gas  or faecal accumulation.
In some cases, the abdomen even becomes flatter at first, from the  sinking
of the uterus in the pelvis"; but it soon increases  again, and by the end of
the third month it is visibly but equally enlarged.   During the fourth month
the womb ascends above the symphysis pubis, and may be felt as a rounded
tumor, which goes on augmenting till it occupies the whole abdomen.   When
it reaches the umbilicus, it pushes it forward, so that in the sixth and seventh
months it is about level with the surrounding skin, and afterwards it projects
beyond it in most women.
  The feel of  the abdomen 'distended by the uterus is  very different from
the impression it gives when the distension is  caused by fluid,  flatus, etc.
The uterine tumor is firm, hard, elastic, and defined, preserving its form in
all  positions of the body, though more remarkably when the patient  is up-
right; whereas in ascites the defined tumor is wanting, the fluid obeys the
law of gravitation, and the abdomen  has not the  same firm, elastic feel.   The
best mode of examining the uterine tumor, is to  make the patient first stand
up, and then lie down ;  this will demonstrate the form of the womb  better
than  keeping in  one  position ; and after lying for some time, the  uterine
parietes become relaxed and less firm.  Percussion  will distinguish between
pregnancy and tympanites.
   Nevertheless, cases do  occur which are very embarrassing;  for the uterus
itself may be distended by air, fluid, or hydatids, and then  the form of the
uterus and  abdomen will be the same as in pregnancy.  In such cases, our
guide  must be the history of the case, and further investigations into the
contents of the uterus.   I have  already described the changes which  take
place in the cervix (§ 158).
   214. Quickening. — This term is popularly applied to the mother's per-
ception of the  first movements  of the foetus, under the erroneous  belief  that
it was its first movement, as it then became alive  or quick.   Wre know that
the foetus is alive from the moment of conception, and have little doubt but
that movements take  place at a much  earlier period.   By modern  writers,
then, the  term  is applied to the first perception of movement on the  part of
 the  mother, which generally occurs  about four  or four  and a half  months
 after conception, though  some feel it earlier, and others  not till afterwards.
 Dr. Montgomery observes :  " Experience  has shown that it  happens from
 the  tenth to the twenty-fifth week; but according to  my experience, the
 greatest  number of instances will be found to occur between the end of the
 twelfth and sixteenth week after conception; or, adopting  another mode of
 calculation, between the fourteenth  and  eighteenth  week after the last men-
 struation."  Out of one hundred cases, Roederer found that eighty quickened
 at the fourth  month, and, of the remaining twenty, some at  the third and
 some at the fifth.
   The sensation  is at first like a feeble pulsation ;  and, though so slight, is
 often accompanied by sickness  of stomach and faintishness, or  even complete
 syncope.   By  degrees it becomes  stronger and  more  frequent, until the
 movements of the different  extremities are distinguishable.   Authors are
 not agreed as to the explanation  of quickening, or  why  the movements are
 felt at the fourth  month  or thereabouts, and not earlier.   I think, upon the
 whole, that the  most probable explanation is the  one  which the late Dr.
 Fletcher, of Edinburgh, used to give in his lectures.  "  The movements of
 the foetus while the uterus is in the cavity of the  pelvis are  not perceived,
 because the uterus is not supplied  with  nerves of  sensation, and it is sur-
. rounded  by parts similarly deficient; but when it emerges from  the  pelvis,
 it comes  in contact anteriorly  with  the abdominal parietes, which are  libe-
 rally supplied  with  sensitive nerves, and which, by  contiguity of substance, 
SIGNS OF  PREGNANCY.
161
feel the movements, and thus the woman becomes conscious of them."  This
view is strengthened by the fact, of which I have repeatedly been assured,
that the movements, unless when violent, are felt in front only.
  Its  value  as  a sign  of pregnancy is  somewhat impaired by the interval
which frequently intervenes between the first faint sensations and their repe-
tition ; by the late period at which  they are felt  in  some cases; and, in a
medico-legal point of  view, by our being dependent upon  the evidence of
the patient herself; or  the patient maybe deceived by flatus in the intestines.
On the other hand, cases occur  where no  sensation  is  perceived  by the
mother.  " Of this fact," says Dr.  Montgomery, "the writer can  speak with
certainty,  having  now in  several  instances,  by applying his  hand  to  the
abdomen, distinctly felt the motions of the foetus  in utero, while  the mother
had no perception of them."   In a case lately under  my care the  movements
of the child were exactly similar,  and scarcely more felt by the  patient at
the termination  of  pregnancy than at quickening, and yet both mother and
chifd  were strong and healthy.
   215. The movements of the foetus may be felt by the practitioner some
little time after quickening, by placing the hand, especially if it be  cold, upon
the abdomen; and the  impression will of course  be in proportion to the vigor
of the motions.   At an  advanced period it would  not be easy to mistake
them ; but we may be  deceived at  an earlier period.  Dr. Blundell relates a
case of a woman who  possessed the power  of  simulating  these  movements
by the action of the abdominal muscles.
   [Dr. Simpson stated, at a meeting of the Edinburgh Obstetrical Society,
a  variety  of observations  and  experiments,  showing that,  contrary to  the
commonly-received opinion, the mere  application of cold (as  a  cold  hand,
etc.) to the  surface of  the abdomen of a pregnant woman,  had  not the effect
of exciting  motions in the foetus.   The application of portions of ice even,
of the size of the hand, had no such effect.1]
   Dr.  Tyler Smith describes two abdominal movements in the latter month
of pregnancy;  one traversing irregularly over the abdomen, giving a feeling
of ridges or prominences to the hand, and the other like a  shock or impulse ;
the former he regards  as due to the peristaltic movements  of the  uterus,  and
the latter only to the foetus, and I  must confess  I think there is great weight
in his  arguments.   I am happy to express my obligations to his work, which
I regard as one of the most important and ingenious that has*appeared for
many  years, both  as  expressing more clearly  the  "idea" of uterine  and
ovarian physiology, and also  as giving it for the first time the  unity of a
system.
   216. Ballottement.—A vaginal examination will enable us to ascertain
not merely the state of the cervix, but also to decide upon the presence of a
foetus, by repercussion, or ballottement, as it is termed by the French.  The
patient should be in the upright position ; or if she be in bed,  her shoulders
should be raised ; the operator must then introduce his forefinger, and place
it upon the  cervix uteri, whilst the other hand is  employed to keep the ute-
rine tumor steady, then suddenly but slightly jerking upwards the point of
his finger, he will feel  a sensation of something having receded from it,  and
which he will perceive to fall  again  on the point of his finger in a moment
or two.  The jerk of the finger upon the head of the foetus 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 foetus 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'

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

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

 A?7^1" th,e TSt coniPlete account of obstetric auscultation will be found in tW wm*
of M. Depanl, Traite" TMorique et Pratique de 1'Auscultation Obstetricale  Pads,  1847 
SIGNS OF  PREGNANCY.
163
the cooing of a dove, and a drone resembling that of  a  bagpipe, accompa-
nying the sound, yet without interfering with it.
   It is stated by Hohl and others to be limited to  the situation of the pla-
centa (§  175), and so it is generally; but in many cases it extends to some
distance, and in others, according to Naegele, it may be heard in  almost any
part of the uterus : he further states, that it may constantly be heard at the
lower part of the  uterus, by applying the stethoscope near Poupart's liga-
ment.  I cannot say that I have been able to verify the latter  statement, but
I have found it very possible to  produce a souffle in that situation by a little
extra pressure of the stethoscope.
   219. The period when it first becomes  audible is about the fourth month,
according to Montgomery, Hohl, and Naegele ; Dr. E. Kennedy states that
he has succeeded in detecting  it  as early as  the  tenth week;  and, on the
other hand, it cannot be heard in some cases until the fifth month.   It may,
however, always be distinguished before the pulsations of the foetal heart;
and even when the foetus perishes, it continues for some time afterwards.   It
is feeble  when first heard, but increases in intensity and strength ; the inten-
sity, however,  is  subject to  some  variation.   It  is synchronous  with  the
mother's pulse, and  subject  to  its  varieties, but without impulse.  During
labor its intensity varies ; in the upper  part  of the uterus  it is frequently
inaudible during a pain; after delivery it ceases entirely, though not always
instantly.
   220.  M. Kergaradec,  as I have already said, placed the seat of this sound
in the placenta;  more  recent investigations, however, have  decided that it
is situated in  the uterus.   M.  TJlsamer and Dr. E. Kennedy conceive it to
result from the difference between  the calibre of the arteries  supplying the
uterus and the uterine sinuses :  that the  expanding current of blood rushing
from an  artery into a larger sinus gives rise to the sound, just  as the passage
of blood through  a constricted  valve of  the heart or aorta does to the bruil
de soufflet.  M. Depaul and M. Caseaux also place  its seat in the uterus,
and the  latter authority considers that it is in part, at least,  owing to a
" serous  polyhsemia," as advocated by M. Beau.1  Other explanations have
been given, but all are  agreed  now that its seat is in the uterus, and not in
the  placenta;  and most, I believe, that it indicates the position of the latter
organ.
   221. As a test  of pregnancy, its positive value (that is, its  being audible)
is very great, though not quite  conclusive,  as it is  heard sometimes in cases
of disease, of  which I had a remarkable instance under my own  care, and
may occasionally be produced by too great pressure of the stethoscope upon
an artery.  Neither does it prove  that the foetus is alive, in  cases of preg-
nancy, as it is  observed to persist  for a  short time after the death of the
child ; it is heard  also in some cases of blighted ova which have degenerated
into moles, and in cases of hydatids.
   On the other hand, its negative  evidence (our not being able to detect it)
is of much less value, as we  may not be able to hear the sound although the
patient be pregnant, probably from the placenta being attached  posteriorly.
   In 212 cases, M.  Jacquemier found it present in 80 cases, and  absent in
132.  In 600 cases  M.  Naegele heard it 238 times on the left, 141 times on
the  right side,  and in 20 cases it was absent.
   222. Pulsation of the Fcetal Heart.—Yery different from the uterine
souffle is the sound which attracted the attention of M. Mayor, the pulsa-
tion of the fcetal heart.   It  consists of a rapid succession of short, regular,
double pulsations, differing from those of the adult heart in rhythm and fre-
quency.   The  sound is  like the muffled ticking of a watch, or, as Naegele
» Archiv. GSn. de MeU, 1850. 
164
SIGNS OF PREGNANCY.
remarks, like the pulsations of the heart of a new-born child.   Their fre-
quency is about double those of the  adult,  or from  120 to 140 pulsations in
a minute—i. e., 240 to 286 audible sounds ; but in  counting, we reckon  the
second sound  only, as it would be impossible to count both, and thesecond
is  the  loudest.  I have  already described  (§ 199) the peculiarities  of  the
double  sound in the fcetal  heart, with the change of rhythm which  takes
place at birth, and which I need not here repeat.  M. Naegele, jun., found
that, in 600 cases, the average frequency was 130 {i.e., 260 sounds) strokes
in a minute.
   The variations in strength and rhythm 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 foetus  itself, and  others by impressions re-
ceived from the  mother; for although  the fcetal circulation is independent
of that of the parent, yet there is so intimate a sympathy, that disturbances
in the maternal system are communicated to that of the foetus, some (in case
of sudden shocks) immediately, and others  (in case  of  disease) more tardily.
   The situation in which the fcetal  heart  is heard most distinctly, is about
the  middle, or inferior abdominal region, more  frequently on the left than
on the right side.  "The extent of surface," says  M. Naegele, jun.,1 " over
which the beating of the heart is  heard,  cannot be  accurately defined in
inches and lines, but it is certainly audible  through a larger space than most
observers have represented.   Its  sounds reached beyond the linea alba to-
wards the other side, in  one hundred and eighty-five  of three hundred  and
seventy  cases, in which the position of the foetus with its back  to the left
side of  the mother was distinctly ascertained by  the ear, and  afterwards
verified  by the result of the labor ; in forty-six, they were audible over nearly
the whole abdomen ; while in one hundred and thirty-seven, they were con-
fined to the left side, and did not reach the mesial line.  The heart's sounds
were audible beyond the  mesial line, only  in forty-five of one hundred  and
eighty-five  instances, in which the  back of the foetus was directed to  the
right side ;  one hundred and fourteen times they  were  distinguishable on the
right side only;  but in twenty-six they extended over the whole abdomen.
In all these instances in which the heart's sounds were not limited to one
lateral half of the abdomen, their greater intensity at one part indicated the
situation of the back, and consequently the position of the foetus."
   So far as the second sound of the fcetal  heart is  concerned, my experience
agrees with that of M. Naegele, but I have found  that the first sound becomes
inaudible at a very moderate distance from the situation of the fcetal heart.
   The earliest period at which the pulsations can  ordinarily be detected, is
 the middle  of the fourth month, or the beginning of the fifth.   Dr. E. Ken-
 nedy has heard them in  a few instances before the expiration  of the fourth
 month.  Dr.  Montgomery names the  end  of the fifth  month.   The  earliest
 period mentioned by Naegele, is the eighteenth  week, in thirty out  of  fifty
 patients who  were examined before the middle of pregnancy.  In some cases
 they did not  become audible before the fifth month.    It is easy to conceive
 that various circumstances may impede the 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 abdominal parietes, or feebleness of
 the foetus.
   223.  When the pulsation of the fcetal  heart is  heard, it is proof positive
 of pregnancy, equally remote from imitation or  evasion.  The only  circum-
 stances at  all likely to embarrass  us  for  a moment, are the sounds of the
 maternal heart, which may sometimes be heard ; the sound of the contrac-
 tion of  the abdominal muscles ; or of the uterine arteries ; but the greater

                 1 On Auscultation, translated by Dr. West, p. 41. 
SIGNS OF PREGNANCY.
165
rapidity, the  rhythm, and the clearer, though feebler, sound of the fcetal
pulsations will distinguish them  with facility.
  On the other hand, the pulsations being-inaudible is not conclusive proof
that the patient is not pregnant, as the child may have died, or, as in some
rare cases, they may be inaudible for a time, though the foetus be living.  I
know this to  be the fact, though I cannot  explain it.  M. Depaul mentions
that in 906 cases it wras only absent in eight cases.
  In some rare cases of pregnancy the pulsations of the aorta are heard, or
rather felt, even beyond the fifth month ;  but why they are thus transmitted
I cannot say.  As a general rule, if they are  distinctly heard, it is good
evidence that the  patient is  either not pregnant, or that  the uterus has not
risen up  out  of the pelvis.
  ±2i.  Pulsation of the Umbilical Coed, or funic souffle.—If the posi-
tion of the funis  be favorable,  as, for instance, if it be  twisted round the
neck, body, or limbs of the foetus, or in any way placed  between the foetus
and the anterior or lateral parietes of  the  uterus, it is quite possible,  as Dr.
K.  Kennedy  has  shown, to hear the pulsation of its arteries corresponding
to  the fcetal heart's  action.   Both Haus and  Hohl have denied this, but
without just reason, in my opinion;  for  Dr. E. Kennedy states that "in
some cases where the parietes  of the uterus and abdomen were extremely
thin, he  has  been able to distinguish the funis by the touch externally, and
has felt  it rolling under his  finger, and then applying the stethoscope, its
pulsations has  been discoverable, remarkably strong."  Professor Naegele,
jun.,  agrees  with  Dr. E. Kennedy as to the seat of the pulsation, and attri-
butes it to the tortuosity of the arteries, and to  the  dilatations observed in
them.   Occasionally the sound is rather a souffle than a pulsation, but fainter
than the uterine  souffle, and  distinguished from  it by its  being synchronous
with the pulsations of the fcetal, and not the maternal heart.   Dr. E. Ken-
nedy found that he could produce  the  souffle by pressing slightly upon the
cord with the edge of the  stethoscope.
  225.  We  have  now examined the principal signs developed during the
latter half of pregnancy —to wit, enlargement of the abdomen, quickening,
the motions of  the child, ballottement, and the results of  auscultation ; and
we  find that whilst all are valuable, there is a degree of uncertainty attached
to the first three which calls  for a very careful estimate on our part :  that
.the positive  evidence of the  latter modes  of investigation is conclusive, but
that the  negative evidence, or absence of the usual results, is not proof that
the patient is not pregnant.   So  that,  as was  before observed, we ought
rather to depend upon the coincidence of  two or more of the signs of preg-
nancy, than  attempt a diagnosis from  any one alone : the only sign  indeed
which can be regarded as proving that the woman is pregnant of a living
child, is the pulsation of the fcetal heart,
  226.  Kiesteine.—There  are  two  other  signs which I have deferred
noticing until now, because they  require more research to entitle them to a
place among the recognized evidences  of gestation, and it seemed better
that the student's attention  should rather be directed to those considered
valid, than embarrassed by doubtful ones.  The first of these tests is  derived
from the urine.   M. Nauche was the first who accurately described the
change which takes place in the urine  of pregnant women.   He found  that
" by allowing the urine  to stand for  some  time, in  thirty or forty hours a
deposit takes place of white, flaky, pulverulent,  grumous matter, being the
caseum, or peculiar principle of  the milk formed in the breasts during gesta-
tion."   This deposit  has lately  received the name of Kiesteine.   M. Egui-
sier has  published the  result of his researches on the subject.1   He states

                    i Lancette Francaise, Feb.,  1839, p. 36.
• 
166
SIGNS OF PREGNANCY.
that "the urine of a pregnant woman, examined in the morning, is generally
of a pale yellow color, and  slightly milky; it first reddens, and then turns
blue the  'papier tournesol,1 as ordinary urine.   Exposed to the contact of
air, a  cloudiness is  observed from the first day, resembling fine wool; from
the first day, also, a white matter is deposited.  These phenomena are not,
however, constant.  From the second to the sixth day, small opaque bodies
are seen rising from the bottom to the surface of the fluid, and then collect-
ing together until they form a layer, covering the whole surface : this is kies-
teine.   It is  sufficiently  consistent to be  raised  from  off  the  fluid.  It is
whitish, opaline, slightly granular, and resembles much the layer of fat which
swims on the surface of fat broth when cool.  Examined  by the microscope,
it appears a gelatinous mass of indeterminate form.   When it is old, cubical
crystals are sometimes detected."  "It persists thus for three or four  days;
the urine then  becomes troubled; small portions are detached from its sur-
face, and sink to the bottom, until the layer is entirely broken up.  Kiesteine
appears to exist in  the urine from  the first month until the period of de-
livery."  Dr. Montgomery seems to think this  appearance constant, when
the deep color and turbid condition of the urine  permit of observation.
  Dr. Golding Bird has published a series of experiments  on  this  subject,1
which confirms the  value of this test.  The pellicle  formed in  the  urine of
twenty-seven out of thirty  pregnant women,  and it was  found only in two
instances out of a number, in the urine of  unmarried women.  I shall  quote
his conclusions: —" 1.  That certain organic matters, closely resembling, if
not identical with,  caseous matter, mixed with abundance of the earthy
phosphates in  a crystallized state,  are eliminated from the blood during
pregnancy ;  and if not  otherwise removed, or taken up, are finally thrown
out of the system by the kidneys.   2.  That certain accidental circumstances,
especially connected with those morbid actions in which the kidney  is called
upon to perform a compensating  function  for the skin, as  indicated by the
abundance of azotized matter,  in the form  of amorphous lithate of ammonia,
in the urine, interfere  temporarily with the development  of caseous matter,
as they do in checking the  cutaneous and  other secretions.   3.  That,  taken
in connection with other symptoms, as the formation of a dark areola round
the nipple,  and cessation of menstruation  and abdominal enlargement, the
formation of a caseous pellicle in the urine affords a very valuable corrobo-
rative indication of  the existence of pregnancy."
   This subject has been investigated by the late  Dr. E.  K. Kane, in  the
Philadelphia Hospital, and  he has arrived at the following conclusions: —
1. That  kiesteine is not peculiar to pregnancy, but may occur whenever the
lacteal elements are secreted without a free discharge  at the  mammae.   2.
That  though sometimes obscurely developed, and occasionally simulated by
pellicles, it is generally distinguishable from all others.  3. That when preg-
nancy is  possible, the  exhibition of a clearly defined  kiesteine pellicle is  one
of the least equivocal proofs of that condition : and, 4. That when  this pel-
licle is not found in the more advanced stages of supposed pregnancy, the
probabilities, if the female be  otherwise  healthy, are as 20 to 1 (80 to 4)
that the  prognosis is incorrect.2
   227. Jacquemier's Test. —This consists in a violet color of the mucous
membrane of the vagina and vulva, dependent probably upon pressure above.
M.  Parent-Duchatelet confirms the result of  M. Jacquemier's observations,
which he states were made upon  a large number of pregnant women,  and
that the change of color was never absent.  I had lately an opportunity of
minutely examining a well-marked case, and found that the violet color  was
caused by a great number of minute veins in a varicose condition.

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

                    DURATION OF PREGNANCY.


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

             1 Dublin Quarterly Journal, vol. xiv. p.  449.  New Series. 
168
DURATION  OF  PREGNANCY.
  The first point to be settled is the ordinary term of utero-gestation ; and
we are met at the outset by the difficulty of obtaining accurate data.   The
common mode of calculation is from a fortnight after the last menstruation ;
and the period so fixed is corrected by the time at which quickening occurs.
In many instances  this proves pretty correct; in the majority, I think, it is
rather overrun; and, at any rate, the  uncertainty as to  the period of con-
ception, and the variation in the time of quickening, are sufficient to render
the computation no more than an approximative estimate.
   Cases, however,  occasionally occur,  where conception   follows  a single
coitus, and if they were sufficiently numerous,  they would settle the ques-
tion ; but they are rare.  Dr. Montgomery relates  the  case of a lady who
went to the sea-side in June, 1831, leaving her husband in  town. He visited
her for the first time November 10th, and returned to town the next day.
She quickened on the 29th of January, 1832, and was delivered August 17th,
exactly two hundred and eighty days from the time  of conception.
   The deductions from such cases, and from general calculation, have led to
fixing the term of gestation at ten lunar months; or nine calendar months
and one week, or forty weeks,  or  two  hundred and eighty  days, allowing for
some variation either way.   In an able  and interesting paper,1 Dr. Matthew
Duncan disputes the accuracy of this calculation, and maintains the truth of  '
Harvey's statement that 275 days is  the normal period of pregnancy, and
that the patient will be confined after  ten lunar months,  on the day the cata-
menia would have appeared, had she not been pregnant.  If  we take the
average  of cases  when  the  period of fruitful coitus  can  be ascertained, it
will certainly fall short of 280 days.
   230.  But then, allowing for the uncertainty of the  ordinary data,  or sup-
posing the "point de depart" unquestionable, are we to  conclude that the
actual duration of pregnancy is determinate and invariable ? We know that
it may be accidentally abbreviated without destroying the child, from  various
causes, but then this is not the natural course.   In some cases, also, the
natural duration may be within the limits here laid  down;  for example — in
Dr. Girdwood's case, the  period was  274  days.2   Dr. Rigby gives three
cases of 260, 264, and 276.   Dr. Lockwood, four cases, of 270, 272, 276,
284 days.3  There is a case in'the American  Journal of 272  days.4   Dr.
Reid5 mentions cases at 276; three of 274, one  275, 273, 271, 278, 263,
280, 264, 274, 276, 280;  two of 266, 265, 272, 275, and  271 days; and in
all these there appear sufficient grounds for believing in their accuracy, most
of them being the result of a  single coitus.  On the other hand, May it also
be prolonged?   So  much diversity of  opinion has  obtained on this point,
that it is very difficult to come to a satisfactory conclusion.   In the celebrated
Gardiner peerage case, the most eminent accoucheurs  in  the  country were
arranged  on opposite  sides.   Drs.  Gooch,  R, Blegborough, Davis, Sir C.
M. Clark, and Mr. Pennington, discrediting protracted  gestation ; and Drs.
Grauville, Conquest,  Blundell,  Merriman, Power, Hopkins, etc., advocating
its possibility.
   Dr. Dewees remarks: "I have had every evidence, on this side of absolute
proof, that it has  been prolonged to  ten calendar  months, as an habitual
arrangement, in at least four females ;  that is, each went one month longer
than the calculations made, from an  allowance of  ten  or twelve days after
 the cessation of the last menstrual period; and from the quickening, which
 was fixed at four months."  Professor  Desormeaux relates a case  of a lady
 whose pregnancy  lasted nine  months and a  fortnight..   The late  Professor
   1 Edin. Med. Journal,  Nov. 1856.                     2 Lancet, Dec. 1844.
   8 Amer. Journal of Med. Science, Dec. 1847.            * Ibid., April, 1842.
   5 Lancet, July 20th, 1850. 
DURATION  OF  PREGNANCY.
169
Hamilton, of Edinburgh, declares his "solemn conviction, that he has met
with at least twelve cases, in the course  of practice, where there could not
be the shadow of doubt of the protraction of human pregnancy beyond the
ordinary period."   M. Yelpeau has recorded nine cases of the kind.
  To these authorities  may be added the names of Harvey,  Smellie,  Zac-
chias, La Motte, Le Roi, Le Bas Fodere Capuron,  Gardien, Murat, etc.
  Dr. Montgomery relates two cases in his work, one of which came under
my observation ; in  the first the gestation continued two hundred and ninety-
one days, and in the second  forty-one weeks and two or three  days  at least.
I have referred to some of the cases on record, because,  the question being
chiefly one of authority, positive  evidence  must infinitely  outweigh  mere
negation.
   In the case of Anderson v. Whittaker, gestation1 had lasted 283  days
from  the only coitus, and in Dr. Lee's case 287 days;2  Dr. Beatty's3 case
was 291 days ;  Mr. Skey's 293 ; Dr. Ashwell's, 300 days;  Dr. M'llvain's,
293 ; Dr. James Reid's, 287 and 293.
   [It is very certain that  there are well-authenticated instances on record
in which the period of  gestation has  been extended beyond the usual term.
In the  cases  of single intercourse, 293 days  form the  longest period, or
eighteen days beyond what  is deemed to be the usual average duration of
pregnancy in the human female.   Now it is  a coincidence with the results
of Lord Spencer's  tables, that of the 764 cows whose data were so accurately
noted, the greatest excess  beyond the  average  term  of gestation in  them
(285 days) was  also eighteen days.   In a case related  by  Dr. Ashwell, of
a prolongation  of  gestation to the 300th day, the exact date  of impregna-
tion is not given ; it is stated that the husband left a few days  after the cata-
menial period ;  now as this is the only case of pregnancy extending to 300
days, some, perhaps, may doubt the exactness of the husband's statement as
to time.
   With a view  to ascertain the experience of those who were  most  likely to
have paid particular attention to this subject, upwards of forty of the most
 eminent obstetric  practitioners in London, Dublin, and Edinburgh, were
 applied to by Dr. Reid.  The large majority of these  expressed a firm con-
 viction as to the occasional extension of the usual period of pregnancy by a
 few days beyond 280.   Several had met with one or two cases of protracted
 gestation, out of many hundred, on the exact data of which they could  rely;
 others, who had not kept notes of their  cases, could not positively speak to
 facts, but had no moral doubt as to the  period  being extended in  some in-
 stances.  Some, who  have had extensive experience in private and hospital
 practice, stated that they had  never met with  an  undoubted case of pro-
 tracted  gestation;  whilst two  affirm it  as  their strong conviction, that no
case ever exceeds the  280th day from conception,  and one, that it is  never
carried beyond  the ninth calendar month.
   In order to show that no other data than the calculation from a single
 coitus is to be depended upon to fix  the commencement  of pregnancy, Dr.
 Reid presents the following  table, the result of 500  cases, in which the  exact
number of days intervening between  the last day of menstruation  and that
 of parturition is shown.  With the exception of about 50, they were private
cases in which  the data were  most correctly kept;  and the others  were
 selected from upwards  of 1000 hospital  and'dispensary cases,  presenting an
 equal certainty as to date, in females superior to the usual class of hospital
 patients.

         i Lancet, July 20th, 1850.               »  Med. Gazette, 1831.
         » Dublin Med. Journal, vol. viil. 
170
DURATION  OF  PREGNANCY.
	Days.	Cases.			Days.	Cases.	
'252 , . .		• 41		f	288.	. . .171	
	253 . .	. 1			289	. . . 8	
	254 . .	. 3			290.	... 9	
37th week. <	255 . .	. 1		42d week. ■{	291	. . . 14	► 63 cases.
	256 . .	. 2	23 cases.		292 .	... 6	
	257 . .	. 4			293	. . . 3	
	258 . .	. 4		.294.		. . . 6J	
	259 . .	• 4j					
	r260 . .	' V		f295		. . . 2"|	
	261 . .	. 5			296	. . .5	
	262 . .	. . 3			297	. . . 8	
38th week. -	263 . . 264 . .	. 9 .10	► 48 cases.	43d week..	298 299	. . .6 . . . 1	-28 cases
	265 . .	. 5			300	... 2	
	^266 . .	.10			301	. . . 4.	
	{267 . .	■ 9]					
	268 . .	.13					
	269 . .	. 5			f 302	... 1'	
39th week. -	270. .	.13	-81 cases.		303	... 1	
	271 . .	. 12			304	... 2	
	272 . . .	.13		44th week. •	305	... 1	- 8 cases.
	273 . .	. 16,			306	... 0	
					307	... 1	
	'274. .	■ .21-			308	. . . . 2,	
		. 20					
	276 .' .	. 16					
40th week. -	277 . .	. 16	-131 cases.	f809 1 310		.v.-.!]	
	278 . .	.22					
	279 . .	. 21		.K . , 311		. . . 1L	
	^280. .	.15		45th week, -j 314		, J- 6 cases.	
	f281 . . 282. .	. 18" .25		I 315 [316		\'.V2| . . . . 1J	
	283 . .	. 14				--	
41st week. <	284 . . j 285 . . 286 . .	. 15 . 14 . . 15	-112 cases.			Total, 500 cases.	
	[287 . .	. 11	i				
  In the case which occurred 314 days after the cessation of the catamenia,
it is noted that quickening did not happen until the 6th month, proving, in
Dr. Reid's opinion, that  conception  had taken  place later than had been
thought.  Had minute investigation been made, at an early period, into the
remaining five cases which went beyond the 44th week, it is most likely that
similar facts might have been observed.
  It will be  seen that the above table  agrees with  that of Dr. Merriman
(114 cases), in showing that the greatest proportion of women complete the
period of  gestation  in the 40th week after the cessation of the  catamenia,
and a very considerable number in the 41st week.
  In Dr. Murphy's  table of 182 cases, the numbers born  in the 39th and
40th weeks were about equal, being 24 and 25 ;  whilst the greater propor-
tion {thirty-two) were in the 41st week, and 25 in the 42d week — equal to
those in the 40th.
  In Dr. Reid's table the 282d day was  that on which the largest actual
proportion of the patients were delivered ; but the number from the 274th
to the 282d day ran so near to each other that we must rather take that as
the average  period.  If we allow a range of from  two to six days after
menstruation, as elapsing probably before conception  takes  place,  it will
then appear that about the  39th week after impregnation is most probably
the ordinary duration of pregnancy; and this will coincide with the result
of the table taken from cases of single coitus. 
STERILITY.
171
  In a note to a former edition of this work, Dr. Huston states that he has
known at least two instances in which he had the  strongest reasons for be-
lieving that gestation  extended, in one case two  weeks, and  in the other
three  weeks, beyond the usual period, or nine calendar months.]
  231. An  additional  argument  has been deduced from the irregularity of
the period  of gestation among  cattle.  According to the researches of M.
Tessier:  out of 160 cows, 14  calved  from 8 months  to 8 months and 26
days;  3 at 270 days ;  50 from  270 to 280 days; 68 from 280  to 290 days:
20 at  300, and 5 at 308 days ; the extremes being  thus 67 days apart.  Of
102 mares, 3 foaled on the 311th day ; 1 on the 314th ; 1 on 325th ;  1 on
the 326 ; 1  on the 330th ; 47 from 340 to 350 days ; 25 from  350  to 360 ;
21 from 370 to 377, and one on the 394th day ; the extremes being 83 days.
With  sows,  the extremes were 15 days; and with rabbits (out  of 139 cases)
7 days.
   [Recently,-Earl Spencer has  communicated the results of his observations
for a  number of years on cows, to the English Agricultural Society.1  Of
764 cases, 314 calved  before the 284th day, 310 after the 285th,  and only
16 after the 295th ; so  that the probable  period of gestation, he thinks,
ought to be considered 284 or 285 days.]
   232. In  conclusion,  there  is  no doubt that the usual  period of gestation
may be anticipated by at  least two months, without  necessary injury  or
death to the infant;  and it appears to me that the evidence we possess,  as
well as the weight of authority, is in favor of occasional protracted gesta-
tion ;  and  that, to use the words of Dr. Montgomery,  I " cannot imagine
why gestation should be the only process, connected with reproduction, for
which a total exemption from any variation in its period, should be claimed."
   But on the other hand, it must be confessed that many of  the cases ad-
duced are valueless, because  founded on data which are necessarily uncer-
tain ;  and I should be  unwilling to  admit any as conclusive, occurring  in
persons exposed  to frequent intercourse,  and calculated in  the  ordinary
manner.
   Dr. Clay, of Manchester,  has  recently published some facts  tending  to
show  that the duration  of gestation depends  much upon the age of the
parents ; that the younger the  parents, the shorter the pregnancy, and vice
versa, and  this  he conceives will explain  the variations  that  have  been
observed.   In this calculation he takes the mean age of both parents, allow-
ing something either way for the earlier maturity of the mother.
                       CHAPTER  VII.

                             STERILITY.

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

              1  fJournal of  the Agricultural Society, part ii. 1839.} 
172
STERILITY.
into curable  and incurable ; into those which cause sterility, properly so
called, and those which merely occasion impotence.   Without adopting any
special classification, I shall enumerate the organic and incurable cases first,
and then the curable,  whether functional  or organic;  and  adding othei
causes, not included in either class.
   234.  The absence of the ovaries will render the person incurably sterile,
as will also the absence of one and disease  of the other, or the disorganiza-
tion of both.   Cases of this kind are  not infrequent.   Disease of the  sub-
stance of the ovary may be extended to the Graafian vesicles, or they  may
be congenitally deficient, and so conception be prevented.   " The most fre-
quent variety of ovarian disease," says Dr. Davis, in his Obstetric Medicine,
"which we may suppose calculated  to produce this effect, is that of an ob-
viously morbid enlargement of the vesicula?  Graafianse, accompanied  by a
degenerated structural condition of their parietes."
   235.  The fallopian tubes may be  congenitally deficient  or imperforate,
though such  cases are  extremely rare.   Their  canal  may be  obliterated
from acute  or chronic inflammation, or their fimbriated  extremities  may
become  adherent to the ovaries.  Even though not  imperforate, yet the
canal may be filled with adventitious  matter.1  In all these cases, sterility is
the consequence, because the contact of the spermatozoa with the  ova is  pre-
vented : and notwithstanding.the daring proposal of Dr. Tyler Smith, I fear
it must still be classed among the incurable causes.   Dr. Tilt considers  sub-
acute inflammation of the ovaries and fallopian tubes as a curable cause of
sterility.2
   [According to Dr. Tilt, the manner in which subacute ovaritis  becomes a
cause of sterility is by the production —
   1. Of morbid lesions of the stroma, or of the vesicles of the ovula therein
contained.
   2. Of a false  membranous deposit  lining the ovaries, so as to preclude
the exit of the ovula.
   3. Of lesions  in the tubes destined to convey the ovula  to  their uterine
abode.   He  likewise stated that sterility was sometimes produced by the
uterine extremities of these tubes being blocked up by a glutinous deposit.
   Dr. Tilt has given the history of three cases in which  the  diagnosis of the
disease  was  fully confirmed, by  an  accurate  examination  of the patient
through  the  rectum, and  the treatment  recommended  caused a cessation
of the sterility after it had lasted five, six, and seven years.    The remedial
measures  prescribed were, leeches, to diminish the chronic  ovarian conges-
tion ; blisters, to break the chain of morbid nervous action, fostered by long
habits of suffering ; mercurial ointment, combined with narcotic extracts and
camphor, to reduce pain and vascular action;  medicated enemata were  also
administered with the same intention.3]
   236.  The uterus may be absent, of which numerous  cases are  recorded;
or it'may be undeveloped, which  Dr. Yanoni  considers a cause of sterility.
If present, its cavity may be partially or wholly obliterated, as was noticed
by Morgagni, Baillie, and Mott;  these cases are  of course incurable.   The
canal of the cervix may be impervious, or its mouth covered bymembrane,
as in many cases  on record ;  but though sterility results so long as it con-
tinues, it is within reach of treatment, and may be cured by  puncturing.
   Diseases of the uterus, such as carcinoma, polypus, prolapsus,  etc., are
enumerated among the causes of sterility, but erroneously, I think.  Madame

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

     1 Gream: Lancet, 1849. vol. i. pp. 91-204. Churchill's Diseases of Women.
     a On Abortion and Sterility, p. 406. 
174
PSEUD 0- PREGNANCY.
no explanation  can  be given;  we can  only conjecture  that the  ovaries or
fallopian tubes are defective, or that some sexual incompatibility exists.
  The uterus and vagina are within  reach of an examination, and their con-
dition can be minutely ascertained  by  means  of the finger, the speculum,
and bougies.
                      C HA P TE R  VIII.

        SPURIOUS PREGNANCY —PSEUDO-PREGNANCY.

  240. It may not be unprofitable hereto say a few words upon that curious
and obscure disease which has received the  above names, and which Dr.
Simpson has proposed to call " pseudo-cyesis."
  Isolated cases of the disease have probably occurred to most men in ex-
tensive practice, and numbers of them have been  recorded  by ancient and
modern writers, but the most, if  not the only, complete monograph  on the
subject is a lecture by Professor Simpson,1 and I think he will forgive the
ample use I must make of it in this chapter.
  241.  The phenomena of the disease have  essentially an  hysterical cha-
racter ;  there is almost always some derangement of the menstrual function,
with certain reflex irritations, and a swollen state of the abdomen.
  242.  Cases of this kind occur in females of all  ages.  Dr.  O'Ferrall has
recorded one in a girl aet. thirteen.  I have seen one in another set. seventeen.
Dr. Simpson thinks the complaint as  frequent during the first year after
marriage as at any other time.   I have seen it in a woman who had borne
several children, and  Dr. Montgomery thinks it most frequent at the  climac-
teric period.   From the undoubted fact of unmarried females being liable
to the disease, it is clear that its recognition is important, not merely for the
purpose of cure, but  to avoid the injurious suspicions to which the  patient
would otherwise be exposed.
  243.  Symptoms.—I have  already mentioned that the abdomen is  swollen
in various degrees, but rarely, I  think, to a very extreme degree.   It feels
firm and elastic, and  as a general rule yields  a clear  resonance on  percus-
sion.   This is  not always the case,  however;  for in  one  case I saw, the
upper part of the tumor was rather dull, whilst  the lower was quite clear,
without our being able to explain the difference.  The abdomen is generally
equably swollen, but protruding more  anteriorly.   In women who have not
borne children the lumbar  region bulges,  and is resonant, but when the
patient has been pregnant, the tumefaction may assume  the exact form of
the pregnant uterus, as in a case I saw, where it filled the mould, as  it were,
left by former pregnancies.
  The catamenia are generally deranged, scanty, irregular,  or, perhaps, al-
together suppressed,  and as  the  breasts very  commonly sympathize  and en-
large, and the stomach exhibits  some reflex  disorder, we can easily excuse
in an ordinary person the suspicion of the existence of  pregnancy.
  244.  Now, if the person be unmarried, and of a questionable character,
it is more than probable that in the estimation of her friends, her character
will soon cease to be questionable.  If she be married, pregnancy will pro-
1 Med. Times and Gazette, Sept. 3, 10, and 17, 1859. 
PSEUDO-PREGNANCY.
175
bably be taken for granted, and the mistake only detected when labor ought
to occur, or when, curious to say, some sort of abortive imitation of labor
does take place.   The mistake is even more likely to occur in women " of a
certain age," as  they seem rather easily persuaded of an event so  creditable
to their virility,  and of this nature are probably all the stories current of
ladies deceiving  themselves  and their friends.   The difficulty is  somewhat
increased at this period of life by a not unusual increase of fat giving to the
enlargement a more resisting feel and a duller resonance.   Having decided
in favor  of pregnancy, from the  assemblage of the foregoing phenomena,
the patient finds confirmation  strong in  certain sensations which  she  sup-
poses to be fcetal  movements, but which, when  questioned, she admits are
not exactly the same as in former pregnancies.   And the difficulty of diag-
nosis is much  increased, as  Dr. Simpson  has remarked, by a repetition of
individual peculiarities which  occurred in  former pregnancies ; as, for ex-
ample, peculiar  discolorations of the  skin, or eruptions, or  neuralgias, or
changes  of temper.
   Nevertheless it should be remembered  that there is  generally some irre-
gularity or defect in the sequence, or grouping,  or character of these symp-
toms which distinguishes spurious from  true  pregnancy when minutely in-
vestigated, and it is upon this mainly that our diagnosis will depend.
   245.  As to the course of the  disease, it will vary.   The symptoms may
disappear after a few weeks or months, or they may continue for  about the
usual term of pregnancy, and then  disappear.  Or in some  few cases the
enlargement and its train  of  symptoms  may go on for twelve or eighteen
months,  or for some years.
   246.  Diagnosis.—Dr. Simpson has truly observed that "however closely
all the  ordinary symptoms of real pregnancy may be represented  and simu-
lated in  the spurious  affection, and however minutely even the  individual
idiosyncracies sometimes seen  in the former may be imitated  in  the latter,
there is usually some deviation from  the ordinary course of events and some
difference in the  order and  correspondence of the ordinary phenomena,
which may serve to  put you on your guard, and lead to the discovery of the
true state of affairs."   The symptoms of early pregnancy may be simulated,
but all those of  a later period cannot.  Suppression of menstruation, sick-
ness of stomach, and increase of the breasts and abdomen, may be present,
but they may not have the  usual  completeness or sequence.  Enlargement
of the uterus, diminution of its neck, the placental  bruit and  the  sounds of
the fcetal heart will not, and their absence at a (supposed) period when they
ought to be present, will in  competent hands be conclusive.
   247.  If the  abdomen be pressed between the two hands placed at its sides,
we can at once detect that there is no such solid body as the  gravid uterus
present;  and if  to this we add careful percussion, we shall be satisfied that
the distension is neither by solid nor fluid.  An examination per vaginam
will reveal to us  the cervix,  and  as far as we can reach it, the body,  of its
normal size when unimpregnated ; with the usual mobility and with an entire
absence of direct shock when the abdomen is lightly struck.
   The only difficulty in coming to a conclusion will be when  the uterus  is
coincidently retroverted or enlarged by fibroid or other growths, or in  case
of an ovarian tumor.
   248. Auscultation affords only negative evidence,  of course ; but in prac-
tised hands even this is of great value at a (supposed) advanced period.  I
need hardly say that on this point we should not trust to  one or even two
examinations.
   249. But perhaps the best aid we  have in our diagnosis is in the effects
of anaesthetics.  Bring the patient fully under the influence of chloroform ;
carefully and cautiously at first, but completely at last, and we may observe 
176
PSEUDO-PREGNANCY.
the abdomen relax in its tension, flatten, and finally subside ;  thus giving us
an opportunity to  ascertain the exact condition  of the abdominal organs.
Wait a little, and as the effect of the chloroform goes off, the abdomen will
rise gradually until it attains its previous size.
  Taken altogether, the evidence thus obtained will hardly fail to be con-
clusive.
  250. Pathology. —There may or may not  be any uterine or ovarian dis-
ease.   Some degree of  congestion or erosion is not uncommon ; with ante-
version or retroversion  it may be, but it is clear that these do not form  an
essential part of the disease.   Dr.  Simpson thinks that "the aggregate  of
symptoms which we class under the designation of 'spurious pregnancy' in
women, is in some way or other dependent upon the changes which occur in
the ovaries and in the uterus at the period of menstruation."  I think this
very likely, but as yet it is only a brilliant suggestion to be tested by minute
investigation.
  251. But what is  the enlargement ?  Is it simply a gaseous distension ?
Apparently not, for in some cases  Dr.  Simpson  introduced a tube into the
rectum, and placed the free end in water, whilst the abdomen subsided under
the influence of chloroform, but not a bubble of air escaped.   He believes
that "the phenomenon  most probably depends on some affection of the dia-
phragm,  which is thrown into a state of contraction, and pushes the  bowels
downwards into the abdominal cavity."  Although I have no better expla-
nation to give, I confess myself far from satisfied with this.
  252. Treatment.—There are three things to be borne in mind in the treat-
ment  of this affection : 1st, that the general health is more  or less disturbed ;
2d,  that  the  menstrual  function is incomplete ;  and 3d,  that there may  be
some  special local  disease.   Whatever the  latter be,  it is of course  to  be
specially treated, and removed if possible, concurrently with which an effort
should be made to improve the  general health.  I have no doubt that if we
succeed in restoring the regularity of the  catamenia, we shall find that a
great step will be gained; but it may be a question whether we should im-
mediately have recourse to  emmenagogues.   It may  be  first desirable,  as
Dr. Simpson advises, to endeavor to allay the irritable condition  of the
uterus and ovaries; and for this purpose he recommends  the bromide and
iodide of potassium.  Five or six grains of the former may be  given three
times a da}-, either alone or with from two to three  grains of the iodide of
potassium.   Or it may be applied locally in the form of a pessary.  Further
carbonic  acid gas,  with or without chloroform,  may be thrown  into the
vagina.  Such soothing remedies Dr. Simpson has found very beneficial.
  * or the nausea and vomiting  we  may have recourse to any of the  remedies
usually recommended.   Opium; acetate of lead, prussic acid, carbonic acid,
ice, creosote, or perchloride of iron or oxalate  of cerium, as recommended
by Dr. Simpson.
  As far as the distension may be  due to flatulence, we may seek  relief by
assatcetida, ox gall, turpentine,  the valerianates, powdered charcoal etc
  Ihe bowels should be kept free by effective but mild purgatives, and'the
diet bland and nourishing. 
SUPERFOETATION.
177
                        CHAPTER  IX.


                          SUPERFOETATION.


  253. The term Superfoetation has been applied to those cases of abnormal
conception in which a female already pregnant  has  been supposed to con-
ceive a second time before the termination of the first gestation.  The belief
in the possibility of such an  occurrence is universal among the older writers,
and cases are adduced in support of this view, but modern writers have been
more  divided  in  opinion ;   it is denied by  Hebenstreit, Ludwig, Nutger,
Schmidtmiiller, Blumenbach, Beck, etc. ; but admitted  by  Haller, Hervey,
Ploucquet, Barzelotti, Velpeau, Cuming, etc.
  254. The cases alluded to are such  as the following : — 1.  It is not un-
common  for women to  be  delivered  of a full-grown  child and a blighted
ovum at  the same  time, and from  the  disparity between them it  has been
assumed  that the period of conception was different for each.
  2. Again, a woman may be delivered of two living children at one birth,
or within a few hours of each other, one  of which  may be fully developed,
while the other appears immature.
  3. Further, the same woman has given  birth to twins, of different color,
as in the case related by Buffon, and quoted by Fodere and all recent writers
on  the subject, of a woman at Charleston, South Carolina, who was de-
livered in 1714 of twins, within a very short time of each other, the one
being black, the other white.   On examination, the woman confessed that
on a certain day, immediately after her husband had  left her, a negro en-
tered her room, and by threatening to murder her in case of refusal, obtained
connection with her.
  Dr.  Moseley mentions a similar  case : — "A  negro woman  brought forth
two children at a birth, both of a  size, one of  which was a negro, the other
a mulatto.  On being interrogated upon the cause of their dissimilitude,
she said  she perfectly well knew  the  cause of it, which was, that a white
man belonging to  the estate came to  her  hut one morning before she was
up, and she suffered his embraces  almost instantly  after her black husband
had quitted her."1   Cases  of the  same kind have been published by M. de
Bouillon, Drs. Dewees, Trotti,  Guerarde, Delmas, Dunglison,  etc.
  4. Lastly, cases  have  occurred  where the birth  of a mature child was
succeeded, after the lapse of some months, by the birth  of another.  Seve-
ral such  cases might be  cited.  In  the Recueil de la Societe d'Emulation,
there is  one of M.  A. Bigaud, of Strasburg,  aged 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
12
1 On Tropical Diseases, p. 111. 
178
SUPERFOETATION.
the College of Physicians, London.   Mrs. T., an Italian lady, but married
to an Englishman, was delivered of a male child  at Palermo, November 12,
1807.  On the 2d of February, 1808, not quite three calendar months after
the preceding accouchement, she was  delivered  of a  second  male infant.
Dr. Maton assured Dr. Paris that "both the children were born  perfect;
the first, therefore, could  not have been a six-months child."   Other cases
may be found quoted by Beck, Velpeau, and  Cuming, and collected in  the
elaborate essay of Dr. Alexander Henry.1
   255. Upon the strength of these cases, it  is assumed that a second  im-
pregnation may be effected,  although the uterus  be occupied by the results
of a previous conception.   Our  first object is, therefore, to ascertain  how
far the cases, considered in themselves,  warrant such a  conclusion, and then
whether, if the cases are  not otherwise  explicable, we  are bound to adopt
this theory as the true explanation.   First, then,  I would  observe  that  the
first and second  class of cases  can be easily explained without having re-
course to the doctrine of superfoetation at all.  When  twins are conceived
from  the  one intercourse, it not unfrequently happens that  one ovum is
blighted, and sometimes  rejected, sometimes  retained,  and  occasionally the
appearance of the ovum, when subsequently expelled, wall  be found to cor-
respond to the period of pregnancy at  which symptoms of uterine disturb-
ance and threatened abortion appeared.  Again, nothing is more  common
in twin pregnancy than to find  one  more fully grown than the other, and
nothing more easily explained.   So that neither of these cases are any sup-
port  to the  doctrine, because  they are susceptible of another and  more
simple explanation.
   The third class, where children of different colors  are  brought forth, is
equally unavailable ;  for, at the utmost, they only prove that a double con-
ception may occur from connection with two individuals, if  such intercourse
take place with a very short interval.  If such cases  occurred with an in-
terval of four or five months between  the  birth of the children, the case
would be  altered; but I  am not aware of any such on  record.
   It must be confessed that the fourth  class of cases is very difficult of ex-
planation, and they are the only ones of any force in support of the theory.
It has been supposed, that in such cases both children  were begotten at the
same moment, but that the tardy birth of the latter was owing to its slower
development:  but this  explanation requires previous proof  that a  slow
growth of the foetus involves a protracted gestation.
   Another  explanation  has been proposed, based on the fact, that when
 pregnancy has occurred with a double uterus, one cornu only is occupied by
 the child.  It may in such cases be possible (so it is argued) for the woman
 to conceive a second time, and the child to occupy the vacant cornu, although
 the woman were previously pregnant; and in support of this view, a case
 is adduced which occurred to Mad. Boivin, and  which  is related in M. Cas-
 san's thesis, On  Double Uterus and Superfoetation :  " On the 15th of March,
 1810, a woman, aged forty, gave birth to a female infant, weighing  about
 four pounds.  As the abdomen still remained bulky, Madame Boivin  intro-
 duced her hand,  but could find nothing in the uterus.   But the examination
 led her to suspect that there was another foetus, either extra-uterine, or con-
 tained in a second cavity in the womb.  At length on  the 12th of May, a
 second female infant was born, weighing not more than about three pounds,
 feeble, and  scarcely able to respire.   The  mother assured Madame Boivin
 that she had no connection with her husband (from whom she had been some
 time separated),  except thrice in two months, viz.,  on  the 15th and 20th of
 July, 1809, and  on the 16th of September following." In this case there

                     1 London Med. Journal, 1849, p. 1087. 
SUPERFCETATION.
179
can be little doubt of the existence of a double uterus, and it would be diffi-
cult to disprove that the second child was not the fruit of the last concep-
tion, and, if so,  a clear case of superfoetation ; but, even granting so much,
it only proves the possibility of  such an event when  the  uterus is double,
and it would not only be very bad logic  to assume that the uterus was double
in all  cases when two children are  born at considerable intervals ;  but it
would be inconsistent with facts,  for it is  expressly stated that  in the case
of M. A. Bigaud,  already quoted, the uterus was found, after her death, to
be single.
  256.  Thus, whilst we need not deny that a double uterus may afford an
opportunity for  a  double conception, at distant periods, we  cannot admit
one such case as explaining all the cases of  that kind on record ; and with
respect to such, we have made no advance  towards  an explanation.  Ad-
mitting this, are we necessarily to  adopt the hypothesis of superfoetation ?
I think not, because the real difficulties  of such a theory appear insurmount-
able ; and if so, our ignorance of the true explanation is no argument for
the adoption of a  false one.   The  physical  difficulties are those which
depend on the changes induced by impregnation.  The reader will find that
it was  stated (§ 160) that,  shortly after conception, the uterus is lined by
the deciduous membrane, a  shut sac, closely adherent to  the lining mem-
brane of the uterus throughout, and covering the orifices of the  os uteri and
of  the fallopian tubes ; that the  canal  of the cervix  uteri is, during preg-
nancy, plugged  with tenacious mucus secreted  by the  glands.   Now if this
be  the case, and if it be an essential condition of generation (§ 143) that the
spermatozoa pass into the uterus, if not through the fallopian  tubes to  the
ovaries, it is evident that the theory of superfoetation involves so much appa-
rent  physical impossibility,  that it must be rejected,  unless it can be shown
how the spermatozoa can obtain  access to the ovaries when the uterus is (as
it were) hermetically closed.
  Another view has been latterly put forth by Dr. J.  M. Duncan, which, if
true,  would  help  us to a  solution of the  difficulty.   He states that  the
decidua reflexa  is not  in contact with the decidua vera till after the third
month, and that up to that  time there may  be free communication between
the ovary and vagina,  and consequent  liability to a  second impregnation.1
Additional evidence, however, would be necessary to establish this opinion,
and until we possess it, I must honestly confess that I have no better expla-
nation to offer of  such cases as Dr.  Maton's; but surely it is more philoso-
phical  to  acknowledge our ignorance, and  patiently to wait for additional
information, than,  in our impatience in  a state of uncertainty, to adopt a
theory  involving such difficulties.
   257.  In conclusion, I would say,  1.  That the theory of superfoetation is
unnecessary to  explain the birth of a mature foetus and blighted ovum ; of
a  mature  and immature foetus, born together  or within a month of each
other ;  or of foetuses of different colors, as they may reasonably be supposed
to  be the product of one act of  generation, or of two, nearly contempora-
neous.   2.  That in cases of double uterus,  it  is possible  for a second con-
ception to take  place, and (judging  from the subsequent birth of the second
child, in the only  case  on record) at a  later  period than the first.   3.  That
in the remaining cases, where one mature child succeeded the birth of another
after  a  considerable  interval, we  have no proof of a  double uterus  in any,-
and positive proof that in one case it was single, and that to the explanation
of these cases, no theory as yet advanced  is adequate; that of superfoetation
being opposed  by  physical difficulties,  which are  insurmountable in  the
present state of our knowledge.
i Edin. Monthly Journal, April, 1853. 
130                EXTRA-UTERINE  PREGNANCY.
  [Notwithstanding this positive  assertion of Dr. Churchill, we have on
record well-authenticated cases of superfoetation, in which it has been shown
that the uterus possessed but a single cavity.   Simpson,  Duncan,  lyler
Smith, and others deny that there is anything to prevent fecundation inthe
condition of the  pregnant  uterus, during the early period of  gestation.
The mucous plug has been shown by Dr. Tyler Smith to be in no respect
different, except in quantity, from the mucus which always occupies the cer-
vical canal of the uterus in the unimpregnated state, and through which the
spermatozoa make  their way in ordinary fecundation.   The cervical plug
therefore presents no insurmountable impediment to the occurrence of super-
foetation.   Neither does any obstacle occur to the passage of a second ovum
into the cavity of the uterus when already occupied  by one; inasmuch as
neither of the layers  of the decidua in the first  month  of pregnancy pass
over the orifices of the fallopian tubes nor the uterine orifice of the cervical
canal.   Until  the end of the third month the ovum with  its envelopes is
attached to a small  portion only of one of the parietes of the uterus, leaving
every other portion  of the decidua  vera perfectly free for the reception  and
development of a second ovum.   " The infrequency of superfoetation," as
well remarked by  Dr. Tyler Smith,  "probably  depends  more upon  the
absence of perfect ovulation during  pregnancy  than   upon any  positive
mechanical impediment to the ascent of the spermatozoa, or the incapacity
of the decidua vera to receive a second ovum."]
       C HAPTE R  X.

EXTRA-UTERINE PREGNANCY.
   258. From certain causes, with which we are but partially acquainted, it
 sometimes happens  that the  ovum, instead of passing into the fimbriated
 extremity of the fallopian tube on the bursting of the Graafian vesicle, and
 being thence transferred into the uterine  cavity, in the gradual  manner
 already described, is arrested in some part of its progress, where an  effort is
 made to supply the  place of the uterus, and afford space and nutrition for
 the foetus.   This, however, can only be partially successful, and the foetus
 ultimately perishes for want of nourishment.   To  this misplaced gestation
 various names have been given — " Extra-uterine pregnancy," " Conceptio
 vitiosa," "Grossesse contre nature," "Exfoetation," etc., etc.
   This abnormal deviation from  ordinary  gestation  was known,  but not
 minutely, to the ancients.   Albucasis relates a  case of foetal bones being
 extracted from an abscess, which had formed near the umbilicus, and similai
 examples were recorded by Cornac, F. Plater, Cordaeus, Horstius, Primrose,
. Hildanus,  Riolan, jun., etc.   In  more  modern  times very numerous  and
 well-authenticated cases have been published,  and have been carefully col-
 lected and referred to by Dr. Campbell in his learned essay on this subject,
 to  which I  have been principally indebted for this chapter;  and if I need
 any excuse for the freedom with which I  have availed myself of his labors,
 it must be  found in the fact that his assiduity in collecting, and care  in
 referring  to the numerous cases on record, as well as the accuracy of his 
EXTRA-UTERINE  PREGNANCY.                181
reasoning and  the  excellence of his practical recommendations, have  left
little or nothing for me to do but to follow in his steps.
  259. All  the varieties of extra-uterine pregnancy may be reduced to
three : —
  1. Ovarian foetation, when the ovum is detained in the ovary; 2. Tubular
f notation, when the fallopian tube is the seat of the  arrest;  and, 3. Inter-
stitial foeUdion, when the ovum enters the parietes of the uterus, but is de-
tained in an interspace  of the fibres before it arrives in the uterine cavity.
  Dr. Campbell has added another variety, which he calls  the ovario-tubal,
a compound of the two first, when the sac containing the foetus is  formed
by the ovary and fallopian  tube jointly.   A fifth species, ventral foetation,
is enumerated by most  authors, where the ovum is found in  the  abdominal
cavity ; but I think Dr. Campbell is right in supposing  such cases to have
originally belonged to  one  or other variety previously mentioned, and for
which a separate section is scarcely necessary.
  A brief notice of each variety,  with the details of a case  or two, will be
necessary before considering the symptoms and termination, etc.  For refer-
ence to cases, I beg to  refer the reader to Dr. Campbell's book.
  260.  1. Ovarian  Fcetation.—By some writers the existence  of  this
species of extra-uterine  gestation  is considered  as rather doubtful,  on
account  of the facility afforded for the escape of the ovum after the rupture
of the Graafian vesicle, but  the evidence of facts is too strong to be resisted.
   The earliest example on record is to be found in the Philos. Trans.,  vol.
ii.,  p. 650, communicated by the Abbe de la Roque.   It occurred in 1682:
the  right ovary was  enlarged to the size of a ben's egg, and lacerated
through its  whole length.  The foetus was found in the abdominal" cavity, in
the midst of a  large quantity of blood.
   The following instance  I quote from Dr.  Campbell; it occurred in the
practice of Dr. Granville, and,  from his  high character, no doubt  can be
entertained  of its accuracy.   " The subject of the  case was a  lady, aged
thirty-nine,  the mother of seven children.   Until Dec. 1818, when she con-
ceived, the  catamenia  were  regular;  and from  this period till June  9th,
 1829, the time of her decease, she  experienced various and severe sufferings,
and there were occasional discharges of a colorless fluid  'per vaginam.'
After death a  considerable  tumor, soft and  movable, was  perceived  imme-
diately above the  pubes, and rather to the  left of the linea alba.   On re-
flecting the abdominal  parietes, blood to the amount of several  pounds was
observed to fill every space which the viscera did not occupy.  The tumor
alluded to was about four times the size  of a hen's  egg, and displayed the
same general black-reddish  hue of all the ambient parts.  A bloodvessel, the
size of a large crow-quill, which penetrated the dense portion of the tumor,
was traced upwards to the  descending aorta, and was ascertained to  be  a
branch of the  left spermatic.  A smaller and much  shorter vessel arising
from the tumor, was also  found to communicate with the spermatic vein,
thus establishing a complete circulation to and from the parts.  The inferior
and left  half of the tumor  presented a surface, consisting at two or three
points of diaphanous  membranes, through which  a foetus of  about  four
months'  growth was  readily discovered.   The left ovarium was the  seat of
the tumor, which, as it gradually enlarged, distended the tunics of that organ
in the same progressive manner, in a ratio with its own size.   As the foetus.
however, increased further, the ovarium burst in three places;  and thus the
membranous sac forming the tumor partially protruded into the abdominal
cavity.   During  this destructive  process,  that part of the  parietes  of the
ovarium  to which the placenta was attached was also lacerated, so as to  tear
the adhesion of the mass, thereby producing sudden  and fatal hemorrhage,
The right ovary was sound." 
182
EXTRA-UTERINE  PREGNANCY.
  261. 2. Tubal  Fcstation.—When  the arrest of  the  progress  of the
embryo takes place at the fimbriated extremity of the fallopian tube, we fre-
quently find that the ovary forms  part of the walls of the cyst in which the
foetus is contained, though it is not always easy to point out the exact locality
Fig. 80.
Tubal Foetation.
of the arrest.  "In some instances," says Dr. Campbell, "it maybe pre-
sumed that in the incipient stages of gestation, the ovulum is connected with
only one of these appendages, either  the  ovary or the tube ;  and that the
second organ, whether ovary or tube, becomes involved merely in consequence
of its state of activity, its progressive enlargement, and the pressure exerted
by the ovum, together with the consequent morbid excitement."  Such cases
constitute the " ovaria-tubal gestation" of this author, and to  this class  he
conceives to belong those which  have been  recorded as examples of " ven-
tral-foetation."
  262. But of all the varieties  of extra-uterine gestation,  that where the
embryo is contained in the tube  itself is the most  frequent.  Riolan pub-
lished the first well-attested example, and he  was followed by Littre,  Sancto-
rinus, Poteau, etc., etc.  The following example is taken from the Transac-
tions of a Society for the Improvement of Medical and Surgical Knowledge,
vol. i. p. 216 : "A married woman in her second pregnancv, in consequence
of a bilious complaint to which  she had  formerly been subject, used some
remedies she had been wont to  employ, and also a warm bath.  She had
been obstructed but one period, and paid  so little attention to this circum-
stance, that she did not make  it known, either to her husband or to the
ordinary medical attendant.   On May 13th, 1791, the  morning  subsequent
to her having used the bath, she  was suddenly seized, without  any previous
exertion, 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 subdue, the  pain, which now attacked  the
loins as well as the abdomen, and recurred in violent paroxysms,- accompa-
nied by vomiting, yawning, and  fainting.   On the 16th she was  somewhat
easier; but towards evening there was an  aggravation of her  suffering
accompanied by cold sweats, coldness of the lower  extremities, interrupted
articulation  great restlessness, with want of pulsation at the wrist,  and she
expired.   Autopsy. — Nearly a gallon of blood was found effused into  the
abdominal cavity;  a laceration of an inch and  a half in length  about  the
middle of the right fallopian tube ; an embryo of the sixth or%eventli week
in the  blood; the  uterus lined with decidua, and its cavity filled up  with
gelatinous matter."                                               F
  I cannot but notice in this place two  cases  published by  Dr. R. Lee*
                      1  Med. Gazette, vol. xxvi. p. 436. 
EXTRA-UTERINE  PREGNANCY.
183
because of the peculiarity of the situation  of the membrana decidua :—"A
lady died  suddenly, in 1829, from internal hemorrhage, produced by rupture
of the right fallopian tube, which contained an ovum.  On opening the tube,
and  examining the different parts of the ovum, I found a deciduous mem-
brane everywhere surrounding the  chorion, and closely adhering to the inner
surface of the tube, as the decidua usually does  to  the lining membrane  of
the uterus in ordinary gestation.   Within the decidua the chorion, placenta,
amnion, and  embryo were distinctly seen."  Again, "on  the 18th of July,
1836, Mrs. K----, after suffering some time with symptoms of inflammation
and  retroversion  of the uterus, was seized with great faintness, and  soon
expired.   A large quantity of fluid blood  was found in the abdominal cavity,
and  the right fallopian tube was extensively lacerated near its  fimbriated
extremity.  On removing the uterus and its appendages from the body, and
carefully examining the  ovum  contained  in the right fallopian tube, it was
evident that a deciduous membrane everywhere surrounded the chorion, and
adhered to the inner surface  of the tube.   The uterus was considerably en-
larged, and its inner surface was coated with a very thick layer of yellowish-
white soft substance, like common adipose matter, and bearing no resem-
blance to  the deciduous membrane.  There was  no trace of any arterial oi
venous canal in this coating."
   263.  3.  Interstitial Fcetation.—This form is the rarest of the three or
five ; but the following case leaves not a  doubt of its existence.  It occurred
in the practice of the late Mr. Hey, of Leeds, and by him was communicated
to Dr. W. Hunter.  " The patient, aged thirty-five, of a healthy constitu-
tion, was  seized, when two months advanced  in  her second gestation, with
pains resembling colic, which were subdued by appropriate remedies ; but in
the  sixth month they returned with much greater violence, and  were more
diffused than formerly."  They  were repeatedly alleviated, but as  frequently
returned.   When the term  of gestation  was completed, the  movements  of
the child ceased.   Pains came on, but with little effect, and vomiting, which
produced great emaciation, and ultimately proved fatal.   "Dissection ex-
hibited adhesions between the omentum,  intestines,  peritoneum, and a large
peculiar sac, which occupied nearly the whole abdominal cavity.  Besides a
well-formed foetus, free from any mark of decomposition, the cyst,  which was
a  line and a  half in  thickness, contained a quantity of chocolate-colored
fluid, and some purulent-looking  matter.  • The  umbilical  cord passed  from
the 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
contained the foetus.  This smaller cyst, which  must have been  the  uterus,
contained a placenta of a size so unusual that it filled three-fourths of the
cavity of  the organ;  both together weighed  two pounds and a half avoir-
dupois.   No trace of  cicatrix could be detected in the uterine parietes.
The membrane of  the ovum, after lining  the uterine cavity, was  reflected to
form the inner lining of the cyst which lodged the foetus."
   264.  Causes.—After the instances I have quoted in illustration  of each
variety, we may now proceed to inquire  as to  the causes of extra-uterine
gestation, which, however, are  by  no means  easy of discovery.   It is pos-
sible that  either congenital malformation  or pathological changes may retain
the fecundated germ in the ovary, or prevent its entrance into the fallopian
tube, or arrest its progress after its  entrance.   Narrowness or obliteration
of the tube may effect this.
   [Velpeau seems to  think that  occasionally too  great density, or preter-
natural thickness  of the  covering  of the  ovule, or envelope  of  the ovary,
may detain the ovum and prevent its entering the fallopian tube at the proper
time, and  thus become the cause of extra-uterine pregnancy;  and  likewise
various pathological conditions of the tube, as paralysis, spasm, excision, or 
184
EXTRA-UTERINE  PREGNANCY.
 insufficient length, engorgement, contraction, or inflammation and ulceration
 of its mucous membrane," etc.   Astruc believed that unmarried  women were
 more liable to this accident than others, and it is supposed to be caused by
 fear or other strong mental emotions.  Two striking instances are mentioned
 by MM. Lallemand and Baudelocque, in which it seemed to be  caused by
 fright.   Dr.  Rigby very properly observes on this subject, that "it  must
 always remain a matter  of great obscurity as to the immediate causes of
 extra-uterine pregnancy, more especially of the ovarian and ventral species ;
 and  the more so as we are still ignorant of the mechanism by which the fim-
 briated  extremity of the fallopian tube grasps the ovary immediately over
 the  impregnated vesicle of De  Graef at the  moment of conception.   In
 many cases we are inclined to believe that this function of the fallopian tube
 is destroyed  by adhesion between it and the ovary, a circumstance  of not
 uncommon occurrence ; but from the alteration in the shape  and size of
 these parts, as also from extensive adhesions which are usually found  after
 death  in such cases,  it will ever  be difficult, and perhaps impossible to
 prove it."]
  In addition, interstitial foetation has been attributed to narrowness of the
 uterine  orifice of the  fallopian  tube, or  an unusually large  interspace be-
 tween the fibres, or to a partially cornuated uterus.
  But these  causes, it is evident, are mainly conjectures.
  2G5.  Symptoms.—The symptoms vary  a good deal.  So long as the part
 in which the embryo is lodged  can  accommodate it, there may be but  little
 disturbance,  and nothing to afford grounds for  a correct diagnosis. In other
 cases, the local symptoms resemble those in disease of the uterus or ovaries.
 In the greater number of cases, there is much suffering from an early period.
 Certain of the signs of pregnancy may be present, but a degree  of irregu-
 larity in their intensity will frequently be observed.   Thus,  the  catamenia
 may be present or absent, and, if present, either scanty or profuse ; and not
 seldom there is hemorrhage, or a discharge of clots, which have  been  mis-
 taken for portions of  the placenta.   The  mammary sympathies are excited
 in most cases, and the changes in the areola take  place.   The patient may
 or may  not suffer from nausea or vomiting, and in some  cases  at an  early
 period the foetal movements have been felt by the patient.  The increase
 of the abdomen generally differs from that in ordinary pregnancy, being
 more to  one  side, and the pain  or  uneasiness may be limited  to the  spot
 where the tumor is felt.  M. Chaussier lays great stress upon a sense  of
 weight and uneasiness, deeply seated in the pelvis, and occasionally extend-
 ing to the kidneys.
  An examination per vaginam reveals a great deviation from  the state of
 the organs in ordinary gestation.  The os uteri may be  high or depressed,
 but it is  very seldom drawn out or dilated; in fact, it is generally as it was
 before impregnation, or nearly so.
  266.  When the cyst in which the ovum is  contained  bursts, however, a
 series of new and alarming symptoms are superadded.   The patient com-
 plains of great uneasiness or pain suddenly occurring, languor, debility, and
 exhaustion to an  extreme degree ; there is sometimes'a sanguineous  dis-
 charge from  the vagina, with dysuria, tenesmus,  irritable stomach, etc.; in
 short, the patient exhibits the symptoms of collapse from  loss of blood,
 _ In tubal foetation, these symptoms generally come on more suddenly  than
 in the other varieties,  so as at once to excite suspicion of  a rupture of some
 internal  organ having  taken place.
  In interstitial foetation, the symptoms are a  modification of those in the
other varieties.   In some there  are  abdominal pains  and sanguineous dis-
charges, in others these are absent;  but in all the cases on record the tume- 
EXTRA-UTERINE PREGNANCY.                Itf5
 faction and foetal movement were confined to one side of the  abdomen.   It
 is also remarkable, that in all, the child  appears to  have lived to the term
 of utero-gestation.
   267. I have already stated that matters may go on more  or less quietly
 for some time, not without injury to  the  health  of the mother, but without
 danger to her life.  However, the crisis must come  sooner  or later, when
 the cyst gives way, and  symptoms of collapse  set in, followed  by those of
 inflammation.  This crisis may be hastened by various circumstances, such
 as violent action  of the  abdominal  muscles, and  the consequent pressure
 upon  the  tumor,  sudden shocks, or blows upon  the abdomen,  coughing,
 vomiting, etc.  The rupture of the  cyst may be  followed shortly by fatal
 results, owing to the shock  to  the system, the hemorrhage, subsequent in-
 flammation, or from one or more of  these consequences combined.
   268. But there are many exceptions to such prompt terminations.   The
 patient may survive the  shock, hemorrhage, and subsequent inflammation,
 and the parts may accommodate themselves to the  presence of the foetus, so
 that  the  patient shall recover a certain  amount  of  health, and suffer but
 little local inconvenience ; nay, she may even again conceive and bear child-
 ren ;  " nine women conceived once during the retention of the extra-uterine
 foetus; two twice; one three times; one four times ; one six times;  and
 one seven times."
   The period during which the foetus may be retained before the mother's
 death or its own expulsion varies much.   Dr. Campbell gives the following
 account of seventy-five  cases;  it was retained  "three months in two in-
 stances ; four months in one ; five months in one ;  nine months in two ;  fif-
 teen months in three ; sixteen months in two; seventeen  months in  two ;
 eighteen months in seven ; one year  in five ; two years in eight; three years
 in seven ;  four years in  four;  five years in one ;  six years in  two ; seven
 years in three ; nine years in one ; ten years in tjiree ; eleven years in two ;
 thirteen years in  one ;  fourteen years in two ; sixteen  years in one ; twenty-
 one years in one ; twenty-two years in one ; twenty-six years in two ; twenty-
 eight years in one ; thirty-one years  in one; thirty-two years in one ; thirty-
 three years in one ; thirty-five years  in two ; forty-eight years in one ;  fifty
 years in one;  fifty-two years in one ; fifty-five in one ; and fifty-six years in
 one case."
   Professor Dyce, of Aberdeen, has favored me with a  case in which the
 foetus was retained in the abdomen eight years :  the patient was twice preg-
 nant afterwards, and delivered of living children, but sunk some months after
 with hectic symptoms.
   These cases afford a striking instance  of the  power of the human frame
 to adapt itself to  new  and apparently  adverse circumstances.  In many
 cases,  after some time, an effort is made to get rid of the foreign body by
 artificial openings ; thus the  foetus  may  be  passed piecemeal through the
 abdominal parietes, the colon, rectum, or vagina.  In some rare cases, the
 foetal bones have  made their way into the bladder.
   269.  Experience alone could have convinced us  of the possibility of the
 foetus  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 foetus 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 ;  ">e in the
third, and one at the end of  the first  month."
  The development during the  life of the foetus appears to proceed at the
ordinary ratio, and  subject to the laws of normal gestation ;  the  placenta, 
186
EXTRA-UTERINE PREGNANCY.
cord, and membranes are obvious before decomposition takes place ; but
the placenta is generally thinner than usual.   Authors have  differed  as  to
whether the ovum  receives an additional covering or not, analogous to the
decidua; but the evidence adduced by Dr. Campbell and Dr. R. Lee's recent
researches  seem conclusive in the affirmative ; and it is probable that this
membrane, which closely resembles the decidua, may perform an office similar
in the  nutrition of the foetus.  The part to which the placenta  is attached
receives an increased vascular supply for the occasion.
   Almost all writers have described the uterus in these cases as lined with
(so-called) deciduous membrane, though in some cases much hypertrophied;
but in one  of  Dr.  Lee's cases it was absent, and he doubts whether, when
present, it possesses " an organized vascular structure, similar to that of the
true decidua."
   270. Treatment. — If  we are satisfied of the nature of the case, the first
indication is to prevent or postpone the laceration of the cyst in which the
ovum is contained, and which so often proves fatal.   With  this view, undue
exertion of every kind is to be avoided, and all  circumstances likely to excite
uterine irritation.  No pressure  should be made upon  the  tumor, and any
uneasiness in it should  be allayed as promptly as possible by venesection,
leeches, or opium.
   When  the rupture  takes place,  marked by  the sudden giving  way, col-
lapse, and exhaustion, etc., the second indication is to moderate the effusion
and  support the strength ; for which purpose  the patient should be placed
on a hard bed, with her  head low, and the abdomen firmly compressed by a
binder, over which cold  should be applied, by means of pounded ice  in a
bladder.
   Acetate of lead  may be of service, with suitable stimulants and  broths.
   Should we succeed in relieving the state of collapse, we must next combat
the inflammation which will set in, by the abstraction of blood, calomel and
opium, blisters, etc.
   As the child dies soon after the rupture of the cyst in most cases, we must
next endeavor, by quietness  and  the absence of excitement and irritation,
to aid the natural  powers in accommodating themselves to  the new circum-
stances of the  case.  The bowels must be kept free by gentle laxatives, and
any renewal of the pain  must be met by the application of a few leeches or
an anodyne.
   If we find after a time that any  effort is made to remove the foetus by the
formation of an abscess  or fistulous communication and discharge of 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
process she commences.
   Any subsequent inflammation must  of course  be treated in the  usual
manner. 
PATHOLOGY  OF  THE FC3TUS.
187
                          CHAPTER XI.

       PATHOLOGY OF  THE FC3TUS.— SIGNS OF  ITS DEATH.

  271.  When describing the contents of the gravid uterus, a short notice
of the  principal pathological changes to  which they are  exposed  was
appended, so that I need  not recapitulate them here.  They, however, with
the diseases to which the foetus is obnoxious, constitute an important devia-
tion from normal gestation.  The latter remain for notice at present.
  Abundant observation  has proved that the foetus is liable to almost all
the forms of disease which attack  the  child; that many of them  are quite
independent of the maternal state ;  but that, in addition, it may be affected
secondarily through the mother.  Amongst the examples of the latter, must
be classed those cases of premature births which occur during epidemics, and
where the foetus appears to have participated in the disease of the mother,
as in the observations of Roedererj Wiigler, Schmurrer, and Russell.  I have
observed a  considerable  quickening of the action of the foetal heart some
days after pregnant women have been attacked by fever.
  According to Duettel, Schweig, Zurmeyer, etc., children born of mothers
suffering under intermittent fever, have exhibited the same disease imme-
diately after birth.
  Many cases have been recorded by Hildanus, Bartholinus, Mollenbroccius,
and, in later times, by Van Swieten, Mead, Baker, Lynn, Jenner,  Simpson,
etc., of  children born with small-pox.   Measles have  also been observed in
new-born infants by Osiander, Stark, Girtanner, Orfila, etc.   Nor  are they
exempt  from  other diseases of the skin, as  erythema, strophilus, pemphi-
gus, etc.
   272. There is scarcely any internal organ  which has not been observed to
be the  seat of inflammation.  The presence of hydrocephalus is the  result
of inflammation (acute or chronic) of  the  arachnoid.  Hogween, Yeron,
and Cruveilhier, have recorded cases of pleurisy.  Mende and  Koelpin have
observed abscesses  of the lungs; Zierhold, oedema; and Wrisberg, scirrhous
induration ;  Husson,  Chaussier, and Billard, have discovered tubercles ;
Cruveilhier, lobular  pneumonia;  and  Lobstein,  calcareous  deposition in
these  organs.  Brachet,  Chaussier, Duges,  Billard, Carus, Simpson, etc.,
have observed cases of peritonitis;  Chaussier, of enteritis,  etc.
   Of the cause of  such attacks we know little or nothing.
  273.  Chronic diseases are  even more numerous : the foetus may suffer from
a general hypertrophy, or atrophy ; may be  attacked with various forms of
syphilitic disease ;  may labor under worms, calculus, dropsy, jaundice, or
hernia: and the pancreas, liver, or kidneys may exhibit organic pathological
changes.
  The bones  and joints are not unfrequently diseased ;  thus, for  instance,
children are born  with rickets, as related by Osiander, Carus, Otto, and
others ; with caries, as observed by Carus and Joerg;  or necrosis, as  in M.
Billard's case.   Numerous cases of fractures and dislocations of different
bones are on record.
  274.  This brief and imperfect sketch  will suffice to prove the truth of the
statement made at its commencement, that the foetus does not enjoy an ex-
emption from disease whilst "in utero ;" unfortunately we possess neither the
means of detecting  nor of curing these affections.  The subject is, neverthe-
less,  one of great  interest: to enable  any  of  my  readers to pursue the
investigation further,  I shall subjoin the  names  of  some of  the  authors 
188
PATHOLOGY  OF  THE FOETUS.
who  have written expressly upon  it: Murat,1  Osiander,2 Joerg,  Carus,
Mende,* C. W. Hufeland,5 Meissner,6 Hardegg,7 Billard,8 Bergk,9 Zurmeyer,10
J. Groetzer,11 Prof. Simpson.12   M. Groetzer's work is an excellent summary
of the labors of his predecessors, and  Prof. Simpson's Essays  are  equally
admirable for their research, careful observation, and logical deductions.13
  275. Death of the Fcetus.—But although we may not be able to detect
disease in the foetus, it is often of great importance to ascertain whether it be
dead  or alive, and is  therefore desirable, if possible, to determine what are
the signs of its death.  The question may be of consequence to the medical
jurist, and is always to the obstetrician, as influencing our decision as to the
best time for operations.
  The diagnosis of a  dead foetus 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 symp-
toms  upon which  we must rely depend  upon the sensations  of the  mother,
and sensations are notoriously delusive.
  276. The signs  which are given as evidence  of  the child being dead are:
the cessation of its movements ; the subsidence or flaccidity of the abdomen ;
the recession of the umbilicus ;  the loose feel of the uterine tumor, and its
rolling about in the abdomen ;  a sensation of  dead weight  and coldness in
the abdomen; the breasts suddenly  become flaccid, and their secretion sup-
pressed ; the health being deteriorated ; the appetite bad;  the countenance
sunk  ; a dark areola round the eyes ; foetid breath ; repeated rigors, etc.
  277. Taken separately, none  of these signs are  certain:  the movements
of the foetus may be suspended for some days without  its being dead ; the
degree of tension  of the abdomen varies much in  the course of pregnancy,
especially in women who  have had  several children ; the uterine tumor  is
occasionally felt as a weight (as  it were a foreign body) by women who bring
forth  the child alive ;  the coldness is a mere sensation, and therefore of little
value, a dead fcetus not being really colder than a  living one ; and the health
may be deteriorated,  and a dark shade appear  under  the eyes, from many
causes beside the death of the foetus.   The breasts, however, seldom become
flaccid, after having been tense,  from any cause but the death of the child.
  Besides, it is a matter of common experience,  that women  retain a dead
foetus "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 labor,  without  any change in  the abdomen,
breasts, or general health.
  278. But although taken singly, none of these  signs are conclusive, yet
cases occur in which the concurrence of several is nearly so.  Suppose, for
example, that in  the  sixth  month  of  pregnancy a patient should  find the
motions of the child,  which up to that period  had  been lively, cease ;  and
soon  after observe that the abdomen and uterine tumor had lost their tense
and rounded form, at the same  time feeling the  latter weighty and rolling
loosely in the lower  belly, and  finding the breasts, which  had  been tense,

  1 Diet, des Sciences Med.   Art.: Foetus.      * Handbuch der Entbindungskunst.
  3 Zur Lehre von Schwangerschaft,  etc.
  4 Ausfiihrliches Handbuch der gerichtliche Medizin.
  6 Die Krankheiten der Ungebornen, 1827.
  6 Kinderkrankheiten, 1829.                 7 De Morbis Foetus Humani.
  8 Mai des Enfans nouveaux-ne's.             9 De Morbis Fcetus Humani.
  ° £« Morbls F«tus-                       " Die Krankheiten des  Fcetus, 1837
  "Ed Med  and Surg. Journal, vol. 1. p. 39; vol. lii. p. 17.   Ed. Monthly Journal of
Med.,  Apnl, 1849.
  13 [An excellent monograph on. the subject of fcetal pathology is contained in  the
"American Journal of  Medical Sciences," for  August,  1840, and October  1841- bv
William Roberts, M. D., of New York.]                               '      '   * 
PATHOLOGY  OF  THE FCETUS.
189
firm, and glandular, subside and become flaccid, we should undoubtedly have
almost proof of the death of the child.
   The value of these signs in  short consists  in their concurrence, and  in
their contrast to the patient's previous condition and sensations.
   279.  We have found the value -of auscultation in detecting pregnancy by
proving the life of the foetus,  and it may  very  naturally be asked, what evi-
dence does it afford  of its death ? in other words,  as the hearing the pulsa-
tions of the fcetal heart proves the child to  be alive, does their being inaudible
prove that it  is dead ?  I have already stated that in some cases, although
the child be alive, yet the sound of its  heart is inaudible,  or temporarily
suspended, and such cases of course prevent a  directly affirmative answer to
the question.   Again, much depends upon the tact and experience of  the
auscultator ; one person may detect a pulsation that is inaudible to another :
to pronounce, therefore, that  a fcetus  is dead because we do not at any one
visit hear the heart, would be too hasty a conclusion.
   But if after  hearing the heart pulsating distinctly, we find it gradually or
suddenly become inaudible, and continue so, the evidence will be very strong ;
and if, in addition, the principal  symptoms above  enumerated be present,
there can be little doubt of the death of  the foetus.   Dr. Simpson attaches
importance  to the sudden  increased frequency of the foetal heart as indicative
of  impending  danger,  and my own  experience would lead  me to concur
with him, although it may certainly be only temporary.
   280.  Thus  far we have considered the signs of the death of the fcetus,
during  utero-gestation previous to labor;  when this process  commences,
other and more distinctive evidence is accessible.
   On the rupture of the membrane when the fcetus has been some time dead,
the liquor amnii is frequently changed, being of a dark color,  and of thicker
consistence than usual; but if the death be recent, no such alteration will be
found.
   ["The liquor" has been repeatedly seen, not only "thicker than usual,"
but actually foetid, although the child was alive and healthy.   In such  cases,
it arises probably from decomposition of a portion of blood which is extrava-
sated by a partial separation of the placenta,— or, perhaps, of a small frag-
ment of the placenta itself]
   Great stress is laid upon the  state of the scalp and bones of the cranium,
and, I believe, justly.  After the foetus has been dead some time, if the  finger
be pressed upon the scalp, it is felt to be  emphysematous, crepitating  under
the touch,  and a portion of the cuticle  will  peel  off.  The bones  of  the
skull  also overlap more, and feel loose within the scalp.
   When present, these signs  are, I believe, conclusive, but  the latter only
will be found if the death be recent.  It is stated  by Dr. Parr and others,
that no tumor is  formed upon  the head of dead children; this, however, is
only true when  the child has  been  some time dead.  I have seen distinct,
well-formed tumors on the head of children who had been dead twenty-four
hours.  The absence of pulsation at the  greater fontanelle, and  its diminu-
tion from the  collapse of  the bones, is admitted to be an important sign.
   281.  In face presentations, when the  child is dead, the  lips  are flabby,
the tongue flaccid and motionless, and the  presenting part slightly swelled.
In breech presentations, the  sphincter of a living child resists  or contracts
upon  the finger, but when dead it  is relaxed.  The discharge of meconium
is of no value in breech presentations, and of very little in any other.   When
the arm protrudes, it shortly becomes livid and cold, and  the pulse at the
wrist  often  imperceptible, but  this does  not  prove  the child to be  dead.
The peeling of the epidermis  is conclusive. In prolapse of the funis,  the
pressure to  which it  is exposed very soon destroys the  child, and in  most
cases the presence or absence  of pulsation in it is  a satisfactory test of the
life or death of the child.   Dr. E. Kennedy, however, records a very instruc- 
190
ABORTION.—PREMATURE  LABOR.
tive exception to this rule;  the cord had  been prolapsed for an hour, and
during a pain no pulsation was perceptible ;  when  the  pain subsided, he
"drew the funis backward towards the sacro-iliac symphysis, and then was
able to detect a very indistinct and irregular pulsation, which corresponded
to a slight fcetal  pulsation over the pubis."  The forceps  were in  conse-
quence applied, and the child was saved.
  282. Dr. Collins and Dr. E.  Kennedy regard the evidence  afforded  by the
stethoscope during labor  of the child's  life or death as conclusive, or nearly
so; certainly the  information thus obtained of the changes  which occur in
the foetal circulation is extremely valuable, and the gradual diminution  in
frequency and force Of the  heart's action, and its ultimate cessation, will
justify our belief in the death of the child.  It must be remembered  that it
is not simply the absence of pulsation that is to determine our opinion, but
its cessation after having been  heard.
                       CHAPTER XII.

                 ABORTION. —PREMATURE LABOR.

  283. The expulsive action of the uterus may be exerted at any period of
gestation, though it appears more easily excited at or previous to the third
month, on account of the  frailty of the connection between the ovum and
uterus.   It is  also more liable to  occur at the time  of each  month, corre-
sponding to a menstrual period,  than during the interval, in  accordance
with the periodicity peculiar to the female generative  system.
  If it occur before the sixth month, it is called an abortion, subsequent to
this  period, premature labor.   It  is always an untoward  event, and may
exert an  unfavorable influence upon the health of the female,  but it cannot
be considered as dangerous,  unless  it be accompanied by great hemorrhage,
aud even in such cases it is rarely fatal.
  284. Frequency. — Dr. Collins  met with at least 393 premature cases in
16,414 ;  Dr. Beatty  met with 21  premature cases in 1200.  In my own
report, 65 cases of abortion  are recorded  in  1705 deliveries ;  Madame La-
chapelle records  116  cases in 21,960 cases of pregnancy ;  M. Deubel 35 in
420; making in  all 530  premature  cases in 41,699 deliveries, or 1 in 78£.
  Mr. Whitehead has recently published some statistics of abortion from
which I shall give an extract.   " Two  thousand  married women  in a state
of pregnancy,  admitted for treatment at the Manchester Lying-in Hospital,
were interrogated in  rotation respecting their existing condition and pre-
vious history.  Their average  age at the time of inquiry was a small frac-
tion  below 30 years.  The  sum of their pregnancies, already  terminated,
was 8681, or 4-38 for each ;  of which rather less than 1 in 7 had  terminated
abortively.  But as abortion  seems somewhat more frequent during the latter
than m the first half  of the child-bearing period, the  real average will, con-
sequently, be rather  more  than 1 in 7."  Of  747, all had aborted once at
least, some oftener,  "Their average age was 32-08 years.  The sum of
their pregnancies was 4775,  or 6-37 ; that of their abortions 1222, or 163
„°J   ,  Person-"  From the preceding statements it appears that more than
 J on    6Very 10° mothers experience abortion before they reach the ao-e
  <•  i yAe,arS™ As t0 the Pre?na»cy most likely to  be  prematurely termi-
nated, Mr. Whitehead states that of 226 women  pregnant for the second 
ABORTION.—PREMATURE  LABOR.
191
time, 20 or 88 per cent, had aborted of the first, and of 230 pregnant for
the third time, 58 or 25 20 had previously aborted.   Of 602 cases, abortion
occurred at the following periods :  in  35 at 2 months, in 275 at 3 months,
in 147 at 4 months, in  30  at 5 months, in 32 at 6 months, in 55 at 7 months,
and in 28 at 8 months.1
   285.  Causes.—The causes of abortion may be either maternal or ovuline.
   1. The maternal causes may arise from the  condition of the mother, or
they may be accidental.   That certain states  of the constitution,  or of the
general health, render  the patient obnoxious to this accident, there can be
no doubt;  and Denman  is  probably correct in attributing many cases to
this rather than to the specific  cause assigned; for as he observes,  "that
about which the patient was employed,  when the first symptom appeared,  is
fixed upon as  the  particular cause, though probably she was before in such
a state that abortion was  inevitable."  The habits  of life have also a con-
siderable influence, for we find abortion most frequent in the extremes of
society.
   On  the  other  hand, it  is  wonderful  with what  tenacity the  ovum  is re-
tained by persons of  delicate constitution,  and under very trying circum-
stances ; thus women far  gone in consumption  conceive, complete  the term
of utero-gestation, and are  delivered of healthy children.  And Mauriceau
mentions a case2 of a  woman who fell from  a window in the third story of a
house, in the seventh month  of pregnancy, and  broke one of the  bones of
her fore-arm,  dislocated her wrist, and  bruised  herself very much; yet she
fulfilled the period of  pregnancy, and was delivered of a living child.   Dr.
Davis also relates the  case of a lady 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 d, priori, that  delicate Avomen
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 mis-
carry after having a tooth drawn, another from making a false  step  going
down stairs, etc. ; and in  one case I attended, it seemed to be brought on
by the lady's reading an  account of a railroad catastrophe, and in another
by a hearty laugh.
   286.  Certain local  disorders are  said to cause abortion, as leucorrhcea,
uterine irritation,  a  patulous state  of the os uteri, diseases of the rectum,
bladder, etc.
   Mr. Whitehead mentions that of  747 women, the sum of whose  abortions
amounted to 122,  the assigned causes were as follows : —
   " Inward weakness," impaired health, and acute disease    .     .  911
   Accident, mental  perturbation, etc.......222
   No assignable cause .........   90
   This  "inward weakness" to which so many attribute  their miscarriages,
is, in fact, leucorrhcea, arising from disease of the lower  portion of the
uterus.  Out of 378  cases  an  examination showed that 275 were thus affected
with inflammation and superficial erosion of the cervix, varicose ulceration,
oedema, fissured ulceration, induration of the cervix, endo-uteritis, follicular
ulceration, syphilitic disease, etc., thus confirming the statement of M. Boys
de Loury and Dr. Bennet  as to ulceration being a common cause of abortion.
   The same consequence  may follow febrile  complaints ; thus a patient will
often miscarry during the  course of typhus fever, small-pox, scarlatina, mea-
sles, etc., but it is  possible that the miscarriage in these cases may result from
the death of the fcetus, and not directly from the disease.   In this way pro-
bably it is that syphilis gives rise to  abortion or premature labor.

       i On Abortion and Sterility, pp. 245-6.              2 Observation 242. 
192
ABORTION.—PREMATURE  LABOR.
  287.  A.mong the accidental causes of abortion may be enumerated blows,
falls, violent concussions, excessive  or sudden  exertions, straining, severe
coughing, etc., which in most cases act by separating partially the ovum from
tli 6 uterus.
  Mental emotions, anger, joy, sorrow, good or bad news suddenly told, may
excite the uterus to action,  and effect the expulsion of its contents.
  Lastly, a female may acquire a habit of aborting.   Each occurrence pre-
disposes to a repetition of the accident at about the same period ; and after
it has happened several  times, it is extremely difficult to carry her safely
over that period.   Thus  Dr. Young, of Edinburgh, had a patient who mis-
carried  thirteen times in succession, and  Dr. Schultze one to whom the same
accident happened twenty-two times at  or about the same period of  gesta-
tion.  I was  myself consulted by a lady who stated that in less than three .
years she had miscarried ten  or twelve  times  during the second month of
gestation.  It is  remarkable, that these patients seem to have as great an
aptitude for conceiving as for miscarrying.
  Dr. Tyler Smith1 has divided the causes of abortion into excentric, centric,
and special, so far  as the  mother is concerned.   The  former includes the
causes already mentioned, which act by irritation of the mammary, trifacial,
vesical  and uterine  nerves; the second, those which act through the medium
of the blood, as scrofula, syphilis, the exanthemata,  etc. ; and the third in-
cludes cases of disease.
   288.  2. The ovuline causes of miscarriage may be stated generally to be
anything which compromises the  life of the child, whether  the ovum  be
thereby  detached  or not.   Thus certain pathological conditions of the
amnion, chorion, decidua, the  erroneous insertion of the funis, diseases of
the  placenta,  especially  fatty degeneration,2 separation  of the  ovum, etc.,
must necessarily interfere with the perfect  nutrition  of the fcetus, and per-
haps cause its  death and subsequent expulsion.   Or the fcetus may die of
some of the diseases  mentioned  in  the  last chapter.  As a rule, it may be
stated that the death of  the fcetus will be followed by its expulsion, but the
period of this occurrence varies very much ; a few days only may elapse, or
"it may  be months, or, in a few rare  cases, years.  I think, also, that the
evidence we possess  shows the much greater frequency of the ovuline than
the maternal causes of abortion ; and if so, we must conclude, that as it is
better that a blighted foetus 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 distention and irritation  of the uterus.   The blood may be
effused  between the  uterus and decidua, between the decidua and  chorion,
between the chorion and amnion, into the substance  of the placenta, or into
the cavity of the amnion.   It has also been poured into the peritoneal cavity,
probably through the fallopian tube, as  noticed by Botal,  Ruysch,  and
Smellie,
   [It is well ascertained that those females who  are subject to membranous
dysmenorrhcea are  also prone to suffer abortion during the  early months  of
pregnancy.  Now  Dr. Simpson has  shown  that the membrane discharged
in  membranous dysmenorrhcea is, in the same manner as the decidua, "the
mucous membrane of the  uterus itself hypertrophied, and  exfoliated,  or
thrown  off at a catamenial  period.  As regards  the decidua Dr. Tyler
Smith  supposes that there is no great difference  between an abortion a few
weeks after conception and membranous dysmenorrhoea, except that in abor-

  1 On Parturition, etc., p. 127.
  2 Dr. Barnes on Fatty Degeneration of the  Placenta,  Med. Times and Gaz., March
IVHd, J.0O0. 
ABORTION.—PREMATURE LABOR.
193
tion the decidua is loaded with the fruit of the womb, and may be discharged
more or less in a state of disintegration.  According to him every abortion
really consists in the throwing off of the mucous membrane of the uterus
and the ovum which has been developed upon its surface.   Dr. Smith be-
lieves that, in many cases of abortion, as in menstruation both of healthy
and of morbid  type, the disintegration and  exfoliation  of  the developed
mucous membrane,  or decidua, is the  first step in the process, and the direct
cause of the loss of the ovum.  From this point of view then, we must con-
sider  the  show in  cases of abortion, and the continuous sanguineous  dis-
charge, as similar to the discharge in menstruation.  In many cases it  hap-
pens that  abortion  is threatened, and there is  a  colored discharge  for many
days without the loss or injury of the ovum.   Abortion does not take place
in such cases, probably because  the  disintegration  of  the decidua does not
occur at the part at which the ovum  or the placenta  is implanted  upon it,
or not to a sufficient extent to injure  it.
   In  all cases of abortion,  Dr. Smith maintains that  the developed condi-
tion of the mucous  membrane, common to the menstrual period and  to preg-
nancy, plays  an  important part, and  is the  chief cause of the  hemorrhage
which then takes place, and in many cases it is  also, in all  probability, the
actual cause  of abortion.   The  tendency of abortion  to  occur at Hie cata
menial periods has  long been a  matter of  observation.  In explanation of
this tendency the periodical influence of the ovaria, as well as of the uterine
mucous membrane must be taken into consideration.1]
   289. Symptoms.—When threatened with  a  miscarriage, the patient gene-
rally  experiences a sense of uneasiness, languor and weariness, with aching
or pain in the back;  after these preliminary symptoms have lasted for some
time, those of labor  supervene,  and  in most  cases they do not differ much
from  those of labor at the full term ;  the pain may even be as great.
   A  slight discharge of mucus or blood from the vagina is observed, pains
are felt in the back, extending round the loins  to the  abdomen, and down
the thighs, recurring  at regular intervals, and  increasing in strength  and
frequency.   The stomach frequently becomes irritable, and discharges its
contents.   The pulse is quickened, the skin hot, voluntary efforts  are made
in aid of the uterus, and ultimately the contents of the womb,  or a portion
of them, are expelled.
   290. But although these symptoms are generally present, yet the progress
of different cases is so dissimilar, that we must enter a little more into detail.
1. Occasionally cases occur where the ovum slips out  of the uterus (so to
speak) with  scarcely any pain, little  or no  hemorrhage, and followed  by a
speedy recovery.  We  see  this  chiefly in persons who  have acquired the
habit  of aborting.   2. Other patients present  the  ordinary symptoms of
labor, as  enumerated above, but which subside after a  time, without the
expulsion of  anything from the uterus,  until the expiration  of the full term
of utero-gestation,  when the birth of a full-grown child is accompanied by
the expulsion of a  blighted foetus, the case being one  of twin conception.
3. Again, the  pains  of labor may come on with more or less flooding, and
after some time  the fcetus alone be expelled, the  shell of the ovum being re-
tained. The  latter is generally detached after a time, or it may be dissolved,
and discharged along with the lochia.  So long as it  remains, hemorrhage
is to be feared ; and in  some cases where it dissolves by putrefaction, irrita-
tive fever  or  uterine phlebitis is  excited ; such cases, therefore, excite great
anxietv, and  require careful treatment; although in other cases the shell of
the ovum dissolves, and is  discharged unconsciously,  with  no unpleasant
symptom whatever.    4.  Yery alarming hemorrhage may precede or accoro

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

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

                                 Fig. 81.
                            Dewees' Wire Crotchet.

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

                                Fig. 82.
Bond's Placental Forceps.
This instrument is well represented in  the accompanying drawing (fig. 82).
" It is about ten inches  long, curved laterally on a radius of about twelve
inches, and the blades are about one inch and a half longer than the handles.
The blades terminate in an oval expansion nearly half an inch 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."1]
  294.  Thus far  I have spoken of the treatment of the simpler forms of
abortion ; let us now proceed to consider those cases which are complicated
with flooding.   When it is considerable, there is little or no  chance of pre-
venting  miscarriage,  and as  the danger  from hemorrhage ceases with the
expulsion of the ovum, our endeavors must be directed to moderate the dis-
charge,  until that event take place. The most direct means of restraint we
possess  is the plug ; but this must never be used, if internal hemorrhage can
take place to such an extent as to destroy life : in other words, not  if the
uterus be empty, and the patient far advanced in pregnancy.  If the uterus
be filled with its natural contents, or be only slightly distensible, even though
empty, we can restrict the amount of loss by filling the vagina, and stopping
the external outlet.   For this purpose Dewees recommends a sponge, others
a silk handkerchief, or tow;  but I have found cotton  wool by far the best,
and most easily introduced through a speculum.   The vagina must be filled
completely, and after six or eight hours the plug should be withdrawn, and,
if necessary, a fresh one introduced.
  [It should be kept constantly in mind that, whenever there is the least
prospect of saving the foetus, the  plug is inadmissible ;  for the blood being
prevented by it from flowing out  of the uterus, will be liable to penetrate
between the internal  surface  of the latter and the  ovum, and thus increase
its detachment.   At the same time, the tendency of  the  uterus to contract
and  expel its contents, is  increased by the  presence  of the plug, and the
coagulum of blood within its cavity.]
  Cold  should be applied to the vulva, by means of a cloth dipped in cold
water and suddenly applied :  it may be removed after the shock is produced,

                 1 [Amer. Journ. of the Med. Sci., April,  1844.] 
ABORTION.—PREMATURE LABOR.
197
and reapplied at intervals.   I have  also seen  great benefit  from enemata
of cold water.   Opium in small doses is very useful, nor does it suspend the
uterine contractions ; and  the tincture of Indian hemp,  as  before recom-
mended.   Drs. Dewees and Conquest recommend the  acetate  of lead; and
others, large doses of dilute  sulphuric  acid in infusion  of  roses, Gallic acid,
tannin, or Ruspini's styptic ; but I cannot say that I  have  obtained  much
benefit from them.
  295. When the plug is removed, we should carefully examine the os uteri,
so as to ascertain if the  ovum  is descending ;  if we  are  able to reach  the
lower end of it, it is often  possible, by a little  dexterity, to hook it down.
If it be beyond our  reach, we may replace the plug, and*give ergot to  excite
the uterus to action.  Borax is highly esteemed in Germany, and has been
recommended by Dr. Copland, for its influence in exciting uterine contrac-
tion ;  it may either be given  alone or combined  with the  ergot.  After the
oyum is removed, it will be well  to  have the vagina syringed twice  a-day
with tepid water.   It soothes the parts, and removes any putrefying  blood
or irritating discharge.   But supposing that although by these means  the
hemorrhage be arrested,  yet that the ovum is retained  without any evidence
of irritative fever,  are we  to interfere for its removal ?   I  think not.   In
such cases,  I give half drachm doses of ergot occasionally, watch the patient
carefully,  plug when necessary and wait.   After the  lapse of days or per-
haps weeks, the ovum may be expelled in one or several masses, or a change
in the amount and character of the discharge will warrant us in concluding
that the ovum is dissolving and coming away.   Longer experience has made
me less fearful  of leaving these cases to nature, and more unwilling to inter-
fere hastily.
   296. In the  majority of cases,  the  natural efforts, or the means  just re-
commended, will succeed in expelling the  ovum ; but in some  they fail,  and
the patient  may be reduced to the verge of death by the  flooding, which is
kept up by  the presence of the ovum.  In such cases a more direct  inter-
ference has been recommended.   M. Levret advises warm-water injections
into the vagina and uterus ;  Dr.  Dewees, the  use of  a wire crotchet;1  and
some  French writers (as already  mentioned), the use of a delicate pair of
forceps.   The  use of any instruments  of this  kind will require  great care,
and can only be  safe so far  as their  application  can  be regulated by the
finger.  In  many cases, where the parts are dilatable, two or more fingers
may be easily introduced, and the ovum extracted, or  the hand may  be in-
troduced  into  the  vagina, and the ovum swept out of the  uterus by  one
finger.  I have several times had occasion to perform  this operation  in ex-
treme cases, and I have  been able to do so with perfect success, as far as
the extraction  of the ovum is  concerned, and without any unpleasant con-
sequences.
   But let rne be quite understood by my junior readers;  such an operation
at an early  period of gestation is not without danger, and requires delicacy,
gentleness,  and tact: to have recourse to it in any but extreme cases  would
be unpardonable rashness ; but I should deem it just as  wrong to allow a
patient to die of hemorrhage without having had recourse to it.
   297. The after-treatment  of patients who have miscarried  requires great
care.   The  popular belief  is, that abortion is more dangerous than  labor,
and I am not sure that it  is far wrong.   No  doubt exists that women are
as liable to  puerperal disease after abortion or premature labor as after de-
livery at the full time, and they require a  more careful management than is
generally  adopted by them.
  The patient  should rest  in bed the usual time, and  then return gradually
  1  [Dr. Dewees, it is  believed, never employed the  "wire crotchet" for the removal of
the ovum, but solely to bring away the secundines after the rupture of the ovum, and the
escape of the foetus.] 
198
ABORTION.—PREMATURE LABOR.
 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 sbculd be bland
 and unstimulating.
   298.  The prophylactic treatment of abortion or premature labor requires,
 in the first place, the removal or avoidance of all possible causes ; and se-
 condly, the adoption of all means  calculated to strengthen the constitution.
   The'state of the stomach and bowels must be carefully regulated, the diet
 be light and nutritious, and exercise taken in the open  air, but not so as to
 occasion fatigue.  If the patient  be robust, the  pulse full and quick, and
 some threatening symptoms present, a  small bleeding may  sometimes  be
 useful; but if she be weak and cachectic, we must have recourse to tonics.
   If the patient have previously miscarried, as she approaches again  the
 same period, she must take  absolute rest, lying  on a sofa or  bed, lightly
 covered, the greater part  of the  day, until the period be passed.   Rest, more
 or less absolute, is one of the most powerful prophylactic means we possess,
 and in all such cases sexual intercourse should be prohibited from the period
 pregnancy is suspected, until after quickening.
   Cold  sponging, the use of the "bidet"  or cold bathing as recommended
 by Mr. White, of Manchester, is  highly beneficial, provided we  guard against
 too  great a shock.   In some cases  I have  seen a  beneficial effect produced
 by daily syringing of the vagina with cold  or nearly cold water, at the time
 of using the bidet or hip-bath.
   [" In the management of cases of threatened abortion," says  Dr. Lever,1
 "it  is my rule, if possible, to get a thorough knowledge of the immediate or
 exciting cause of the hemorrhage or pain,  or both ; secondly, before using
 opium, to ascertain the state of the os uteri, and especially whether the  ante-
 rior part of the  neck has lost its plumpness and firmness,  and  has become
 soft and baggy.   If with the discharge we have  a patent state of the os
 uteri, and if the neck be soft and loose, the  exhibition of opium will do harm,
 by retarding the  emptying of the uterus, which  must sooner  or later take
 place.  But while I  do not advocate the use of this drug under  the circum-
 stances related,  I can  speak loudly  in its praise after the  abortion has
 occurred, especially if such have been attended with a large loss of blood ;
 it will then allay  excitement, tranquillize the circulation, and procure sleep.
 These remarks,  however, do  not  altogether apply to  those cases which
 menace from accident, or from mental causes, or those which may be said to
 be due to  habit.   In these, with the application of cold, perfect quietude,
 and  unstimulating diet, I have known the exhibition of opium by the mouth^
 or, what I prefer, a cold starch injection with opium, thrown into the bowels,
 and  repeated every night,  or more often according to existing circumstances,
 followed by the best results."]
   When the habit of miscarrying has been acquired, one  of the most effective
 means of breaking it, is to give the  uterus a long rest, by separating the
 woman and her husband for several months.
  [This habit  is  sometimes so firmly fixed as to be very difficult to over-
 come.  Dr.  Huston  states, in  a  note to  a former edition, that he has suc-
 ceeded in some  very obstinate  cases by confining the  patient to a  sofa
commencing some time before the usual period of miscarriage and continuing
several weeks  after  the time had  gone  by —carefully avoiding the  erect
position and all unnecessary muscular exertion, and using at  the same time
injections daily of opium, in  sufficient doses to prevent uterine action —the
quantity varying from two to five grains in the state of powder, suspended
in mucilage.  By these means a condition  of tolerance on the part of the
uterus may  be acquired, which will allow gestation to go to  the full  period ]
1 [bond. Med. Gaz., 1849.] 
PART  III.
PHYSIOLOGY OF  THE  UTERUS.  PARTURITION.
                           C HAPTER  I.

                CLASSIFICATION. —DEFINITIONS, ETC.

   299. We have now arrived at the last great function of the uterine system—
 that of Parturition, with its abnormal variations.
   It consists in the expulsion of the fcetus and its appendages from the cavity
 of the uterus, and ends in the separation of the child and the mother.
   It occurs, as we have seen already, at the end of nine calender months and
 a week — ten lunar months — forty weeks — or 280 days, a few days being
 allowed either way.
   300. The magnitude and importance of the event, and the regularity with
 which it takes place, have induced physiologists of all ages  to assign  causes
 for it, but as yet without success.
   Thus it has been supposed that the uterine  action is excited by the  strug-
 gles of the foetus for want of adequate nourishment, .or from the constraint
 of its position, or from the endeavor to breathe; by others it has been attri-
 buted  to the acrid nature of the liquor amnii.  Buffon has likened the pro-
 cess to the dropping of ripe fruit.   Hervey, Burdach, and  others attribute
 it to the uterus  having attained its maximum of irritability at the exact time
 that the foetal development is complete.   It would be easy to fill pages with
 similar explanations, but  these may suffice : they are all either more  elabo-
 rate expressions of the fact, or  mere hypotheses.
   301. But though all search has hitherto failed in discovering the exciting
 cause of labor, it has established the fact, that the periodicity which we found
 to characterize  the other uterine functions prevails here also.  For example,
 abortion or  premature labor, when not  the  result of external  accidental
 causes, occurs very generally  at a  monthly — or what, but  for conception,
 would have been a menstrual period.
   Again, as  remarked by Stark and others,  the normal period for partu
 rition corresponds to a menstrual period :  on  this principle Kluge calculates
 the duration of  pregnancy in every case at 280 days, and so much more or
 less, as impregnation  took  place immediately before or after menstruation.
 Speaking generally, labor may be looked for at about the tenth period after
 the last appearance of the catamenia.
  Lastly, in extra-uterine gestation, an  attempt at  labor occurs very gene-
rally at the same period.
  So that,  taking  the  monthly discharge as the type of utero-ovarian peri-
                                                           (199) 
200            classification.—DEFINITIONS, etc.
odicity, we may observe that it continues, though at times less demonstrably,
throughout the whole period of the functional activity of the sexual system.
  After a most ingenious and  elaborate investigation, Dr. Tyler Smith con-
siders that he  has proved that " ovarian excitement is the law  of parturition
in all its forms of ova expulsion."   "When the ovarium is  severed from the
rest  of  the  sexual apparatus, as in  the  mammalia and human female, the
ovarium is connected with the rest of the parturient canal by a  series  of
reflex arcs.  By means of the spinal excitor nerves of the  ovaria, thatpor-
tion  of  the spinal centre which presides over the actions of the uterus is, at
the end of  utero-gestation, thrown into a state of excitability or polarity,
somewhat resembling the general spinal  excitability of  tetanus.  It is curi-
ous that at this time, besides the ovarian excitement of the catamenial period
which ushers  in parturition, there  is upon the  surface of the ovarium the
cicatrix (corpus luteum)  left by the ovarian phenomena of conception, but
which speedily disappears  after delivery.  The  uterine nervi-motor system
being thrown  into such a state of persistent excitability, that the  uterus
firmly contracts equably upon its contents, the fcetus itself, hitherto defended
by the liquor  amnii,  becomes an ordinary excitor, and  the  reflex actions of
labor are gradually  established.  The equable contraction of the  uterus
preceding labor is, in effect, just as though the membranes  had been punc-
tured in the operation of inducing premature delivery, and the head  of the
fcetus brought to exert pressure upon the os and cervix  uteri."
  Admitting that ovarian excitement thus excites uterine  action, I do not
think that Dr. Smith has  satisfactorily explained the cause of that  excite-
ment occurring regularly at the  tenth menstrual period rather than at any
other.
  302.  Classification of Parturition. — The basis  of  all classification
must be the definition of natural labor, inasmuch  as the other classes and
orders are but deviations  from or complications of it;  but upon this defi-
nition writers  are  much at variance.  Some make the  efficiency of the ex-
pulsive force the sole question, and include under natural labor, all such as
are terminated by the natural  powers.   Thus Hippocrates, Smellie, Baude-
locque,  Rigby, etc., etc.,  include face, breech, and foot presentations in this
class.   Others conceive that  the presentation  ought to be taken into con-
sideration, and therefore Denman, Blundell, Davis,  Ashwell, Ramsbotham,
etc., etc., limit natural labors to head presentations.
  I  prefer the latter arrangement, because I  deem  it better  that what we
take  as natural labor, should  present as  nearly as possible a perfect type.
Now the elements of labor are three : — 1, the expulsive force ; 2, the child
or body to be expelled; and 3, the passages through which it is to be expelled.
If these be equably adapted to each other, the natural  objects of the labor
will  be attained —viz., the  delivery of  a living  child with  safety to the
mother; and  the labor may well be termed natural.  But this result does
not obtain except with head presentations, or  at least not  in anything like
the same  proportions; for in breech cases 1 in 3| are lost, and 1 in 2£ in
foot  presentations, which is far more than when the head presents,   this
alone would, I conceive, be a valid reason for limiting natural labor to head
presentations; not that the  natural  powers alone  may not terminate the
labor with other presentations, but  that  the  average  mortality is much
higher.                                                       J
  Again I think that the preponderating frequency of head  presentations
ought to have much  weight in determining the most natural form of labor;
and I find that in 327,802 cases the head presented 321,503 times  whereas
breech presentations  occur only once in bU and footling cases  once  in  9G4
pases.                                                                 4 
               CLASSIFICATION.—DEFINITIONS,  ETC.           201

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

            Class I.  Natural labor.

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

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

   This  arrangement is nearly the same as  that given by Dr. Merriman in
 his valuable Synopsis of  Difficult Parturition ;  and I think  it will be found
 to include all the important deviations from natural labor.   I have not made
 any distinction dependent upon the kind  of assistance required in certain
 difficult labors (as, for  instance, the "manual  or instrumental labors" of
 some authors), but I shall interpolate the necessary chapters on operative
 midwifery, after treating of pelvic distortions; and add a chapter or two, in
 conclusion, on  some of  the more formidable diseases  of child-bed.
   304.  Presentations.—We understand by  the presentation, that part
 which presents itself at the brim of the pelvis.   Some writers, especially the
 French, enumerate a great variety  of presentations, all of which, I  think,
 may be advantageously included under four heads.
      1.  Presentations of the head.
      2.       "       " breech, including  the hips and loins.
      3.       "       " inferior extremities, including the knees and feet.
      4.       "       " superior extremities, including the shoulder, elbow,
                           and hand.
   Others, such as  the back, belly, sides, etc., are so extremely rare, if they
 occur at all at the  full term, that  it would be superfluous to treat of them
 separately.   Their practical management would be the same as for presen-
 tations of the shoulder or arm.
   The following table will be  sufficient to  give  some notion  of their relative
 frequency in the practice  of the same individuals. 
202
CLASSIFICATION.—DEFINITIONS,  ETC.
Author.
Mad. Boivin.  . .
Mad. Lachapelle.
Dr. Jos. Clarke.
Dr. Merriman . .
Dr. Granville  . .
Edin. Hospital. .
Dr. Maunsell  . .
Mr. Gregory . . .
Dr. Collins. .  . .
Dr. Beatty ....
Mr. Lever ....
Dr. Churchill. . . .
Drs. M'Clintock"!
  and Hardy.... J
Drs. Sinclair and "1
  and Johnston. /
Total No.
of Cases.
20,517
15,652
10,387
 2,947
  640
 2,452
  839
  691
16,414
 1,182
 4,666
 1,640

 6,634

13,748
Head pre-
sentations.
 9,810
14,677
 9,748
 2,735
   619
 2,225
   786
   645
15,912
 1,105
 4,266
 1,119

 5,815

11,874
   Breech
presentations.
372
349
 61
 78
  2
 17

 14
242
 28
 59
 35

140

309
 Inferior
extremities.
238
255
184
 40
  3
  8
 21
  7
187
 15
 29
 22
 61

181
 Superior
extremities
80
68
48
19
 1
 4
 4
 4
40
 4
12
 9
26

60
   305.  The diagnosis  of different presentations  may  be thus  generally
stated.   The head may be known by its hardness, by the  sutures and fon-
tanelles.
   The breech,  by its softness, by the cleft between the buttocks, the 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, etc.
   The elbow, by the olecranon process rendering the joint sharper than  the
knee.
   The  hand, by its  shortness, the  unequal  length  of the fingers  and  the
divarication of the thumb.
   306.  Positions. — The position  is the relation which some part  of the
presentation bears to a given part of the pelvis ;  thus  the  positions  of the
head are determined  by the relation of the fontanelles to the foramen ovale
and sacro-iliac  synchondroses; or, in more general  terms, the position may
be said  to be the relation of the extreme points of certain  diameters  of the
child to the extreme points of the pelvic diameters.   These we shall examine
in detail in  the next chapter.
   307.  Stages of Labor.-For the convenience of description, it has been
the practice to divide the process of labor into so many parts or stages, some
making three others four  five, or six :  I shall  content myself with  three;
the first extending from the commencement of labor to the passage  of the
head through the  os  uteri, the second terminated  by the  birth  of the child,
and the third occupied by the expulsion of the placenta 
MECHANISM OF PARTURITION.                203
                         C HAP TE R  II.

                  MECHANISM OF PARTURITION.

  308. Before describing the phenomena of natural labor, it will be better
to investigate the mechanism by which the expulsion of the child is effected,
and with this view we shall first examine  the elementary agents  of parturi-
tion, separately, and  afterwards  their joint  action.  These primary condi-
tions, or agents, are,  1, the expulsive  force;  2, the passages;  and 3, the
child.
   309.  1.  The Expulsive Force.—The uterus is  in  all  cases the main
agent in the expulsion of the fcetus, and in some, the sole  power employed ;
as, for instance, when the death  of  the  mother precedes  the birth of the
child ;  or when the mother is delivered in a state  of syncope or asphyxia,
as related  by Haller and Henke ; or in cases of prolapsus uteri, as men-
tioned by Wimmer, Chopart, etc.
   We  have heretofore  seen that the uterus, if not  muscular, possesses at
least the character of muscularity, that it  is composed of regular and irregu-
lar layers of fibres ; at the time of labor these fibres contract, become shorter
and thicker, and by their joint action diminish the size of the uterine cavity.
The contractions are periodical, with distinct  intervals, and  each one is
called  " 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 annexed cuts will exhibit the arrangement of the muscular fibres of
the uterus according to Madame Boivin, M. Doville and other authorities.]

                [Fig. 83.]                          [Fig. 84.]
      External Layer of Uterine Muscular Fibres. ^^   Internal Layer of Uterine Muscular Fibres.

  The contractions commence in the cervix, according to Miiller, Michaelis,
and Wigand, and  there  is reason to believe, some time previous to the be-
ginning of real labor, and without suffering;  for in  most cases, at the com-
mencement of labor, we find a slight degree of dilatation  of the os uteri,
without any complaint on the part of the patient.   After this unconscious
 
204
MECHANISM  OF  PARTURITION.
uterine dction has continued for a time, it is attended with pain, which marks
the commencement of labor.   The suffering increases with the increase of
the pains.   They are seated at first in the loins, and gradually extend round
to the abdomen and down the thighs.  From their acute, stinging character,
these pains, which are limited  to the  first stage,  are  called " cutting or
grinding pains :" during the second stage, the suffering is less acute, though
not less severe, and the uterine contractions being aided by voluntary efforts,
the pains are called "forcing or bearing-down pains."   The former occasion
the patient  to cry out, but the outcries  are suppressed during the second
stage, from  the necessity of holding the breath, to fix the chest as a "point
flappui."   The cause of the suffering is, first, the forcible distension of the
cervix, next, the pressure  of the fibres during contraction upon the nervous
filaments, and, lastly, the dilatation of the passages.   The amount of suffer-
ing depends a good  deal  upon the  temperament of the  patient, and upon
her habits of life; among  savages it appears  slight, but it is excessive in
civilized  life.
   310. Each uterine contraction has a peculiar character ; slight at first, it
gradually increases until it arrives at its maximum of force, remains station-
ary for a short time, and  then quickly subsides :  and this is characteristic
of the entire labor;  for the pains  which are slight at first, go on increasing
in frequency and  force, until, having  arrived  at the maximum degree of
power, all obstacles yield before them, and delivery is accomplished.
   Another remarkable peculiarity  is their periodicity ; each pain is followed
by a distinct interval of rest and  ease, diminishing as the labor advances, but
in a regular manner.   M. Saccombe has given  an exact record of  the fre-
quency and  duration of the pains, in one case, which I shall extract.1   Be-
tween 10 and 11 o'clock, A. m., the  patient had seven pains, and from 11
A. M. to mid-day eleven pains, as follows : —
                                            Minutes.            Seconds.
    From the 1st pain to the 2d the interval was 15 and its duration 21
2	it	3
3	ii	4
4	a	5
5	<<	6
6	u	7
7	a	8
8	n	9
9	n	10
10	n	11
11	a	12
12	it	13
13	it	14
14	tt	15
15	it	16
16	it	17
17	it	18
18	it	19
14	a		27
10	11		27
8	a		29
7	n		32
6	it		35
6	u		36
6	a		40
6	a		42
5	a		45
6	u		45
5	it		47
5	ii		49
5	it		55
4	it	V	' 2
4	it	V	'10
4	it	V	'27
4	it	1	'33
  At this period the waters escaped^nd the head was soon expelled   M
baccombe remarks that, "it resnlts^om  this observation : —1. That the
interval between the pains is in inverse ratio to their duration.   2 That the
duration of  each pain is in direct ratio to its intensity;  that is  to  say in
proportion as the interval  between the pains gradually diminishes  so does
their  duration increase, and in proportion  as their duration increases so
Etemens de la Science des Accouchemens, p. 202. 
MECHANISM  OF  PARTURITION.
205
does their intensity."  The same  conclusions equally apply to  the severer
pains of  the second stage.
  311. The pains, as  I  have  already said,  commence in the  cervix, and
gradually involve both the  body and fundus ; their first  effect, as Wigand
has observed, being  to elevate, as it were, the  presenting part, and  after-
wards to force it down.   During  a pain, the uterus becomes hard, round,
and prominent, with the fundus tilted forwards ;  when  the pain subsides, it
softens, but does not quite recover its former flaccidity.
  It  is impossible to  estimate exactly the amount of force exerted by the
uterus ; it is always  in proportion to the resistance, although the mode in
which it  is exerted varies; in some cases, it overcomes the obstacles by  rapid
and  energetic  pains, in  other  cases, the  same end  is attained  by a longer
and slower process.
  The first stage of labor is  completed  by the  uterine action alone,  but
during the second stage it is aided by the voluntary muscles, especially  those
of the abdomen, which press directly upon the uterus, and by the depression
of the diaphragm, which  diminishes the cavity of the abdomen.  The  addi-
tional effort made during the second stage is owing to the increased amount
of resistance to be overcome.
   Towards the termination of  labor, expulsive efforts are made by  the
vagina, and these are still more evident in the extrusion of the placenta.
   312. Uterine action is  not  directly  subject to the  control of  the will,
although mental emotions exert a considerable influence  upon it.  For in-
stance, labor may be brought  on  by mental excitement; and, on the  other
hand, anger, fear, surprise,  etc., may suspend the pains.  Betschler relates
a case where  the labor was arrested by the fright  occasioned  by  a violent
storm, and many of my readers are familiar with the case related by Baude-
locque, in which the pains ceased each  time that  the pupils who were to
witness the case came in sight  of the patient.   A temporary suspension  of
labor on the arrival of the accoucheur (especially if sudden and unexpected),
is a very common  occurrence.
   I have spoken of  the voluntary exertions made during the second  stage
of labor :  these, it is true, are  at first under the command of the will, but at
a more advanced period it is scarcely possible for the patient to withhold the
co-operation of these muscles.
   Dr. Tyler Smith thus  sums up  the motor  actions of the uterus : " Voli-
tion may be said to affect the process only indirectly.  Emotion has a  direct
influence, but it is accessory rather than essential to its performance. Reflex
action is the great physiological power, which being absent,  the function of
parturition  could  not be properly performed.   Peristaltic,  or immediate
action, is the basis or radical element upon which the other causes of motor
action operate."1
   313. 2.  The Passages.—Let me recall in a few words to  the reader's
recollection the diameters  of  the pelvis: those  of the  brim being — the
antero-posterior, 4 to 4\ inches, the transverse,  5£ inches, and the oblique,
4^ to 5 inches ; the relative proportion  of these gradually changes in  the
ca,vity, until at the lower outlet the  transverse  is 4 inches, and the antero-
posterior 5 ; in other words, that  which was the  longer at the upper outlet,
is the shorter at the lower.   From these diameters, a deduction  of a quarter
of an inch in the antero-posterior, and half an inch  in the transverse diame-
ters, must be made, on account of the soft tissues clothing the pelvis.
  I also remarked before, the great changes in the axes of the pelvis,  which
form  an obtuse angle with each other, that of the brim looking upwards  and
forwards, and that of the outlet downwards and forwards. Lastly, I pointed
1 Parturition and Obstetrics, p. 48. 
206
MECHANISM  OF  PARTURITION.
out, as an important mechanical agency, the inclined planes of the cavity
of the pelvis, the direction of which is downwards and forwards.#
  [As no correct  idea  of the  mechanism  of labor can be acquired unless
attention is paid to the several planes  of the pelvis, and the variations pro-
duced in the direction of these planes by changes in the position of the body,
and bv disease,  we have taken the liberty to introduce here an extract from
Dr. Meigs' " Obstetrics—the Science and the Art," which, with  the accom-
panyingIllustrations, places this subject in a very clear light.   ^
  "Plane of the Superior Strait.—The  plane  of the  strait is an imagi-
nary superficies, the anterior margin of which is at the  symphysis pubis, its
posterior margin at  the promontory, while the rest of its margin touches the
inner lips of the linea iliopectinea.
  " When the woman stands erect, or lies at length on the back, the plane
of this strait dips at an angle  of 50° to the  axis of her body.
  " Inclination of the Plane.—It must clearly appear that the plane of
the superior strait dips at a variable angle in various  positions of the trunk
of the body ; for if  the subject be standing,  it dips as above at 50°,  but if
the trunk be inclined forwards, the dip will be lessened ; or if the trunk be
inclined far backwards, it may be increased.   Now this is an important item
of obstetric knowledge, since upon it is founded advice  as to the decubitus
of the patient,  whom we may direct to extend her trunk or to flex it more
or less, as we may desire to bring the plane of the superior strait into a posi-
tion that may favor both the entrance of the presenting part into the  strait,
and its passage through it.
   " The figure is designed to show  that the plane of the strait may give
different angles with the spine, according  as the spine is  brought more for-

                                Fig. 85.
Planes of the Pelvis.
ward, or carried further backwards over the opening.   Thus e e e is a circle
of which the diameter bf represents the inclination  of  the  plane of the
upper strait, equal to an angle of 135°  fa, which is the  ordinary altitude
of the spinal column or axis of the trunk.   If the  patient lying upon her
back should have her shoulders raised, so as to carry the spine forward to c,
equal to  22'30°, the angle would be reduced to 112-30°.   But if  the shoul-
ders should be still more elevated to d,  the  axis of  the trunk would be at
right angles to the plane of the strait bf.
  " The same effect as to the inclination of the plane  of the  strait is pro-
duced in the patient, lying on  her side, whenever she  bends her head and
trunk forwards; and, indeed, in labors, we  see women  constantly prompted 
MECHANISM  OF  PARTURITION.
207
by an instinctive sense of the utility of it, bending the trunk quite over the
abdominal strait, to which, moreover, the old nurses and experienced crones
urgently exhort them.  A child's head, that in one inclination  of the  plane
should be driven against the symphysis pubis, would with a lesser inclination
of it plunge at once to the bottom of the pelvis.
  " Justus Heinrich Wigand, the lamented author of the celebrated volume
entitled Die Geburt des Menschen,  was deeply impressed with the import-
ance of a careful attention to the inclination  of the  plane  in labors.  He
often  made use of his knowledge of it as a foundation of his prognosis.   I
have copied these outline  figures from the  second edition  of his work, by
Froriep. They represent the female torso in profile.  Each figure has marked
upon  it six lines, of which the two  horizontal ones extend  parallel to each
other, from the promontory  of the  sacrum  and the symphysis  pubis re-
spectively.
   "In a well-formed pregnant female, the profile will resemble the outline
figure, provided the child  be  not very large, nor the liquor of the amnios
excessive in quantity.  As in fig. 86, the back bone will not be excessively
Fig. 86.
Fig. 87.
                             Planes of the Pelvis.

curved.  A line drawn horizontally forwards from the top of the sacrum will
pass out at the navel, and equal angles will be formed by a line drawn from
the top of the sacrum to the symphysis pubis, which indicates the inclination
of the superior strait, and one drawn from the same point to the scrobiculus
cordis.   A line from the scrobiculus cordis to the symphysis pubis, will be
perpendicular to the one first mentioned.
   " Inspection of such a figure  might well serve to establish a  favorable
prognosis ; since, casteris paribus, any untoward  circumstances would be very
little to be expected with so perfect a form, proportion, and arrangement of
parts.
   " Figure 87 is a copy of Wigand's figure 3d, in which he proposed to
represent the profile  of a pregnant woman of  apparently perfect  form, but
the inclination of whose superior strait is excessive, as may be  seen by ob-
serving the line drawn from the top of the sacrum to the top of the symphysis 
208
MECHANISM  OF  PARTURITION.
pubis.  In such a patient the plane of the strait looks almost backwards, and
the indication of Conduct would be to cause her to bend her body strongly
forwards, flexing her thighs very much upon  the  pelvis.   Such a direction
alone might suffice to correct the excessive inclination of the plane, whereas,
if she should lie on the back with the shoulders low, and the limbs  extended,
the presenting part could hardly fail to be  driven upon  the  top of the ossa
pubis.   In this figure the back is much more curved than in the former one.
The horizontal line, from the base  of the sacrum to the symphysis, rises  far
above the navel, and the  upper triangle or that  of the  scrobicle  is much
smaller than that of the pubis.  The  line  falling  from  the scrobicle to the
pubis retires, whereas in the former figure it is perpendicular.  In this figure
the perpendicular line from the base of the sacrum is far in advance  of the
upper dorsal 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 (fig. 88), in which is the profile of a woman with a
pelvis so deformed as to imply a necessity for the operation of perforation, en
Fig. 88.
Fig. 89.
                             Deformed Pelvin.

account of its vitiated'conjugate diameter.   The angle formed by the back
part of the sacrum and spinal column is much too small.  The bend is quite
different from the gentle curve seen in the first profile.  The  scrobicle oro-
l1° "J61"7 ™  K°Ver ^ sJm^s]s Pubis> a*  by the line  uniting them may
be seen   The horizontal line from the  base  of the  sacrum comes out just

ttTfrot Zf  ThGt 1,n+ie fr°mK-the SCr0bide t0 the base of the sa™> 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 retire™

"" Wi^nd0 G ,°tVVS " ?«" °f  thG UPP^ Part 0f «"> SPinal  Sn
    Wigand's  5th figure  (fig. 89) represents  a pregnant woman, the conin-
gate diameter of whose superior  strait does not exceed one inch or one inch
and a half; and which, according to most of the German accoucheurs indi-
cates a resort to the Cassarian operation.                   uucneur&, inai
  " The belly is quite  pendulous  over the pudenda.   The plane of the strait 
MECHANISM  OF  PARTURITION.                209
makes  a very sharp  angle with the horizontal line which  comes out high
above the umbilicus.  The back is extremely hollow, in  consequence of tht,
sinking of the sacral promontory  down towards the pubis, and the line from
the scrobiculus  cordis to the ossa pubis retreats  strongly in  a backward
direction, leaving the breast to hang far over the pudenda in  front.  The
curve of the sacrum is sharp, and the compensating curvature of the upper
part of the vertebral column is highly characteristic of this malformed pelvis,
and is  an evil omen to the unfortunate woman.
   " Such are some  of Wigand's  outline  figures.  I  believe that the study
of them will be very useful to the student.   It takes many years of practice,
and  a  great clinical experience  and close  observation like Wigand's, to
enable one to become possessed,  at a glance, of the peculiarities of the case.
He, however, was a Master  in our art, a man who devoted his  time  to  its
improvement,  and  spent the  last moments  of his  truly missionary life in
laboring to complete the beautiful volume from which I have taken  his
drawings.   It is a privilege and an honor to evoke  such a  man from his too
early grave, in  order that he, though dead, may yet speak in  this distant
land.
   " Plane  of  the Inferior  Strait. — The plane of  the inferior strait is
usually regarded as bounded by the inner lips of  the two tuberosities of the
ischial bones, the rami of the ischia and pubis, the ischio-sacral ligaments,
and  the point  of the coccyx.   In this way we speak  of  the plane of the
inferior strait as one plane only ;  whereas, there are, in fact, two  such planes,
an anterior and a posterior.
   " This figure  exhibits the contour of the  outlet.   The line c d represents
the transverse diameter.  The letters c e ae  d show the anterior semi-circum-

                                 Fig. 90.
Outlet of the Pelvis.
ference, while cfbfd show the posterior semi-circumference of the outlet.
Now from c d to a is an inclined plane, and from c d to b is another inclined
plane.   These planes intersect each other at an angle of 140°,  and they
ought  to  be distinguished  as the anterior  and as the posterior inclined
planes of  the perineal strait.
   " In midwifery it  will be found  that as the child descends, in order to
escape from the womb, it  first impinges upon the  posterior inclined plane,
which it depresses first, and then begins to depress the posterior edge of the
anterior inclined plane.   When it has succeeded in depressing the edges of
the two planes, it escapes betwixt them, whereupon they resume their place
like two valves,  whose floating  margins  had  been  first violently separated.
and then allowed to  close again."]
       14 
  210                MECHANISM  OF  PARTURITION.

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

                                  Fig. 91.
Foetal Head Diameters.
  318.  3. The Child. — I  have not much to add of the mechanical in-
fluence  of the child in the process of labor, inasmuch as it is altogether pas-
sive.  The measurements of  the child's head are as follows: — 
212
MECHANISM  OF  PARTURITION.
	4	toH	inches
	°2	" 4 5	
	4 o 1	" 4.1 " 4 3 H	
       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
  The first of these diameters corresponds  to  the  oblique diameter of the
brim and  antero-posterior  of the lower outlet; the second  to the antero-
posterior diameter of the brim  and  transverse of the lower outlet  in  ordi-
nary cases ;  the third to the antero-posterior diameter of the lower outlet
in face presentations : the others to certain diameters of the pelvis, to which
the  head is only transitorily applied.
  The transverse diameter of the shoulders is  from 4f to 5^ inches.
           a         tt       a  hips       a      4   «  5     a
  These diameters being at right angles with the long diameter of the head,
it follows that when the latter corresponds to the  longer (or  antero-poste-
rior) diameter of the outlet, they will be exactly in  apposition with the long
diameter of  the brim.
  319.  The diameters are  pretty regular in well-developed infants, and cor-
respond very closely to those of the clothed pelvis.   Yet certain adaptations
facilitate the transit of the child—viz., the compressibility of the head and
body  of the  child, which it is calculated will permit it to be forced through a
pelvis whose antero-posterior diameter at the brim is only three inches.
And further, the head enters and passes through the pelvis  obliquely,  both
as to its longitudinal and transverse axes, i. e., one fontanelle and the ante-
rior part  of the presentation are lower than their  opposites, thus diminish-
ing the longitudinal transverse diameters from a quarter to half an inch.
  This appears to be the proper place to notice some very interesting re-
searches,  published by Prof. Simpson, of Edinburgh,1  on the  different  size
of the head  in male and female children, and the consequences which result
to the mother and child.
  He states that the  head  of the male at  birth is larger than that of the
female, in its circumference, by fths  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 natura*
labor.
Tedious labor
Convulsions .
Puerperal fever
Ruptured uterus
Hemorrhage
Forceps.
Crotchet cases
Total Cases.	Males.	Females.
119	65	54
28	17	11
88	54	34
34	23	11
44	31	13
24	16	8
74	50	24
Proportion.
148 to 101
153
161
207
240
200
200
  From a large collection of facts bearing upon and illustrating the sub-
ject, the author has drawn  the following conclusions of the dangers conse-
quent upon this slight excess of size in male children.
'Ed. Med. and Surg. Journal, Oct., 1844. 
MECHANISM  OF  PARTURITION
213
  1.  Of the mothers that  die under parturition and its  immediate conse-
quences a much  greater  portion  have given birth to male than female chil-
dren.
  2.  Among labors presenting  morbid complications and  difficulties,  the
child is much oftener male  than female.
  3. Among the children of the mothers that die from labor  or  its conse-
quences,  a larger proportion of those that are still-born are male than
female ;  and on  the contrary, of those that are born alive, a larger propor-
tion are female than male.
  4. Of still-born children, a larger proportion  are male than female.
  5. Of the children that die during the actual  progress of parturition, the
number of males is much greater than the  number of females.
  6. Of those  children  born alive, more  males than females are seen to
suffer from the morbid states and injuries resulting from parturition.
  7. More male than female children die in the earliest periods of infancy,
and  the disproportion  between  the mortality of the two  sexes gradually
diminishes from birth onwards until some time subsequently.
  8. Of the children that die in utero and before the commencement of
labor,  as large a proportion are female as male.
   9. In  laborious labor  with the head presenting, in proportion as the order
of  labor rises in difficulty, the  amount of  male births  in them rises in
number.
  ,10.  Of the morbid accidents  that are liable to happen in connection with
the third (second) stage of labor, as many take place with female  as with
male births.
   11.  More dangers and deaths occurs both to mothers and children in  first
than in subsequent labor.
   12.  The  average duration of labor is longer with  male than with female
 children.
   The long axis of the  child in general corresponds to the long axis of the
 uterus, though  occasionally it is somewhat oblique :  this, according to  De-
 sormeaux, occurs once in  249 cases, according  to  Meckel once in 287, and
 to  Osiander once in 300 cases.
   320.  Having now considered these elementary powers  or  conditions of
 labor  separately, we are  prepared to examine them in action ; in other
 words, to ascertain the Mechanism of Parturition.   Nothing can be more
 simple, but certainly nothing more erroneous,  than  the views held by the
 older  writers on midwifery.  They concluded that  the head passed through
 the pelvis, in the same position  as  that in which it emerges from it — that
 is,  with  its long diameter  antero-posteriorly.  The first writer  who corrected
 this opinion was Sir Fielding Ould, of this city, who wrote in  1742, and  who
 stated that in the first part of its progress the  face is turned  to one side or
 other of the pelvis, " so  as to have the chin directly on one of the shoulders."
 Dr. Smellie in  1752 corrected the error of Ould with regard  to the contor-
 tion  of the  child's neck,  but in  other respects agreed with Sir F. Ould.
 Similar opinions were  promulgated  in 1770 by Deleurye in France, and
 subsequently by Sehmitt and Mampe in Germany.
   The next step in advance was  made (without inter-communication) by
 Saxtorph of Copenhagen, and  Solayres de Renhac of Montpellier, who  in
 1771 published two essays, which agreed in this fact, that the long diameter
 of the head of  the child, in natural  labor, entered the pelvis in a direction
 neither  parallel to the conjugate,  nor to the  transverse diameters of the
 brim,  but parallel to one of its  oblique diameters; that is,  with the sagittal
 suture running  in a line directed at  one extremity to the sacro-iliac synchon-
 drosis behind, and to the  foramen  ovale anteriorly.   They further showed
 that of  the two oblique diameters, the long axis of the head, in a very large 
214
MECHANISM  OF  PARTURITION.
 proportion, occupied the left, or that running between the right sacro-iliac
 synchondrosis and left foramen ovale.   M. Baudelocque adopted the opin-
 ions 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 correction ;
 and for the full demonstration of that which was true, and  the correction of
 that which was erroneous, with the  addition of many new observations, we
 are indebted to the labors of Naegele of Heidelberg,  who in 1818 published
 his essay On the Mechanism of Parturition, which was  translated  into  our
 language by Dr.  Rigby in 1827.   The  more closely his opinions have been
 tested by experience and careful observation, the more clear does their cor-
rectness appear.
   Having  so high an estimate  of the labors of  M. Naegele, the reader will
 not be surprised  at  my adoption of  his descriptions in the present volume;
 and it would give me great pleasure if,  on my recommendation,  all my read-
 ers would peruse his excellent essay.
   321. We have already  stated that the position of the  head is the relation
 which its diameters bear  to those of the brim of the  pelvis ;  or,  in other
 words, the situation of the extreme  points  of the longitudinal  diameter of
 the head compared  with the extreme points of  the oblique diameter of the
 brim.   Now the  former are sufficiently well indicated by  the  anterior and
 posterior fontanelles,  and the latter by the foramen ovale, right  and left,
 and the sacro-iliac synchondrosis, right and left.
   Naegele  states that the child usually presents with the head  in either of
 two positions corresponding to the two  oblique diameters, but with the supe-
 rior fontanelle at either extremity ;  thus those I have called 1st and 3d will
 belong to the  left oblique, and the 2d and 4th to the right oblique ; but it
 is more convenient, with the majority of German and English modern writers,
 to make four, which therefore I have adopted.   In  the first, the posterior
 fontanelle  corresponds  to the left foramen ovale ;  in the  second, to the right
 foramen ovale ;  in  the third,  to the right  sacro-iliac  synchondrosis ;  and
 in the fourth to the left  sacro-iliac synchondrosis;  the anterior fontanelle
 of course corresponding to the opposite extreme of the  oblique diameter.
   These numbers do not  correspond with those affixed to  the presentations
 of other writers  ; but  in  order that no confusion may  arise, I shall give a
 table  of the corresponding numerals of different authors:
Numbers affixed to Presentation by						Description of Presentation.
	■a a	3	a>		a	
	• u s					
	<2 o-r . §>	i ■; a „	03	•"S 3	o	Anterior part of Cranium
be	ir, 5 r1'? 3	iud( uboi ml it wis. ewee	J3	> 5 £	s	pointing to
1	*; o S a R	KfiCfiP	^5	«£3	K	
	1	1	1	1	3	Right sacro-iliac synchondrosis.
	2	2	2	2	4	Left do. do.
2	3	4	3	4	6	Left foramen ovale.
	4	5	4	5	5	Right do.
		3		3	7	Promontory of sacrum.
		6		6	8	Symphysis pubis.
			5	7	1	Right os ilium.
			6	8	2	Left do.
 
MECHANISM OF PARTURITION.
215
  322.  Now let us trace the progress of the head in the different positions.
  In  the  first position (fig.  92), it is, as I have stated, placed obliquely,
corresponding to the right oblique diameter of  the brim, the posterior fon-
tanelle being towards the left foramen ovale or  acetabulum, and the anterior
towards the right sacro-iliac synchondrosis, the two fontanelles being at first
on  a level;  consequently the  sagittal  suture  will  run nearly in the left
oblique diameter of the  brim, but rather nearer to the sacrum than the

                                  Fig. 92.
Mechanism of Parturition—First position.
pubis, because the anterior half of the presentation is almost always lower
than the posterior.  If the finger be at this time introduced into the centre
of the os uteri, at the very commencement of labor, it will impinge  upon/
the right tuber parietale, above which and on the upper edge of the parietal
bone, the primary tumor is formed.

               [Fig. 93.]                            [Fig. 94.]
Vertex Presentation: first position.                  mechanism of labor.
        I
  By the action of the uterus the head is forced downwards into the cavity,
preserving in some cases merely the obliquity it possessed at the brim ;  but
in other cases  it assumes an oblique  position as  regards its longitudinal
axis ; one fontanelle—generally the posterior—being lower than the other :
this is more remarkable as the head advances.  In  other respects, the  posi-
tion of  the head and the presenting part is unaltered in the cavity, the pos- 
216
MECHANISM  OF  PARTURITION.
terior fontanelle  still corresponding to the foramen ovale,  and not, as fre-
quently stated, to the arch of the pubis.
  When the head arrives at the lower  outlet, Naegele  observes, "by con-
tinued pressure of the uterine contractions the posterior fontanelle gradually
moves itself by slight degrees, repeated at equal intervals, in  a direction from
left to right (frequently more or less from above downwards), and the occipi-
tal bone advances from the side  of the pelvis under the arch of the pubis.
It is not, however, the centre of the occiput  that advances under the pubal
arch, but the head  approaches the os externum with the posterior and supe-
rior part of the right parietal bone and remains in  this position until it has

                   [Fig. 95.]                               [Fig 96.]
Outlet of the pelvis, with the fcetal head passing through in the   First Position of Vertex: third step
  first position. The asterisk marks the presenting portion.         in mechanism of labor.
passed through the outlet of the pelvis with the greatest circumference which
it opposes to it, when it then turns itself  with the face completely towards
the right thigh of the mother."  That the head really passes thus obliquely
through even the external parts may be proved by tracing the sagittal  suture,
which will be found running obliquely from left to right, and  by examining
the tumor of the scalp, which, after delivery, occupies the posterior and supe-
rior quarter of the right  parietal bone, and a portion of the occipital bone,
if there has been sufficient delay at the vaginal orifice.

                                  Fig. 97.
Mechanism of Parturition — Second position. 
MECHANISM  OF PARTURITION.
217
 _ 323.   When the head is in the second position, (fig. 97), its longitudinal
diameter corresponds  to the  right  oblique  diameter of  the pelvis,  and it ia
placed obliquely as in the former case, acquiring the  second obliquity as it
descends ;  and it passes through the pelvis and lower  outlet precisely in the
same mode as in the  first position, only that the slight rotation is from right
to left, and that when expelled it completes the  quarter-turn, bringing the
neck under the arch of the pubis.

                                 [Fig. 98.]
         Outlet of the pelvis and the foetal head passing through it in the second position.
                      Ihe'asterisk marks the presenting position.

  324.  In the third position (fig. 99), the anterior fontanelle  corresponds
to the left acetabulum, and the posterior to the right sacro-iliac synchon-
drosis, at nearly the  same level, until  the  pressure occasions one or other
(generally the posterior) to descend.  The sagittal  suture divides  the  os

                                  Fig.  99.
Mechanism of Parturition — Third position.
uteri obliquely and unequally, and the tumor of the scalp is found upon the
upper edge of  the  left parietal  bone, nearly at an  equal distance from its
angles,  and the finger, passed in the central line, rmpinges upon it.
  " As  soon as the head is engaged in the cavity of the pelvis,"  Naegeifc
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 oart of 
»   218
MECHANISM OF PARTURITION.
the pelvic cavity opposes to it, or, in other words, the oblique surface which
is formed by the lower end of the os sacrum by the os coccygis, the ischia-
tic ligaments, etc., by which it is compelled to move from its position back-
wards, in a direction  forwards, it  turns  by degrees with its  great diameter
into the  left oblique diameter of the pelvic cavity ; i. e., the posterior fon-
tanelle is directed to  the right foramen ovale, and as  the  head approaches
nearer and nearer to  the  inferior aperture, it is the  posterior and superioi
quarter of  the left parietal bone,  which is felt in the  cavity of the pelvis,

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

                                 [Fig. 102.]
Outlet of the pelvis and foetal head in the fourth position.
     The asterisk marks the presenting portion.
   326. When the head presents in the third or fourth position, if the pelvis
 be unusually large, or the fcetal head unusually small, or even with a pelvis
 and head of ordinary proportions, if the pains come on very violently when
 the head is at the upper  outlet, the changes into the second and first posi-
 tions may not take place, owing to  the absence of sufficient resistance or
 adequate time, but the head be driven through the pelvic cavity and lower
 outlet in the position (or nearly so) in which  it presented  at the brim, the
 upper and anterior part of the left (third position) or right (fourth position)
 parietal bone, and a  portion of the superior part of the frontal of the same
 side corresponding to the arch  of the pubis, and the posterior part of the
 right  or left  parietal bone, and part  of the occipital, sweeping over the
 perineum.  As the head passes out,  the forehead looks  upwards, under the
 arch of the pubis.  Naegele states: " Of ninety-six cases of the third vertex
 position, which I observed with  particular care, and described  in my note-
 book,  I remarked the head three times to come through the external pas-
 sages with the head upwards or forwards."
   This occasions more suffering, and some delay, as the  longitudinal diame-
 ter of  the head is presented  to the lower outlet without adaptation or modi-
 fication.
   ["The mechanical form of the pelvis," says  Dr. Meigs,  "is  so miracu-
 lously  adapted to the wants  of  the economy in labor, that it has power, in
 a major part of these fourth  positions, to rotate the vertex  from the right
 sacro-iliac junction to the right  acetabulum, and thence  to  the pubal arch;
 and that without any assistance given by the accoucheur.
  " It  is true that this favorable rotation sometimes requires the aid  of  the
hand, or even of an instrument.  It also occasionally happens, that neither
the hand alone, nor any  instrument, can enable the surgeon to bring  the 
220
MECHANISM  OF  PARTURITION.
vertex round to the front.  In  such case, it  slides  into  the hollow of the
sacrum, and  the  labor is thenceforward rendered  more painful and more
difficult.                                          „  ,    ,,      ,  ,  ,
  " When in fourth positions, the vertex can rotate first to the acetabulum,
and then to the arch, the labor is not seriously retarded ;  but when the pos-
terior fontanelle gets into  the hollow of the  sacrum, and will not sutler ro-
tation, then the flexion becomes  greater and  greater as the fontanelle slides
down along the point of the sacrum, along the face of the coccyx, and down
the mesial line of the perineum,  until having  pushed off the perineum 4.10,
the occipito-frontal diameter, the vertex  slips over the fourchette, and im-
mediately turns over backwards, in  strong extension, which allows the fore-
head, eyes, nose, mouth and  chin  successively to emerge from  underneath
the crown of the  pubal arch, to  complete the birth of the  head.  The an-
nexed figure  of a head in an occipito-posterior position, show these truths
clearly enough.
                                Fig. 103.
                   Head at the Lower Outlet in the fourth position.

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

        i Prov. Med. Surg. Journal.
        2 A Treatise on Obstetric Auscultation, translated by Dr. West, p. 71 
222
NATURAL LABOR.
it has to pass-*, e., first against the  circle  of the os uteri, and secondly
against the circumference  of the vaginal orifice, and it always forms on the
lowest or presenting part, so that the primary tumor indicates5  the part of
the head which presented  at the  os  uteri, and the  primary and second to-
gether  that which occupied the  lower orifice.  The tumor itself consists
most  frequently of  serum, sometimes with  blood mixed, and in  a few cases
of blood alone.1
  We have already seen, that, in the first position, the primary tumor occu-
pies the right tuber parietale, and the  secondary, in addition, the posterior
and superior angle of the parietal bone, with  a part of the occipital bone :
in  the second position, it occupies the left tuber parietale primarily, and the
posterior angle  secondarily: in the third, the primary tumor is somewhat
anterior to the left tuber parietale ; but by the change to the second posi-
tion the tuber and posterior part of the bone becomes the seat of the second-
ary tumor : and in the fourth, the primary tumor is anterior to the right
tuber parietale, but the secondary tumor includes it and the posterior part
of the bone.
                       CHAPTER  III.

           PARTURITION. —CLASS I.  NATURAL  LABOR.

  331. Definition.—The term "natural labor" is applied to those cases iu
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
foetus  having  arrived at the full term ; but these variations are of compara-
tively little importance.  Within  the  limits I have laid down there will be
found  room for great diversity in  the peculiar  features of  each case, and
experience teaches us that scarcely any two labors are  exactly alike.   First
labors  are in general more tedious than subsequent ones, at least when the
resistance is chiefly from the soft parts.
  332. The following table will show the proportional  duration of labors:—
	Total No.	Terminated	In 12	In 18	In 24	Above 24
	of Cases.	in 6 hours.	hours.	hours.	hours.	hours.
Dr. Merriman .	500	206	398	442	450	
Dr. Collins	15,850	13,012	15,084	15,346	15,586	264
Dr. Maunsell	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 12 hours		104
Drs. M'Clintock and Hardy I	6634	3882	5280	5706 1 5852		269
Churchill on Diseases of Children, p. 66. 
NATURAL LABOR.
223
  In addition to these specific details, I may mention that Dr. Smellie cal-
culated that 990 in 1000 are  natural labors: Dr. Leake 900  in 1000 ;  Dr.
Bland  found  1792 cases  of natural labor in 1897 cases; Dr. Jos. Clarke
9748 in 10,199 ; Dr. Merriman 2607 in 2735; Dr. Lever 4266 in 4666 ;  and
Professor Assalini, out of 269 cases, reports 205 as "quick and easy."
  333. It will be  observed that I have inserted a parenthesis in  the defini-
tion, to the effect that each stage should be in due proportion to the other
'i. e., the first to the  second  as 2 or 3 to 1), and this I have done to guard
against the error of making time (or the entire duration of the labor) our
sole standard, instead of  symptoms;  for a labor may be natural  as to time
{i. e., completed within twenty-four hours), and yet if the first stage be very
short (say one or two hours),  and the second prolonged (say twenty hours),
the character of the  labor may be altogether changed, and the formidable
symptoms of powerless labor be developed.
  334. Precursory Symptoms.—Before  describing the ordinary course of
labor,  it is necessary to point out  certain symptoms  which indicate its
approach.   These vary in intensity in different women : in  some they are
but slight, and may  perhaps  pass unnoticed ;  in others they are very  well
marked.   The most important are, — 1, the subsidence of the abdomen ;  2,
frequent micturition ;  3, griping and tenesmus ; 4,  painless uterine contrac-
tions ; and 5, mucous discharge from the vagina.  Let us examine each of
them briefly.
  335.  1.  Subsidence of the abdomen,—We have heretofore seen (§ 157),
that at the commencement of the ninth month the fundus uteri reaches to
the ensiform cartilage ; but that during  the last month  it subsides : this  is
especially remarkable during the last fortnight, and is sufficiently marked
to attract the attention of the patient.   The uterine  tumor becomes appa-
rently  less,  and sinks forward.   It may probably  be owing  partly to the
absorption of  the liquor amnii, partly to'the lower end of the uterus sinking
into the  pelvis, and partly to some relaxation of the uterine tissue permitting
a greater amount  of  lateral expansion, and a consequent diminution in its
height.  The  tilting  forward is owing  to  a  relaxation of  the  abdominal
parietes, and increases in  successive pregnancies: sometimes, though rarely,
it is so excessive as to require the support of a bandage, and even to retard
the first  stage of labor by deranging the axis of the uterus.
   336.  2.  Frequent  micturition.—In proportion to the  enlargement of the
uterus, is the  pressure exercised by it upon the neighboring viscera.   During
the last  month, when it sinks down into the pelvis,  and falls forward, the
pressure upon the bladder is considerable, and its capacity is so much dimi-
nished as to  render a frequent evacuation of its  contents  necessary.   In
addition, there is  a certain reflex influence from the  uterus to the bladder,
and an increase of irritability in the latter, on account of which  it is  less
tolerant  of the presence  of urine than under  ordinary circumstances.  Its
value as  a sign of approaching labor, however, is lessened by the fact that it
occurs from the same causes, just before  the uterus rises out of the pelvis,
and that it  may  be present during several weeks in  the  latter part of
gestation.
  337. 8. Griping, tenesmus, or diarrhoea.—Similar mechanical and reflex
effects  of advanced gestation to those just noticed, may  be produced in the
rectum and large intestines, and the result will be an  irritable  state of the
bowels, occasional griping pains, and a desire to go to stool when but little
is passed.   It must  ever be  remembered that this  frequent  passing of a
small quantity of  fluid faeces is quite compatible with a great accumulation
of faecal matter above the seat of the irritation, and  may often be relieved
by a free evacuation.   It is an uncertain sign of the approach of labor.
  338.  4. Painless uterine contractions.—During  the last month of gesta 
224
NATURAL LABOR.
tion, and  especially  towards its termination,  patients frequently notice a
squeezing sensation in  the  abdomen, which lasts for a little time, then sub-
sides, and is not attended with  pain.   As was remarked by Leroux  if the
hand be placed upon the abdomen, the uterus will be felt tolerably hard, *ell
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.   Yelpeau states  that the  cervix uteri may also be
felt alternately relaxed and contracted.                          m
  It appears extremely probable that by this painless mechanism is effected
that change in  the cervix  and  os  uteri which have been  observed to take
place previous to actual  labor.
  339. 5. Mucous discharge of the vagina.—This is called "the shows" by
nurses : it is generally observed  about twenty-four hours previous to the
commencement of actual labor, and evidently prepares the passages for the
transit of the fcetus.   The  quantity and quality vary : sometimes  the fluid is
thin, in other cases thick and viscid (which Wigand says is more  favorable),
becoming thinner at the time of labor ; some women have it profusely, others
scantily.   It is generally  colorless until labor has set  in; but during the
dilatation of the os uteri, striae of  blood are mixed with it, arising from the
rupture of some of the small vessels of the cervix uteri.
   340. Of these precursory symptoms, it will be remarked,  that the  first and
third only indicate an  advanced period of gestation ; the fourth, according
to  my experience, that labor is  not far off;  but the fifth is the  only one
which shows that it is close at hand.
   In addition to these more marked symptoms, many minor  ones might be
enumerated ; such, for instance, as swelling of the labia  and lower  extremi-
ties, cramps in the thighs  and legs, the improvement of the appetite  and
spirits, diminution of the dyspnoea, a sense of greater lightness and facility
of walking, etc. ;  but these being unequal and  uncertain, are therefore of
less value.
   341. Symptoms of Labor.—I shall now proceed to the  description of
labor in each stage; first detailing the phenomena, and afterwards  prescrib-
ing the requisite management.  Before I proceed, I should wish to impress
upon  my junior readers the extreme  importance of carefully and  minutely
studying the subject of natural  labor, not merely in books, which must neces-
sarily be  imperfect,  but  at the bedside  of the patient.   No case  of labor,
however simple, can be attended without some addition to our knowledge,
if we are vigilant:  almost all recent improvements in practice have  arisen,
 and I believe all future ones will arise, from  a more perfect  knowledge of
the natural process, and a more correct appreciation of the natural powers.
   As I have already treated of the mechanical and vital agencies employed
in effecting delivery, I shall now confine myself to a practical consideration
 of the results.
   342. The commencement of labor is dated by the patient from the mo-
 ment  that the uterine contractions become  painful, and  correctly so,  pro-
 vided the entire uterus be  engaged, if they recur regularly and  continue
without suspension.   But  this is not  always the case; the  uterus not unfre-
 quently at first acts  partially, irregularly, and inefficiently: such efforts are
called "false or spurious pains."  They arise from various causes, such as
over-fatigue, indigestion, constipation, cold, etc., and are occasionally excited
by the motions of the child.   A little careful observation will  enable us to
distinguish them  from  true pains,  as they commence  about  the fundus,
 and are of limited  extent, recur  at regular intervals, are  not attended with
 the mucous discharge from the vagina (§ 339),  and do  not dilate the os
 uteri, or protrude the "bag of the waters;" on  the other hand, true pain9 
NATURAL LABOR.
2 25
generally commence in the lower part  of the uterus, and are first felt in the
back, extending gradually to the front, recurring with regularity though in-
creasing in frequency, dilating the os uteri, and protruding the membranes.
  As these false pains may occur at any period of gestation, and  sometimes
bring on  labor prematurely, or wh^n at the full term occasion distress and
loss  of rest, it is always desirable to  relieve  them :  this may generally be
done by rest, if the patient have been fatigued, or by aromatic purgatives,
followed by an opiate, if the stomach and bowels are deranged.
  343. The true pains recur  at regular  intervals, gradually increasing in
frequency and power; and each  pain  from its commencement augments in
intensity, until, having  arrived at its  maximum, it remains stationary  for a
short time, and then subsides: thus  presenting, as  it  were, a type of the
entire course of the pains.
  The pains exhibit, however, different characteristics according to the stage
of labor, and have therefore been divided into two kinds, "cutting or grind-
ing pains," and " bearing down or forcing pains."  The  cutting or grind-
ing  pains" are indicative of, and confined to, the first stage of labor, during
the  dilatation  of the os uteri.   They are short, severe,  and not very fre-
quent, obliging the patient to suspend  her occupation, and partially arresting
respiration, but not  inducing  any voluntary efforts.   They  are  generally
(but not always) seated in the  back, gradually extending round the loins to
the abdomen and thighs.   The suffering they occasion  is very considerable,
and  although  (except in some irritable subjects) it is  less than that which
accompanies the stronger pains of the second stage, yet it  appears  more
difficult to bear, and the patient gives  utterance to groans and loud outcries.
The outcry which attends  upon the cutting pains, is an excellent diagnotic
mark of the first stage of labor, and in some cases we are obliged to  depend
upon it alone.
   344.  During the first stage we generally find the patient  more irritable
and restless  than subsequently,  moving  from one place to another, and
changing both occupation and position frequently: she is  low spirited and
fearful, weeping from dread rather  than suffering,  anticipating evil, and
scarcely to be  comforted.  This distressing state disappears, however, as the
labor advances.   In  some cases the despondency  which has darkened the
last  few months of pregnancy is exchanged for cheerfulness  and courage the
moment  labor sets in.   In  general I have remarked, that,  whatever the
mental condition may have been during pregnancy, and even  the first  stage
of labor, the violent  pains, severe  suffering, and hard  work  of the  second
stage, occupy  the  mind as  well as body,  to the  exclusion of desponding
anticipations, and,  as it were, rouse up all the patient's energy and courage
to meet the exigencies of the case.  A singular  deviation  from  mental in-
tegrity, apparently from extreme suffering,  has been the  subject of a valuable
essay by my friend, Dr. Montgomery; I allude to  the  partial and  tempo-
rary delirium which occurs occasionally, just as the head is passing through
the  os uteri or os externum.  • It seldom lasts more than a few minutes, and
in one case I attended the patient was conscious of talking incoherently, but
felt  quite unable to arrest herself.
  345.  During the first stage of labor, and especially at the  time the  head
passes through the os uteri, severe rigors occur; not from cold, as they are
observed  equally when the patient is warm,  but  as the  prelude to  a  pain.
The surface is generally of the usual temperature, and free from perspiration,
at least  till near  the end of the stage.   The pulse is  seldom permanently
quickened until the second stage : although, as Hohl has remarked,  if  it be
carefully examined, it will be  found  to  become more  frequent during the
first  part of a pain, then to remain stationary for a moment, and  afterward*
to subside.
       15 
226
NATURAL  LABOr..
  During this stage also, the stomach is apt to become irritable, and dis-
charge its  contents, probably from sympathy with the uterus, rather than
from" mechanical  pressure, as the abdominal muscles are as yet inactive.
This is always beneficial, as  it not only removes indigestible matters which
may be in the stomach, but certainly relaxes the cervix uteri.
  346. If the hand  be  placed upon the abdomen when the pains come on,
the uterine tumor will be observed to contract, become hard, and tilt itself
forward,  so as  ultimately to  bring  the axis of its  cavity into  complete
accordance with  that of the brim ; and  after remaining  in this state for a
longer or shorter time, it relaxes, but does not quite return to its pristine
flaccidity.
  The results of auscultation  are very interesting:  M.  Hohl1 thus describes
them :  " If we direct our attention to the changes of tone which the uterine
pulsations present, we shall find them generally stronger, more distinct, and
varied in tone during labor, and this is especially the case just before a pain
comes on.  Even if  the patient wished to conceal her pains, this phenome-
non, and  more especially the rapidity of the beats, would enable us to ascer-
tain the  truth.   The moment a  pain begins, and even  before  the  patient
herself is aware of it, we  hear a sudden short rushing  sound, which appears
to proceed  from the liquor amnii, and to be  partly produced by the move-
ments of the child, which seems to anticipate the coming on of the contrac-
tion ; nearly at the  same moment all the  tones of the  arterial pulsations
become stronger ; other tones, which have not been heard before, and which
are of a piping resonant character, now become audible, and seem to vibrate
through the stethoscope,  like  the sound of a  string which has been  struck,
and drawn tighter while in the act of vibrating.   The whole tone of the ute-
rine circulation rises in point  of pitch.  Shortly after this, viz. :  as the pain
becomes  stronger and more general, the uterine  sound seems, as it were, to
become more and more  distant, until, at length, it becomes very duii, or
altogether inaudible.  But as soon as the pain has reached its  height, and
gradually declines, the sound is  again heard as full as at the beginning of
the pain, and resumes its former tone, which, in the  intervals between the
pains, is  as it was during pregnancy, but somewhat louder.."
  347. An internal  or vaginal examination reveals to us the condition of
the passages, the state of the  os uteri, and the rate of progress.  At an early
period, the vagina will be found cool, moist or dry,  and undilated, of nearly
the calibre it was  before labor commenced ;  as  it  advances, however, even
during the first  stage, the entire canal becomes  more flaccid, and if not
dilated, at  least  relaxable and dilatable.   The os uteri is high up, but not
always in the same situation :  in  first labors it is nearer to the promontory
of the sacrum than the symphysis pubis ; in subsequent confinements this is
often reversed.   The lips of the orifice  are sometimes soft and thick ; in
other cases hard  and thin ;  the former dilate more readily, and the latter
generally become softer and thicker, before dilatation  takes place.   At the
commencement of  labor the orifice will readily admit  the point of the fore-
finger, and by the repeated pains it is gradually widened, so as to allow the
child to pass.  The rate of dilatation is slowest at the beginning ; it is said,
and I  believe truly, to take as much, or more time to dilate the os uteri to
the size of half-a-crown,  than to complete the process; and for a very evi-
dent reason —viz., the want of a mechanical dilating  force (§303), the bag
of the waters not being protruded until  some progress has been made
  If the  finger be maintained in the orifice during a pain, we feel the circle
tighten and become hard, until the head is pressing through the cervix • after
which time the lips  are retracted by each contraction.  We ascertain the
1 Die geburtshiilfliche Exploration, part i., sect. 105. 
NATURAL LABOR.
227
progress of the labor by carefully estimating the advance  made  by each
pain.
  34S.  Towards the end of the first stage, or at the time when the os uteri
is pretty well dilated, we remark an increase of the sanguineous striae in the
vaginal discharge, and the accession of voluntary efforts, slight at first, but
gradually increasing.   About this time generally, the membranes give way,
the liquor amnii escapes, and by the next pain the head is forced  through
the os uteri, and enters upon the second stage.
  The phenomena are now somewhat changed, especially in  their intensity.
The pains are more frequent and longer, the intervals shorter, and the suffer-
ing greater in general: but owing to  the necessity of fixing  the chest as a
fulcrum for muscular exertion, the  breath  is  suspended  during a pain, and
the outcry suppressed, except at its termination.  The character of the outcry
is therefore as good a test of the second stage as of the first.  At the acces-
sion of each pain the patient holds her breath, and seizing  hold  of some-
thing with her hands, brings the muscles of the extremities, of the back and
abdomen, to aid the expulsive efforts of the uterus.   These  are the " bear-
ing-down pains" of the second stage.
   It is not easy to explain  the change in the character of  the pains, nor
why straining should occur  only in the second stage.  Wigand attributes it
to sympathy between the os uteri and  vagina, and between  the abdominal
and other muscles.   It certainly cannot be merely owing to the presence of
the foetal head in the vagina.   No doubt the increased  resistance, and the
necessity for more power to overcome it, is the final cause, though we cannot
thus explain the immediate change, which I believe to be a reflex action, due
to pressure upon the lips of the os uteri, and soft  parts of  the cavity and
outlet,  as the same effect may often be produced by pressure with the finger,
just as we may double the strength of the pains by pressure upon the edge
of  the  perineum, at a later period.
   Further, the arrest of the circulation, from the suspension of  respiration,
distends the cutaneous vessels, the surface becomes florid, the face almost
purple, the veins of the forehead, temples, and neck are distended, and the
eyes are bright and  prominent;  the  heat of the skin is greatly increased,
and a profuse perspiration ensues.  The pulse, which was quiet  during the
first stage, or at most quickened during a pain, is now increased in frequency
during an interval, and the changes  noticed  by Hohl,  are very remarkable
during the pains; i.  e., it becomes more frequent at the setting in of each
pain, until it attains its maximum rapidity, at which it remains for a short
time stationary, and then subsides.   At the termination of the second stage
it will  generally be  found  to range between ninety and one hundred and
twenty beats in a minute.
   The effects of this arrest of respiration and forcible bearing down are
sometimes very injurious.   Dr. Blundell mentions having seen a case of
general emphysema during labor, which he thinks is owing to a rupture of
the larger air tubes.  A similar case is reported by Dr. Abbot, in which the
whole face, neck,  and chest, were  emphysematous.   It  subsided,  eight or
nine days after labor, without any unpleasant consequences.
   349.  Vomiting  also frequently occurs; but in the second stage it is as
much the result of pressure as of  reflex irritation, and it is generally favor-
able,  as it seems  to  relax  the  soft  parts.  However,  as it is a  symptom
developed also in unfavorable cases, it may be well to observe, that it may
reasonably excite uneasiness when it  comes on with symptoms  of collapse
(during this  stage),  after the sudden  cessation  of  uterine  action ;  when
symptoms of fever, such as rapid pulse, furred tongue, heat of skin,  etc., are
present; when it is accompanied by abdominal tenderness;  and especially
if the fluid be sanguineous or dark colored. 
228                       NATURAL  LABOR.
   If the second stage be prolonged, the patient often feels heavy and sleepy,
and may doze between the pains, — the result of the fatigue, combined with
the congestion about the face and head. Under ordinary circumstances this
need excite no uneasiness, as the patient is refreshed by it; but if it be ex-
cessive, and accompanied with headache, especially in  primapara, we must
be watchful, and on our guard against an attack  of convulsions.
   As the head advances through the pelvis, it presses more  or less upon the
nerves which pass through  that cavity to  the lower extremities,  and  gives
rise to spasms and cramps, which add to the  suffering of the patient.  They
may be partially relieved by friction.
   The pressure  of the head also evacuates the contents of the  rectum, but
effectually prevents the emptying of the bladder.
  350.  If an internal examination be made at the beginning of the second
stage, we shall find the vagina dilatable, and as though it had been dilated,
its walls rugous  and  flabby, and prepared  to yield  to  the  pressure of the
head.   The head itself will be perceived  at  the  upper part of the pelvis,
filling it more  or less completely, descending with  each pain, and receding
at its conclusion ; the advance exceeding the recession, and the excess mark-
ing the rate of progress of  the labor.'   At a later period the head will be
felt on the floor  of the pelvis, where it meets with  considerable resistance,
but which  is  overcome by  the  mechanism already described (§ 303) :  we
observe here the same repeated advance and  recession, the  head each time
propelled a little further than before, and often with a kind  of spiral move-
ment, until, after a time proportioned  to the difference between  the  force
employed and  the resistance, the obstacles yield, and the head presses  upon
the perineum, which undergoes the same process of dilatation.
  351. At this'period of the labor, when the head  is  distending the  peri-
no'jm and dilating the external orifice, both the suffering and the exertion

                                Fig. 104.
Head at the Lower Outlet
reach their maximum point; and yet it is beautiful to observe how cautiously
(so tospeak) and how securely the  process is effected.   Adequate expulsive
'oree  is called into action;  and if it were continuous nothing could save'tne 
NATURAL LABOR.
229
patient from injury; but each pain is just  long enough to gain upon  the
advance made by its predecessor ; and the head, detained for a few moments
at its furthest point of advance, then  recedes ;  and this is repeated until the
perineum is completely softened, and  the os  externum dilated.   Nor is  this
all;  the resistance offered by the perineum carries the head forward, so that
its lowest point (the tumor) shall press against the os, and by the time the
perineum yields, the orifice is sufficiently wide to secure the proper direction
of the head in its transit.
   At the latter part of the second stage, the pains are often what is called
"double ;" i.  e.,  they succeed each other so quickly, that a new one com-
mences before the former has quite terminated.   At length the force  con-
quers all resistance, and with a throe of agony the head is  expelled ; after
which there is a  short rest, equal  to two or three pains, then  the uterine
power is again exerted to expel the body of the child.
   The second stage is now completed ; the  suffering,  which was intense, is
exchanged for perfect ease, and  the sense  of  relief is inexpressibly great.
If the hand be placed on the abdomen, it will be found flabby, the uterus
large, and moderately contracted.
   352.  The third stage of labor includes the detachment and expulsion of
the  placenta.   In some cases, the  contractions which expel the child, expel
the  after-birth.   In almost  all cases, however, it is partially or wholly de-
tached, remaining in the uterus or vagina, from whence it  may be expelled
by the natural powers alone, or aided by general traction.
   The interval  which elapses  after the expulsion of the  child, before the
uterus again actively contracts to  expel  the placenta, varies somewhat  in
different cases, apparently according  to the  fatigue that organ has under-
gone.  Dr. Clarke found the average interval  to  be  twenty minutes.   Out
of 654 cases which I have accurately noted in my own private practice, 1
find that in 468 the placenta was expelled in (within)  five  minutes ; in  119
cases, wi.thin ten minutes; in 35,  within  fifteen minutes;  in 16, within
twenty minutes ; and in 18 within half an hour.
   Where due attention has not been paid, the interval will be longer;  but
from the above data we may conclude that  in natural labor the  placenta  is
more or less detached by the concluding pains of the  second stage of labor,
and that it ought to be expelled within an  hour or an hour and a half,  and
that when the interval exceeds this, the case fairly comes  under the order
of " retained placenta," of which I shall treat  hereafter.
   When  this interval, whatever it be, has  elapsed, the uterus again con-
tracts, but much less forcibly, and by one or two pains, the connection be-
tween the placenta and  uterus is  completely  severed, the now useless  ap-
pendage is extruded into the vagina, and by the contraction  of this canal
is expelled, with a gush of blood  or  clots {dolores cruenti).   The bag of
the  membranes is  generally turned inside  out, especially if the after-birth
have been  extracted by pulling the cord, and the situation of the perforation
in the membranes through which the child passed will enable us to estimate
the  distance  of the placenta from the os uteri;  the distance of the perfora-
tion from the placenta being exactly  the same as the  distance of the latter
from the os uteri.
   353.  Management of Natural Labor.  —Let us  now turn from the de-
scription of the phenomena of natural labor to a consideration of the duties
of the attending accoucheur,  and the mode of managing such  cases.  I
have already stated that most of the modern improvements  in midwifery
have resulted from a more correct  appreciation  of the natural  powers; so
in the management of natural  labor the  great improvement  has been the
absence of interference.  There is, in  truth, but  very little for the accoucheur
to do, if the case be natural and the circumstances favorable, and very little 
 230                      NATURAL  LABOR.

 that he needs, except patience and gentleness; and  therefore the old-prac-
 tice of carrying certain instruments  and certain medicines  about with  him
 is strongly to be deprecated,  as to say the least, a  needless exposure of him-
 self to temptation.   All the  surgical appliances needed are, an elastic-gum
 catheter (male) and a  lancet; and, if in the country, a  small quantity of
 laudanum, ergot, and tartar emetic.   He ought also to be  provided with a
 few strong pins, and  some ligatures of twine or tape ;  and if there be a
 prospect of much delay, he will not be the  worse of a book in his  pocket.
 But to return ;  although there is little to do in a natural labor, we cannot
 of course assume that any case to which we may be called  is of this class,
 without inquiry; our first object, then, when  summoned  to a patient, is to
 ascertain her present state, whether she be  in labor  or not,  etc. ; if  she be,
 the presentation and position of the child, the rate  of progress and probable
 termination of  the labor.
   354.  As to the present state of the patient, a careful examination of the
 bodily functions generally, and  of the pulse,  tongue, skin, etc., will show
 whether the patient is in ordinary health, or whether we may have to con-
tend with any complication, as fever or organic disease;  and the informa-
tion may  enable us to  anticipate, and  perhaps prevent some attacks.   A
 more  minute  investigation must be instituted into the state of the  uterine
 system,  as to the presence of true pains ; their frequency, force, and regu-
larity; the character of  the outcry, the amount of voluntary effort,  the
quantity and quality of vaginal  discharge, etc.   By  these symptoms, we
shall be able  to  form an opinion as to the existence of  labor, the stage and
rate of progress, and the preparedness of the passages, etc., and also as to
the propriety of seeking for more special information, by  means of a vagi-

                                Fig. 105.
Vaginal Examination.
nal examination   This will add to the information previously acquired  a
knowledge of the presentation and position.                 y dcquirea' a
  255. It is not possible to fix a definite time for this examination ; for in
many cases it will depend upon the patient.   It  may, however  be stlted
generally, that it is satisfactory to make it as early as convenient and that 
NATURAL LABOR.
231
certainly no time should be lost after the escape of the waters, Kst we miss
the best opportunity for  rectifying a mal-presentation.  Further, the at-
tendant should never leave his patient for more than a few minutes, unless
ne has ascertained that all is right.  The frequency with which the exami-
nation should  be repeated must  depend  chiefly upon the rate  of progress.
During the first stage (judging by the outcry and cool skin) it is  scarcely
necessary, if once we have  ascertained  that all  is  right;  but during the
second stage,  it may be repeated  according to the rapidity of the  advance,
every four, six, eight, or ten pains;  and when  once  the head  distends the
perineum, the  accoucheur should  keep his finger upon the head during each
pain, so as to  regulate the support  necessary for the perineum.   To the
junior student only can any directions as to the mode of making an exami-
nation be necessary, and they may be brief.  The patient  should  lie  upon
her left side, with the hips near to the edge of the bed, and the knees drawn
up towards the abdomen.   The forefinger of the right hand (or two fingers,
and  in some cases those of 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 foet:-!
head, during  a pain.  If the  membranes be  entire, an experienced  tinge*
will  in most cases detect the presentation ; if they have  given way this wil1
be much more easy and certain;  and if  it be the head, by finding the fon
tanelles and comparing their situation with certain parts of the pelvis, the
position may be determined.
   It is generally recommended to introduce the finger  during a pain, as less
unpleasant to  the patient; but  the  examination  must occupy both a pain
and  an interval, if we hope to obtain full information.  A comparison of the
Knowledge thus obtained, with the frequency and  force of the pains, will
enable us to estimate the  rate of progress of the labor; and these results,
combined with  the  local  and  general condition  of  the  patient, will  afford
adequate grounds for  our prognosis.   In  conclusion, I would  earnestly
recommend to my junior  readers to take  every opportunity of passing the
catheter and making vaginal examinations in the dead subject as well  as the
living.
   356. We will now suppose that the conclusion from  these investigations
is favorable, that  the patient is in  good  health, is really in labor,  that the
head presents,  and that  she  is  making  a sufficiently rapid progress, with
every prospect of a safe termination.
   It is not necessary during the first stage, that the accoucheur should stay
in the room with the patient, nor even in the house, if the progress be slow ;
before leaving her, however, he must be  certain that all is right, that every-
thing is in readiness ; and he must give some general directions to the nurse.
The  patient is  better  out of bed during  the early part of the labor, if it
happen in the daytime, as she will  be less fatigued, and probably less impa-
tient than if she lay in bed the whole time ; she may rest on the sofa when
tired, and occasionally walk about, or pursue any slight  occupation  if she
be able.
   It is very desirable to keep her tranquil and cheerful, for which  purpose
she should be  told of all that is favorable in her case, and all subjects calcu-
lated to depress her spirits should be avoided.  In this matter much depends
on the nurse,  who  should receive proper cautions.  I am satisfied that in
most, if not in all cases, it is  better  to  deal frankly with  our patient, and
not to make false promises iu hopes of encouraging  her  to  bear the pains. 
232
NATURAL LABOR.
Let her be told  that  all is favorable, and that, as far as we  can judge, the
labor will terminate safely for herself and her child, and she will bear to be
told  that she has yet some time to suffer.  Moreover,  as it is impossible to
calculate with accuracy upon  the duration of a labor, an assurance that it
will be over in a  certain time will, in all probability, issue in disappointment;
and if so, in distrust either of our  truth or skill.   I  have dwelt upon this
the more' because  nothing is more  common than for the  patient to beg of
the attendant to say how long she will have to endure the pains.
   During this first stage the patient may be allowed her  usual  diet, but
without stimulants, as it is rather advantageous to have the  stomach  occu-
pied.  The  bowels should be freed by medicine or  enemata, if necessary,
and  the urine regularly evacuated ; and it may be as  well to put my junior
readers on their  guard against a frequent error of nurses, in confounding the
dribbling  of the liquor  amnii, after the rupture of the membranes,  with
"passing  water."   I need not  say that this may take place,  and yet the
patient suffer from retention of urine.
   357.  The patient should be cautioned against making any voluntary effort
during the first stage ; at least, until obliged by the  increasing violence of
the pains, as no  effort can at  this time hasten the labor.  "Women," says
Dr.  Denman, "may be assured that the best state of  mind they can be in
at the time of labor is that of submission  to the necessities of their  situ-
ation ; that those who are most patient actually suffer the least; that if they
are resigned to their pains, it  is impossible  for them to do wrong,  and that
attention  is far more frequently required to  prevent hurry than to forward a
labor."
   Neither is it necessary, as was  formerly taught, for the  accoucheur to en-
deavor to hasten the labor by manual dilatation of the os  uteri or passages;
such an "abominable  custom," as Denman justly calls it, would  rather  have
the  effect of retarding the  labor by the irritation it  would occasion, and
might, as in a case I witnessed,  give  rise to inflammation,  and sloughing
afterwards.        .
   358. Among  the matters which  should be in  readiness are two or three
short  pieces of  tape  or twine, for tying the navel-string, a pair of scissors,
some strong pins,  and a binder.   The  latter should be  made of a double of
diaper, nearly half a yard wide, and long enough to go round the hips, and
to allow for pinning over.  These things ought to be provided by the nurse;
but  as labor sometimes occurs unexpectedly, or the nurse may be forgetful,
it is well  for the attendant to have a supply of twine and pins, with a pair
of scissors, in his pocket-case.  Towards the end  of the first stage  it is cus-
tomary for the nurse to "make the bed," which is done  by placing  a skin of
leather or a square of oiled silk over the blanket and  mattress, to protect it,
at that part of the bed which will be occupied by the  patient's hips ;  over
this is placed the sheet, and upon this two or three sheets folded square, on
which the patient is to be placed.  These folded  sheets will absorb most of
the  discharges,  and  can afterwards be removed  without  disturbing the
patient, leaving  dry bed-linen  underneath.   The skin  or oiled silk is allowed
to remain for some time longer.
   359. Soon after the second stage of labor  has  set in, the patient (espe-
cially if she have borne children before) should undress,  and go to bed.  The
position for delivery has varied in different  times, and still varies in different
countries.  In the earliest times  the sitting posture  was preferred ; and in
Ambrose Pare,  Deventer, and other old writers,  we have a description and
plates of labor-chairs, one  of which the late Professor  Hamilton used to
exhibit to his class.  In China and Cornwall the patient is delivered upon
her knees, or leaning over something.   In Darfour a  pole is fixed across the
room, which the patient holds with both her hands, and  is delivered  standing 
NATURAL LABOR.
233
In France, and some parts of Germany, the woman is placed upon her back,
with the knees drawn  up ;  but  serious objections exist to either of these
plans; by far the best  and  most natural position  is the  one now adopted
almost universally in Great Britain and in  many parts  of the Continent —
viz., on the left side, the hips being close  to  the edge  of the bed, and the
knees drawn up towards the abdomen.  It  is usual to place a pillow between
the knees to keep them separate, but I cannot say that  I think it of any ser-
vice.   The patient's night-dress  should be  drawn up underneath her,  above
the hips, to escape soiling ; and she may be allowed to grasp a sheet fastened
to the bed-post, or, what is much better, the hand of an attendant.
  But although I have advised that the patient should  lie down soon after
the commencement  of  the second stage, it is  not necessary that she  should
remain in the one position  the whole  time, provided that  the proper one be
assumed before the head presses upon the perineum.
   [The position upon  the left side, with the knees drawn  up, is that almost
universally directed by American  accoucheurs, and  it  is certainly the one
which is the most convenient to the practitioner, and productive of the least
possible exposure  of the female's person.   It is  only, however, when the
labor is proceeding rapidly that it is  necessary for the female to retain, un-
interruptedly, the position  described.   Change of position,  or even  rising
from the bed and sitting in  an  easy chair, in cases where  the  labor is pro-
ceeding slowly, will conduce to the comfort of the patient,  while, at the same
time, it will often  prevent  injurious  consequences  from the  heat, pressure,
and constraint liable to result from long continuance in one position.]
   360.  In most cases the liquor amnii escapes about the beginning of the
second  stage, but  occasionally,  when the membranes  are unusually tough,
they remain entire until the head has cleared  the os uteri,  or even, but more
rarely, until it is passing through the  os externum.   When we are  quite
satisfied that the head  has passed through the os uteri, we may rupture the
membranes by  pressing the finger  against  them during  a  pain, as  their
integrity is an impediment to the advance  of the child after this time ; but
it should not be done  hastily, nor until we  are certain  that their usefulness
is at an end.   When  the  patient becomes hot, the bed-clothes should be
lightened,  and the room at all times  be kept  pleasantly cool and  fresh.
Food cannot be taken  at an advanced period of the labor, but warm  drink,
such as whey, gruel, or tea,  may be allowed.
   361.  When the head is on the floor of the pelvis, the accoucheur  should
take his place by the bed-side, and examine gently during  each pain for the
purpose of deciding when it is necessary to support  the perineum.   The
object in supporting  the perineum  is  twofold ; first,  to  afford a moderate
counterpoise externally to the pressure exerted from within, so as to prevent
the structures yielding under sudden or severe pains ; and  secondly, to pro-
long (as it were) the curve of the sacrum, and so make certain of the head
being carried forward  to the orifice  of the vagina, instead of being forced
through the  perineum  for want of such a direction forwards.  Now to fulfil
these two objects, it is clear that we need not interfere at all until the peri-
neum is distended and protruding; but.when we  find  this to be the  case,
then we  should cover the left hand with a soft napkin, and apply the  back
of it along or across the perineum, commencing at the coccyx and reaching
to the anterior edge.   The amount  of pressure needed  is  but little; no
attempt must be made  to retard the  progress of  the head ;  but whilst the
perineum near the coccyx  is firmly supported, the  more  anterior  portion
should be left free to yield before the pressure of the head.  Neither is the
skin to be  retracted when the  head  presses  through the orifice, but rather
carried forward, so  as  to lessen the chance of laceration. 
234
NATURAL LABOR.
  Either hand may of course be  used ;  I prefer  the  left, because it leaves
the right at liberty to examine,  and to receive the head of the child.
  Let me repeat, that to make our  assistance useful, and not injurious, the
support should be moderate, equable, and rather firmer near the coccyx (but
yielding as that bone yields), than towards the anterior edge ;  that it  need
not be  afforded until the perineum protrudes ; that then it should be afforded
during each pain, and until the pain  has  entirely ceased.  I really believe
that it  would  be  better not to touch the perineum than to make injudicious
pressure ;  it has  been  my lot to witness  more than  one  case where rupture
was owing  to excessive and injudicious support.
  362. As the head  passes  through the vaginal  orifice,  the  accoucheur
should  receive it into his right hand, allowing it to make  the usual rotation,
and carrying  it forwards as the  pains  expel  the shoulders and body of the
child.  The left hand  must be employed in supporting the perineum as the
shoulders press forward.   When the head is  expelled, the nurse should be
directed to make  gentle steady pressure upon the  uterus, and to follow it
down, keeping her hand firmly upon it  until the  binder  is  applied ;  by so
doing we shall rarely have any trouble or delay with the after-birth.  In the
large majority of cases in which I have taken care that this practice was
adopted, the  placenta was expelled within ten minutes, as I have recently
shown.
  When the  child is  born, its  mouth should be  examined, and any mucus
that may have accumulated in it removed.
  It not unfrequently happens  that the funis is  coiled  around the child's
neck, and fears have  been expressed of its  retarding the expulsion of the
body, or causing the  rupture  of  the  cord, or the inversion of  the uterus.
These fears I believe to be  unfounded,  for extensive  researches show that
the funis is never twisted round the neck, unless it be beyond the ordinary
length, and yet the ordinary length is sufficient to permit the birth of the
child, after deducting the  amount lost in the coiling.  A very few cases are
on record of cords so short (six or eight inches) as to require division before
the child could be delivered ; but in ordinary cases, if we find, on examina-
tion with the finger when the  head has escaped, that the  cord is twisted
round the neck, all we need do  is to draw down more of the cord, and slip
the loop over the head or shoulders.  If we cannot do this,  we must loosen
the cord as much as we can, so as  to prevent the strangulation of its vessels,
and then wait for the uterus to  expel the child.
  363.  There is  generally a short interval after the head is  born before the
pain expels the body, and it occasionally, though  seldom, happens, that this
interval is prolonged, to the manifest  risk of the child, whose face and head
become livid  and swollen, and  it endeavors  in vain to  breathe.  If it be
allowed to remain thus,  it will die of  apoplexy ; but, on the other hand, if
w%  extract it hastily, without uterine action,  there is danger of hemorrhage.
Under these circumstances, we have the choice of two evils, and must choose
the least:  the nurse should be directed to use friction over the uterus, and,
if this fail in exciting it to action, she must make firm pressure on that organ!
whilst  the accoucheur takes hold of the child's head, and inserts a finger into
the axilla, and gently extracts the body.   The hemorrhage may be prevented
by pressure, but nothing can save the  child but removal.  I have repeatedly
acted thus, and without any ill  consequences.
  364.  If  the child be healthy, and have not suffered fro.n pressure, etc., it
will cry as soon  as it is born, and when  respiration  is established, it'may be
separated from its mother, rolled in flannel, and removed.  This having been
done, the hand should be placed  upon  the abdomen  to ascertain (from the
size of the  uterus) whether there be twins ; if not, we may proceed to apply
the binder, which should embrace the hips interiorly and the whole abdomen. 
NATURAL LABOR.
235
It should be pinned  firmly, but not  too tight, and  be kept on during the
whole time the patient is in bed.   I do  not  know that we can consider the
binder absolutely necessary.   Dr. Davis states that he has not used one for
fifteen or twenty years, except in  cases  of flooding ; and Mr. Kesteven has
written an elaborate paper to  disprove its necessity and to show that its
supposed advantages have  been  exaggerated.1   I  cannot agree with these
gentlemen, however, for I am  satisfied that it is very useful, at first in main-
taining a certain degree of contraction  of the uterus, and giving support to
the abdomen,  and afterwards in promoting a return  to the natural condition
of the uterine and abdominal parietes ; for which reason I think it deserving
of rather more attention than  is usually paid  to it, at least after the first day
or two.  1  believe  that,  if it  be duly applied during  the time the patient
keeps  her bed, she will avoid that loose state of the iuteguments, which gives
rise to what is called " pendulous belly."
   [It  is not  the general custom in this country to apply the binder until
after the delivery of the placenta, nor  until then do we think  it necessary.
When, however, the labor is completed, the application of a proper bandage
adapted to embrace the entire abdomen from the pubes to the cartilages of
the ribs,  and  to  gently and  moderately compress  the  uterus,  is a measure
from which the best effects are always derived.   It gives an agreeable sense
of support—prevents the  faintness which is liable to follow the expulsion of
the fcetus and secundines, especially iu cases  of rapid labor occurring in deli-
cate subjects — assists the  contraction  of the uterus,  and in  this manner is
an  additional guard against hemorrhage.   The bandage should be so ap-
plied as to make the most pressure  at the hypogastrium and the least at the
upper portion of the abdomen.  In many cases  it  may be desirable to aug-
ment  the  compression directly over the uterus  by the application  at this
point of a napkin, once or twice folded, beneath the binder.]
   365. When the binder is applied the hand should be placed firmly upon
 the fundus uteri,2 and the patient may be allowed to rest awhile, if there be
 no  flooding ;  after which, when  the uterus contracts,  gentle traction should
 be made by the funis, to ascertain  if the placenta be  detached ;  if so, and
 especially if  it be the vagina, it may be removed by continuing the traction
 steadily in the axis of the upper  outlet at first, at the same time making
 pressure upon the uterus ;  if the  cord do  not  yield, the after-birth is not
 detached as yet, and no force must be used.  A little patience, with occa-
 sional frictions to the uterus,  will be all that is necessary.
   [In our attempt to extract  the placenta by careful and judiciously directed
 traction on the cord, the latter is to be taken hold of, with  one hand, near
 its cut extremity, and entwined about the two first fingers to render the hold
 more  secure,  while the first two  fingers  of the other hand are passed, along
 the course  of the cord, into  the vagina, as  well to  note the progress  of ex-
 traction, as to facilitate this  by gently  depressing the cord and by serving,
 at the same time, as a pulley  to  give a proper direction to the tractive force
 exerted upon the cord.   Traction  is to be made in  the first  instance in a
direction downwards and  backwards,  until the placenta has reached the
 vagina, when the direction of the traction is to  be  changed to  upwards and
forwards, in   the direction  of the  axis  of the vagina.   The  position of the
hand is very  well illustrated by fig. 106.]
   After the  placenta has  been expelled  or withdrawn, the  binder may be
tightened  if  necessary, and a warm napkin applied  to the  external parts.
The soiled sheets underneath the  patient may  be  removed, and the night-
dress  drawn down ; but  no further change should be made for two or three

   1  Med. Gazette. Sept. 12th, 18-51.  The binder is the  subject of a paper in the  Lancet,
July 7, 1855, by Dr. Gilmour, of Liverpool.
   3  Robertson's I'hys. and Diseases of Women and Midwifery, p. 354. 
236                      NATURAL  LABOR.
hours, as it is most important for the patient to avoid ah exertion at .his
time   In some  places and with  some practitioners it is customary to giv<
stimulants on the completion  of labor ; but as they are unnecessary in ordi
nary cases, they must be used very moderately.   Rest and quiet are th(
[Fig. 106.]
                    Extraction of the Placenta and Membranes.

best  and only necessary restoratives.   A  still stronger objection  exists in
my mind against the practice of giving a dose of laudanum, unless specially
called for, as it  may suspend uterine action, and give rise to hemorrhage.
We may depend upon  it that nature is fully equal to the emergency, and
that  the less we interfere the better for our patient; in the  words of an emi-
nent writer,  "Meddlesome midwifery is bad."
  Although our duties are now ended as far as the  mother is concerned, we
should allow an  hour to elapse before leaving the house, and before we go
we should carefully examine the surface, pulse, uterine tumor, etc., and ascer-
tain  from the nurse the amount of discharge, so that we  may  be satisfied
that all is right, or if wrong, that we may remedy it promptly.  We ought
also  to visit the patient after  six or eight  hours, to  see that the  progress of
the convalescence (to be presently described) is favorable.
  366.  Now let us return  to the child :  after waiting until  respiration is
fully established, or until the pulsation in  the cord cease, a ligature is to be
placed upon the funis about two inches from the navel, and a second a few
inches further on ;  and the  cord  divided between  the two by the scissors.
Some  foreign writers  object to the ligature as unnecessary, and the  case of
animals has been brought forward as a proof; but  Dr. Hunter has shown
that their mode of dividing the funis prevents hemorrhage by the "torsion"
exercised upon  the vessels,  and  most practitioners  of any standing must
have met with cases where hemorrhage occurred in spite  of a ligature ;  so
that in these countries the  propriety of the practice  is generally  admitted.
In former times,  as we find from the writings of  Johnson, Aikin,  Whyte,
and  others,  but  one ligature was used ; but on the authority of Denman,"the
second ligature was added to prevent  mischief, if there should be a second
child with  a vascular communication (as sometimes  happens)  between the
two  placentae.   Dr. Dewees objects to this, on the ground that the loss of
blood  hastens the  extrusion of the placenta ; and Dr. Wood's1 experiments
so far  confirm Dr. Dewees' opinion.   The end  of the funis should  alwavs be
examined before  the  child is dressed, and if any oozing  have  occurred, an
additional ligature must be applied nearer to the umbilicus.  This frao-ment
1 Edinburgh Monthly Journal, June, 1849, p. 853. 
NATURAL LABOR.
237
of the funis  gradually dries up, withers, and falls off on the fifth or sixth
day generally, though  the time may vary from  the second to the fifteenth
lay; and the surface contracts and cicatrices.  In some cases, however, the
centre remains red, prominent, and moist, like a large granulation, with or
without bleeding.   I have found it cured easily by alum or nitrate of silver.
In one case  Dr. Simpson mentions1 that the granulation increased to the
size of a cherry, and was not relieved  by  caustics ;  he applied a ligature
around its base, and it dropped off in a few days.
   367. Thus  far I have described the ordinary management of ordinary
cases,  both as regards mother and child ;  but there are not unfrequently
slight deviations from  this simple course, and some of them  as regards the
child  must now be noticed.   For instance, when  born it  may be in a state
of defective  vitality, asphyxia, or apoplexy.
   1.  It  may be in a  state of anosmia, syncope, or asphyxia, from uterine
hemorrhage, too early detachment  of the  placenta,  or defective nutrition.
In these cases very feeble, if any, efforts at inspiration  take  place, there is
no pulsation in the cord, and  the action of the heart is very weak.   There
is consequently no object in  preserving the utero-foetal connection ; the funis
should be  tied and divided, and the child, plunged into a warm bath :  if this
fail, cold effusion must be tried :  but that  which 1 have seen  most effectual,
is light and  rapid friction  of the body and extremities with warm flannel,
 with   or without stimulants.  Tickling the nose  or fauces with a feather,
electricity, and stimulating enemata, have been recommended  ; but I am not
 aware that they have  been very successful.   Inflation  may be  tried by  means
 of a  proper tube introduced into the larynx, or a flexible catheter passed
through the nose, and with greater prospect of success  than most  of the
 other means.  Great  care must be  taken  to introduce the instrument cau-
 tiously  and correctly, and  to inflate  slowly and gently.  The "Marshall
 Hall" method has recently been successfully employed in these cases,  and in
 all it ought to be tried, but I have found friction the most effective.  In
 some  cases, the infant, apparently healthy,  is born dead, without anything in
 the nature of the labor to account for death ;' and in  such cases,  I have been
 led to believe, it may  be owing to intra-uterine pressure upon the cord, per-
 haps  from its being coiled round the body  or limbs.
   2.   In other cases, the child may be in a state of oppression or asphyxia
 from prolonged labor, or from some deviation from the normal presentation,
 etc. ;  but in such instances the pulsations of the funis, though weak, are
 perceptible,  the color of the surface is natural, and the shape of the head is
 unaltered.  Here it would evidently be wrong to divide the cord until respi
 ration has been established ; therefore, placing the infant in  such a position
 that  there shall be no impediment to  the  circulation  through the cord, we
 must  adopt some  of the plans already mentioned for its restoration.   Fric-
 tion with  hot flannel, warm baths, aspersion 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.
 [f these means fail, we may try the effect of loss of blood by cutting  across
 the cord and allowing a dessert or table-spoonful of blood to escape  before
applying the ligature.  Should this not succeed, the  case is hopeless.
   3.   There is a  third  class of cases when the child  is threatened with or
attacked by apoplexy, from  prolonged labor, the pressure of a narrow  pelvis,
or (as already noticed) from  an  interval elapsing between the  birth  of the
head and body.  In such, the heart's action is labored, the pulsation in the
cord  feeble and oppressed, the surface blue", the face livid, and in some cases
 the form of the head is changed.  The treatment is  exactly the opposite of
1 Edinburgh Monthly Journal, July, 1847. 
238
NATURAL LABOR.
that for the first class of cases;  unless the circulation ,oe relieved, the child
will die of  cerebral congestion or apoplexy; therefore the first thing to be
done is to divide  the cord, and allow from  half an  ounce to an ounce of
blood  to escape;  after 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.                                         .      ,
  Dr. Ogier Ward read an interesting paper before the Royal Medico-Chi-
rurgical Society, upon the immediate and more remote effects of compression
of the head during parturition.   To this he attributes symptoms of imperfect
cerebral development and its consequences, epilepsy and  paralysis.   The
remedy he  considers to consist in establishing full respiration as soon as pos-
sible, during which the depressed portion of the skull may be observed to
expand and assume its natural shape.1
   I  have  only to  add, that in all  these cases  we should not be easily dis-
couraged,  but continue  our efforts for  a considerable  time,_ as we  often
succeed after a longer time than we should have believed possible.
   [The assertion has been made by authorities of great weight, thatin  every
case of simply suspended animation in the new-born infant—that is to say,
in  every case where  there is no  defect  of  development in  any important
organ, and where  no  vital part has received serious  injury either before or
during birth—it is possible, by proper management on the part of the medi
cal attendant, to induce respiration, and by so doing secure life and viability
to  the still-born  foetus.   This assertion  is entirely  confirmed by  our own
experience.
   In  a  very  able lecture  on suspended fcetal animation, its causes and
management,  published by Dr. J. Gaillard Thomas, of New York, in the early
 part of 1860, the cases of still-birth are arranged into four classes.   In the
 first, the  non-occurrence  of respiration  is referred to non-oxygenation of
 the blood  of the fcetus  during the latter portion  of  its  intra-uterine  exist
 ence, in consequence  of compression of the cord, of  severe and protracted
 compression of the placenta, from a spasmodic or unintermittent contraction
 of the uterus, as  takes place  especially under the  influence of ergot,  to he-
 morrhage from partial or complete separation of the placenta, previously
 to birth, and  finally to maternal loxsemia.   In  this form  of still-birth, there
 is duskiness of the infant's face, purple  and pouting lips, glassy eye, non-
 flaccid, unyielding limbs, a very feeble intermittent, or no pulsation  of the
 heart, and entire  absence of respiration.  The treatment of this  form  of
 asphyxia neonatorum is  to excite, if possible,  respiration, by removing any
 mucus that may be accumulated about the fauces of  the  infant, by slapping
 it smartly upon the buttocks  and chest; by blowing suddenly and forcibly
 in its face and mouth, and dashing cold water upon it with the hand.  These
 failing, we should expose the  infant to a draught of cold air,  and while thus
 exposed, put  at once in practice Marshall Hall's  plan  of postural respira-
 tion.   The action of the lungs being  thus induced, the  circulation is to be
 promoted by  upward friction  of the  limbs with the hand, without intermis-
 sion of the respiratory efforts, and when the stagnation of blood in the lungs
 is disappearing, but not before, by the use of the warm bath.
   A second form of still-birth is  produced, according  to Dr. Thomas, by
 the fcetus  being subjected during birth  to  causes which produce a sudden
 cessation  of  the heart's  action,  as  compression  of the fcetal brain, from
 overlapping of the bones of the skull at the sutures in its passage through
 the pelvis, loss of blood,  from rupiure of the cord,  or an arrest of the  supply
 of blood to the fcetus by the  compression of the flaccid coats of the veins,
1 Lancet, March 15th, 1851. 
NATURAL LABOR.
239
while the more unyielding coats of the arteries allow a flow of blood from
it towards the placenta.   The child still-born from these causes is pallid, its
limbs are flaccid, and its  face sunken  and cadaverous.   In these cases, the
first endeavor should be to establish respiration and circulation by the same
means as have been just detailed.   The cord should not be divided or tied,
until respiration is fully established ; it should  be  gently stripped by the fin-
gers in such a manner as  to press all the blood  it contains slowly and steadily
into the infant's body.
  The third form of still-birth is from cerebral congestion.   It is caused by
obstruction of the circulation through the vessels of the  neck, in cases of
face presentation, by the  constriction  of these vessels by the  cord, and by
the compression  of the chest  in cases of tardy delivery of the shoulders.
The infant presents a dark purple congested condition of the face, puffed and
violet-colored lips, protruding eyes, and general intumescence of the head.
The treatment in such cases is embodied, according  to Dr. Thomas, in the
following three directions:  1st. Let blood flow freely from the severed cord,
to the extent of  an ounce or more, as  the symptoms may demand;  2d. Es-
tablish artificial respiration ; and 3d, Avoid  the warm bath.
   The fourth form of still-birth is from hemorrhage of the brain, the result
of  intense or persistent congestion  of  the encephalic vessels, or of injury of
the  fcetal head by its being forced, by violent  uterine efforts, against some
prominence  of a deformed pelvis, or by the unskilful use of instruments.
Cerebral hemorrhage may be  suspected in the still-born infant when, in addi-
tion to the symptoms of congestion, there is a stupid, listless  condition con-
tinuing after the establishment of respiration,  or when an attack of convul-
sions supervenes, followed, in both instances, within a short period by death.
In  the very few  cases in  which the infant survives, it  may continue  hemi-
plegic for  many  months, and ultimately recover.   The treatment is the same
as in still-births from cerebral congestions.]
   368. The tumor  of the  scalp, already noticed, subsides in a very short
time, without requiring any application in most instances; other cases, how-
ever, are not so  tractable.  The more  simple tumors consist of serum effused
underneath the scalp; others,  of serum mixed with blood :  again, in more
rare cases, we find blood  effused under the pericranium ; and  lastly, in addi-
tion to the blood effused,  the pericranium appears to secrete a ridge of bony
substance  limiting the effusion.   These  cephalasmatomata, which are very
rare, are about the size of an almond, apparently not  painful, and may be
distinguished by their persisting for several days, and by the semicircular
ridge or boundary, which can be felt by the finger.1   No doubt they are fre-
quently the  result of pressure, but not always, as I have  seen them form
twenty-four hours after birth ; and they do not disappear as  do  the other
forms of tumor.  Spirit  or stimulating lotions  may be used, and in some
cases they will be successful;  in others it will  be necessary to lay open the
tumor and apply simple dressings.   The reader may  consult  upon this sub-
ject, essays by Wagstaffe, Gedding, Naegele,  etc., and the works of Osian-
der, Michaelis, Grcetzer and Valleix.
   369. The  only remaining deviation from the  normal condition  of the
infant which I shall  notice, is umbilical hemorrhage, either before, or much
more frequently after, the separation  of the  remains of  the navel-string,
and which is always very  difficult to manage, and often fatal to the infant.
  It is not of very frequent occurrence, which  may be the reason why it has
been omitted from most systematic works, or  treated very slightly.  How-
ever, increasing attention  has  been  shown to it latterly, and we possess valu-
1 Chui'chill's Diseases of Children, p. 66. 
240
NATURAL LABOR.
able papers on the subject by Radford,1 Homans/ Ray,3 Bowditch, Pont,
Manley,5 Bailey,6 Minot,7 Willing,8 and Smith.9
  It is remarkable that the majority of the  cases  on record were male in-
fants  and also that in  some cases there appeared  something like an here-
ditary predisposition, two or three children of the  same family having  been
attacked   Mr. Ray's case was the third male child (of the  same mother)
who had died of umbilical hemorrhage, and he mentions having been in-
formed of a family in which four male children died from the same cause.  Out
of thirty-two cases collected by Dr. Minot, twenty-two were males and ten
females   He mentions one case, communicated by  Dr. A. Hooker, of  a
woman who lost four children, and another who lost two, in this way.
  370 The causes of this hemorrhage are somewhat obscure ; in some cases
it seems to be owing to a defective ligature of the  cord ; but in others, and
these are  the more numerous, to causes more deeply seated.   I  think the
cases, as far  as our knowledge extends,  may be classified as follows :
  1.  If violence be  used  to the  remnant of the funis at any period before
its  decadence, it may give rise to  hemorrhage, as  in the case recorded by
Dr. Hill.10                                        ,  ,
  2.  If, when the remains of the  funis fall off, the vessels have not undergone
the process of closure and healing, a  very alarming hemorrhage may result,
and one it may be impossible  to arrest.  Of this  kind were Dr. Radford's
and Mr. Willing's cases.
   3.  In a case which occurred in my own practice, about a fortnight  after
the child's birth, the navel became  inflamed, a small collection  of matter
formed, and  its spontaneous discharge was accompanied by a good deal  of
blood.   When the  abscess was  empty, I succeeded fortunately in stopping
the bleeding, by pressure and  astringents.
   4. Some of these cases seem  to depend  upon  an unclosed  state of the
umbilical vessels, or defective hepatic ducts ; although this does not in-
variably cause bleeding.  An American  physician, Dr. Anderson, of New
York, has favored me with an example, in which the ductus communis cho-
ledochus was imperforate, giving rise to jaundice, and umbilical hemorrhage.
Dr. Minot mentions that in one case the gall ducts were wholly absent;  in
another the ductus communis  terminated  in a "cul-de-sac ;" and in a third,
 it was closed by a plug of inspissated bile.
    5. In a  large proportion  of cases, the hemorrhage  is accompanied by
 jaundice,  whether dependent  upon malformation  or not, and certainly not
 always connected with organic  disease of  the  liver; although  Dr.  Minot
 mentions that in three or four out of  seven cases it presented  deviations
from the ordinary healthy appearance.  It has been suggested by Dr. West,"
 and  maintained  by  Drs. Bowditch,  Homans, Bailey, Manley, and Minot,
that the disposition  to hemorrhage from the navel may, and probably does,
 depend upon some morbid condition  of the blood,12 as shown by the dispo-
 sition to hemorrhage  in other  parts, analogous to what we see in adults.
 As Dr. Minot remarks, "the facts which  I have collected lead me to think
 that idiopathic hemorrhage from the umbilicus in  young infants is only one
 of the various manifestations  of the hemorrhagic diathesis, which in other

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

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

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

           1 British and Foreign Med. Chir. Review, April,  1855, p. 359.
           * See the Chapter on Convulsions. 
246
NATURAL LABOR.
have recourse to the crotchet or Caesarean section.   Under the influence of
chloroform we may compare the  breadth of our hand across the knuckles
with the brim of the pelvis, and  arrive at a very  accurate  measurement,
without pain to the patient.  This Dr. Simpson tells me he has found very
S3 tisitic torv
  3  As to'its exhibition in natural labor, as I do not believe that in the
lar"-e majority of cases  convalescence  is at all impeded  by the suffering, I
cannot see the necessity, or even  the propriety, of urging the employment
of anaesthesia in every case; and I do  feel that even greater  caution ought
to be used than  in  operative midwifery.   We  may  be justified in running
some risk where  an  important point is to be gained, such as  perfect quiet-
ness during an  operation, which  we  should not be justified m  incurring
merely to relieve pain.   Thus  in hysterical or nervous  patients, in  those
laboring under nervous  affections,  or organic disease of  the lungs or heart,
etc., I do not think we  ought to employ it.
  But on the other hand, as pain is undoubtedly  an  evil  in itself, if there be
no  counter-indication, and if the  suffering  be  either great or prolonged, I
cannot see that we are prohibited  from the employment of anaesthetics, more
especially as it is not  necessary in  such cases to produce  insensibility.  It is
quite possible to afford  immense relief,  to "render the pains quite bearable,"
as a patient of mine observed,  by  a dose which does not produce sleep or
impair the mental  condition of the patient, and which  all our experience
would show is absolutely free from danger.
   In my own practice  I have  never urged a patient to  use  chloroform in
natural labor, and,  on the  other hand,  I have not felt justified in refusing a
moderate dose of it when  the  patient  urgently desired it, and none  of the
conditions were  present which seemed to me to counter-indicate it.
   378.  The period at which it has been administered, varies with different
practitioners; some commence  before  the  os uteri  is dilated, others about
the time the head escapes  through it.   There can seldom be  any necessity
for its use, I think,  before the os uteri  is fully dilatable, and it is more  likely
to interfere with the uterine action at an earlier than a later period.  At the
commencement of the second stage would, I should  think, be soon enough,
and this seems to be Dr. Simpson's practice.
   379. There is a difference of opinion as to the extent to which the  anaes-
thesia should be carried.   Prof. Simpson prefers inducing complete insensi-
bility at first, and then  keeping up just so much  of  the  effect as  he deems
advisable.  Dr.  Rigby prefers commencing with smaller doses in  natural
labor, and increasing them if necessary ; and the Obstetric  Committee of
the  American Med. Association, in their Report, agree  with this view.  Of
course, if we are to operate, the patient should be placed thoroughly  under
the  influence of  the chloroform before  we commence, and its  effects kept up
by occasional inhalation.   But in ordinary cases, as I  have said, I  prefer
beginning with  a moderate dose and watching  its effects, and, if necessary,
increasing the anaesthesia.
   The dose should be administered at the  beginning of each  pain, and in-
creased when the head  is passing  over the perineum.  The anaesthetic state
may be kept up for hours without mischief, especially when complete insensi-
bility is not required.
   I have tried various  modes  of administration, instruments  specially con-
trived for the purpose,  sponge, lint, etc., and I believe that by far the best
is the one originally proposed by Dr. Simpson, viz., a clean white, pocket-
handkerchief, folded funnel-shape  ; into which half a drachm or a drachm of
the  chloroform is to be  poured, and which may then be first placed near the
mouth of the patient,  and after  a few respirations, over both  mouth  and
nose.   It is a good plan to allow the  patient to  hold the handkerchief her- 
CONVALESCENCE  AFTER  NATURAL  LABOR.         247
self, unless we wish to produce deep anaesthesia, as it will fall from her hand
when  sleep commences.
  [The employmeut of anaesthesia in all cases of labor, as a matter of rou-
tine, merely for the purpose  of securing to  the  parturient female freedom
from pain, has, it is believed, at present few advocates, while the number of
those who are in favor of the  practice in certain forms of difficult, tedious,
and instrumental labor, is evidently augmenting.
  It must be admitted, that, in a very large number of cases of natural labor,
anaesthesia has  been induced without,  apparently,  any evil consequences
accruing to either mother or child — whether,  however, all the  instances in
which injury has resulted from the practice have been made public we  have
no means of judging.   That so few should  have been heard of is  really a
matter of surprise, considering the powerful influence the several anaesthetic
agents necessarily exert upon the nervous  system, and the extensive  and
careless manner in which they have too often been resorted to.
  It is true that, in the  practice of  midwifery, anaesthesia has seldom  been
carried to the extent of producing entire  unconsciousness,  and even when
inordinate doses  of ether or of chloroform  have been administered, the
patient has been probably saved from any bad effects in consequence of the
accoucheur's rashness, by the careless manner in  which the agent has  been
used, causing the greater portion of it to escape into the air of the chamber
instead of passing into her lungs.
   The time is near at hand when, from a full and honest comparison of facts,
the question as  to the propriety of  employing anaesthesia in obstetric prac-
tice will be definitely settled,  and the cases and the period of labor, and the
extent in which it may be safely and beneficially resorted to, become  fixed
upon certain  and well-established data.   Already the  ultraism  of the  early
 partisans of the  practice  is rapidly abating,  while  many of those  who at
 first  objected to  it, as under all circumstances dangerous, if not positively
 injurious, are willing to avail themselves of its  aid in certain forms of  labor.]
                         C HA P TE R  I Y.

            CONVALESCENCE AFTER  NATURAL LABOR.

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

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

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

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

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

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

   A  horizontal posture is peculiarly favorable to the general condition  of
 the patient, and especially to the uterine  system, in the  relaxed  state-in
 which it is after delivery; the patient cannot assume  an  upright  position
 without a certain  amount of displacement, and  a  risk  of hemorrhage, or
 possibly of sudden death.  By keeping the  patient on  her  back,  we may
 even  remedy old displacements.  A lady had prolapsus uteri after her second
 confinement, which lasted till she became  again pregnant;  this was men-
 tioned to me when I  was called to her in her third labor.   I kept  her  un-
 usually long in bed, and subsequently on a sofa,  and the parts completely
 recovered their natural state, so that she suffered no more from the displace-
 ment.  In ordinary cases, the after-pains require no treatment; but if they
 should deprive the patient of sleep, we  may give an aromatic purgative or
 a dose of laudanum.
   The only attention which  the  lochia  require, is, that the napkins should
 be changed sufficiently often, and applied warm, as  any sudden impression
 of cold to the external parts  may  be followed by  suppression  of that
 discharge.
   391. Directions should  be given for  the patient  to voi& urine within six
 or eight hours after delivery, or sooner ; and this should be  done as nearly
 in the horizontal posture as possible.   Owing to the distensible state of the
 abdominal parietes, the  patient will often wait much longer, if not reminded;
 and the consequences may be very troublesome, if not serious.  The bladder
 may  become paralyzed,  or inflammation may spread from it to the perito-
 neum.  If there should be any difficulty in  evacuating the bladder, as some-
 times happens, a cloth  wrung out in warm  water, and applied to the vulva,
 will  probably  remove it; or, if not, we  must have recourse to catheterism.
    392. The state of  the bowels after delivery is of great importance ; it is,
 perhaps, better that they should continue quiet for twenty-four or forty-
 eight hours after delivery ; but after  that  time has elapsed, we should pro-
 cure  a discharge by medicine, if there  should  be none  spontaneously.   A
 dose  of castor oil, senna,  or rhubarb, may be given,  and, if  necessary,
 repeated.   The frequency of repetition must be regulated by the state of the
 bowels previous to labor.   If we suspect  any accumulation, we should not
 be satisfied until the intestines are  well cleared out; and if  the patient do
 not suckle her child,  purgatives will be the  more necessary, for the relief of
 the breasts.    In the latter case, the saline purgatives will be found the more
 useful.
    393. The state of the surface will point out the propriety of not exposing
 the patient to a draught of cold air.   She should be allowed to cool gradu-
 ally, and then  the bed and bed-clothes so arranged as to afford a comfortable
 degree of warmth.  The chamber should be kept cool  and fresh.   The
 smaller the fire (if there be one) the better.
    394. When the breasts begin to enlarge  and become painful, relief may be
 obtained by friction with warm oil or fomentations,  at  the same time giving
* a dose of aperient medicine.   But the best remedy is the application of the
 child ; and the sooner this is done the better,  as the secretion and escape
 of the milk will be facilitated, the  feverishness diminished, if not  avoided,
 and  a good nipple more easily formed than when the breasts are distended.
    It is better  to do this, even if it should not be the intention of the patient
 to suckle her  infant,  as  it will afford relief;  and by not suffering  the child
 to do more, we insure  the  ultimate subsidence of  the  secretion,  which is
 always in proportion to the demand upon it:  if this  be very slight, it will
 soon cease altogether.
    395. The importance of  preserving  the horizontal posture has already
 been  stated ;  I shall therefore  merely add,  that the patient should never
 leave her bed, even  to have it made,  before the eighth  or  ninth day; far 
          VARIATIONS  FROM  ORDINARY CONVALESCENCE.      25o

more  mischief results from premature exertion than from all  the  errors in
diet added together.
  396.  The regulation of the diet is, nevertheless, of considerable import-
ance,  as excess, by inducing feverishness,  may retard the convalescence.
The patient should be confined to slops— gruel, panada, arrow-root, milk,
whey, weak tea, etc.—with bread or toast and  butter,  or biscuit, for five or
six days.   When the excitement produced  by the secretion of milk has sub-
sided, if there be  no counter-indication, she may take  some  broth, and on
the seventh or eighth day some chicken, or  a mutton chop, with some wine
and water.
   In  all that concerns the diet, or the assumption of the upright position,
or  making exertion, it cannot be too strongly impressed upon all, that an
excess of caution  is an error on the safe side.
   397.   On  certain Variations  from  ordinary  Convalescence. —
Although the following  observations are  a deviation from the plan I pro-
posed, yet I should not  feel  justified in their omission, and I do not know
that a better opportunity will offer for them than the present, as they may
be usefully compared with the preceding description of ordinary convales-
cence.  These deviations may depend upon the constitution, or the character
of the labor, or upon pressure exercised locally.  Even without reference to
the influence  of the  labor, there are certain irregularities which occasion
anxiety both to the  patient and to  her physician.   Some of these issue in
serious disease ; others, more numerous, are mere temporary deviations from
the normal course, but requiring familiarity and tact  to  distinguish them
from  the more important attacks.  Of the more serious affections — such as
fatal  syncope, puerperal fever, etc. — I shall enter fully in the latter part of
this volume.
   398.  1.  The nervous shock may be very  severe.  In these  cases the
patient  complains of great  exhaustion ; the senses are either unnaturally
dull,  or  morbidly acute, the breathing is  hurried and  panting, and the
accordance between  the respiration and circulation is broken.  The aspect
of the patient is that of a person in a state of collapse.   The countenance
is expressive of suffering, anxiety, and oppression.   The pulse may be either
very  slow and labored, or unusually rapid, very small, and fluttering.  There
are many cases, however, where the shock, though far from being so severe
as in the case I have supposed, is quite sufficiently so to excite the fears of
the medical attendant.   Reaction is long before it occurs, or it  may take
place imperfectly  or excessively,  and the  patient remain for some time in a
very  weak condition.
   Under proper treatment, the patient will gradually recover from this state
of  exhaustion or collapse, unless the shock be  extreme, and then death may
supervene in a few hours.  I have seen several cases of this kind ; in one
case  the  labor was tedious,  but  terminated  naturally; two  others were in-
strumental  deliveries; but in none, where a post-mortem examination was
obtained, was there either injury or disease discovered.  A due estimate of
the nervous shock is of great importance in'severe cases ; for in almost every
instance the progress of the convalescence is  in inverse  proportion to the
amount of this disturbance.
   The best remedy in these cases is opium, either in a large dose, or in small
and repeated ones; 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 to exceed, or they  will
do mischief instead of gpod.  The  amount  of stimulants given in cases of 
254     VARIATIONS  FROM  ORDINARY CONVALESCENC
collapse should have some reference to the probable reaction as well as to
the present state of the patient.  Ammonia or musk are the best medicinal
stimulants, and they may be combined with the opium.   The  diet  of the
patient, when the effects of the  shock have subsided, must be nutritious  It
may be necessary to  postpone the application of the child to the breast for
some days, or even to give up sucking altogether in some cases. _
  All that has been said already upon the necessity of perfect quiet, applies
with tenfold force to these cases of extreme nervous shock.
  [These remarks  of the author are deserving of the serious attention of the
joung  practitioner.  "I  have seen more than one instance," says Dr. Hus-
ton, in a note to a former edition, "in  which there was reason to believe the
life of the patient was sacrificed from ignorance of the true character of the
condition here referred to.   If the attention of the practioner be at the time
particularly directed to puerperal fever, he is liable to confound the exhaus- .
tion in which he finds the patient, with the early stages of that disease.  The
cold extremities constitute the chill, while the haggard countenance, hurried
respiration, and frequent pulse, are regarded  as  conclusive evidence of a
rapid  peritonitis.  Bleeding from the arm or by leeches, is the instant re-
sort, and a few short hours confirm  the worst anticipations,  by  the  fatal
termination, a result which the efforts of the attendants have but too success-
fully aided in producing.
   " The author speaks vaguely in recommending  ' Opium, either in a large
dose, or in  small  and  repeated ones.'  Where much pain  and jactitation
occur, the dose should be large, say a grain and a half, or two, or even three
grains;  but when the  object is to soothe the  nervous system, and sustain
the circulation, small  doses, as  half a grain or ten  or fifteen drops of lauda-
num, repeated  every hour or  two,  with or without  carbonate of ammonia,
wine whey, or other mild stimulants, are appropriate remedies.   When reac-
tion ensues, of course these are to be  laid aside.]
   399. 2. The state of the pulse.—One variation from the usual alternations
of the pulse has just  been noted, in cases of great nervous shock, when it
either sinks below its due proportion,  or more frequently remains very quick,
 weak, and fluttering, during the period of collapse.
    In almost all the cases of flooding after labor, when I have had an oppor-
 tunity of examining the pulse up to the time of the occurrence, I have found
 it  remain quick, and perhaps  full, instead of sinking after delivery.   This
 has been so marked in several cases, that I now never leave a patient so
 long as  this peculiarity remains ; and in  more than one instance I believe
 the patient has owed her safety to this precaution.  Three cases occurred
 within a very short time of each  other, in which  I noted this undue quick-
 ness of the pulse without any  other untoward symptom ; at that time there
 was no  excessive discharge,  and the uterus was well  contracted.   In  all
 these, alarming hemorrhage occurred  within an hour, and was with difficulty
 arrested.  I have also remarked  an undue frequency of pulse when  the after-
 pains  are extremely violent; and as the uterus is in such cases rather tender
 on pressure, it requires  care to' distinguish between this state and the com-
 mencement of inflammation.  This observation will also apply to the quick-
 ening of the circulation, which takes  place when lactation commences, and
 which, in addition, is accompanied by rigors.  A careful examination, how-
 ever,  will generally lead  us to  a correct  conclusion, and the subsequent
 diminution of the frequency of the  pulse will remove all doubt.   Again, the
 pulse  is quickened when  a large coagulum is contained  in the uterus, or if
 the patient suffer from diarrhoea, or gastric disturbance.   In some of these
 cases  the diagnosis may be obscure, and it may be  necessary to suit our
 treatment rather  to the  anticipated  attack  than to the present symptoms • 
         VARIATIONS  FROM  ORDINARY CONVALESCENCE.       25b

thus, we may give small  doses of blue pill or calomel in combination  with
opium, along with medicines suited to  the peculiar symptoms present.
  All the observations I have been able to make confirm Dr. John Clarke's
remark, that no  patient can  be considered safe whose pulse exceeds one
hundred.
  400. 3. The state of the  uterine system.—Instead of a gradual decrease
in the size  of the womb, I  have occasionally found on  the fifth or six day
that its  bulk has increased, and that it has felt less firm than previously :   •
this, combined with increased frequency  of the pulse, has apparently threat-
ened an attack of hysteritis ;  nor was this anticipation lessened, by the un-
comfortable  sensations of  the patient, nor  by the  sudden increase  of the
lochia.   However, in most of these cases, I found upon applying hot fomen-
tations to the abdomen, that more or less coagula were discharged, afford-
ing instant relief to the patient, and indicating the source of the symptoms.
Purgative enemata also favor the expulsion  of the clots ;  and in such cases
may be given with great benefit.
  Dr. Simpson has published some interesting observations on the morbid
deficiency and morbid excess  in  the involution of the uterus  after delivery,
and he has given several cases in which the uterus continued for a consider-
able time as  large as after delivery.   It  is not  the result of any deposit, and
the histological characters  are those  of the pregnant uterus.   These cases
are not common, but  the  opposite extreme is still more rare.   In one case
related  by Dr. Simpson, the patient after  her  confinement  suffered  from
amenorrhcea, anaemia, and  diarrhoea, under which she  finally sank; and on
examination the uterus was diminished one-third below the natural standard.1
Similar conditions of the uterus had been pointed out by Dr. Montgomery.2
  It has been  already mentioned that the uterus is not free from tenderness
in cases  where the after-pains are severe ;  and if it be rudely pressed, the
outcry of the patient may lead us to suspect the presence of serious disease.
It will be observed, however, that this tenderness  is greatest during  each
uterine  contraction, and that as these contractions subside,  the  soreness
diminishes.
   Fomentations to the abdomen will generally mitigate this sensibility; but
if the after-pains be severe, and the  tenderness considerable, a full dose of
laudanum, followed  by an aromatic purgative, will probably relieve both.
  The vagina may be attacked  with inflammation, which sometimes proves
extremely distressing; this will form the subject of  a separate notice.
  In cases where the lochia are acrid, the orifice  of the vagina, with the
labia and external parts, are apt to be excoriated.   The patient may suffer
extremely either from  a smarting pain, or from itching;  and it is difficult to
say which is  the more distressing.   Extreme cleanliness, frequent  bathing,
lead lotions,  black wash, or vaginal injections of warm water, may be tried,
and will  ordinarily  afford relief: if not, the disease will generally subside
with the cessation of the lochia.
  401. 4.  The after-pains.—Instead of the  after-pains coming on about
half an hour or an hour after the  labor, in moderate  degree, and ceasing
after a short time, they occasionally commence immediately after the extru-
sion  of the placenta, with  great severity, and long continuance.   In these
cases the tenderness of the  uterus is marked, but when 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

              i Edin. Monthly Journal, Aug. 1852, p. 127.
              2 Dublin Journal,  Nov. 1835.  Ibid., vol. xxiii. p. 161. 
256      VARIATIONS  FROM  ORDINARY  CONVALESCENCE,
 of opium, which should be repeated if necessary.   At  the  same time  hot
 flannels may be applied to the abdomen and vulva.
   The after-pains sometimes continue at intervals unusually long, and are
 very severe whenever the child is applied to the breast.   They occasion dis-
 tress and exhaustion by preventing sleep, and should  therefore be relieved
 if possible, by cordials, aromatic purgatives, or a dose of opium.
   402. 5. The lochia.—Yariations  in the  quantity, quality, or odor of the
 lochia, not unnaturally excite great  alarm in the  mind of the patient, who
 regards any deviation  in this secretion as a proof of serious  disease.   Yet
 very remarkable differences do  occur, without any morbid  affection  of the
 uterus or vagina.
   The discharge may cease a few hours after delivery,  especially after the
 birth of still-born or putrid children, without any unpleasant symptoms.
   The discharge may continue the usual time, but  in very small quantity ;
 and this is commonly the  case when flooding occurs during or after delivery.
   On the other hand, it may be  excessive, though not  prolonged beyond the
 usual time ; or without being excessive, it may continue  unusually long.  In
 these cases it may be  necessary to allow the patient  a better diet, and to
 give tonics, such as bark, preparations of iron, etc.
   In some cases, the lochia, after decreasing in  quantity for some time, are
 suddenly  discharged in  double  quantity, and of a  red color, but without
 coagula.   This generally happens when the  patient  is permitted to sit up
 too  soon.  Or it may happen  at a later period, in consequence of walking
 about too much.   A  little extra rest will, however, suffice  to  restore  the
 patient to her former state.
   Again, the os uteri is sometimes obstructed by a clot, and the lochia are
 greatly diminished, or  perhaps altogether restrained, until the expulsion of
 the clot affords an exit to the accumulation.
   Instead of the  usual  changes, from red to yellow, or greenish, the red
 discharge may persist; or after these  changes  have  taken place, the red
 discharge may return.   In these cases it is  necessary to be on our guard,
 as the change may be the precursor of secondary  hemorrhage.  The patient
 should be confined to the  horizontal  position, and clothed very lightly.
   The lochia, after going through their ordinary  changes, may terminate in
 uterine leucorrhcea,  which may  become permanent.   This will be best  re-
 medied by counter-irritation to  the  sacrum, and  the internal  exhibition of
 copaiba, iron, or ergot of rye.
   Again,  the  unusual color of the lochia may excite  alarm.   Instead of the
 transition from red to a pale red, yellowish, or greenish  color, they are some-
 times a dark brown,  and perhaps more tenacious  than  usual,  or acrid  so as
 to excoriate the vulva.
   Lastly,  examples occasionally occur where the lochia  have a very offensive
 foetid  odor occasioning  great  annoyance  both  to the patient  and  her
 friends.^  The discharge  is generally of a dark color,  and often acrid   It
 may arise from the decomposition of a small portion of  the placenta or mem-
 branes which were left  in  the uterus or vagina, or from the putrefaction of
 coagula   In such cases the vagina  should  be syringed two or three times
 &  SW7 mfm,,miK and Water' 0r a ver? weak solution  of chloride of lime.
 ? !°\:^   blfder--" After severe  labor'" says Dr- Burns, "the  neck
 of the bladder and urethra are sometimes extremelv  sensible, and the whole
of the vulva is tender,  and of a deep red color.   This  is productive of verv
distressing stranguary, which is  occasionally accompanied with a conside-
rable degree of fever.  It is long in  being removed, but yields at last to a
course of  gentle laxatives, opiates, and fomentations.    Anodyne clysters are

uLTfXcatiiete"'111'7 t0 "* *"  "^ ™»*™ ^ regul&r and sPeed? 
TEDIOUS LABOR.
257
  Retention of urine is  not very nnfrequsnt after a prolonged  first labor.
[t is distressing, but not dangerous, and I have generally found the bladder
resume its  functions after  seven or eight days; during which catheterism
will be necessary once or twice a day.  I have no doubt that it results from
a slight degree  of inflammation, caused by pressure, or  from a spasmodic
action of the sphincter.
  404. 7.  The  breasts.—Yariations in  the period  at which the milk is
secreted are common, but of no moment.   If the vascular action  be exces-
sive, it must be moderated by antiphlogistic remedies, such as tartar emetic,
purgatives, fomentations, etc., and by the frequent application of the infant.
  If,  as in some rare  cases, no secretion  should  take place, the  child will
require a wet nurse, but  the mother will not suffer.
  When the nipples are  deficient or mal-formed, we must endeavor to drr w
them out  by the breast pump ;  but if this do not succeed, we must obviate
the ill effects of the secretion of  milk, by tartar emetic, saline purgatives.
fomentations,  etc.
                         CHAPTER  Y.

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

  405.  Definition. — The head of the child presents, and the labor is ter-
minated without manual or instrumental assistance, but it is prolonged beyond
twenty-four hours, from causes which occasion delay in the first stage.  The
placenta is expelled naturally.
  406.  Yery slight experience is sufficient to show that  delay in labor may
occur in either the first or second  stage, and a more extended  observation
will  prove,  1, that when the delay is excessive, the relative duration of the
two  stages  is destroyed, so  that they bear  no  steady proportion to  each
other;  thus, for instance, in a labor of sixty hours, the first  stage may oc-
cupy fifty-nine, and the second only  one, or vice versa;  2, that the effect of
a prolonged labor  upon the constitution of the  patient, depends upon the
stage in which  the delay occurs :  and 3, that  delay in the  first stage involves
per se  very little if any danger, no matter how tedious it may be, but that
delay in the second stage, beyond a comparatively short time, is always of
serious  import; therefore, the only injury done by a prolonged first stage,
is  the influence it  may have upon  the patient during the second  stage, by
rendering her less tolerant of the constitutional  suffering.  Although these
deductions are not  distinctly enunciated by writers  on midwifery, yet they
appear  to be involved in  their practical remarks, inasmuch as  they distin-
guish the causes of delay in  the first stage from those in the second, as being
much le'ss dangerous.  The above conclusions, drawn from  numerical esti-
mates, and  supported practically by high authority, are sufficient, I think, to
justify  our making the distinction between "tedious" and "powerless"
labors to depend upon the stage at which the delay occurs.
  407.  Statistics. — Unfortunately our best statistical reports only give
the entire length of the labor, without distinguishing the stages, so that the
first  Table I shall give will merely show the frequency of  those labors whose
duration exceeds twenty-four hours.
      17 
258                      TEDIOUS  LABOR.
Dr. Jos. Clarke
Dr. Merriman .
Edinburgh Lying-in Hospital
Dr. Maunsell  .
Dr. Thomas Beatty .
Mr. Lever
Dr. Churchill  .
Total Number of	Above twenty-
Labors.	four hours.
10,387	134
2,947	128
2,452	48
839	46
1,182	69
4,666	62
1,285	166
  Thus in  23,758 cases of labor, we have 653 prolonged beyond twenty-
four hours, or nearly 1 in  36.
  I may add, that delay is most common among first cases.
  408. The following Table is intended to exhibit the relative duration of
each stage in  labors of twenty-four hours and upwards, in which the delay
occurred in the first stage, and the results to  the  mother and child.   The
registers of the Western Lying-in Hospital have furnished the data,  and as
the cases are therein entered under the inspection of Mr. Speedy and myself,
I believe they may be depended upon.
Number	nuration	Length of	Length of	Results	Results to Child.	
of Cases.	of Labor.	First Stage.	Second Stage.	to Mother.		
	hours.	hours.	hours.			
5	24	23$	$	favorable.	favorable.	
13	24	23	1	£<	12 " 1 putrid.	
2	24	22	2	"	1 " 1 still-born.	
3	25	22 to 24	1 to 3	((	t«	
1	25	19	6	(<	u	
2	25	17	8	((	(<	
2	25	16	9	it	1 " 1 still-born.	
1	26	25$	*	(t	i<	
7	26	25	1	(<	6 " 1 still-born.	
2	26	23	3	tt	n	
3	27	26$	i	((	a	
2	27	26	1	l(	tt	
1	28	27$	J	a	it	
3	28	27	1	it	u	
2	28	26	2	it	u	
1	28	25	3	tt	a	
1	28	22	6	it	tt	
1	29	28$	*	u	it	
2	29	28	1	<<	a	
2	29	27	2	tt	tt	
1	30	29$	$	tt	tt	
2	30	29	1	tt	«<	
1	30	28	2	tt	tt	
1	30	26	4	tt	tt	\
1	30	23	7	it	tt	
1	30	19	11	tt	tt	
2	31	30	1	it	it	
2	31	29	2	tt	tt	
1	31	27$	3$	tt	it	
1	31	27	4	tt	tt	
1	32	31$	$	tt	(<	
4	32	31	1	tt	<<	
1	32	24	8	ii	unfavorable.	
1	33	32$	i	it	favorable.	
1	33	32	1	tt	n	
 
TEDIOUS LABOR.
259
	Number	Duration	Length of	Length of	Results		
	of Cases.	of Labor.	First Stage.	Second Stage.	to Mother.	Results to Child.	
		hours.	hours.	hours.			
		33	31	2	favorable.	favorable.	
		34	33	1	<<	i«	
		34	30	4	tt	ti	
		34	29	5	tt	ii	
		35	34$	$	ti	ti	
		35	33	2	a	it	
		36	35$	$	it	n	
		36	35	1	tt	a	
		36	33	3	a	a	
		36	31	5	tt	tt	
		37	36$	$	it	tt	
		37	32	5	tt	n	
		38	37	1	tt	a	
		38	34	4	it	tt	
		39	38$	$	it	tt	
		39	35	4	tt	tt	
		40	39f	i	tt	1 " 1 dead.	
		41	39	2	tt	dead.	
		41	33	8	tt	favorable.	
		42	41f	i	it	tt	
		43	41	2	tt	ti	
		44	26	18	it	ti	
		45	44	1	tt	<t	
		45	44$	$	tt	ti	
		46	36	10	ti	i<	
		47	43	4	a	ti	
		48	47	1	ft	ti	
		48	44	4	tt	i<	
		48	34	14	it	tt	
		•49	38$	$	tt	a	
		49	46	3	ti	n	
		49	41	8	tt	dead.	
		50	49$	$	<<	favorable.	
		50	49	1	a	tt	
		51	50	1	tt	ti	
		51	48	3	ti	tt	
		52	48	4	a	tt	
		53	52*	a	it	tt	
		53	52	1*	tt	a	
		53	46	7	it	ii	
		54	53$	$	tt	it	
		54	53	1	tt	ii	
		54	33	21	tt	it	
		55	54*	$	it	ii	
		57	56$	$	(<	ii	
		57	56	1	((	tt	
	o	57	53	4	(<	it	
		58	57	1	if	t<	
		59	67	2	(<	dead.	
		59	55	4	it	favorable	
		60	59$	*	■ <	tt	
		66	62	4	(1	ti	
		69	63	6	n	ii	
		74	72	2	tt	tt	
		74	73|	i	a	it	
		76	71	5	ti	ii	
		78	72	6	it	ii	
		96	66	30	it	dead.	
		100	84	16	a	favorable.	
		103	74	29	a	it	
		177	176	1	it	k	
 
260
TEDIOUS LABOR.
  409. Some apology may be due for the length of this Table, and I trust
it will be found in the fact that, at least as far as I know,  it is the only one
of the kind on record.  The reader will understand that from this list I have
excluded all presentations but the head, all operative cases, all  cases which
were prolonged in the second stage, and all such a* were of doubtful accu-
racy, but that beyond this  I have in no degree selected the cases.   The
entire number amounts to one hundred  and forty-three.   Of these not one
of the mothers died,  although in some cases the first stage was enormously
prolonged,  and but ten of the children, one  of which was putrid.   If the
relative length of the stages be examined, it will be  found that it did not
follow, because the first was very long, that the second should be long also;
and in many cases (not included in the Table) when the second stage was
delayed, the first was extremely short.   Thus  I think that, so far as it goes,
this Table  proves the propositions with which I started;  viz.,  that "when
the delay is excessive, the relative duration of the two  stages is destroyed,
so that they bear no steady proportion to each other," and that "delay in
the first  stage involves very little if any danger, no matter how tedious it
may be."
  The only apparent exceptions to this  rule, of which I am aware, are those
cases in which some mechanical impediment exists, and which belong to an
order to be hereafter  considered.   In these cases mischief arises, not from
the prolonged first stage so much as from the impediment to the completion
of the second ;  and 2, certain cases in which, from some peculiar irritability
of constitution, prolonged suffering in the first stage disposes the patient to
"powerless labor" in the second.   In such, the uterine  power becomes ex-
hausted, and the pains, instead of increasing  when the obstacle is removed,
gradually diminish in force,  and  without any mechanical cause,  the labor
may be indefinitely prolonged,  and constitutional  symptoms set in.   Such
cases  are, however, comparatively rare.   Moreover, a prolonged first stage
is a bad preparation  for undue  prolongation,  or for any accidental compli-
cation of the second.
  These conclusions  I think are fairly deducible from the premises, but there
are others which I would guard against, and these are, first, that because no
evil  happened  in these cases, therefore nothing is to be  done in any case
where the  delay is in the first stage ; and secondly, that the  delay was  the
result of bad management, whereas  in most  cases the patients were  not
brought under our care until the  greater part of the time had elapsed.   I
do think that when we find no evil resulting from the delay, we are not war-
ranted in too active interference ; but I am equally convinced that when we
can remove the cause of it, we are bound to do so.
   I may add, in confirmation of my own conclusions, the statement of Den-
man,  "that neither mother nor child is ever in any danger  (except in hemor-
rhage or convulsions) on  account  of the labor, before  the  membranes  are
broken," i. e., in the first stage.
   410.  Symptoms.—I conclude, then, that these  cases of  labors  prolonged
in the first stage, present nothing formidable  as regards the  mother, and
very little  as regards the child ;  but yet we find that the continued suffering
produces  a great  degree of fatigue, and in nervous women especially, the
loss of sleep is very much felt; the spirits are  depressed, and the patient
expresses a great dread of the result.  Notwithstanding  this, however, the
condition of the patient is favorable.   The skin is cool, the pulse quiet, the
tongue clean and moist; there is rarely any headache;  the stomach may be
more or less disturbed, but the other bodily functions  are  performed in a
healthy manner.  The pains recur regularly, though their extent is often
limited, and their power inefficient, their duration and frequency varying
occasionally.   Still, a perceptible though slow progress is made. 
TEDIOUS labor.
261
  The strength is seldom impaired, and the patient  often gets some quiet
Bleep, which tranquillizes the mind, and restores the bodily powers; there is
neither fever nor inflammation, the vagina is cool and moist, and both urine
and faices are evacuated easily and spontaneously.
  The tranquil pulse, cool skin, and loud outcry, are all indicative of the first
stage of  labor, and on examination, the head  is found not to have passed
through the os uteri,  whether or not the  membranes be broken.
  The nervous shock is never in proportion to the length of  the  first stage
of labor, but of the second.
  411. Causes and Treatment. —The causes which occasion delay in the
first stage of labor are various, and not  always peculiar or confined to it,
and the treatment must be adapted to  each.   No doubt can  be entertained
of the propriety of removing them, when this can be done, even though the
delay they occasion may be innoxious.   Let us examine the principal causes
and their treatment separately.
  412. 1.  Inefficient action of the uterus is a very common  cause of delay,
and occurs most commonly in delicate  women confined for the first time.  It
may arise from constitutional weakness,  a deranged  state of the digestive
organs, mental depression, uterine  plethora, or irritation of the os and cervix
uteri, etc.
  [It not unfrequently occurs in women  who present no striking indications
of delicacy, but rather the reverse, and who are  not known  to labor under
any constitutional weakness.  The inefficient uterine action  in these cases
results, apparently, from some constitutional peculiarity—and often  descends
from mother to daughter.   The females of some  families are, on the other
hand, remarkable for the ease with which they give  birth to  their  children,
independently  of  any physical   peculiarity  discoverable  on the closest
scrutiny.]
  I  have also found that when from any cause (diarrhoea, for example,) the
labor is precipitated  a few days before the time, the first stage is a tedious
one,  and also with the first child in cases of twins. It may also happen that
when the  patient is  attacked by false pains (producing no  effect upon the
os uteri) these may run on  into  real  pains with a prolonged first  stage in
consequence.
  We find the pains  feeble, of short duration, limited in extent, often seated
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.
  413. Treatment.—The first element in the management of these cases is
time.  We must exercise patience ourselves, and  encourage  our patient to
do  so.  All that  is calculated to cheer her should be communicated, and she
should be occupied, if possible, and amused.   If it be day-time,  she should
not  lie down, but may rest on a sofa, and walk about occasionally, taking
the  pains sitting or  standing.   The bowels must be freed  by medicine, if
necessary, and for this purpose enemata of a stimulating character may be
used, as they very often also quicken  the  uterine action.  The diet should
be bland and  nourishing, but not stimulating.
  These palliative measures will  be sufficient in  many cases, in others they
are of no use, and the patient  may be exhausted from the prolonged suffer-
ing and  want of  sleep ;  and the best thing we can then  do (if there be no
counter-indication) is to give a full dose of opium, so as to suspend the pains
for a time  and procure  sleep.   If it succeed,  the  patient  will wake up 
262
TEDIOUS LABOR.
refreshed and strengthened, and the pains most probably return with increased
strength.   In some cases the inefficient uterine  action  seems due  to  some
excess of uterine irritability, and in such cases I have  found the opium of
great use ;  and the pains, instead of being suspended, increased in force and
efficiency.   Perhaps this may explain the success  which Dr. Soma states that
he obtained from the exhibition of  belladonna, without attributing to  that
drug any special power of increasing the uterine action.  A purgative enema,
administered when the patient awakes, is often of  great service.
  When the inefficiency of the pains depends on intestinal disturbance, it
will be right to evacuate the bowels freely before the opiate be given, if one
be necessary.   Should there be indigestible matter in the stomach, it is pro-
bable that  it will be evacuated  spontaneously.
  In cases of plethora of the  uterus, or  irritation of  the  cervix, we shall
often derive benefit from the  abstraction of blood, after which the  pains
generally  become  stronger;  if they do not, we may have  recourse to the
opium for temporary relief.
  414.  So far the remedies mentioned  tend merely to the removal  of ob-
structions to uterine action; but as it does not follow that in all cases this
relief is followed by vigorous  action, we have next to seek for some  agents
which shall act directly upon the uterus.  The one upon which most reliance
is placed is the ergot  of rye.  This vegetable  substance  appears to have
been known for a long period in Germany, under the name of Rockenmutter,
Mutterkorn, etc., and  to have  entered into the composition of various nos-
trums for hastening labor.  It is mentioned by  Camerarius in the Actes des
Curieux de la Nature  for  1668 ; and in 1777 Desgranges published his first
researches upon it, in the Gazette de Sante.  Its introduction  into British
practice was, I believe, owing to Drs.  Stearn and Chapman, of New York,
whose  favorable experience of its effects has  been tested by many prac-
titioners, and apparently with different results.   [The attention of the pro-
fession was first called to  this  article by Dr.  Stearns  of  the  State of New
York, in a letter addressed to Dr. Ackerly, in  the year 1807 ;  and in the
year 1813, attention was further directed  to  it by Dr. Prescott, in a letter
which he read before the Massachusetts Medical Society.  Subsequently the
high authority of  Dr. Dewees  has served to bring it  extensively into prac-
tice—too much so it is to be feared for the credit of the profession and the
interests of humanity.]  Desormeaux, Lachapelle, Beclard, Capuron, Jack-
son, Hall,  etc., deny that it has any effect at all; on the other hand, we have
the  authority of  Bordot, Chevreuil,  Gendrin, Bigeschi,  Luroth, Davies,
Blundell, Jewel, Smith, and  many  others, in stating that it is effective and
beneficial.   From repeated trials, I can bear witness to its efficacy, though
it is somewhat irregularly exerted; but I must  add that  I  have seen it  do
mischief.
   The substance itself, according  to Decandolle, "is a peculiar species  of
fungus which attacks  the  ovary of grasses, and protrudes from them in a
lengthened form, especially from  rye;" hence  the popular term, "spurred
rye."
   [Recently,  Mr.  Smith,1  and  Mr. Quekett,2 have  maintained  that the
ergot is not, properly speaking, itself a fungus, but rather a diseased state
of  the grain occasioned by the presence of a  fungus; to this fungus Mr.
 Quekett gives the name Ergotcetia abortans.   By the  microscope, sporules,
sporidia, or jointed bodies,  are  discovered, which appear to be the repro-
ductive particles of the fungus.3]
   It is an oblong,  slightly curved  grain, about as thick, and twice  as long

  1 [Transactions of the Linnean Society of London, part xviii. p. 449, London, 1840.1
  •'■ [London Lancet, June 22, 1839.]
    [Dunglison's New Remedies, 3d edition, p. 431.] 
TEDIOUS LABOR.
263
. 3100	grains
5-50	ii
9-00	a
7-00	it
. 11-40	n
3-50	tt
. 26-00	it
310	it
3-50	it
100-	it
as a grain of wheat, of a dark-brown color externally, but lighter, and with
a shade of pink, internally.  It has been analyzed by Vauquelin and Wright
The latter chemist states its component parts as follows :
     A thick white oil
     Ozmazone
     Mucilage .
     Gluten
     Fungin
     Coloring matter
     Fecula
     Salts
     Loss
  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 cer-
tain, is to mix the bruised  or powdered  grain with a little water or milk,
and simmer it for a few minutes over the fire, then give the grounds along
with the fluid.   Both vinous and acetous tinctures have been prepared, but
I have not found them as effectual as  the  powder.   Mr. Battley has also a
"liquor secalis cornuti," which seems more certain than the tinctures ; and
I have also  tried  an extract which succeeded pretty well.  From  fifteen
grains to  a scruple of the powder, half a drachm  to a drachm of the tinc-
ture, and  from five to ten grains of the extract, may be given every twenty
minutes, until the  effect be produced, or until we  are  satisfied that  it will
not act.   I would not give more than a drachm, or at the  utmost  a drachm
and a half of the powder (or its equivalent in tincture  or extract) ;  for if
that do no good, more will be useless and  may be injurious.  If it succeed,
we find in five or ten minutes after its exhibition that the pains are stronger,
longer, and more  frequent;  their increased frequency, indeed, is  often re-
markable, even when their force is but little augmented.   I have noticed,
that shortly after an effective dose has been taken, the pulse becomes  slower
until after the pain is over, but that ultimately it remains quicker.  Besides
this power of strengthening feeble pains,  the  researches of Dr. F. Rams-
botham and others have proved it capable of originating uterine action.
  415.  So far we  have spoken of its beneficial effects ;  and although in by
far the majority of cases no injury is produced by it, yet in five or six cases
I have witnessed cerebral disturbance in  different degrees, from a  severe
headache  up  to delirium, coma, and insensibility, follow its  use.  By others,
it is said to disorder the stomach, and if given in large doses, to cause gan-
grene ;  but such cases must be very rare.   I think  I have seen retention of
the placenta, from irregular uterine contraction after the birth of the child,
fairly attributable to it.
  By Girardin, Burns, Moreau, and others, the child is  stated to be  morn
frequently still-born after the use of ergot, either from  some  poisonous in-
fluence indirectly exerted upon it, or by the greater pressure of the  uterus
upon the cord.  I have seen some cases confirmatory of this statement, and
of the latter  mode of explanation, as the  uterine  action was almost  inces-
sant.   Dr. F.  H. Ramsbotham's cases rather support this view, for he states
that when the ergot did  not  bring  on uterine  contractions, no bad  effects
were produced upon the foetus.  Dr. Beatty has published a very interesting
paper, showing that in certain cases the ergot does exert a poisonous effect 
264
TEDIOUS LABOR.
upon the foetus, and he concludes that the child is not safe unless the labor
be concluded within two hours from the administration of the ergot.  More
recent  observations seem to confirm this view.
  416.  From what has been said, we may conclude that ergot of rye may
be tried, 1, when the pains are feeble aud inefficient, without especial cause ;
2, if the os uteri be soft and dilatable ; 3, if there be  no  obstacle to a natu-
ral delivery;  4, if the head or breech present, and be sufficiently advanced ;
and 5, if there be no  threatening  head symptoms,  nor excessive general
irritability.
  But on the other hand, it should  not be given :  1, if the os uteri be hard
and rigid;  2, if the  presentation be beyond reach ;  3, if there be a mal-
presentation ;  4, if the pelvis  be deformed;  5, if  there be any serious ob-
stacle to delivery in the soft parts ;  and, 6, if there  be head  symptoms, or
much general irritation.
  Though  in  some 'cases, when timely administered,  it may anticipate the
use of the forceps at a later period, it is  not  likely, as some have supposed,
ever to supersede the use  of that instrument, and  it is not suited in those
cases in which the crotchet is required.
  [Of the power of  ergot to  excite uterine  contractions there can be  no
doubt; but that it often fails to do so under circumstances apparently favor-
aide for its action, will be admitted  by all who have  had much experience
with it.  Why this is so, we know not.   Yery generally it will be found to
act with decided  energy in cases where the parturient action of the womb
has already commenced increasing this  action  in force, and  rendering  it
more continuous.  In this country its too extensive employment has left no
doubt on this point.   The only  questions which remain to be settled are as
to the  circumstances under which it  is proper to be used,  the dose, and mode
of administration.  The experience of Dr. Huston, as he states in a  note
to a former edition, confirms the observations of Drs. Patterson and Rams-
botham, as to its power of bringing on  premature labor, and its  fatal in-
fluence on the child when employed for that purpose, although he " cannot
admit that this occurs  in consequence  of the child being poisoned by the
ergot through the system  of the mother."   Consequently, it should never
be administered previously to  the setting in  of  labor, and even then  only
with the greatest caution, at the proper period, and  under the most favor-
able circumstances for its use.
  The incessant action of the uterus, under the influence of  ergot, is very
unlike  the  intermittent contractions which  occur in  natural labor.   This
state of permanent contraction of the organ either detaches  the placenta,
or so compresses it as to destroy its functions before the  child is in a situa-
tion to respire.   The appearance of the  children born under these circum-
stances confirms this statement.
  The intelligent practitioners of this city use the ergot chiefly in the ad-
vanced stage of  labor,  or after the birth  of the  child, to overcome uterine
inertia.   They  always  avoid  its administration where  any obstruction  or
great disproportion between the size of the child  and the passages of the
mother exists.   It is a rule with them also to abstain from its employment
until the os uteri is not  only dilatable, but fully dilated, and the other soft
parts  in a favorable state of relaxation.  Even when thus  cautiously had
recourse to, the child will not unfrequently be dead-born.
  The  dose given is from  one to two scruples of the powder,  or an amount
of the  article  equal  to that, whatever may be the preparation employed.
Some prefer smaller doses, as ten or fifteen grains, repeated every fifteen or
twenty minutes until  the desired  effect is produced.
  Some practitioners always administer the powder in the form of electuary,
or diffused in water.   The best  mode of giving the  ergot is, perhaps, re- 
TEDIOUS LABOR.                       265
cently powdered, in hot water, in doses  of a scruple  every twenty minutes,
until a drachm is taken, unless the proper effect occurs sooner :  more than
that quantity is never required, if the  article be good, and the case  one
adapted to its use.
  Experience has shown that ergot, especially when  powdered, rapidly de-
teriorates;— to avoid this and at the same time furnish an article in a con-
venient form for immediate use,  the Pharmacopoeia of the U. S. prescribes
a 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.]
  417. Borax is said by German writers  to have the power of quickening
uterine action, though it is  seldom used in  this country.  Dr. Rigby says,
"We have combined these two  medicines (ergot and borax) with the best
effects^ and  generally give them in the following manner ;  R Secalis Cor-
nuti 9i—ij ;  Soda? subbarat. gr. x; Aq. Cinnamomi  5iss.   M. fiat  haustus.
Cinnamo'h, which is a remedy of considerable antiquity, has also a similar
action upon the uterus, although to a less degree."
  418. At  a meeting of the Edinburgh Obstetrical Society,  Dr.  Simpson
mentioned that he had tried the Indian hemp, and found that uterine action
seemed to be markedly and directly increased by it, but that his experi-
ments were  too few to be decisive.1   I  have never given it for this purpose,
but it seems worthy of a further trial.   Dr. Grigor, of Nairn, has since tried
it in  sixteen  cases ;  in  nine there was no perceptible increase of uterine
action,  but in  seven  it  succeeded very well, without  any anaesthetic or
unpleasant effects.2  Dr. A.  Christison  tried it in seven cases3 successfully.
  419. Dr.  Maguire  mentioned to me  that he had tried a drop of Croton
oil as an oxytoxic, and that it succeeded admirably, whether it acted upon
the bowels or not; it did so in  the only case in which I have had an oppor-
tunity of trying it,  but it left  a very  unpleasant sensation  of heat  in the
throat.
  Dr. Harris, of Alabama, has recently stated that  a strong  decoction of
the Uva Ursi has produced the  same effect in  five cases, without any unplea-
sant symptoms.*
  420. Dr.  Radford, of Manchester, has lately proposed the application of
galvanism in tedious labor from want of power in the uterus, in accidental
hemorrhage, irregular contraction, and  to bring on premature labor, and he
relates a  case of hemorrhage  in which he  employed it successfully,  and
another in which the  pains had  ceased.   Professor Simpson tried it in eight
cases of protracted labor, and thus sums  up the results:—"In one instance,
the pains  were more frequent in their occurrence, but shorter in their dura-
tion, during the application  of  the galvanism.  In five other cases, the em-
ployment  of the galvanism neither increased the average frequency of the
pains, nor their average duration.  In one, the pains ceased while the gal-
vanism was  applied, and returned upon its removal.   In  another the uterine
action ceased  while  the  galvanism  was applied, and did  not return for
twenty-four hours afterwards."   In Mr. Houghton's excellent paper, I find
it stated that Mr. Dorrington used it successfully in  five cases ; Mr. Clarke
in two;5  Mr. Cleveland  in  one; and Mr.  Dempsey in ten  cases.  Mr.
Houghton himself succeeded admirably  in five cases.6   Thus the effects have
been decided in twenty-five cases, equivocal in one,  negative in seven, ouv
of thirty-three cases, which  is,  I think, amply sufficient  to justify a further
trial.

  > Ed. Monthly Journal, July, 1830,  p. 91.             2 Ibid., Aug. 1852, p. 124.
  a Ibid., Aug. 1851.            * Philadelphia  Med. Examiner, Nov. 1853, p. 727.
  6 Dubliu Hosp. Gazette, March  1st, 1845.     6 Dublin Quarterly Journ., Feb. 1852. 
266
TEDIOUS LABOR.
  421. M. Kiwisch states that he has found the water douche of  great  nse
in stimulating the uterus to action.   M. Paul  Dubois  relates one case in
which he tried it;  and with sufficient benefit, I think, to justify our repeating
the trial.1
  Dr. Washington relates that he has  found dry cupping to the sacrum
effective in augmenting uterine action.  The first class should first be applied
to the lowest point of the sacrum, and after about  ten minutes, another
higher up.2  I have had no  opportunity of testing this,  but it  does  not
appear to me unlikely that such an effect might be produced.
  I have already alluded to the beneficial effects of stimulating  purgative
enemata; and I  may add that  some writers have recommended stimulants
externally, such as mustard  poultices, or friction with stimulating liniments.
I have never found them of any use.
  [Labor  is occasionally rendered tedious,  during its  first stage, by  the
occurrence of irregular and spasmodic pains.  " They are recognized," says
Dr. Lever,3 "by their acuteness, by the want of consentaneous action in the
uterine fibres — some portion of the uterus, during their continuance,  being
hard and contracted, while the other portion is  soft and yielding ; there is
also no distinct or regular interval of  time between the paroxysms of pain.
If untreated or unrelieved, the strength of the patient is exhausted before
the establishment of true labor pain ;  or, the child, which at the commence-
ment  presented normally with the head,  may even have its position changed
to that of the shoulder, in consequence of the uterus contracting on one side
only,  and  thus forcing  its contents over to  the  uncontracting or yielding
side.   In such cases, the utility and value of opium are  most marked.   It
maybe exhibited by the mouth or per anum.  It will calm the spasm, subdue
irregular action, alleviate pain, procure sleep ; and after this, true and regu-
lar uterine action will be established.   Manifold are the instances of its value
I have witnessed under such circumstances."]
   422.  2. Undilatable os uteri. — In order to put the reader in full posses-
sion of all that concerns rigidity of the  cervix uteri, I shall have to  trans-
gress the strict limits of this chapter,  and include a class of cases which in
their  effects more properly belong to  the chapter on Obstructed  Labors.
The large majority of cases of  right cervix offer resistance in the first stage
only ; i. e., they yield before any symptoms " of powerless labor " set in, but
a small  number  resist  permanently.   Anatomically  speaking, the  labor is
still in the first  stage, for  the head is within the  os  uteri;  but virtually,
taking the symptoms as a standard, they run  on into the second  stage, of
which they exhibit all the characteristics.
   Trusting that  the advantage of having the whole subject under view at
once  may compensate for the irregularity,  I shall first speak of the ordinary
class  of cases.  With the first child the  cervix uteri is more unyielding than
subsequently, and also in women of advanced age.  It may give way, how-
ever, within a reasonable time ; but in  some cases  it does  not, and on ex-
amination we  find  the  lips thin,  hard, and rigid,  or soft, semi-pulpy, or
cedematous, and that little progress in dilatation is made during  each pain.
The pains themselves may be frequent, and very severe, notwithstanding the
slight effects they appear to produce.   The thick pulp or cedematous  cervix
uteri is  carefully to be distinguished  from  the soft  and  flabby condition,
which is a kind of transition state in the ordinary process of dilatation, and
into which the thin  and rigid  cervix must pass before it will dilate.   The
pulpy cedematous cervix is  as undilatable as the thin and hard.   The latter
is more frequent in  primipara ;  the former occurs indifferently, and appears

      1 Moniteur des Hopitaux, 12th Feb. 1853.
      2 Association Journal, May 27th, 1853,  p. 469.               a [Op. cit.] 
TEDIOUS LABOR.
267
to be the result of irritation, caused in some cases, doubtless, by too frequent
examination.
   423.  Treatment. — Several remedies have undoubted power in most cases
of this  'cind,  and a suitable  selection of them should  be  tried before we
conclude that further interference will be necessary.   In fact, the failure of
these is in many cases the only test we have whether the rigidity be such as
will yield or will resist.
   The  first, and perhaps the  most effectual, when the  patient can bear it, is
loss of  blood.   Some  caution is  necessary, not to  carry it to too great an
extent;  but, within reasonable limits, we need not  fear any ill effect upon
the patient or the progress of the labor.  Dr. Dewees  recommends it even
with delicate women ;  in one case he took away two quarts of blood, and
the patient did  well.  Dr. Davis has taken between  thirty and forty ounces;
but it will not in general be necessary to abstract so much.   Neither ought
we in any  case to bleed in anticipation of the difficulty, as has been advised.
   In most cases of rigidity, fourteen or sixteen ounces  rapidly taken from an
ample orifice in  the arm will be sufficient, and if it make the patient feel faint,
so much the better ; after which,  if  she  be much  fatigued, rest  may be pro-
cured by means of an opiate ; and this will generally  be  succeeded by a
softened, yielding condition of the parts.
   424.  Should  the venesection only partially succeed,  however, or in case it
be not desirable to have recourse to it, we may then  try the tartar emetic,
which I believe was first used in these cases  by Dr.  Every Kennedy,  of this
city.   It is an exceedingly valuable  remedy, perfectly safe, and very success-
ful.   It should  be given in small doses, so as to excite  and keep up  a state
of nausea, and it may  be advantageously combined with  a purgative, — take
for instance the following formula :  R. Magnes.  Sulph. |j ; Infus.  Sennaa
5viiss;  Antim.  Tart.  gr. iij ;  Syr. Zinzib. 5ss.   M. capiat  cochlearia duo
oinni semihora,  vel omni hora.  Dr. Hall, of Montreal,1 recommends larger
doses, a grain every half hour; but this  I have never found necessary, and I
can conceive cases in which much depression and prolonged vomiting might
be very injurious.
   Emetics  were recommended by Lowder, and  by many others since  his
time, founded on the observation, that the spontaneous  vomiting in labor is
almost always followed by relaxation of the os uteri; but as the same bene-
fit results  from  exciting nausea,  it  is much  better to avoid the shock of
vomiting.
   Opium has been used to suspend uterine action ;  but it is far more effec-
tive  when  given after bleeding.  Tobacco enemata have been proposed and
tried; but their effects are so uncertain and occasionally so formidable, that
their  use is hazardous, and to be deprecated.  Dr. Dewees says  that they do
not succeed in softening the cervix.
   425.  Belladonna was  recommended by Chaussier, from  its effects in  re-
laxing sphincters : but there are very serious objections against its use.  Dr.
Rigby states,  "for our  own  part we  must confess,  that although we have
seen this application tried repeatedly, it has  never produced  the desired
effects; but has invariably brought on very troublesome and distressing symp-
toms, such as  sickness, faintness, headache, vertigo," etc.
   French practitioners are in the habit of using mucilaginous injections,
after  the  recommendation of Gardien, nor is there  any objection  to them,
although I cannot say I have seen much good from them.   The  hip-bath
was tried by  Dr. Dewees, but without  adequate benefit;  it weakens the
patient, and may possibly give rise to hemorrhage.
  ["In practice," remarks Dr. Lever,2 "we find women, who  have suffered

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

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

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

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

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

water, and to place between the labia a strip of lint  siheared with simple
cerate, and if necessary we should satisfy ourselves by a careful examination
as to the state of the parts.   If  much inflammation  arise, a large soft poul-
tice of linseed meal, or "stirabout," may be applied over the external parts,
and black wash to the vulva.
   I must  beg of the reader  to  reperuse  the  chapter on Abnormal Conva-
lescence, in  connection with this and some of the  subsequent chapters, as
the deviations therein described occur most frequently after the  more dan-
gerous labors.
   457. Before concluding this chapter, I  would wish to allude  more  dis-
tinctly than  I have as yet been able to do, to  an  interesting, though  not
numerous class of cases, exhibiting the  symptoms,  more or less intense, of
powerless labor, with the exception of the inefficiency of the pains.   The
pulse  is rapid, the  patient very feverish,  the  head  may be affected, or the
abdomen tender, etc.; yet the labor, though sufficiently tedious to give  rise
to these  symptoms,  does actually advance, and may be completed by  the
natural efforts, but at a serious expense to the  mother, and great risk to the
child.   I was  called to such  a case some time ago : the  patient had been
allowed to deliver  herself, and she died of the shock in a few hours.   The
local  injury already described is  also more frequent  after these  cases than
even after those where assistance has been given.  I know not any cases in
which the physician has more need of all the tact and judgment which expe-
rience only can give, nor any more difficult to  describe in a book  so clearly
as to guide the junior practitioner, than  such as these.  The natural powers
are not inadequate to the delivery, yet bad symptoms are present, the danger
imminent, and greatly increased by delay.   On  the  one  hand, we have to
guard against unnecessary interference,  and on the  other, against the evils
of hesitation when assistance is required.   As it is clear that the  possibility
of the labor being  finished by the natural powers alone is not in itself a pro-
hibition of all interference, I can only repeat that the necessity for our aid,
and the time when it ought to  be given,  must be deduced from a careful
estimate  of  the present symptoms,  and the rate at  which they have been
developed ; and if we find that the probable time required for the completion
of the labor will  be so great as to add to the  patient's risk, then  ouo-ht we
undoubtedly to put in requisition all our resources for her liberation.
                        CHAPTER VII.

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

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

  1 Works, vol. iii. p. 55.                2 London Med. Gazette, 1846, p.  688.
  3 Ryan's Journal, vol. vi. p. 87.         * Lancet, 18:-'! 1-2, vol. i.  p. 749.
  5 L'Kxpgrience, May, 183y.             6 Guy's Hospital Reports, vol. ii.  p. '258.
  7 Ibid., vol. iv. p. 120.                 8 Ibid., vol. iv., p. 137, from Naegele's Thesis.
  9 Lectures on Midwifery, by  Skinner.    10 Diet, des Sciences Med., vol. xxiii. p. 301.
 « Ibid.                             u Ibid.
 13 New York Journal  of Med., March, 1843, and American Journal of Med. Science,
April, 1848.
  If  the reader will consult  my work on Diseases of Women, he will find the cases given,
and fuller details upon the subject. 
280
OBSTRUCTED  LABOR.
small opening, there is  hope that time, pains,  and the remedies mentioned
for rigidity of the os uteri, may succeed.   If these fail, then the remarks I
made on that subject apply to these cases.   The natural result of such cases,
and,  & fortiori, of those of complete closures  of  the os  uteri,  are,  1, ex-
haustion and collapse;  2, separation of a part  or  the whole of the cervix;
3, rupture of the  uterus.
  In cases of so serious  a character, a correct diagnosis is of the last import-
ance, and should  be made with  the  utmost care and caution.   " We may
suspect," says Dr. Rigby, "that the protraction of labor arises from agglu-
tinated os uteri, when at an early period of it we can discover no vestige of
the  opening in the globular mass formed  by  the inferior segment of the
uterus, which is forced down deeply into the pelvis, or at any rate  when we
can only detect a  small fold or  fossa, or  merely a  concavity, at the bottom
of which is a slight indentation, and which is usually a considerable distance
from the median line of  the pelvis.  The pains come on regularly and power-
fully, the lower segment  of the uterus is pushed deeper into the cavity of the
pelvis, even  to  its outlet, and becomes so tense as to threaten rupture ; at
the same time it  becomes so thin, that a practitioner who sees such a case
for the  first time would be induced to suppose the head was presenting,
merely covered by the membranes. After a time, by the increasing severity
of the pains, the  os uteri at length opens,  or it  becomes necessary  that this
should be effected by art; when once this is attained, the os uteri goes on
to dilate, and the labor  proceeds naturally, unless  the  patient is too much
exhausted by the  severity of the labor."
  461. Treatment. — Our first object will be to see what the natural powers
will be able  to effect; for which  purpose the patient must be managed as in
natural labor, and allowed to continue her efforts for some time; there is no
danger in so doing, as it will be a considerable time before any unpleasant
symptoms will arise.
  If the continued pressure discover the os  uteri,  but the cervix resist still,
then we  may try  any of the remedies  advised  for  "undilatable  os  uteri,"
audi as  venesection, tartar emetic, etc., and in most cases they will be found
useful.
  In some cases,  when the os uteri is more or less closed  by agglutination,
although, as Dr. Rigby  observes, " the obstacle is  capable of resisting the
most powerful efforts of the uterus, a  moderate degree of pressure against
it, whilst in  a state of strong distension, either  by  the tip  of the finger or a
female catheter, is quite sufficient  to overcome  it;  little or no pain  is pro-
duced, and the appearance of a slight discharge of blood will show that the
stricture has given way."
  If these methods fail, we  must have recourse to the knife, and make one
or more incisions  as near the situation of the os uteri as possible.   Moscati
recommends a number of small incisions around  the os uteri, for the purpose
of securing  its equable dilatation.
  [The  young practitioner should not be too hasty in deciding that a case
is one of agglutination or absence of the os uteri, in which the latter cannot
be reached by the finger for some hours after labor has set in—and that an
operation is  necessary to obviate the  consequent impediment to the birth of
the child.  In first labors, the os  uteri is not unfrequently found high  up, in
front of the  promontory of the sacrum, and almost out of reach of the finger.
It may remain thus for many hours undiscovered  by the inexperienced,  and
although it  may  cause much delay in the labor, it'will in time be brought
into  the axis of the strait by the force of the pains.  This may be expedited,
after labor has continued some time, by drawing it forward with the fino-ers'
as advised by Baudelocque.]
  It is  gratifying to know that this formidable operation is  not attended 
OBSTRUCTED  LABOR.
281
with so much danger as we might expect.  In  five cases, both mothers and
children were saved ; in four, the mothers were saved, but not the children ;
and in two only did death occur after the operation, and in both great delay
had been permitted.
   462.  2. Carcinoma or scirrhus of the uterus.—Strange as it may appear,
conception has been known to take place not only when the cervix uteri was
carcinomatous, but when it was the seat of open cancer.  Zeppenfeld, Sie-
bold,  Lachapelle, Oldham, and  others, have put  such  cases  upon record.
Madame Lachapelle records  seven cases, of whom four recovered from the
delivery.  Of course such a hardened and undilatable state of the cervix will
offer  a  very serious obstacle to the  descent of the  child's head, and that in
proportion to the extent of the disease.   In a  few instances it  has yielded
to the pressure, and the child has been born naturally.
   I attended myself a case in which corroding ulcer proved a cause of delay
for some hours, but  just as we were debating the propriety of  incising the
cervix, spontaneous rupture took place  under the pressure of a powerful  pain,
and the child (still-born) was expelled.   The mother died afterwards from
the consequences of  the rupture,  which had extended into the body of the
uterus.   And  more  recently, I was consulted in another case of malignant
ulceration, where conception afterwards took place ; the patient went nearly
to the full time, and had a natural labor, but sank a few hours afterwards.
   463.  Treatment.—Fortunately such cases are extremely rare;  but  from
those who have been most conversant with them, we find, according to Bayle,
Cayol,  and  Lachapelle, that  some  have terminated without help ; others,
according to  Siebold, have  been  delivered by version : or, according  to
Madame Lachapelle, by the forceps and by vaginal hysterotomy.  If the
cervix resist all the efforts of the uterus, I suppose we must, as a " dernier
ressort," have recourse to the knife ;  but it is for the sake of the child  only,
as the mother's end  will only be hastened by it, and therefore, before doing-
it, we must  be  sure that the child is alive.   If it be not, it would be better
to open the head.
   464.  3. Narrow and undilatable vagina.— In some women the  vagina is
naturally small and contracted ; but this is rarely a serious obstacle to the
natural powers, unless it be the first child, and the patient advanced in life.
   The  calibre  of the vagina may also be diminished by callosities or cica-
trices, the consequences of former  inflammation and  sloughing, and which,
consisting of a  semi-cartilaginous substance, may form rings or spirals around
the vagina,  and offer great  resistance to the descent of the child.  These
obstructions will be detected  at  once,  on examination, by their hard gristly
feel, and their form.
   Lastly, more or less perfect occlusion of the vagina  may be present, owing
to the adhesion of its sides, sometimes leaving  a portion of the  vagina per-
vious  inferiorly, sometimes obliterating nearly its whole length.1
   The  impediment which a congenital narrowness of the vagina offers  is
overcome by patience and pains,  aided by fomentations  or injections before
unfavorable symptoms arise ;  but when it is obstructed by adhesions or con-
tractions, this  may not take  place.  The labor is prolonged beyond a cer-
tain time, and then the symptoms of powerless  labor (§ 447) set in, and  on
examination, the cause of the delay is  sufficiently clear.
   But this is not till.  My friend, Dr. Doherty, has very justly observed, in
a paper read before  the Obstetrical Society, "It is very seldom, even when
a single and prominent band  encircles  the canal, that this is  the only mis-
chief  which  has been done ;  for, generally speaking, we  have more or less
puckering of the parietes, and not infrequently,  as I have already mentioned,
1 Churchill on Diseases of Women. 
282
OBSTRUCTED LABOR.
communications with the  adjoining  viscera.   The  consequence  of these
changes is. that the canal is less able to bear a forcible dilatation ;  and if
the narrowed portion be  permitted to delay the fcetal head too long, a rup-
ture of the vagina above it may occur, even if no breach of surface already
exist.  But if  even  a small  opening  into an adjacent cavity be already
formed, it is very likely  to be converted into a rent, which  throws  both
chambers into  one, constituting one  of the greatest calamities which  can
befall a woman.
  Still worse, if possible, is the result occasionally ; for abundant testimony
is on record, as I have elsewhere  shown, to prove that this obstruction of
the vagina, when left to the natural efforts beyond a certain time, may give
rise to rupture  of the uterus, and death.
  465. Treatment. —As in the cases last described, we must wait until ex-
perience has proved how far the natural powers are capable of overcoming
the resistance.   In some cases we find, contrary to our expectations, that
after the  pressure of  the  child's head has continued for some time, the stric-
ture yields, and, as it were,  unfolds, so as to permit the passage of the child.
In other cases, laceration  takes place  (not without  danger), and delivery
follows.
  Should the parts continue to resist steadily, then we must have recourse
to bleeding and tartar emetic, which will very often  preclude  the  necessity
of relief  by the knife.  If they fail in producing benefit within a reasonable
time, we  must interfere to  prevent worse results — either the constitutional
symptoms already noticed or local injury.
  To avert such a catastrophe, we must have recourse to  the knife, if the
previous  remedies  fail; two, three, or  more incisions should be made,  just
through the resisting band, if it be circular;  but  if the sides of the vagina
be adherent, they must be  carefully  and gradually divided.  The pressure
of the descending head will dilate the passage.   The greatest care must be
taken not to wound the neighboring viscera.  The hemorrhage may be con-
siderable, and occasionally the case terminates fatally.
  Should the uterine action be exhausted by the length of the labor,  and
unfavorable symptoms develop themselves, it may be necessary to terminate
the labor promptly by instruments.  I am  myself satisfied that, in  the more
aggravated cases of stricture, premature labor or abortion ought  to be in-
duced, if we are cognizant  of the fact at an early period.
  I need not say that in  the after treatment the most careful attention should
be paid by the  accoucheur  himself to the state  of  the vagina, and as soon
as the inflammation and tenderness subside, a bougie  should  be introduced
daily, to  guard  against the  re-formation of the stricture.
  466. 4.  Tumors in the pelvis.—Tumors of various pathological charac-
ters may  form in the different parts of the  pelvis : thus we may have fibrous,
adipose,  steatomatous, sarcomatous, and scirrhous growths, and they may
be situated either behind the rectum, between  the rectum and vagina, or in
connection with the proper tissues of the vagina.   Again,  the os uteri may
give origin to a tumor, as polypus.   Dr. Denman met with a case  of cauli-
flower excrescence of the os uteri.
  This is nat the place for the  description of these various diseases, which
I have fully discussed in  another volume.   Our object at  present is to in-
quire what is their effect upon labor.   The obstructions they offer to the
descent of the child's head  will depend upon their  size, their mobility,  and
their compressibility.   If small, the delay may be immaterial, and the'diffi-
culty overcome  by extra  force ;  but if beyond a certain size, they may delay
the labor so long as to give rise to the unfavorable symptoms of a prolonged
second stage, or absolutely  prohibit the  passage of the child.  But this effect
of their size is  sometimes  obviated by their mobility, i. e., the tumor  may 
OBSTRUCTED  LABOR.
283
be pushed to one side, or drawn up out of the way of the child, as in a case
published by my friend, Dr. Beatty, in which the  tumor was  so  large,  and
apparently so fixed, that Caesarian  section was anticipated ;  nevertheless, at
the time of labor it was elevated  sufficiently to allow of the birth of the
child without any assistance.  In the case of a polypus too, we find that in
some cases the pressure of the child's head  has detached the  tumor, or ex-
pelled it without separation, as related by Dr. F. Ramsbotham.  Lastly, in
cases where the  tumor is too large, and immovable, it has been found so
far compressible, that after some delay  and  extra compression of the child's
head, the labor has terminated naturally.
   The chances in favor of the  tumor being elevated or pushed out of the
way, are increased in proportion as it is high up in the pelvis ;  next to these
the most favorable situation is on one side of the promontory of the sacrum,
and the least so, in the antero-posterior diameter.  The difficulty occasioned
by the size is augmented by the hindrance  they offer to the adaptations of
the head, and to its successive changes  of position.

                                 Fig. 107.
Polypus Uteri.
   467. When we  have reason to believe  in the  presence  of any of these
 tumors, a most particular investigation should be instituted.  The  examina-
 tion, as Mr. Ingleby observes, "should be made in the absence of pain, and
 (if possible) before the presentation has  become engaged in the pelvis, lest
 the tension which the mass undergoes during strong  labor  should obscure
 the diagnosis.   If the  presentation be in part only below the brim, it may
 be difficult to determine whether the apparent firmness of the tumor is not
 owing to  obstructed circulation.  Whilst making the usual examination 'per
 vaginam,' it will be advantageous to pass the forefinger of the left hand into
 the rectum, with a view of  ascertaining more correctly the contents of the
 tumor."1
   468.  Treatment.—If, owing to the moderate size of the tumor, its mobility
 or compressibility, there is  a probability of the natural powers being ade-
 quate to the delivery, we have nothing to do but wait patiently; but if the
 delay be so excessive as to  threaten bad symptoms, or if the obstruction be

  1 Facts and Cases in Obstretric Medicine, p. 121.  I beg to refer the reader to this ex-
cellent essay, and to Dr. Merriman's paper in the Med.-Chir. Trans., vol. x., for much
valuable detail which I have been obliged to omit. 
284
OBSTRUCTED LABOR.
  insurmountable, we must then  afford assistance, and  the  mode will depend
  upon the size, mobility, contents, or mode of attachment of these tumors
    Thus, if the'tumor be movable, and we see the patient sufficiently early,
  we should endeavor to raise the tumor above the brim of the pelvis, as was
  done by Dr. Merriman, during an interval between the pains, and  maintain
  it there during the next pains, so as to allow the head to  become  engaged
  in the brim; and to do this the patient should be placed on her knees and
  elbows, so as to have the  influence of gravitation in our favor;  if we suc-
  ceed, the.labor will go on regularly;  but if, as is most frequent,  we fail, we
  must then try if the tumor be removable. If it be a cauliflower excrescence
  or a polypus, it will be advisable to pass a ligature around it.  In the case
  of polypus this has repeatedly been done with impunity.  Other tumors have
  been removed, as in Mr. Drew's case of one between 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 tumors are  composed of fluid or semi-fluid matter, and
  such may be emptied by passing a trocar and  canula, or by a free  openiag
  with the scalpel;  after which the walls  of the cyst will subside, and  allow
  of the passage of the child.   This  operation  should  always be performed
  before we attempt delivery by  operating upon the child.
    If a slight operation upon the  tumor is likely to be successful, there can-
  not be the least doubt that it ought to be preferred, nor do I myself feel that
  we  should be justified in sacrificing the child where  there  existed  any hope
  of being able to extirpate the tumor.
    469.  But suppose the tumor  be solid, immovable, and incompressible ;
  then it is clear that our only means of delivery is to act upon the child,  and
  the mode will depend upon the  size  of' the tumor.  If it be small, though
  sufficient to obstruct a labor attended with feeble pains,  then perhaps the
  addition of extracting force by  means  of the forceps may suffice.  These
  cases, however, are very rare, and we must take care that the force employed
  do  not add to the subsequent risks, by inducing the evil results of  excessive
  pressure upon the soft  parts of the mother.
     If  the tumor be too  large to allow of the use  of  the  forceps, or if they
  have been tried  unsuccessfully (extirpation being out of  the question), we
  have then no  alternative but the reduction  of the bulk of the  child by
  craniotomy, and, if necessary, evisceration.  This, however, is so painful an
  alternative, that it should never  be  thought of until we  are satisfied that
  nature is inadequate to the  delivery, that the  obstacle  cannot be pushed
  aside, nor lessened by puncture, nor removed,  etc., and that interference has
  become imperative in order  to save the life of the mother.
     Some few cases occur in which even craniotomy will  not enable  us to
  effect the delivery; in which the pelvis is very nearly filled by a firm incom-
  pressible tumor, as in the cases related by Dr. Montgomery, Dr. Shekleton,
' and others.  We have no remedy for such, except by providing an artificial
   exit  for the child, by performing the Caesarian section;  a formidable and
  very  fatal  operation, it is true, but which is infinitely better than leaving
  mother and child to perish.   But before having  recourse to it, we must be
   perfectly satisfied that no other means afford a hope of success ; and I need
   hardly add, that none of these serious operations should be undertaken with-
  out a consultation, if that be possible.
     47K). 5.  Diseased ovary.—The ovary maybe enlarged from disease origi-
   nating previous to or during pregnancy, and not  suspended  by it.   The
   enlargement is  sometimes solid, but more frequently it  contains fluid, or
   matter the consistence of honey.  If the disease progress slowly,  the uterus
   with the ovaries by its side, will have emerged from the pelvic cavity in time 
OBSTRUCTED  LABOR.
285
to remove the obstacle, which will then be in the abdominal cavity.  But in
other cases, either from the situation or rapid increase of the ovarian tumor,
or by adhesions between  it and the  neighboring parts, it is retained in the
pelvis, and may offer  serious obstruction  to the second stage of  labor.
" There are two forms of ovarian tumor," says Mr. Ingleby, " which obstruct
the passage of the child.   In  the one a small cyst in connection with  a very
bulky cyst, or else a  portion of a large cyst, passes  into  the recto-vaginal
septum, and bulges through the posterior part of the  vagina.   In the other,
and that which occurs by far the most frequently, the whole ovary, moder-
ately enlarged, prolapses within  the septum.  The descent is peculiarly liable
to happen at two  periods :  the first, near the end of  gestation ; the second,
during labor;  the prolapsus  being promoted by the -relaxation of the soft
parts.   The changes which the ovary undergoes when long detained in the
septum, will depend upon the capacity and yielding state  of the parts.   If
the  woman have  not  previously borne children, it may remain small, and
scarcely retard delivery :  but under contrary circumstances, it acquires a
large size, and nearly fills the vagina.   In rare cases, the bulging is said to
have appeared at  the anterior part of the pelvis.  Again, the ovarium, when
moderately enlarged, and confined within the abdomen, may alter the course
of the gravid  uterus in its ascent out  of  the pelvis, so that the organ can
neither preserve its perpendicular direction, nor freely develop  itself on the
side on which  the tumor is situated, and thus  the  lateral obliquity, as de-
scribed by writers, is  almost necessarily produced.  Although this mal-posi-
tion of the uterus may fail directly to obstruct the entrance  of the presenta-
tion with the brim, the axis of  the organ as respects the pelvis is no longer
maintained, and labor will probably prove tedious."
   A very remarkable case has  been published by Mr. Rankin and Dr. Wil-
 son, in which  an  ovarian tumor  occupied  the  pelvis in  two labors, during

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

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

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

      1 Association Journal, May 27th, 1853, p. 469, from Deutsche Klinik, 1852. 
288
OBSTRUCTED LABOR.
may be caught by the head  of the child in its descent, and pushed before it
into the cavity.  Fortunately such cases are very rare, for their consequences
may be very serious.  Two  very interesting cases, however, will  be found
recorded by the late Mr. Crosse  of Norwich,1 and one by Dr. Doyle.2
  The patient will complain of  fulness, tension, a feeling  of pressing down
and dragging, with a desire  to evacuate urine frequently, and of inability to
do  so.  On examination we  detect a tumor in  front  of the pelvis, partially
covering the head, and containing fluid.   The finger passes  easily posterior
to the tumor, but not anteriorly, and the catheter cannot be passed in  the
usual direction, indicating clearly its nature.   With care, there is not much
danger of an incorrect diagnosis, but if not on our guard we may mistake
it.   Dr.  Merriman relates a  case 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 waters, and
punctured.
  No  doubt, a bladder  sufficiently distended and prolapsed  must  occasion
difficulty and delay in the second stage, but the danger to the mother from
the rupture of that organ is at least equal to the risk of mischief from  the
delay.
  474.  Treatment.—This double danger  renders it necessary that when we
are assured of the nature of the impediment, we should be prompt in our
endeavors to remedy it.   A  male elastic catheter must  be introduced, with
the point directed downwards and backwards, and if the head have not de-
scended too low, we shall probably  be  successful in  emptying the  bladder.
Fig. 109.
Vaginal Cystocele.
The head may also be  raised a little with the finger during an interval to
facilitate the introduction.  Even if we succeed, it will be necessary to watch
carefully against the effects of the previous pressure; but if we fail and
either the labor be arrested by the obstacle,  or the pressure threaten a'rup-
ture, our  only resource,  I  believe, is to tap the  bladder with a very fine
trocar, through  the vagina.  Let me, however,  impress upon  my junior
readers the necessity of being quite certain  of the  nature of the  case and
1 Cases in Midwifery, p. 62.          2 Dublin Med. Press, No. 95, Lect. 28, 1840. 
OBSTRUCTED  LABOR.
289
of the prolapsed bladder being really an impediment, or in danger  of rup-
ture, before attempting so serious an operation.
   Should the quantity of urine be moderate, and the pressure not excessive,
and especially if the head of the child be small, the case may perhaps be left
to nature ; but then, after the labor is over, we must  immediately evacuate
the bladder, and watch the patient carefully.
   475.  7.  Calculus in the bladder. — It is very rare  that urinary calculus
has been found an obstacle to labor; but such cases are on record.   Guille-
meau was  the first to relate  one : the result was contusion, sloughing, and
vesico-vaginal fistula.   La Gonache performed  the operation of lithotomy
under similar circumstances, and extracted  a calculus  several inches in cir-
cumference.   Smellie relates a case which occurred in the practice  of Mr.
Archdeacon, in which the calculus was expelled  by the pressure of the head,
after a long and tedious labor : the patient suffered  from incontinence  of
urine  afterwards.   M.  Dubois detected a  calculus in  the bladder  pressed
down by the head of the child ; and M.  Phillippe,  of Rheims, extracted one
in the fifth month  of  pregnancy.  M. Monod has published a case  of this
kind, in which he removed a calculus, weighing nearly three ounces, by vagi-
nal lithotomy.   It  had proved  an insurmountable obstacle to the progress
of labor, filling the entrance of the vagina.   The labor  was completed  by
the  forceps, but  the child was  still-born.   The  patient recovered  well, the
urine passing by the urethra the following  day.1  Mr. Erichson also relates
a similar  case which  rendered perforation necessary, and afterwards the
removal of the stone by vesico-vaginal section.2
   So long as  the bladder and calculus remain above the brim of the pelvis,
no mischief will result; but if  it project backwards,  and be caught by the
head,  and pushed down before it, the bladder will  be  seriously bruised, and
the labor impeded  in proportion to the size of the calculus.
   A careful examination will show that the tumor is covered by the bladder
and its hardness will indicate its nature.
   476. Treatment,—If the calculus be  discovered during the first stage  of
labor, it may be impossible to raise it  above the  brim, and  to maintain it
there until the head is engaged, after which there will  be no danger; but if
we cannot do this,  I fear our only resource is vaginal lithotomy ; as it is much
better to have to deal afterwards  with an incised wound than a laceration.
   477. 8  Vaginal hernia. — It  is very possible for a loop of intestine  to
slip down  behind the uterus into the "cut de sac" between the vagina and
rectum, and if it be  empty, it will  be  no impediment; but if it contain a
mass of scybalae, that will form an obstacle to the  descent of the head, but
one that is seldom  attended with danger, except from  the  pressure to which
the intestine is exposed.
   478. Treatment,—If the hernia can be reduced, it must be done  as early
as possible ; but if not, we  may  be  able  to deliver with the forceps.  I
never heard of its being necessary on this account to lessen the child's head.
   479. 9.  Collection of fasces in the rectum. — This is  not a very uncom-
mon cause of delay towards the end of labor, nor is such an  accumulation
inconsistent with frequent  and fluid, but  small, evacuations daily.  It is
easily detected ;  the tumor is felt  in the  situation  of the rectum, and  its
irregular form and want of elasticity would almost be sufficient to indicate
its nature.   It  is possible, however, to press it downwards, and then the
escape of fasces will put the question beyond doubt.
   480. Treatment.—If proper care have been taken during pregnancy, and
the first stage of labor, we shall never be troubled by this obstacle  ; but if

   1 Med. Gazette,  March  20th,  1850, from L'Utiion Medicale.  Also Crosse's Case3 in
Midwifery, p. 64.
  2 The  Lmcet, Dec. 8th,  1855.
        19 
290
OBSTRUCTED  LABOR.
not, we must remedy the neglect by enemata of warm water whener-v w*
detect the state of the intestine ; and if, as in some  rare  cases, this be oor
sufficient, the faeces must be removed by a spatula or scoop.
  481. 10. Swelling of the soft parts—The late Professor Hamilton  was,
I believe, the first to notice this state as  an  obstacle to the delivery of the
head.  Dr. Campbell observes, " The capacity  of the  pelvis may be dimi-
nished bv general tumefaction  of its  linings, consequent on interrupted cir-
culation/from a detention of the child's head, or from frequent examination.
This cause of protraction is one of no  ordinary nature, since, unless the
case be promptly and energetically atttended to, the result may be calamitous
from lesion of structure.   Unless a practitioner have had the management
of the patient from the commencement of labor, he is apt to view this variety
of diminished capacity as arising from  original defect  in the development
of the  bones  themselves."
  4S2.  Treatment.—Great relief is afforded by venesection; and, if neces-
sary, small closes  of tartar emetic  should  be administered.   Dr. Campbell
advises the application of  the  forceps, if there  be  room; but if  the pains
be adequate,  I would rather leave  the labor to the natural  efforts,  because
of the risk of injuring the passages.  If the pains be feeble, we must, of
course, expedite the delivery.
  483. 11. Perfect hymen.—Impregnation is quite possible without injury
to the hymen : cases have been recorded repeatedly of  women in whom the
hymen was found perfect at the time of labor.   I myself  attended one some
time ago.   In most cases the membrane yields to the pressure of the head
at once ; but it  may (as  in the cases  I  attended)  offer  a long resistance ;
though I am  not  aware  of its having ever been the cause  of powerless labor.
  484.  Treatment.—The  remedy is very simple ; if the hymen do not yield
to the  pressure of the head after a reasonable time, it  must be divided by
the scalpel.   A very slight incision will  suffice, and great care must be taken
so to support the perineum, as to prevent the laceration  extending  beyond
the fourchette.
  485. 12. Rigidity of the perineum. —I mention this among  the causes
of delay, especially in women  of mature age, although  I believe it never
causes such delay as to give rise to unfavorable symptoms, except when  a
tough cicatrix has formed  after a former laceration.
  In ordinary cases of excessive resistance, much benefit will be derived  from
venesection and tartar  emetic, followed by fomentations, or gentle friction.
with hog's lard.   If it be  clear from any cause (though such cases  must be
extremely rare) that the perineum cannot dilate, an incision must be  made
through the obstacle.
  13. Sanguineous tumor of the labium.—When this accident occurs before
the head is passing through the vaginal orifice, it may  speedily assume such
a size as will offer a decided  obstacle, yet delivery is  of course  necessary.
The question to be decided will be whether to deliver with the forceps first,
and then evacuate the tumor, or to open the tumor first and then deliver.  I
should say that we must be guided by the size of the tumor: if it be possi-
ble to deliver without danger of laceration, I should prefer that, and then to
allow some time to elapse  before incising the tumor.  But if it be very large,
it will be better to have to deal with an incised wound than a laceration, and
we  must make sufficient pressure at the time and afterwards, to guard against
serious hemorrhage.
   486.  Other causes have been enumerated as protracting the second stage,
as shortness  of the funis, prolapse  of the uterus, etc.;  but though, to a cer-
tain extent, they may have such an effect, yet not so far as to give rise to
 the symptoms of powerless labor.   Prolapse of the uterus  at the  time  of
 labor can only be partial, and must  arise from excessive amplitude of the 
OBSTRUCTED LABOR.
291
pelvis :  careful pressure around the external orifice will retain it within the
vagina,  and the child will be expelled naturally.  Brevity of  the  umbilical
cord, or its coiling, has also been said to delay the descent of the child, but,
I believe, without any reason.   Those  who  supposed this, remedied it by
dividing the cord, which  I believe to be very rarely necessary.           '
  487.  Symptoms.—It is unnecessary that I should do  more than allude to
the symptoms which arise, when,  in consequence of any of these causes, the
labor is delayed in the second stage;  as I have fully described  them under
the head of Powerless Labor, from  which they differ in nothing,  except that
we  do not so frequently find the character of the pains changed.   It is evi-
dent that the  fault is not  in the want or  inefficiency  of pains, but  in the
obstacles opposed to them.  The symptoms then will be in proportion to the
delay, making due allowance for difference of constitution  and  temperament,
and the delay will be in proportion to the extent of the obstruction, assuming
that no interference  has been attempted.
  For some time (from twelve to  twenty hours) after the first stage has been
virtually or really completed, the  labor will go on apparently favorably ;  but
after this, the pains  producing no effect, we  find that the patient becomes
feverish, restless,  and thirsty ;  the  pulse rises, the skin is hot,  the tongue
dry and furred, and the gums and teeth coated with  sordes. In  some cases,
but not always, the character of the pain is changed ; the outcry and suffer-
ing increased, but the force  diminished and the voluntary  efforts  suspended.
  If the patient be neglected, the unfavorable symptoms increase : the abdo-
men becomes tender, and sometimes  tympanitic ; vomiting is  frequent;  the
urine is retained ; the vagina is hot and tender; the discharge becomes
yellow or brown,  and perhaps offensive ;  violent rigors occur, and the patient
is irritable and despondent,  and ultimately sinks into a delirious or comatose
state.
  488.  Prognosis.—In any'case  to which we are called, our prognosis must
depend  upon the actual state of the patient, and the possibility of removing
the cause, or the  facility with which labor may be terminated by instruments.
If called early, before bad symptoms  are developed,  and the cause of delay
be one we can  remove, the prognosis  will be favorable, as far as delivery  is
concerned, with a reservation as to  the results of the operation necessary for
the removal of the cause.   If the obstacle  cannot be removed,  and we  are
obliged to  operate upon  the child, there will be, in addition to  the usual risk
of the  operation, something additional in proportion to the difficulty of ex-
traction.  If we  be  not called until serious symptoms appear,  the  shock  of
any operation  will add  much to the patient's  danger, and our prognosis
should be very guarded.   In these cases it  should be distinctly  stated that,
although there is danger to the patient if the operation be attempted, there
is much greater danger, or  perhaps  the certainty of death to mother  and
child, if nothing  be  done.
  489.  Treatment.—For each cause  of delay I have mentioned the special
treatment necessary.  I shall, therefore, now merely recapitulate a few general
principles.   1. In no case need we interfere when the obstacle can be over-
come by the  natural powers within  a  reasonable time.   2.  That the  less
serious  the mode of interference  the  better;  so that, if the natural efforts
are insufficient, we should endeavor to push  the obstacle out of the way; to
puncture it;  or to remove  it.  3. That if the uterine  efforts be vigorous,
the mere removal of the  obstacle  will  enable them to complete  the labor.  4.
That in some cases, besides  removing the cause  of delay, it is necessary to
employ  extracting force;  and, in  such cases, the less violent  the operation
the  better ;  thus the vectis (if effectual) would be preferable to the forceps ;
the  forceps to the crotchet; and  the  crotchet to the Caesarean section.   5-.
But in  our estimate of the risk of these operations, we must  not omit  the 
29 2
DEFORMED  PELVIS.
time they occupy, with reference to the condition  of the patient; thus the
time gained by the  forceps may render it more useful than the vectis.^  6.
When the forceps cannot be used, no false humanity should make us hesitate
to destroy the child (I assume, of course, the necessity for an operation) in
time to save the mother ; because its life cannot be saved ; and  both it and
the mother will be lost if we do not terminate the  labor.
                       C HAP TE R  VII I.

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

  490. Definition. — The progress of the labor is impeded by abnormal
deviations in the form of the pelvis, giving rise to delay in the second stage,
or rendering the descent of the child impossible without  assistance, or alto-
gether impracticable.   The symptoms are those of powerless labor.
  491. If the reader will have the kindness to turn back to the chapter on
Abnormal Deviations in the Pelvis, he will find that I there  described the
following variations from the  ordinary standard: 1, the equably enlarged
pelvis  {pelvis osquabiliter justo  major) : 2, the  equably diminished pelvis
{pelvis osquabiliter justo minor) : 3, special distortions of the brim :  4, of
the cavity :  5, of the lower  outlet:  and 6, oblique distortion.   As  in that
chapter these deviations were described, and the means of diagnosis pointed
out, it only remains for us now to consider their effect upon the labor, which
I shall do in a few words.
  492. 1. The "pelvis sequabiliter justo major" can scarce'ly be included in
the practical consideration of the effect of distortion ;  but as it does modify
the labor, a few words may not be amiss.   As the adaptation of the child's
head to the pelvis, and the changes  observed  in  its  descent, depend  upon
the combined effect of the propelling force and the resistance, it is clear that
if the pelvis be so large as to afford little or no resistance, these changes will
not take place ;  nor is that of much consequence.   Further, the absence of
resistance will render the labor so rapid as to preclude due preparation on the
part of the mother, as in the cases related by Drs. Montgomery and Rigby.
In  one, a patient of Dr. Douglass, the child was born in the night  without
waking the mother.  Nor are  these  rapid labors from  deficient resistance
without  inconveniences:  the  uterus may be depressed to the edge of  the
vaginal  orifice, and even somewhat beyond it, and there is  certainly more
danger of subsequent hemorrhage.  The only danger to the child arises from
the chance of its falling on the ground, when expelled without warning.
   Little can be  done in such cases, even if we happen to be  in time, except
to  support the external parts, so  as to prevent partial prolapse of the uterus,
and by pressure over the uterine tumor to guard against flooding.   During
convalescence, the patient should be  kept a  longer time than usual  in the
horizontal position.
   2.  The opposite extreme, the " pelvis asquabiliter jnsto minor." may offer
very serious resistance to the progress of labor.  In general, however  it
renders  the labor difficult and tedious, but not impracticable by the natural 
DEFORMED  PELVIS.
93
powers.  The moulding and adaptation of the fcetal head occupies a longer
time,  the. compression is greater, the pains more violent, and  the  second
stage more  prolonged, but the amount of delay varies, and its effects also
upon the constitution of  the patient.
  492. 3. The special distortions of the brim are very important, and it may
generally be  remarked, that a  small  special deformity will prove a greater
obstacle than the same  amount of equable diminution  of size.   When the
oval of the brim  is transposed so that the antero-posterior diameter is the
longer, the position of the child's head will  of necessity be changed, so as
to bring  its long diameter into accordance with that of the pelvis.  The
heart-shaped brim may have no influence  upon the head unless the promon-
tory of the sacrum be much projected ; then we  shall find a corresponding
indentation upon the  skull of the child, and perhaps  a fracture of one of the
bones, as  remarked by Dr. Michaelis, of Kiel.   And not only this, but the
head, if prevented from freely entering the  pelvis, and  if the pains be very
violent, and the patient have had several children, 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 preclude the entrance of  the head altogether.
   4. Distortions  in  the  cavity may be merely a continuance of deviations
in the  brim, or they may be limited to the cavity ; in the latter case, we may
find the head enter the pelvis with tolerable facility, and descend in the usual
manner, until it arrives  at the  impediment.  If the sacrum be too straight,
there will be  danger of the head being driven through the perineum for want
of the  forward direction  which is ordinarily communicated to it by the curve
of the sacrum : on the other hand, too great curvature of the sacrum may be
a serious  difficulty, even insurmountable without assistance, or if overcome
it may exert injurious pressure  upon the skull of the child.  Exostosis of the
sacrum, or fibrous tumors growing  from  the periosteum, will prove an ob-
stacle  in  proportion to the size : if small,  it may be overcome  by the uterine
efforts alone, or with assistance :  if large, it may be incompatible with the
delivery of a living child, or even a mutilated one.   And it should be always
remembered  that these tumors  increase really though slowly, and that the
impediment they offer to the passage of the child in one labor is a deficient
measure  of the obstruction they will  give in a subsequent one.
   5.  Distortions of the  lower outlet  may depend upon those in the upper
part of the passages, or, which is rare, they may occur alone.   The latter
consist generally in an approximation of the tuber  ischii, or narrowing of
the pubic arch, or in anchylosis of the coccyx.   If the pubic arch  be nar-
rowed, 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 ex-
pulsive force, it may  be indent or fracture the bones of the cranium.   When
the pelvis is  funnel-shaped, the resistance  will not be felt until the head is at
the lower outlet, and it  may then require assistance.
   6.  Oblique distortions of the pelvis offer great obstruction to the passage
of the child, and although, if slight, a modification of the usual adaptations
of position  may  allow its descent, yet in  many cases it is requisite to inter-
fere and  terminate the labor artificially.
   494. So far I have merely sketched the  kind of influence which the various
deformities are calculated to exert upon  the labor ;  but  another most im-
portant consideration remains, viz., the amount of the difficulty. A due appre-
ciation of the limitation caused by the distortion is absolutely necessary to
the practical management of such cases,  and in forming our judgment we
must take into account the relative as well as the positive size of the  aper-
tures or cavity;  for although they should be much reduced, yet if the  fcetal 
294
DEFORMED  PELVIS.
    head be very small, there may be comparatively little difficulty ; and, on the
    other hand,  if the head be large and the sutures ossified, a very slight dimi-
    nution in the usual capacity of the pelvis will offer great obstruction.   In a
    practical point of view, we may make three degrees of distortion :  first,
    where the pelvis is sufficiently  reduced in size as to offer an amount of  diffi-
    cultv which  in some few cases  may be overcome by forcible pains, if time be
    allowed, but which generally require extracting force in addition, there being
    space enough to allow the  use of the forceps.   Secondly, where the head is
    unable to enter the pelvis, or having entered, is tightly wedged in the cavity
    or impacted, as it is called.  In these cases there  is not space enough to
    admit the forceps, nor if they could be introduced, would the head bear the
    compression necessary to enable us to extract the child alive ; there is  no
    resource but to evacuate the contents of the  cranium.   Thirdly, there are
    very rare  cases of extreme distortion, where the  canal of  the pelvis is  so
    reduced that it would be impossible to extract even a mutilated child.
      495. It is not easy to name the actual diameters  answering  to each of
    these classes, because,  as  I have already  observed, the size of the pelvis
    must always be considered relatively to  the child's head.   But this much
    may be stated,  that a living child cannot pass through a pelvis whose small
    diameter is  less than three inches.  M. Le Roi  fixes upon 3^ inches,  Drs.
    Osborn and Aitkin 3 inches,  Dr Jos.  Clarke 3+, Dr. Burns 3£, Dr.  Ritgen
    2. Dr. Busch 2^ to  3 inches, as the  smallest diameter.   It is clear, then, that
    unless there be a space of full  three inches,  it would be useless, probably
    injurious, to use the forceps.  In such cases  Dr. Simpson proposes  to turn
    the child ; and if we are certain  of  the exact diameter, it may be applicable
    occasionally, but as a general rule its propriety is  not as yet established.  In
    the majority of cases, if it be  under this, the case will belong to the second
    class, in which the perforator and crotchet must be used, provided that there
    be  space enough for the extraction of the  child  after mutilation.   Dr. Os-
    born states  that one inch and  a half diameter will be space enough for this
    purpose.  M. Baudelocque conceives that  craniotomy is inadmissible when
    the diameter is only an inch and two-thirds ; Dr. Dewees when it is less than
    two inches  ; Drs. Hull and Burns think that  it  may succeed when  it  is an
    inch and three-quarters; Drs. Gardien and Hamilton  when it is an inch and
    a half; and Dr. Davis when it is one inch.   We  must not forget the safety
\   of the mother  in our measurements.  It may be possible to extract  a muti-
    lated child  through the smaller of these diameters, but it would be at  the
    expense  of  the mother's life ; and  I feel satisfied that if it be much below
    two inches,  the case will come under the third class, and our  only remedy be
    the  Caesarian section.
       496.  If deformity be suspected, an external as well as an internal exami-
    nation should  be carefully made ;  if we can reach the  promontory of  the
    sacrum and the presentation,  we can then  estimate the relative size of  the
    head and the brim ;  if the presentation be beyond reach, we may  still be
    able to ascertain the  distance  between the sacrum and pubis with tolerable
    accuracy.   In  addition there is a peculiarity about the first  stage of labor.
    "Besides the general appearance of the patient," says Dr. Rigby, "we fre-
    quently find that the uterine contractions are very irregular; that they have
    but  little effect in  dilating the os uteri; the head does not descend against
    it, but remains high up ; it shows  no disposition to enter the pelvic cavity,
    and rests upon the symphysis  pubis, against which it presses very forcibly,
    being pushed forwards by the promontory of the sacrum."  There is less
    difficulty in  detecting the disproportion in the cavity or lower outlet, as it is
    within reach, and on examination during a pain,  we find that no progress is
    made, and during an  interval  we can perceive that  the head is larger than
    the passage it  has yet to traverse. 
DEFORMED  PELVIS.
29ft
  497. Symptoms. — If the labor be allowed to continue beyond a certain
time, we  shall have all the constitutional symptoms of powerless labor (ex-
cept perhaps the change in the pains), because the.delay is in the second
stage, really or virtually.   It is true the head may not be able to clear the
os uteri,  on account of the obstructions at the brim, but the os uteri becomes
softer and  dilatable, the pains forcing, and the cry suppressed ;  all marking
the transition from the first to the second  stage, and it is never until after
this change that bad symptoms set in.
   But besides these constitutional symptoms, which I need not  recapitulate,
other effects not unfrequently result, even where  we are successful in de-
livering the patient.  The long and forcible pressure of the  head of the
child against the soft parts at the brim and in the cavity may be followed
by inflammation and sloughing.  Thus the lower part of the uterus and the
vagina may be seriously injured, and if the slough be  deep, the bladder or
rectum may be  perforated.   I have already pointed  out the possibility of
rupture of the uterus.
   The child, too, may suffer considerably :  if the head  enter the brim and
be much compressed, its life may be sacrificed ; or partial pressure on any
part may fracture one  of the  bones of  the  cranium, or give rise to inflam-
mation or  sloughing of the scalp.
   If  the os coccygis be anchylosed,  so as to offer a decided obstacle to the
passage  of the head, it may be broken by forcing it backward, as in Dr.
Summer's  case,1 rather than risk the loss of  the child.
   498.  Treatment.—If the distortion be slight, it is possible that the extra
force which will be exerted may be sufficient after a longer time for the ex-
pulsion  of the  child, and a fair trial should be given.  But if the dispro-
portion be so marked that it  is evident that the child cannot pass without
assistance, or if unfavorable symptoms are present, we ought to lose no time
in determining  by the degree  of deformity to which of the classes (§ 494)
the case belongs, and acting accordingly.   If  it come under  the  first, and
there be space  enough, we may try the forceps ; if under  the second, ver-
sion  or  craniotomy, and,  if necessary,  evisceration, will  be  our only re-
source ;  if under  the  third, the  Caesarian  section.   I would caution  my
 junior friends against coming to a  conclusion and acting upon it without a
consultation.
   The greatest care will be  necessary after delivery to guard against the
consequences I  have mentioned.   Vaginal  injections of warm water should
be used  twice a day, and externally fomentations and poultices, if necessary.
I have found great benefit from the exhibition  of small  doses of calomel
and opium at moderate intervals, or of a full dose of opium at bed-time  in
these cases.
   I shall now proceed to consider in detail  the operations to  whith I have
as yet only slightly referred.

           1 Ed. Monthly Journal for Oct. 1850, from American Journal. 
296
INDUCTION  OF  PREMATURE  LABOR
                        C HA P TE R  IX.

OBSTETRIC OPERATIONS.—1. INDUCTION  OF PREMATURE LABOR.

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

            i Journal  des Connoiss. Med.-Cliir., 29 Fe"v. 1852, p. 13C. 
298
induction  of  premature  labob
 (four  times), Betschler, Froriep, Wenzol, 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), etc.  etc.; but opposed  by Stein,
 Osiander, sen., Bernstein, Ebermaier, Gumprecht, Piringer, Joerg, etc.
   In Italy it seems to have met with less opposition ;  or, at any rate, less
 aversion has been expressed.  Successful cases have been published by MM.
 Ferrario, Billi, Lovati, Bongoianni, etc. etc.
   Paul Scheel in Denmark, Solomon de Leyden  and Professor Vrolik  in
 Holland,  and M. Marinus in Belgium, have each advocated the practice.
   503. So  much for the  history of  this  operation, and  the difficulties
 attendant upon its introduction into practice.
   As  to the origin of it,  all writers are agreed in attributing it to the fol-
 lowing circumstances :—It has not unfrequently happened that the life of a
 seven  or  eight months' child has been preserved  by accidental premature
 labor, in cases where the birth of a child at the full term had been previously
 found impossible from pelvic distortion.  From the complete success of such
 cases, as regards  both mother and child, it was inferred that premature labor,
 artificially induced, might, in certain cases of  pelvic deformity, be employed
kto supersede an operation (craniotomy) which involved not only the destruc-
 tion of the child, but considerable risk to the mother.   The proposal was
 not, it must be remembered, to deliver the fcetus artificially, but merely,  a?
 was stated by Ritgen, "to  communicate a  slight but certain impulse," by
 virtue of which the process  of parturition may be carried on and completed
 by the natural powers.
   504. The reasoning of  Dr. Denman appears to  me conclusive,  as to the
 |' moral rectitude" of the operation ; the next question, therefore, is as  to
 its safety to the  child and  the  mother,  confining ourselves for a moment  to
 the  consideration of the  cases originally proposed to be benefited  by the
 operation.
   It is perfectly established that a fcetus is " viable" at the completion  of
 seven  months of  utero-gestation,  and many instances  are on record of chil-
 dren born at that period living to a good old  age.  M. Chaussier (of Dijon)
 and his wife were both seven months' children ; his Majesty George III. wa?
 also a seven months' child ;  and M. Fodere  relates the ca:e of the wife of
 a judge, whose pregnancies always terminated  at the seventh month.   Ex-
 amples of " viable" infants born at  an earlier period  are  likewise to be
 found; but I beg to refer to the able work  of my friend Dr. Montgomery
 for further details ; concluding, from  all the evidence  we possess of the via-
 bility  of seven months' children, that premature labor, accidentally or arti-
 ficially induced, at the completion of the seventh  month, does  not involve
 danger to the child from the immaturity of its growth merely.
   As  to the actual risk of labor  to the  fcetus, as ascertained by an estimate
 of facts, I may adduce the following testimony :__
   Of  twelve cases mentioned by  Denman, the majority of the children were
 saved.  Mr. Barlow reports seventeen cases —six children were  still-born
 five died a  few  hours  after birth, and six lived.  Of Dr. Merriman's ten
 cases, four  children were  saved.  Dr. Merriman, jun., mentions  forty-sis'
 cases—sixteen children lived, and all the mothers recovered.   Dr  Conquer
 says, that  out of nearly one hundred cases, about half the children were
 born alive.   In Mr.  Gregory's case, the child  was born  alive, but died sub-
 sequently.   In Dr. Collins's case, the child  lived.  In Mr. Corry's and Dr
 1 aterson's cases, the  infants were saved.   Dr. Hamilton states'that "pre-
 vious to the 26th of January, 1836, the author brought on premature labor
 m twenty-one individuals, on account of defective apertures, viz  in four-
 teen, once ;  in one, twice ; in three, thrice ;  in two, four times;  and in one 
                induction of  premature labor.             299

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

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

       In Great Britain.......T2 times
       In Germany      .    .     .    .     •     •     .   79  "
       In Italy........T  "
       In Holland........3  "

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

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

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

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

  1 Die Geburtshiilfliche,  Praxis, etc., zu Wien, p. 234.
  2 Moniteur des Hopitaux, 10 and 12  Feb. 1853.
  s Med. Times and Gazette.                * Lancet, Dec. 4, 1852, p. 517.
  6 N. Zeitschrift  fiir Geburt., 1846, vol. xxi.   6 Monatschrift fur Geburts., 1853, vol. i.
  1 Deutsche Klinik, 1834, Jan. 14th, et seq.   8 Med. Times and Gazette, Oct. 11  1856
  »Ibid., Jan. 7th and 14th, 1854. 
VERSION,  OR TURNING.
309
  7. Prof. Scanzoni has tried, and  in two cases successfully, to bring  on
premature labor  by applying an india-rubber apparatus, like  a sucking-
pump, over the nipples for about  two hours.   In one, seven, and in the
other, three  applications  were  sufficient.1  The chief objection seems to
be the chance of  irritating  the  breasts, and of failure in exciting  uterine
action.
  8. Dr.  Radford has proposed galvanism as a mode of inducing  labor in
1844, and Dr.  Simpson wrote in favor  of it about  the  same  time.  The
former practitioner has used it four times successfully to induce premature
labor in cases of contracted pelvis;  in a fifth case it failed.  Dr. Barnes and
others have also successfully employed it.
  It has been suggested, that the application  of the  extract of belladonna
might aid in the dilatation of the os uteri; but independent of the fact being
rather  doubtful,  the practice would  be  dangerous, in consequence of the
active absorption and  the  development  of the  poisonous effects of the
medicine.
  517. An interval, varying from twenty-four to ninety-six hours, generally
elapses after the  operation,  before  uterine' action commences, which it does
sometimes by shivering and feverishness.   " Great disturbance in  the nervous
system," says Dr. Gooch, " is produced by it; severe rigors, rapid pulse, and
delirium are the occasional consequences ; but these  symptoms, proceeding
from nervous irritation, do not continue long enough to produce any serious
consequences."   In many cases these symptoms are altogether absent.  The
patient will require the  same management as after ordinary labor.   It will
be advisable to have a nurse in readiness, to supply the infant with its natural
nourishment, until the mother shall  have milk for it.
C HAP TE R  X.
     OBSTETRIC  OPERATIONS. —2. VERSION,  OR  TURNING.


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

                » Med. Times and Gazette, Oct.  1st, 1853, p. 359. 
310                  VERSION, OR TURNING.
519.  Statistics : —
Date.	Author.	Hospital, etc.		O DC & £ — ei ceo	References.
			OS » 9	1° 1,897	
1781	Dr. Bland,	Westminster Dis-			Merriman's Synopsis.
	Dr. Jos. Clarke,	pensary, Dublin-Lying-in Hospital,	48	10,387	Trans, of Assoc, vol. i.
	Dr. Merriman,	London Private Practice,	14	2,947	Synopsis, 4th edit., p. 335.
1816	Dr. Granville,	Westminster Dis-pensary,	8	640	Report of, p. 25.
1826	)				
to	[ Dr. Collins,	Dublin Lying-in	33	16,414	Prac. Treat, on Mid., p.
1833	)	Hospital,			73.
1828	Dr. Cusack,	Wellesley Dispen-sary,	5	313	Dublin Hosp. Rep., vol. v. p. 495.
1832	Dr. Maunsell,	tt	2	442	Edin. Journal, No. 117.
1833	it	n	0	416	Dublin Jour. vol. v. p. 367.
1828	Mr. Gregory,	Coombe Hospital,	3	691	Dublin Hospital Report,
1834	)				vol. v.
to	[ Dr. T. Beatty,	Cumberland-street	6	1,182	Dublin Jour., vol. viii. p.
1837	J	Hospital,			66; vol. xii. p. 273.
	Dr. Beid,		28	5,691	Ranking, vol. iv.
1836	)				
1837	[ Dr. Churchill,	Western Lying-in	11	1,640	See Reports.
1838	j	Hospital,			
	Mr. Mantell,		8	2,510	Amer. Med. Jour., vol. iv. p. 245.
	Dr. Adams,		9	628	Ranking, vol. iv.
1842 to 1845	1 Drs. M'Clintock	Dublin Lying-in	23	6,634	Pract. Obs., p. 181.
	and Hardy,	Hospital,			
.1847 to 1854	1 Drs.Sinclair and	Dublin Lying-in	47	13,748	Pract. Med., p. 514.
	1 Johnston,	Hospital,			
1842	1				
to	Y Dr. Hall Davis,	Royal Maternity	35	7,302	On Diff. Labor, p. 271.
1857	i	Charity.			
	Mad. Lachapelle,	Maison d'Accouch.	155	15,652	Practique des Accouch.,
Dec.	'				p. 198.
1799					
to	]■ Mad. Boivin,	Maternity,	218	20,517	Memorial de l'Art, etc.,
July					p. 354.
1811	J				
1808	M. Ramboux,	Clin, de Liege,	1	216	Bull de la Faculte", etc., vol. ii. p. 73.
1825 1826	I Dr. Merrem,	Cologne,	3	157	Ibid., vol. xvii. p. 283.
1828	M. Papavoine,	St. Louis Paris,	1	240	Jour, du Progres de M4d. vol. xiv.
1829		Hotel Dieu, Paris,	2	280	Velpeau, l'Art d'Acc. p. 50. Gaz. MeU de Paris, 1835.
1830 1831	| M. Ciniselli,	Clin, de Pavia,	2	94	
1833	M. Mazzoni,		18	481	Prospetto Ragionato, etc.
 
VERSION,  OR TURNING.
311
			° s	6 t£	
Date.	Author.	Hospital, etc.			References.
1834	)				
to	V Dr. de Belli,	Milan,	51	2,739	Ranking, vol. iv.
1843	J				
1789	1				
to					
1792	1				
and	[>M. Boer,	Vienna,	151	29,961	Die Natiirliche Geburt-
1801					shiilfe, etc., vol. i. pp.
to	|				72, 148, 237; vol. iii.
1806	J				pp. 62, 130, 245.
	M. Naegele,	Heidelberg,	22	1,411	Velpeau's Tab. View.
1801	) G. M. Ritcher,	Moscow,	25	2,571	^ Synop. Prac. Med. Ob-( stetric, p. 416.
to 1807	J "	Private Practice,	27	624	
1812	)				
and	Y E. Von Siebold,	WurzburgHospital,	6	310	Siebold's Jour. fiir. die
1813	)				Geburtshiilfe, etc., vol. i. pp. 114, 576.
from	1 \				
1818 to		Berlin Hospital,	60	2,055	Ibid., vol. iii. to x.
1829	j				
1819 1820	i M. Ritgen,	Giessen,	1	180	Ibid., vol. vi. pp. 84, 262.
1814	1				
to	V M. C. G. Carus,	Dresden,	29	2,133	Ibid., vol. vi.
1824	j				
	M. Kilian,	Clin, de Prague,	63	2,350	Bull, de la Faculty, etc. vol. xxv. p. 352.
	M. Klein,		216	35,417	Arneth, p. 135.
	M. Bartsch,		40	4,425	Ibid.
1824	^				
to	Y M. Kluge,	La Charity, Berlin,	19	1,254	Siebold's Journal, vols.
1827	j				vi. vii.
1825	Prof. Andre"e,	Breslau,	5	181	Ibid., vol. vi. p. 154.
1825	]				
to	v Dr. Brunatti,	Dantzic,	3	380	Ibid., vols. vii. ix.
1828	J				
1825 1826	| Dr. Theys, Dr. Henne,	Trier,	1	49	Ibid., vols. vii. viii.
1826		Konigsberg,	2	156	Ibid., vol. viii. p. 121.
1826	Dr. Voigtel,	Magdeberg,	1	29	Ibid., vol. viii. p. 831.
1827	Dr. Kiistner,	Breslau,	6	176	Ibid., vol. ix. p. 92.
1829	^				
to	I Dr. Adelmann,	Fulda,	1	166	Ibid., vols. xi. xiv.
1832	i				
1830	)				
to	[ Dr. Siebold,	Marburg,	8	321	Ibid., vols. xi. xii. xiii.
1832	j				
1833	1				
1835 and	t "	Gottingen,	7	504	Ibid., vols. xv. xvi.
1836	Prof. Schwerer,		183	21,804	Ranking, vol. v.
	Dr. Arneth,	Vienna,	44	6,608	Die Geburtsh. Praxis, etc. p. 71.
1821 to	I Dr. Ricker,	Nassau,	2473	304,150	Med. Times and Gazette,
1842					Oct. 11, 1851.
/ 
812
VERSION, OR TURNING.
  Thus we see that the records of English practice yield 11,483 cases, and
247 cases of version, or about 1 in 247 ;  French practice, 40,376 cases, and
451 cases of version, or about 1 in 89^; and German practice, 393,823 cases,
and 3393 cases  of version, or 1 in 116.  The  whole  number  of  cases  is
505,691, and of version 4133, or about 1  in 122^.
  520. It is not so easy to make  out a satisfactory table showing the danger
of the operation to the mother and child, from the want of details.   Many
writers do not mention whether any of the mothers died, and some omit the
result as regards the child.
  In the following table, I have taken all the numbers upon which  I could
depend,  and  though  the  list is  not  extensive, I believe that the  average
mortality will be found pretty correct.
Authors.	Numher of Version Cases.	Mother lost.	Children lost.
Mad. Lachapelle ....	155	Not stated.	45
	218	Not stated.	48
	48	6	35
	33	3	13
	5	0	2
	3	0	0
	6	1	6
	11	0	8
Drs. M'Clintock and Hardy .	23	1	5
Professor Andr6e ....	5	0	3
	7	1	3
	6	0	2
	1	0	0
	26	0	10
	18	0	7
	44	3	14
	183	14 '	93
	2473	176	1431
  Thus, in 2939 cases, where the result to the mother is specially mentioned,
212 mothers died, or nearly  1 in 14.
  I do not give this result as the exact mortality of the operation, because
it is evident that the deaths in many cases must have been owing to the cause
which demanded the operation, as in  placenta praevia; but as we find that
even in several of these cases the fatal termination was  evidently more owing
to the operation than to the hemorrhage, I am inclined to think  the calcu-
lation not very far from the  truth.   However, any erroneous inference  from
these statistics will be guarded against by the recollection of the various and
serious accidents which require  the operation.
  In 3347 cases, where the result to the  child  is detailed, 1472  children
were lost, or rather more than 1 in 3.
  To a certain extent the same observations apply to this calculation of the
mortality amongst the infants, and similar allowance must be made.
  521. The object of the operation is threefold :—
  1. To  place the head in a more favorable relation to the pelvis, or to sub-
stitute the head for some other  presentation.
  2. To substitute the inferior extremities for some other less favorable
presentation.
  3. To hasten the termination of labor, in  consequence of complications,
as convulsions, flooding, prolapse of the funis, etc.
  It has been proposed to turn and deliver instantly, in case  of the sudden 
VERSION,  OR TURNING.
313
death of the  mother, instead of having recourse to the Caesarian section :
but the mortality amongst children so delivered would preclude this appli-
cation  of the operation.
  There is so much  difference in the means by which the  first and  second
objects are attained,  that it is necessary to say a few words upon each.
  522.  1.  Version by the head, or cephalic version, as it is termed, consists
(a) in  clearing the upper outlet of any part which may hinder the descent of
the head ;  {b) in seizing the  head, and  bringing it down to the brim of the
pelvis; (c) or in rectifying the  mal-position of the head.
  As the majority of children enter the  world head foremost, this mode was
decided to be the standard  of natural  presentation at a very  early  period,
and attempts were  made to correct any deviations.  Rhodion,  Raynalde,
etc., endeavored to change footling into head presentations, but not by in-
ternal  manoeuvre.   After the discovery by  Amb. Pare,  Guillemeau,  and
others, of the ease with which  labor could be terminated by bringing down
the feet, cephalic version went  very much out  of fashion.  By the great
bulk of recent writers (especially in our own  country) it is either not  men-
tioned at all, or with reprobation.  Still  there are cases in which its suita-
bility could not be  overlooked, and in consequence we find an admission
here and there of its utility.  Smellie recommends it in certain mal-positions
of the  head; Mauriceau advises it if the neck present;  and  De la Motte,
Melli,  and Roux speak of success obtained in this manner.   Le Roi preferred
it generally to version by the feet.
   These, however, were only exceptions to the rule : it remained for Flam-
mant,  professor  at Strasburg, to recall the attention of the profession to the
operation,  in such a  way as to procure its  readmission (at  least on the Con-
tinent) into the  number of valuable obstetric  operations.  His example has
been  followed by several German and  French  writers.   Labbe, Eckhardt,
and Wigand, published  successful  cases in  1803;  Schnaubert  in 1815;
D'Outrepont  and Regnaud  in 1825.  Busch gave an  account, in 1826, of
fifteen cases, in  which fourteen infants were  born  living.   In  1827 Ritgen
collected forty-five successful cases.  Riecke has had sixteen cases.   It has
been eulogized by MM. Vallee, De Roche, TJbersaal, Stoltz, and Toussaint.
Joerg and some others advise the head  to be  seized and placed  in  position
when  nearest the cervix, and  Gardien  seems  inclined  to recommend it
strongly, " if practitioners were  only as well versed in the  use of the forceps
as the professor of Strasburg."
   One of the few British writers who speak well of it, is the late distin-
guished professor at Glasgow, Dr. Burns, who says : " For  instance, if the
patient be  known usually to  have a short labor,  if the pains be brisk, the os
uteri dilated, or in a relaxed and easily dilatable  state, the liquor amnii re-
tained, and the  head movable, then the head may, without any difficulty or
much  irritation, be placed in the proper position, with a fair and reasonable
chance of success."   I  may also cite the testimony  of  Dr.  Dewees,  who
acknowledges that  "should nothing but the position of the  head, with a
slightly diminished capacity in the antero-posterior diameter, affect the labor,
we may sometimes enable the woman to deliver herself, provided the waters
have  discharged themselves, by  the aid of two  or three fingers within the
vagina, and  applied to the  side of the head, so  as  to carry the vertex to-
wards one of the acetabula;" — "when thus placed,  we may commit the
termination to the natural efforts, provided no other circumstance complicates
the labor."
   523  It  is stated as an objection to the employment of this kind of mani-
pulation, that it is more difficult to catch firm hold of the head and to bring
it to the upper outlet;  that  if  we succeed in bringing it to the brim we  can
do  no  more,  but must then leave it to nature, or use the forceps.  To these 
314
VERSION, OR TURNING.
and similar objections, Yelpeau  has returned the following  answer:  " 1st,
It is not always very difficult to  seize the head, and to exert considerable
force upon it; 2dly, if the waters have not been  long discharged, one may
often  without difficulty seize the vertex, and  bring  it to the centre of the
brim,  however far  it may have  been distant; 3dly, that in general it  is
better to force the head to descend, by pushing up the presenting part, than
by bringing down the head ;  4thly, that delivering by the breech is far from
being a simple and safe operation ; as regards the  child, it is  less so than
cephalic version, even if the forceps should afterwards be applied."
  No one can for a moment deny that there  is considerable Aveight in the
objections I have named; but a more detailed investigation will show that
they are valid only  against an indiscriminate  employment of the operation,
and not against its  use in  the cases  to which it ought to be confined.  These
cases  may be  divided into two  classes:  1, where the pelvis is  of sufficient
size, and nothing but the mal-position of the child's head  calls for  inter-
ference ; 2, in certain mal-presentations, such as  the neck or shoulder, and
perhaps in a few arm cases, if the uterus be  not strongly contracted, and
especially if the waters have not escaped.   It is evidently not calculated for
any case where prompt delivery is necessary.
  Its advantages are found to be, —first, a greater facility in reaching the
head, for it  is not proposed to be used in cases where the feet are near the
os uteri;  and secondly, a vast saving of infantile life.   This operation will
be no more fatal to the child than natural labor, if performed early, whereas
in footling cases and in version by the feet, more than one in three are lost.
  [In a prize  essay on " Difficult Labors and  their Treatment," Professor M.
B. Wright, of Cincinnati,  states  that he  has  succeeded  in effecting cephalic
version  in cases of shoulder presentation, etc., even where  turning by the
feet  was impracticable.   He attributes  his  success  mainly to  his  manner
of proceeding, which is certainly one of the best that  has  been yet suggested.
It consists in  returning the  arm of the  child, should it be  prolapsed, and
placing it as nearly as possible  in its original position across the breast,
when the operator is to apply his fingers to  the  top of the shoulder, with
the thumb in  the axilla or on such part  as will give him command of the
chest and enable him to apply  a degree of lateral  force.   Whilst  the left
hand is applied to the abdomen  of the mother over the breech of the fcetus,
with the right, lateral pressure is to be  made upon the shoulder in such a
way as  to give to the body of the fcetus a curvilinear movement.   The left
hand at the same  time makes  pressure with  the view of dislodging, as it
were, the breech, and moving  it towards the centre of the uterine cavity.
The body is thus  made to assume its original bent position, the points  of
contact with the uterus are loosened, and perhaps diminished, and the force
of adhesion  is in a  great degree  overcome.  Without any direct  action upon
the head, it  gradually approaches the superior strait, falls into the  opening,
and will, in  all probability, adjust itself  in a favorable vertex presentation.
If not,  the head may be acted on as in deviated positions of the vertex,  or
it may be grasped, brought into the strait, and placed in correspondence with
one of the oblique  diameters.]
  524.  2.  Turning by the feet, or  podalic version. — This was known  to
the ancients, but confined by most  of them  to the  case of dead children.
To Ambrose Pare, we  are indebted for  demonstrating its facility and com-
parative safety, and  for inculcating in practice.   His distinguished  pupil,
Gillemeau, followed in his footsteps, to be himself succeeded by others  of
brilliant talent and profound research, who  cleared  up the difficulties, and
settled the limits, and laid down the rules for the operation.
  The peculiar advantages of version by the feet are : —
  1. That it gives  to the  operator the entire control over the whole process 
VERSION, OR  TURNING.
315
of the labor, so that he can regulate its duration, either acting with, or inde-
pendent of, the pains.
  2. That though inferior in  its results to labor 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 —
  1. From the distance the hand has to traverse, and the difficulty of seizing
the feet and of turning the child in utero, there must ever  be a fearful risk
of injury  to the mother.
  2. The mortality  amongst the infants thus brought into the world is very
great; as far as our statistics extend, they yield 1472 out of 3347 delivered,
or more than  1 in 3.
  525.  From all that I have said,  it  will not be difficult to specify the cases
to which the operation is applicable.
  1. It may be  used in all cases of mal-presentation, whether of the supe-
rior extremities or trunk.
  2. If,  upon the introduction of the hand for  cephalic version, it be found
impossible to rectify the mal-position of the head, we are advised to seek for
the feet, and bring them down.
  3. In all cases of placenta prosvia, many cases of ruptured uterus, convul-
sions, prolapsed funis, etc., the operation is available, and has been used
with great success.
   4.  Dr. Simpson has  revived the recommendation of Exton, Pugh, Ould,
and Burton, to substitute turning, in  certain cases of distortion of the pelvis,
for craniotomy, on the grounds  that  the  base  of the skull being  narrower
than the  inter-parietal diameter, and  the head more compressible under trac-
tile than  expulsive efforts, the child might be delivered, and perhaps saved
by a less  severe operation.  And further, that as turning might be attempted
at  an earlier period than is  usual for craniotomy  in such cases, we might
thereby afford the niother greater security of a favorable result to  herself.
And he has supported his views by statistics taken from Dr. Collins's work,
but without sufficient care and caution, as it appears to me.
   Now let us examine into the practical application of his proposal.  The
bi-mastoid diameter in the six cases of measurement he gives, varied from
2|  in. to  3|  in.; and  a living child can pass through a pelvis  of 3£ in.
antero-posterior diameter with or without  the forceps.  With a pelvis of this
size the operation is then unnecessary, and if the antero-posterior diameter
of  the  pelvis  be less than 2f- in. the  operation  would be  impracticable.
Then these are the limits of the operation  : for  us to attempt to drag a child
through a smaller space would be unjustifiable.   For the success of the ope-
ration, then, we must be able to ascertain that  the pelvis is within these
limits, and perhaps in some few cases, with whose former labors we are accu-
rately acquainted, we may do  this, but  in an immense majority of cases  it
will be, I think, impossible; and it happens, as Dr. Collins has shown, that
the greater number  of cases of difficult labor he met with were first cases, in
which, of course, no such  precise  judgment could  be  attained.   It  is only
fair, however, to state that, by putting the  patient under the influence of
chloroform, and introducing the hand into  the vagina, Dr. Simpson has an
opportunity of estimating the diameter  of the brim more accurately than by
any of the ordinary modes of measurement.
   Again, the  life of the child is not secured  and  its chance but  little in-
creased, even if our estimate of the pelvic diameters  be accurate;  for if in
turning with  an ordinary-sized  pelvis,  rather  more than one-third of the 
316
VERSION, OR TURNING.
children are'lost, the mortality will be surely much increased if its diameter
be reduced more than one-fourth.
  Moreover, if we should miscalculate the size of the pelvis, or if the head
should be a  trifle larger  than  usual, so far from the safety of the mother
being increased, it  would be very seriously diminished ; for we  must then
craniotomize the child after incurring the hazard of turning, and in a most
unfavorable position.
  Lastly,  even if we  succeed in selecting a suitable case and  in  extracting
the child,  it has yet to be proved that the mother would not incur consider-
able danger from contusion or  laceration  in forcibly dragging the child
through a narrow pelvis; for I  must remind  my readers  that we  have no
statistics of the proposed operation to compare with those of the old method,
the few cases adduced by Dr. Simpson being of no value for this purpose.
  I must therefore object to the  general adoption of Dr. Simpson's plan, for
the reasons above stated : the difficulty of ascertaining the  exact diameters
of the pelvis, the very little benefit to the child, the great risk to the mother
of doubling the operation.  At  the same time I do not mean to deny that
there are  some cases in which  it may be worth trying, as  every successful
case is a rescue of a life from destruction.   So far  as it is applicable, it is
one mode of limiting the operation of craniotomy, an object we must all have
at heart.   Iu these conclusions  I am very glad to  adduce the concurrence
of Dr. Radford, whose papers  are no doubt familiar to my readers  in  the
pages of the Provincial Medical and Surgical Journal.
   526. The next point  for our investigation is the period most suitable  for
making the  attempt;  so as not to interfere rashly on the  one hand, nor to
delay too  long on the other, " neque  temere  nee 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
mal-position,  it is clear that the operation can  only be safely, if at all  per-
formed, before the uterine efforts have wedged the head into the upper  strait;
the attempt should be made so soon  as it is  evident that the natural powers
will not rectify the mal-position.  It will be an additional motive for prompt
assistance, if we find the pains violent, and that the  patient have had many
children, lest the head,  not being able to enter the brim, should be  turned
aside, and forced through the uterine or vaginal parietes.
   2. (a) If we are called to an arm presentation, or any demanding podalic
version, before the escape of the liquor  amnii, and we find  the os uteri hard
and undilatable, it will be advisable  to wait until some change takes place,
before we introduce the hand ;   neither  is there any risk worth mentioning,
provided  we remain with  the patient, to operate instantly when the waters
break.
   {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 advantage in
operating while the uterus is distended.   If we act  as soon as the os uteri
will admit the hand, it  is the better time, because we then  turn the child as
if in a bag  of water;  and this  gives us so clear an  advantage that it needs
no explanation.
   (c)  If  the os uteri be dilatable, the sooner the attempt is made  after the
escape of the waters the better.   Gardien says that the most favorable mo-
ment is just when the waters break.
   {d) After the escape of the waters, we sometimes find the os uteri  neither
rigid nor much dilated, and the pains moderate.   In such cases, no time
should be lost; the hand should be introduced into the vagina,  and gentle,
yet firm and persevering, efforts made to pass it into the uterus.  Dr. Blun-
dell says: " In ordinary cases,  if the mouth of the womb be as broad as a 
VERSION, OR TURNING.                   317
    crown piece, and if the softer parts be relaxed thoroughly, the introduction
    of the hand is not exposed to greater risks than usual, there seems to be no
    circumstances preclusive of the  operation, and the sooner you commence the
    better. •
      (e) So far, although these cases are each more serious than the other, yet
    in none  of  them has any very great difficulty, either of decision or of execu-
    tion, been experienced.  We are, however, often called to a  class  of cases
    where our utmost judgment, patience, and skill will be  needed.   I  refer to
    those cases of arm presentation, where, in the language  of Foster, "the
    membranes have been a long time ruptured, the waters totally evacuated, and
    the womb  closely contracted around the fcetus, which is then  thrust con-
    siderably into the  pelvis, the parts of the woman being dry,  hot, tender, and
    often in a state  of inflammation  and tumefaction, especially when  unskilful
    endeavors  have been  used to  extract  or turn  the  fcetus, or to dilate  the
    parts."
       In such a case, to force the hand through the  os uteri would be to rupture
    that organ, and cause the death of the woman.  It is admitted by all authors,
    I believe, that the operation must be postponed for a time,  an,d means tried
    to soften the uterus and suspend  its contractions.  For this  purpose all are
    agreed in the propriety of taking sixteen or eighteen ounces  of blood from
    the arm, and  following up this with a large  dose  (gtt. lxxx. to gtt. c.) of
    laudanum.   Dr. Collins has proposed another  remedy of great value.   He
    says :  " In such a situation, where the  individual  is strong and plethoric,
    twelve or fourteen ounces of blood  should  be  taken from  the arm, and a
    tablespoonful of the following  mixture  given every half hour, which I have
    found exceedingly useful, both iu  quieting uterine  action,  and in  inducing
    relaxation:—
                          R  Aquas  fontis,  |vj.
                             Antim. tartar, gr.  iv.
                             Aceti opii, gtt. xxx.  M."

       By these means, after the lapse of a short time, we  shall find the uterus
    relax, and the os uteri soften,  so that with a little  patience, gentleness,  and
    time, we may attain our object.  It is very probable, though I cannot speak
    from personal experience, that the full  exhibition of chloroform will render
*   the introduction of the hand under such circumstances much more easy, as
    it surely renders the operation painless.
       3.  When the case is one of placenta prcevia  or even of accidental hemor-
    rhage (if it demand delivery),  it  is a general rule to operate as  soon  as pos-
    sible.   The os uteri seldom offers any resistance, when the loss  of blood has
    been great;  and as this loss is necessarily increased by the natural efforts in
    unavoidable  flooding, it is evident that  the earlier we deliver, the better for
    the  patient.
       If we decide upon trying this  operation in convulsions, prolapsed funis,
    or ruptured uterus, it will be  wise to attempt it as soon as the state of the
    os uteri will  permit.
       527. Method of operating.—This operation is usually divided into three
    stages :  the  introduction, the  turning, and  the extraction.   I shall shortly
    describe these, in each kind of version.
       1. Cephalic Version, — The rectum and bladder having been previously
    emptied, the  patient is to be placed in the posture  most convenient to the
    operator ; some reconfmend that she should lie on  her back, others that she
    should  kneel, or lie on her left side, as in ordinary labor.  The latter posi-
    tion is generally adopted in this country.  Whichever hand we choose to
    operate with is to be well oiled or soaped, and  then insinuated through the
    os externum edgeways.   Mr. Roberton recommends that the vagina should 
318
VERSION, OR TURNING.
be filled with lard previously, and that the left hand  should be used.1  Aa
most men are right-handed, I think the greater facility in  using  that hand
will counterbalance any supposed inconveniences.   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 head is in
the vagina, it will be necessary to change its direction from that of the axis
of the lower outlet to that of the upper outlet.  This 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 aceta-
bula—i. e., in the first or second position.    If our object be to change the
presentation—for example, to substitute the head for a shoulder—we must
gently push up the  shoulder, and then  seizing the head,  bring it down to
the brim, and place it in the most favorable relation  to  the pelvis ; and it
might facilitate the operation if  the patient were  placed on her hands  and
knees.
   Having now done all that we can by the hand alone, it may be withdrawn,
and the  further progress of the  labor left to the efforts of nature; should
these be found inadequate, recourse must be had to the forceps.
   528. This is the ordinary method of placing the head in position for de-
scending ; but Wigand has stated that it is possible, before the waters have
escaped, to  change the position of the head, or even the presentation, by
external abdominal manipulations.  Yelpeau confirms this  from his own ex-
perience, and something similar is stated by Sennert and Martins.   Riecke
has also related several such cases, and Meissner four quite recently.   Dr.
Burns, in a  note to his ninth edition,  states that: " Mr. Buchanan, of Hull,
informs me that he succeeded in one instance lately, ' where the left side of
the breast of the fcetus lay diagonally over the pelvis, with the head  for-
ward,' in bringing the head right, by making the  patient kneel and raise
the  breech, whilst the shoulders  were  brought as low as possible.  The
water had not been  discharged.   The situation of the head, when it came
down, was made more favorable by the finger.  The child  was alive."        %
   A  very interesting memoir has been published by Professor Martin, of
Jena, on turning  by external  manipulation alone, founded on thirty-four
cases, seven of which occurred to himself.   The conditions which render the
operation eligible are — 1. The non-necessity for immediate  delivery; 2.
Mobility of the child, which generally ceases after  the  discharge of the
waters; 3.  Absence of great sensibility of the womb or abdomen; 4. Suf-
ficient capacity of pelvis,  but a moderate  contraction is no counter-indica-
tion ;  5. A normal activity of pains; 6.  The child being alive  is a subor-
dinate condition.   The mode of operating is as follows : — As long as the
os is undilated and the pains irregular, the patient  is kept upon  the  side
upon which the part desired to be forced  into the  pelvis is placed.   When
the os is dilated, and the waters are  expected to escape, the bladder  and
rectum having been  emptied, she is laid on her back,  the lower part  of the
body  being  somewhat raised.   With  one hand  (warm),  continuous  and
moderate pressure, downwards, is made on that part.of the fcetus which lies
nearest the  os, whilst the rest of the  body is pressed  upwards.  This simul-
taneous pressure  is  begun during the  interval of  a  pain, and continued
during its commencement,  while during  the height of this the uterus is

               1 Phys. and Dis. of Women and  Midwifery,  p. 328. 
VERSION, OR TURNING.
319
firmly supported on every side.   After  a short  pause the manipulation is
again commenced;  and if the operator's hands  become tired, an  assistant
may support the belly on each side while he rests.   If the pains  are long
absent the patient may be placed on her side, the projecting part being sup-
ported by a band or cushion, and this position should be  maintained when
the head has entered the pelvis.   When the manipulations have succeeded,
and the head or breech is within the os uteri, the membranes should be rup-
tured,, to secure from further change.  The pressure  may  be sometimes dif-
fused, sometimes special, by the points of the fingers ; and it should  always
be double and simultaneous : downwards of the  part we wish to engage in
the pelvis, and  upwards towards the fundus of the rest;  and  for this pur-
pose an accurate recognition of the parts of the child is indispensable.1   It
appears that this operation has the support of  M. Ritgen's authority,  and
Dr. Spingler has recorded a case in which he succeeded.2
  529. 2. Podalic Version.—I shall not repeat  what I have said  as to the
mode of  introducing the hand through the os externum and os uteri.  The
hand and arm of the infant will be our guide ;  for it is better not to attempt
to put it back,  much less to separate it,  "after the manner of the ancients."

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

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

               1 Edinburgh  Med. and Surg. Journal, vol  xiv. p.  29.
       21 
322
VERSION, OR  TURNING.
operations ?  There is,—and this practice consists in never Winging down
more than one foot in the manual operation of turning a child."
  The following measurements were obtained from children born at the full
period of utero-gestation ; —
The circumference of that  portion of the head which
  presents in labor, is from.....12 to 13£ inches.
Do.  of the breech, with the thighs flexed upon the abdo-
  men, as in breech presentations, from     .     .     .   12 to 13^   "
Do.  of the breech, with one thigh turned upwards to-
  wards the abdomen, the other extended, from   .     .   11 to 12^   "
Do.  of the hips, the legs  extended as in  feet presenta-
  tions, from........10 to 11^   "
  It is evident from these measurements, that it will be safer for the child to
bring down only one foot, for inasmuch as the breech with the thigh  turned
up is more bulky than  the hip with the legs  extended, by so much will the
passage be better prepared  to  admit  the  quick transit of the  child's head,
upon which the safety of the infant depends.
  Dr. Simpson recommends seizing one knee, and that the  opposite to the
upper extremity which presents, i. e., if the right arm present, the left knee
is to be brought down.
  533.  From what has been stated, it will  appear that the difficulties of the
operation are almost entirely owing to the uterus being  in  action.  When
it is quiescent, or nearly so, the  operation is easy; but when the contrac-
tions are violent, it is  often tedious, difficult, and very painful, both for the
patient and  operator.  These contractions equally impede the introduction
of the hand, the finding of the  feet, and the turning of the child.  Once so
much is accomplished, they become of valuable  assistance in completing the
delivery.
  534.  The danger to the  mother may arise — 1.  From the  operator not
changing the direction of  his hand, in accordance with the pelvic axes, and
consequently pushing his fingers through the  vagina.
  2. The hand may be forced through the walls of the uterus, if too much
force be used in  searching for the feet.
  3. The uterus may bruise itself against the hand, or the  limbs  of the
fcetus,  during the turning.
  4. Rupture of the cervix uteri may occur, either during the introduction
of the hand or  the  extraction of the child,  especially, if the  operation  be
hurried or too much force be used.
  5. Without any evident injury, the irritation of the operation may give
rise  to subsequent inflammation.
  6. The nervous shock may be serious, or even fatal.
  The simple enumeration of these dangers  ought, one would think, to  go
far  towards obviating most of them.
  535.  The danger to the child consists— 1.  In compression of the funis,
which commences about the  time the buttocks appear at the os externum.
After this time, if there be much delay, the child will perish from the inter-
rupted circulation, unless by chance the funis should have lodged in the angle
at the junction of the os sacrum with the os ilium.  To obviate this danger,
it was proposed by Pugh  to introduce a pipe into the child's mouth, and
excite respiration, while the head was yet in the vagina.  Bigelow and  Bau-
delocque are said to have employed this in practice.
  2. If much extracting force be used, the spine may be dislocated ; the hips
also; and the leg has been pulled off.
  3. Compression of the head  is enumerated by Dewees as one of the dan-
gers to which the fcetus is exposed. 
THE VECTIS,  OR  LEVER.
323
  536. It only remains for me now to say a word as to the after treatment
The  patient will probably need an  anodyne after  the  operation, and it is
good practice to join  a few grains of calomel with the opium or Dover's
powder; or a mixture  containing sixty drops of landanum, two drachms of
sal volatile in six  ounces of camphor mixture, may be ordered, of which a
table-spoonful may be taken every two or three hours.  It will be necessary
to exercise great watchfulness to detect the first  inroads of inflammatory
action, which must be met  by antiphlogistics, according to 'the strength of
the patient, and the violence of the attack.
   Careful inquiry should be made as to the character of the lochial discharge
each day, and if necessary the vagina be syringed with warm water.
   The most absolute  quiet and rest are desirable.   If the  infant be  alive,
the mother should not be teased with it for some hours.
                        CHAPTER XI.

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

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

             Fig. 112.                                   Fig. 113.
         Roonhuysen's Veptis.                             Modern Vectis.

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

           1 Records of Obstetric Consultation Practice, etc., p. 63, et seq. 
328                  THE VECTIS,  OR  LEVER.

vectis — viz., the secrecy with which it  may be used.   Now this I consider
a decided disadvantage.  I most fully agree with the opinion of Dr. Osborn,
and shall make no apology for transcribing it at length, as it  applies forci-
bly to all midwifery operations : " In the  first place I am persuaded, that
if concealment in the use of the means intended for relief in laborious or dif-
ficult  labors be not permitted, but that the  absolute necessity  of such means
be  first established, and that every practitioner be  obliged openly  and
avowedly to use  them, we should  never again hear or read of one  person
having  used the vectis  in 800  and another in 1200 cases (Yan  Swieten,
Camper, and Herbiniaux).   Nor shall  we  again hear of the great number
of women which  some practitioners are constantly boasting  of having de-
livered ; for no man can attend  a great number of  women in labor, in the
manner he ought, in the way nature demands, or a conscientious discharge
of his duty requires.  Nor do real difficulties occur so often as to render it
possible to believe that any man's life could afford such numbers of difficult
cases  as are  stated in  the  printed  accounts  from  abroad.  As  I  feel
thoroughly  convinced of the propriety and necessity of  a fair and  candid
avowal  of the use of instruments, in every case of midwifery where they are
to be  employed, so I must insist that their concealment cannot be justified
by any proper motive.   Such an open avowal  implies a conviction  in the
practitioner's mind of that irresistible necessity for their use that supersedes
every other consideration : it implies  a consciousness of the rectitude of his
conduct, and  it implies  a voluntary acceptance of the consequences of the
operation, which ought to make  part of his professional duty :  and it  clearly
demonstrates  to  the satisfaction of the patient and her  friends, that no
motive of convenience to himself could urge him to  an operation which may
prove ruinous to his  own reputation and  interest.   Besides, not  to insist
upon  that  responsibility from the operator, is to deprive the patient of the
best and surest security against  a precipitate performance  of the operation.
If once the practitioner can rest assured that,  let the event  of the case be
ever so unsuccessful, the injurious effects of his operation will be buried in
eternal  oblivion,  by blending the mischief arising from the  indiscreet use of
instruments with the  natural  consequences of labor, he will  certainly have
nothing to weigh against the tempting advantages of convenience or emolu-
ment  to himself;  but while he is shortening the duration of the most irksome
part of his  professional duty, the waiting upon a slow and lingering labor,
he will  flatter himself that, by delivering, he is doing an acceptable  service
to his patient, in shortening the duration of her sufferings."1
   547. Method of operating.—Premising then that the case is one adapted
for the vectis, that there is space enough, that the os uteri is  fully dilatable,
if not dilated, that there are pains,  and  that the  patient and her friends have
been  made acquainted with our intention, it next remains for us to consider
the method of using the instrument: —
   lstly. As a lever, and,
   2dly. As a tractor.
   1.  As a lever. — The first point  to be decided is, over what part  the in-
strument is  to be applied; and here we have latitude enough.
   " Some," says Dr'. Gooch,  " apply it over the occiput; others behind the
ear, by which it has a bearing against the  prominence of the mastoid  pro-
cess,  and others against  the chin.   The two first are perhaps the best when
the head is high, as considerable force  is required to move it, which  may
 be employed with more safety against either the occiput or mastoid  process
 than  against the chin.  But when the head is low down, resting on the peri-
1 Essays on Midwifery, p. 144. 
THE VECTIS,  OR  LEVER.
829
neum,  less force will  be necessary, and the vectis  may  then  be applied
against the chin ; but  the  instrument  requires to be used with  great cau-
tion, lest the jaw should be injured."   De Bruyn applied it over the mastoid
process; Camper over the lower jaw;  Lowder on the forehead,  etc.,  etc.
  I have already pointed out the temptation to make the soft parts  of the
mother the fulcrum, and the mischiefs which result.  As far as my judgment
extends, it would seem that the vectis  ought never to be  used as a lever of
the first class ;  even as one of the second class, much caution will be  neces-
sary.   "When an instrument of this sort is used, it  is proper to make the
hand the fulcrum on which it acts:  now if the force required is  but  small,
this may certainly do well enough, but where  great force is required,  this is
a very bad support; besides, the bony parts of the pelvis lie so  convenient,
that we may rest our  instrument on any part of it.   Yet we should  recol-
lect, that whatever part we convert into a fulcrum, we injure more or less,
according to circumstances.   If we apply it  over the symphysis pubis, we
press upon the urethra; or if in other situations, we  shall injure  the clitoris
or vagina."1
   "The injuries inflicted,  indeed," Dr. Ramsbotham observes, "must have
been frequent and great — and this led Peu, in 1772, to  suggest the  possi-
bility of delivering by the  vectis, without making a fulcrum of the mother's
structures.  He proposed  a practice,  which is  now sometimes adopted, of
grasping the shank of the  instrument with the left hand—the outer edge of
the little  finger being applied towards  the vulva — making that hand the
fulcrum, and pressing the  extremity of the blade on the child's head, by
raising the handle firmly on the right."2

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

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

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

          OBSTETRIC OPERATIONS. —4. THE FORCEPS.

   550.  It will be at once admitted, I  believe, that the greatest triumph of
surgery is to diminish  the  frequency of operations, and to substitute those
of rniuor severity and danger for others involving more serious risk.  If this
be true, then it must be granted that the  invention of the forceps,  and their
employment  in practice, is one of the greatest improvements recorded in
the annals of operative midwifery.  Before the introduction of this instru-
ment, the only extracting  force at command was obtained by the insertion
of a hook into the head of the child;  such as is now used in the operation
of craniotomy.
   This  proceeding must of course have been fatal to the child in an immense
majority of cases,  and the very few who  were born alive, must have  been
subsequently endangered by the mutilating process employed in  the delivery.
But this was not all;  every man  possessing common feelings  of  humanity
must have shrunk from the painful necessity of such a proceeding,  and have
deferred the operation  as long as possible, by which the  danger to the
mother  was  greatly increased.   Now, from  this  double risk and fearful
mortality we have been relieved by the invention of the forceps ;  for although
we are still obliged to  destroy  the child occasionally, to secure the  safety of
the mother, yet this class of cases is incomparably smaller.than that in which,
by the timely application  of the forceps,  both the  child and  mother escape
injury.
  For these reasons, I conceive that I am justified in  stating  that the in-
vention  and employment of this instrument is  one of the greatest improve-
ments that has ever occurred in  midwifery, even though I may not go the
length of certain  of its advocates, in  asserting that it is entirely without
danger to the mother or her  infant.
  551.  It cannot be said that the  ancients were altogether ignorant of this 
332
THE forceps.
method of extracting the infant, although  it does not appear to have been
generally known.   Mulder, in his valuable  work, gives the following extract
from a translation of the works of  Avicenna: " Oportet ut inveniat obste-
trix possibilitatem hujusmodi fcetus, quare  subtilietur  in  extractione ejus
paulatim; tunc si valet illud in eo,  bene est; et si  non  liget cum cum mar-
gine panni et trahat cum subtilitur valde  cum quibusdam attractionibus.
Quod si  illud non confert administrentur forcipes, et attrahatur cum  eis;
si vero non confert illud extrahatur cum incisione, secundum quod facile fit,
et regatur regimine  fcetus mortui."   This  very distinct  allusion to the for-
ceps seems to have made no impression, for we find  no similar attempt  to
extract the child until the  middle of the sixteenth  century; at which time
(1554) Rueff recommended  an  instrument  resembling a pair of  lithotomy
forceps, for the purpose of extracting dead children, or of supplying a de-
ficiency of manual force.   It does not appear, however,  that he appreciated
the value of the forceps as subsequently employed, nor did his contempo-
raries carry out his suggestion, for it was not until a century later that the
instrument was brought into practice.  Before the time of the  Chamber-
lens, it was unknown in England, and even at the time that Dr. Hugh  Cham-
berlen  published his translation  of  Mauriceau, in 1672,  it was still a  secret.
No allusion to such an  instrument is to be found in Raynalde's work (1634),
nor in the translations of Portal (1705), Deventer (1716), or LaMotte (1745).
  552. In his preface to the translation of Mauriceau,  to which I have re-
ferred, Dr. Hugh Chamberlen, after  mentioning the  method of extracting
the child by hooks, observed : "But I can neither approve of that practice,
nor of those  delays, beyond twenty-four hours, because my father, brother,
and myself (though none  else in Europe, as I know) have, by God's bless-
ing, and  our industry,  attained  to,  and long  practised a  way to  deliver
women in this case without any prejudice to them or their infants ; though all
others  (being  obliged, for want of  such an expedient, to use the common
way) do and  must endanger, if  not destroy, one or both, with  hooks.   By
this manual operation, a labor may be despatched (in  the  least  difficulty)
with fewer pains and sooner, to the  great  advantage and without danger,
both of woman and child ; if, therefore, the use of hooks by physicians and
chirurgeons be condemned (without thereto necessitated  through some mon-
strous  birth), we can much less approve of a midwife using them, as some
here in England boast they do, which rash presumption in France would
call them in question for their lives."
  This extract, however, does not  fix the date of the invention by Dr.
Chamberlen, nor have we  any very accurate data  for doing so.  Through
the kindness of a friend, I possess a pamphlet (A Yoice 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 fami-
liar to  us.
  From some vagueness of expression in the  extract I have quoted from
Dr. Hugh Chamberlen's preface, it  was even doubted whether the  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  Chamber-
len's own instruments.   " The estate of  Woodman Mortimer Hall, near
Maldon, in Essex, was  purchased by Dr. Peter Chamberlen, some time pre-
vious to 1683, and continued in his family  till about 1715, when it was  sold
by Hope Chamberlen to William Alexander, wine-merchant, etc."   In an
old chest,  found in one  of the chambers of this house, certain obstetric in-
struments were discovered, along with "old coins, trinkets, gloves, fans, 
THE  FORCEPS.                        333
spectacles," etc., and were presented to Mr. Cansardine, who thus describes
them :  " First, we have a simple vectis, with an  open fenestrum; then we
have the idea of uniting two of these instruments by a joint, which  makes
each blade seem as a fulcrum to the other, instead of making a fulcrum of
the soft  parts  of  the mother ;  and which also unites a power of drawing
the head  forward.   This idea  is at  first by a pivot, which being riveted,
makes  the instrument totally incapable of application.  Then he goes to
work again, and having  made a notch in  each vectis for the joint, he fixes >
a pivot in one only, which projecting, is to be received into a corresponding
hole in the other blade, after they have been applied  separately.  It may
be observed, that although there is a/worm to a projecting part of the pivot,
yet there is no corresponding female  screw in the hole which is  to receive
it.  Every practical accoucheur will know, that it  is not easy,  or always
possible, to lock the joint of the forceps with such accuracy as to bring this
pivot and  hole into opposite contact.  This Chamberlen  soon discovered,
and next produced a more light and manageable  instrument, which instead
of uniting by a pivot, he passes a tape through the two holes, and winds it
round  the joint, which method combines  sufficient accuracy of contact, se-
curity, and mobility."1
   There can now  be no doubt of the credit of the invention being due  to
Dr. Paul Chamberlen, and I have proved  that it took place before the year
1647.   The  secret was, however, carefully preserved, nor had it been com-
municated in the year 1716, for in Dr. Hugh Chamberlen's third edition of
Mauriceau, published in that year, the passage I have quoted is continued
in the  preface.
   ["The accompanying cut is taken from a drawing of the most perfect of
Chamberlen's instruments.  No. 1 is the  forceps locked :  a, the  blades;  b,
the handles ; c, the hole in  the joint,  through which is passed the string  to
connect the blades.
   " No. 2, the front view of a single blade : a, the fenestra ; b, the groove
in the  shanks forming the lock, by which the  two blades, perfectly similar
in form, are adapted to each other; c, the handle.
Fig. 115.
Chamberlen's Forceps.
  "The following are the dimensions:  extreme length, eleven inches and a
half- length of blades, seven inches and a quarter; of handle, four inches

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

               Fig. 116.                            Fig. 117.
                                               Long Forceps.

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

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

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

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

             1 American Journal of Med. Science, July, 1850, p. 70.
 
THE  FORCEPS.
337
Schmidt, Stark,  Siebold, Briinninghausen, Naegele, Osiander, etc. ;  and in
Italy, the forceps of Levret or Assilini are employed.
  Since the first edition  of this work, I  have taken some pains  to  modify
the shape and proportions  of  the short forceps, and from the testimony of
many practitioners, I think I  may say that I have  succeeded  in  improving
the instrument,  although the  alterations  are but slight (fig.  119).   I  still
prefer the single curved forceps.  The length should be 12 inches, of which
the handles occupy 4.   The interval between the points of the blades when
closed should be 1 inch, and at the  widest part of the curve 3 inches.   T'ne
breadth of each blade at the widest part should be  1 inch, the fenestrum 2-j
or 3 inches long, having the  lower part of the blade solid steel,  to give
greater  firmness.  The curve of the instrument should not commence  for
fully 3^ inches above the handle, and will consequently be much increased
towards the point.   Lastly, the edges of the blades and fenestra must be
nicely bevelled off.   The advantages  I have found  from these changes are
an increase of tractile power,  without the necessity of grasping the handles
so tightly, and compressing the head  ; the exact fitting  of the head into the
hollow formed by the curves, so as  to avoid distending the perineum by a
part of  the instrument not actually of use, and the  prevention of springing
and slipping by  the solidity of the  lower  part of the blades.
  The hand that is to use  the instrument is, however, of more importance
than the instrument itself, of which it maybe observed with truth,  that "that
which is best administered  is best."
  555.  The object of the operation with  the forceps is,
  1.  To facilitate  delivery, when its  progress is arrested by certain mal-
positions of the head, at the brim,  or in the cavity of the pelvis.
  2.  To supply the want of uterine action, or to render it effective  for the
expulsion of the child.
  3.  To save the mother from the evil  consequences  of a labor too pro-
longed, and from the necessity of a severer operation.
  4.  To save  the life of the child,  or at  least  afford it a chance of escape
from certain destruction.
  That these objects are attainable will, I trust, appear from the nature of
the aid afforded by the forceps,  and that they have been  in many instances
attained, the statistics of the  operation  will prove.  It was  not for some
time after the invention of the instrument that its powers, and  the limita-
tions of  those powers, were understood.   The story of Chamberlen's Paris
adventure  is a good illustration.   He visited Paris, and  offered to  deliver
any patient the  faculty chose,  with  his instrument;  they gave him a  case of
distorted pelvis  ; he tried,  and of course failed, and left the city in disgrace.
Had he carefully studied the cases  to which the instrument was  applicable,
he would have been spared the annoyance.
  It is evident that the forceps possesses a  twofold power.
  1.  That of  grasping and compressing the head of the child.
  2*  That of  acting as a lever of the first kind, and as an extractor.
  The compression0exercised  by it must be limited within the degree the
head  can bear without injury,  and may be limited by the form of  the instru-
ment   The extracting force  will be  in  proportion to  the firmness  of the
jrrasp 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 sufficient to injure the
mother • thus the forces may  supply the want of uterine pains.
  Many cases occur in  which  the transverse diameter of the child's  head is
dio-htlv greater  than the antero-posterior diameter of the brim, or the trans-
       22 
338
THE  FORCEPS.
verse diameter of the lower outlet; but where a slight additional compres-
sion would enable it to pass : now, if this do not exceed  the  amount  of
compression which  the  head will safely bear, and if the force required for
extraction be not sufficient to injure the mother, such compression and ex-
tracting power may  be  afforded by the forceps, which will thus  render the
uterine action effective.  No doubt it requires great  tact and long  expe-
rience to decide  upon the probability of success, but we have high authority
for the propriety of  the attempt in such cases.   To those who  lack  expe-
rience, the failure of a  very cautious effort will  be a sufficient evidence  of
its impracticability,  and with ordinary care no mischief will be done.
  Lastly, in most cases where  the  head is not impacted, a sufficient grasp
may almost always be obtained, either at the upper outlet or in the cavity,
to enable us to change the position  of the child.
  556. Statistics.  — I trust I have made it appear, from the nature  of the
aid afforded, that the first and second objects of the  operation are attain-
able; how far this is the case with  the third and  fourth must be shown by
statistics.  But before I give the results of the operation to the mother and
child, it may be well to ascertain the average frequency of its  occurrence.
For  these purposes, I have searched all the records within my reach, and
the result is the following Tables : —
FREQUENCY OF  THE  OPERATION.

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

b.  Among French and Italian Practitioners.
339
Bate.	Authors.	Total No. of Cases.	No. of Forceps Cases.	i References. |
1797 to 1809	Mad. Boivin .	20.517	96	— - ---- ■ 1 Memorial, p. 387. j
1803 to 1811	Mad. Lachapelle .	22,243	174	Pract. des Accouch.
1808	M. Ramboux .	216	2	Velpeau.
1815 to 1828	M. Pigeotte de Troyes .	1,362	2	<i
1819	M. Papavoine .	24	1	•'
1829	Hotel Dieu, Paris .	280	1	t<
1830, 1831	Sig. Ciniselli .	94	1	u
1834 to 1843	Dr. dejBelli . . .	2,739	62	Ranking, vol. 4, p. 184.
c Among German Practitioners.				
i Date.	Authors.	Total No. of Cases.	No. of Forceps Cases.	■ References.
1801 to 1807	M. Ritcher, Moscow	3,195	49	Velpeau.
1811 to 1827	f Moschner and Kursak, "1 \ Prague . . J	12,329	120	Siebold's Jour., vol. 9
	M. Boer, Vienna	29,961	119	Arneth, p. 134.
	M. Klein ....	35,417	730	Ibid., p. 135.
	M. Bartsch . .	4,425	61	Ibid.
	Prof. Schwerer	21,804	194	Ranking, vol. 5.
1812 to 1813	C. v. Siebold, Wurtzburg.	318	26	Siebold's J]., vol. 1 to 3.
1817 to 1826	" Berlin	1,634	212	Ibid., vols. 3 to 8.
1827 to 1829	E. v. Siebold, Berlin	491	77	Ibid., vols. 9 to 11.
1829 to 1833	" Marburg .	344	34	Ibid., vols. 10 to 13.
1834 to 1837	" Gottingen .	507	37	Ibid., vols. 15 and 16.
1825 to 1827	Dr. Kilian, Prague .	2,350	120	Velpeau.
1808 to 1814	Dr. Henne, Copenhagen .	555	1	Siebold's Journal, vol. 2.
1826	a tt	130	4	Ibid., vol. 8.
1821 to 1825	Dr. Riecke	219,303	344	Velpeau.
1819, 1820	Dr. Ritgen, Giesen .	180	20	Siebold's Journal, vol. 6.
1825	Dr. Merrem, Cologne	142	5	Ibid., vol. 7.
1814 to 1827	Dr. Carus, Dresden .	2,908	184	Ibid., vol. 9.
	Dr. Naegele, Heidelberg.	1,411	22	Velpeau.
1825, 26, 27,	Dr. Kluge, Berlin .	809	,55	Siebold's Jour.vols. 7.8,9.
1825, 1826	Prof. Andr6e, Breslau	351	8	Ibid., vols. 7, 8.
1825, 26, 27,	Dr. Brunatti, Dantzic	284	22	Ibid., vols. 7, 9.
1825, 1826	Dr. Theys, Trier	49	3	Ibid., vols 7, 8.
1826	Dr. Voigtel, Magdeberg..	29	3	Ibid., vol. 8. i
1827, 1828	Dr. Kiistner, Breslau	370	8	Ibid., vols. 9, 10.
1830, 31, 32,	Dr. Adelmann, Fulda	170	7	Ibid., vol. 14.
1797 to 1837	Dr. Jansen, Ghent .	13,365	341	Med. Gazette, March 6, 1840. Schmidt's Jahr-biicher.
1847 to 1849	Dr. Arneth, Vienna .	6,608	45	Die Geburtsh. Praxis, p. 92.
1821 to 1842	Dr. Ricker, Nassau .	304,150	4223	Med. Times and Gazette, Oct. 11, 1856.
  Thus among British practitioners  we find 594 forceps cases in  147,645
cases of labor, or about 1 in 249.
  Amono* the French, we have 339 forceps  cases in 47,475 labor cases, or
about 1 in 140.
  And among the Germans,  7074  forceps cases  in  755,593 labor cases, or
about 1 in 106^. 
340
THE  FORCEPS.
  If we add the whole together, we find 8007 forceps cases in 850,713 cases
of labor,  or about 1 in 106^.
RESULTS OF THE OPERATION TO MOTHER AND  CHILD.
Authors.
Dr. Smellie
Mr. Perfect
Dr. Jos. Clarke .
Dr. Merriman
Dr. Granville
Dr. Ramsbotham
Edinburgh Lying-in Hospital
Dr. Maunsell
Dr. Beatty, sen .
Dr. Gooch ....
Dr. Ashwell
Mr. Warrington .
Dr. R. Lee .
Dr. Collins ....
Dr. Thos. Beatty
Dr. Churchill  .
Drs. Hardy and M'Clintock
Dr. F. Ramsbotham .
Dr. Murphy
Dr. Pagan ....
Dr. Roberton
Dr. Storer ....
Mr. J. Thompson
Drs. Johnston and Sinclair
Mad. Boivin
Mad. Lachapelle
Dr. Boer   ....
Dr. Siebold.   .   .
Dr. Ritgen ....
Dr. Andree....
Dr. Brunatti
Dr. Voigtel....
Dr. Kiistner
Dr.  Adelmann .
Prof. Schwerer .
Dr. Arneth ....
Dr.  Ricker ....
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.
140	4	a
15	Not stated.	5
4	0	1
111	0	0
6	1	0
6	Not stated.	3
1	0	0
42	3	31
24	4	8
8	0	5
9	0	0
18	5	8
73	3	17
4	0	1
82	9	19
43	0	7
8	0	3
46	0	0
200	11	29
96	Not stated.	20
79	14	23
19	• 2	5
312	11	47
20	3	4
8	1	4
23	1	6
3	0	0
8	2	1
7	1	1
194	7	48
45	7	14
4223	93	684
  Now if we add together the number of forceps cases where  the result to
the mothers is stated, we shall find, that of those detailed  by British prac-
titioners, of  812 forceps cases, 38 mothers were lost, or 1 in 21|.
  Amongst the  French and Germans, in 4941 cases, 142 mothers were lost,
or about 1 in 34.
  Whilst of  the children, the British statistics give 142 lost in 694 cases, or
about 1 in 5 ; and foreign statistics 858 in 5037 cases, or about 1 in 5|.
  The total  result is, that in  5753 forceps cases, 180  mothers were lost, or
about 1 in 32;  and  in 5731 cases,  998 children were born dead, or about 1
in 5.
  To those who, like myself,  regard the wider employment  of the forceps as
the best mode  of diminishing  the  frequency of the employment of crani-
otomy, it is a matter of rejoicing  to  find this instrument  increasingly em-
ployed, and that with each enlargement of our statistics, the death-rate for
mother and child has diminished. 
THE  FORCEPS.
341
  I am unable to explain the greater proportional frequency of operations
in some of the German  reports, except by supposing that their hospitals,
being on a small scale, are reserved for the worst cases met with in extern
practice among the poor.  Were I quite  sure of this being  the case, how-
ever, I should have omitted them  from Table I., as they would  then  mani-
festly be an unfair record of the proportional frequency of the operation.
  It would be unjust to compare the frequency of forceps cases  among the
Germans and British, without recollecting the minor  degree of  mortality
amongst the children in the practice of the former,  and the very much
smaller number of crotchet cases.   It would seem, that although the Ger-
mans use the forceps much more frequently than we do, they often thereby
avoid a much more fatal operation.
  The rate of mortality exhibited by the last Table is undoubtedly an over-
estimate, as many of the* deaths included in it were unconnected 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.
  If it were possible  to collect a sufficient number of cases from private
practice, I have no doubt that our estimate of the value of the forceps would
be  at once truer and much more favorable.  For example, Dr. Beatty's cases
in the foregoing table occurred chiefly in private or consultation  practice,
and we find that in 111  cases he lost neither mother nor child.
   Mr. Crosse used the  forceps in 23 cases; the  mothers all recovered:  7
children were still-born,  and  3 died soon after birth.
   I can add to these 65 operations either in consultation or in my private
practice ;  out of these 2 mothers died subsequently of puerperal fever, which
was epidemic at the  time ; in both the  operation was extremely easy and
quick.  All the children were saved but  six : of these  one was putrid, one
had the funis prolapsed, one  occurred in a case of convulsions, two breathed
but soon sank, and one  was dead-born.
   It-is greatly to be regretted, that the statistics of the result of the opera-
tion to the mother and child are  so limited.   Many writers who have care-
fully recorded the number of operations, have very carefully omitted to sta,te
whether the mother  recovered, or the child was  saved, leaving us to make
the inference that both  were saved.  But we know that such an inference
would be incorrect.  Can any one believe, that whilst British practitioners
lose one woman in twenty-one, Mad. Boivin and  M. Baudelocque lost none
at  all ?  I  have, therefore, omitted or marked in the latter Table, all tho.se
who have neglected to state  the results.
   [In a very elaborate  paper on  "the more frequent use of the Forceps  as
a means of lessening  both maternal and foetal mortality, by Mr.  Philip II.
Harper, read before the Obstetrical Society of London, June 1st, 1859, the
author has endeavored  to show,  and we think that  he has succeeded in  so
doing, that there is no especial maternal risk  which necessarily attaches  to
the use of the forceps, and that the various injuries and other ill effects which
are usually attributed to them, are not the result of their use, but of their
abuse.  That when maternal death occurs after their use, it  is generally the
result of  the length  of time the  labor has lasted before their application.
That so long as they are applied as the last resort in tedious labors, so long
will the maternal mortality  after their  use appear to  be very high.   The
author of  the  paper shows from the only statistics which furnish  the neces-
sary data, that one mother in twenty-two, and one child in five died in cases
of  unassisted tedious labor, whilst one  mother in fifty-six and one child.in
8 4 died  where the forceps  were used, and  one mother in  ten died after
craniotomy.  Showing  that the maternal risk is less  after the  use  of the
forceps than after craniotomy or even'unassisted tedious labor. 
342
THE  FORCEPS.
  The author endeavors also to prove that we may safely avail ourselves of
the power of these  instruments as compressors within certain limits, if they
are used early and properly applied.   That there are a large number of
tedious labors, from abnormal or diseased action of the uterus itself, where
they are  most valuable, and where they ought to be most freely used, and
that the period for  their use is early in labor, as soon indeed as the os per-
mits, and long before the maternal system has begun to suffer, either locally
or generally.1]
   557. If  we fail  in our endeavors  to extract the infant with the forceps,
we have no resource but to employ the perforator and crotchet; and, there-
fore, in estimating  the utility of the forceps, we  must also compare it with
its alternative operation, inasmuch as every successful  case  of the former
may be considered  as so much gained from the latter.
   Now, in craniotomy all the children are destroyed, and one in five  of the
mothers is lost; whereas we have seen, that by the forceps we save four out
of five of the children, and twenty out of twenty-one of the  mothers.  If we
had more  minute  reports,  the success would  undoubtedly appear much
greater.
   558. The special advantages of the forceps are said to be :
   1.  That they are easily applied.
   2.  That their powers are calculated to attain the object for which they
are used.
   3.  That they do this by imitating the natural powers.
   4.  That they aid the expulsive efforts of the uterus better than any other
instrument, and supply their place, which no other instrument can.
   5.  That they are less liable to slip than the vectis.
   6.  That they are attended with less fatal consequences than the perforator
and crotchet.
   On the other hand, those writers who have defended the use of the vectis,
as  compared with the forceps, have enumerated several disadvantages of the
latter — such as,
   559. 1.  The  difficulty of their application in all  cases, and in  some, the
impossibility of using them, owing to the position of the head  or want of
space.
   That the  introduction of two blades may be  more difficult than that of
one, in certain cases, is very evident, but that there is much greater difficulty
in  introducing  the forceps than the vectis,  in the majority of cases proper
for its use, I do not believe.   The latter part of the objection is of no force,
because those cases where the' introduction  of the instrument is impractica-
ble are not cases in which its employment is contemplated, and, undoubtedly,
if the impaction were so great as to prevent  the application of the forceps, it
would more surely  render the vectis impotent.
   2.  The risk of bruising the os uteri in the application of the forceps.
   I do not think  that there  is much risk,  if  the operator be a  competent
person.   Dilatation or dilatability of the os uteri being an essential condi-
tion of the operation, the supposition would involve great  want of skill and
care  in the operator.
   3.  That when the forceps are applied, they are  apt to slip and lose their
hold.
   This may sometimes happen, but it is much more likely to occur with the
vectis.
   4.  That the pressure upon the child's head may destroy life.
   No doubt; but as the pressure is regulated by the resistance,  this ought
never to happen, except in cases in which  the  crochet must otherwise  be
used, and in which the vectis  would be powerless.
    1 [See Transactions of the Obstetrical Society of London, vol. i., 1860, p. 142.] 
THE  FORCEPS.
343
  5. That by adding to the volume of the head, they are apt to lacerate the
perineum.
  That the compression exercised upon the head of the child is amply suffi-
cient to compensate for the additional bulk of the blades, there can be no
doubt, even in  those  cases  where the extraction is most easy;  but we have
an additional safeguard in the removal of one of the blades just before the
head passes over the perineum.
  6. That as they can never be used secretly, they have a tendency to alarm
and intimidate the patient, and in this respect are inferior to the vectis.
  When speaking of the vectis,  I mention its secret employment among its
disadvantages ;  and I now quote this objection, for the purpose of entering
once  more my earnest protest against the employment of  any instrument
secretly.
  [The forceps and vectis  are calculated for different cases.  Under some
circumstances one,  and under some the  other is to be preferred.   When the
object is merely to  change the position  of the head, to facilitate its rotation,
or to apply a very  moderate degree of extractive  force, the veCtis answers
very well; but whenever much traction is necessary, or the head is high up
in the pelvis, it is nearly useless.]
  560. Having now given  the history  of the operation, stated its objects,
and shown that they are attainable, from the nature of the aid afforded, and
from numerical calculation  ; and, having enumerated  the positive and com-
parative advantages of tne  operation, with the objections that have at differ-
ent times been made  to the use  of the instrument, I shall next proceed to
mention the cases to which the forceps has been considered applicable.   I
would wish, however,  that  it should  be remembered, that'as I am not writ-
ing the history of my own  experience only, but that of others, so I am not
to  be considered as necessarily the advocate of the forceps in all these cases.
I have selected them  from  authors of  the  highest authority, and their evi-
dence is altogether independent  of support from me.
   I must also premise, that in no cases  is the forceps for, indeed, any in-
strument) to be applied,  until we are perfectly satisfied that the obstacle
cannot be overcome by the natural powers, with safety to the mother and
child.  This limits the operation in one direction : the other limit is deter-
mined by the  impossibility of  extracting  the child without laceration  or
serious contusion of the soft parts in the pelvis, as this would involve great
injury and peril to the mother without saving the child, as the compression
involved  would almost certainly  destroy it.  As a general rule, if  the child
be  dead, craniotomy is preferable to the forceps.
   1. When the head is unable  to enter the brim of the pelvis from mal
position (suppose with its long diameter corresponding to the antero-posterior
diameter of the upper outlet), which is not rectified  by the pains, the long
forceps may be applied to change the position, provided the os uteri be fully
dilatable, and that the change cannot be made by the hand alone. _
   2. When the head is in the upper outlet, fitting closely,  but not impacted,
 and the pains are  inadequate to overcome  the  resistance, a little help with
the forceps, applied laterally or  obliquely, will often overcome the difficulty
   3. When the head, presenting at the brim, is somewhat too large for the
antero-posterior diameter of the pelvis, if the excess be not more than may
be remedied by the allowable  degree of compression, the  operation may be
successful.   It will require some experience to ascertain this, before a trial,
and great skill and care in making the  trial, but as the alternative is turning
or  the crotchet, it is surely worth while to make a cautious attempt with the
forceps, from which no harm need result in case of failure.
   In all these  cases it will  be necessary to use the long forceps ;  in the fol-
lowing the shorter are sufficient, but, of course, either may be employed. 
344
THE  FORCEPS.
   4. When the head is in the cavity of the pelvis, and is there detained by
want of space, if the compression required for its extraction be not greater
than the head of the child will bear with safety, and the violence to the soft
parts of the mother in extraction be not  such as necessarily to injure her,
the forceps may  be  safely used, either laterally,  obliquely, or antero-poste-
riorly.   Siebold is said to have been able to reduce the transverse  diameter
of the head of the child six lines with Levret's forceps ; Osiander, nearly an
inch ; Baudelocque, four and a half lines ;  Thouret and Yelpeau, five or six
lines ; and Flamant, five and a half lines.  Of course  the amount will be in
inverse proportion to the degree of ossification.
   5. In face  presentations, the longest diameters of the child's head are
brought to bear upon the pelvis, adding greatly to the  difficulty of its transit
through the lower outlet, even when the pelvis is large,  and still more if it
be under the average dimensions.   In such cases, aid may often  be  given by
the forceps, so as to save the child's life, and  to mitigate the suffering and
its  consequences  to the mother.   It is not, however, to be assumed,  that
because the child descends faceling, assistance will be necessary; the majo-
rity are delivered by the natural efforts.
   6. The  same observations apply to certain, though more rare  cases,  when
the forehead is turned towards the symphysis pubis.
   7. But  the utility of the  forceps is seen more clearly in  those  cases in
which the  pains,  at first very strong, have gradually  declined so as to be
nearly or altogether powerless,  but not from the resistance occasioned by a
narrow pelvis.  There may be sufficient space, the os uteri and external  parts
well dilated, and yet the labor does not advance.  In such a case, the second
stage cannot  be  very  much prolonged without certain  symptoms arising,
indicative of danger to the mother; and  here we are able to relieve her
without difficulty  or risk, and to save the child (if it be alive) by the timely
use of the forceps.  In such cases (and every one must have  met with them)
I think I may say, that the operation adds absolutely nothing to the danger
either to mother or child.
   8. When the hand or arm descends with  the head, the additional bulk will
require more expulsive  force, and occasionally, aid must be afforded by the
forceps.
  9. In some cases of convulsions, hemorrhage, and rupture of the uterus,
where the head is within reach, the forceps  are  found extremely useful in
expediting the delivery.
   10. In certain  cases of breech  presentation, it is very difficult to extract
the head after the body is  expelled, either from  mal-position, or from the
incompressibility of the base of the  skull; in  these cases the difficulty may
be removed or overcome by the forceps.
  11. The forceps may be used after vaginal hysterotomy or symphyseotomv.
   12. In prolapse of the funis, when it is  an object  to hasten the  labor, in
order to save  the child.  The pulsation of the cord will  show whether the
operation  affords  a chance.
  561.  These are, I believe, all the cases  in which  the  forceps have  been
used or recommended  by high  authority ;  to  complete the  subject, I may
mention certain cases in which they ought not  to be employed.
  1. In distortion of the pelvis, or when its calibre is  diminished from any
cause, such as tumors, exostosis, etc., if the narrowing of the pelvis be too
great to admit of* the  passage of the  child's head,  when moderately com-
pressed ; these cases can only be terminated  by the  perforator, or hyste-
rotomy.
  2. When  the os uteri is rigid  and undilatable, or when the passages are
much inflamed and swollen, the forceps ought  not to be used.
  3. In some cases, where the  patient has been  mismanaged, and  allowed 
THE  FORCEPS.                        345
to remain too long, the system is in such a state that we are obliged to have
recourse to the most expeditious mode of delivery.   In these cases, if there
be a strong doubt of success with the forceps, it  may be wiser to  have re-
course to the perforator, more especially as, in such cases, the child is gene-
rally dead.  But such  cases could  scarcely happen  under the care of a well-
educated practitioner,  nor are they at all frequent.
  4. If the child be dead, we are  advised to prefer craniotomy.  If we are
quite certain that the  child is dead, the principal  objection against crani-
otomy is^ removed, and the operation is easier and safer than  the  forceps;
but this is not always  easy to determine.   The stethoscope is a most valu-
able source of information ; but it must be remembered, that while  its posi-
tive evidence is unquestionable, the  negative  evidence (i. e., no  sign being
audible) is not equally conclusive.   Dr. Collins, whose experience has been
very extensive, remarks:  "I know of no case where the advantage derived
from the use of the stethoscope is more fully demonstrated than in the infor-
mation it enables us to arrive  at, with  regard to the  life  or death  of the
fcetus,  in the progress  of tedious and difficult labors."
  562.  We next come to consider the period for operating.   "It is one of
the nicest  points in practice, correctly to decide, whether any given case of
protracted labor may be trusted with safety to the further exertions  of the
natural agents, or whether the means of art ought to be  promptly brought
to their assistance.  In determining this important question,  the whole'of
the symptoms are to be collectively and severally considered, and their differ-
ent tendencies accurately examined, that we may equally escape the  impu-
tation  of  haste  and indiscretion on the one  hand,  and of delay and inde-
cision  on  the  other;  yet, let us ever bear in mind, that more  injury may
possibly accrue from too long delay, than arise from premature assistance."1
  The decision of this point must, in a great  measure, be left to the judg-
ment and experience of the practitioner.   No very definite  rule can be laid
down : we find both individuals and nations differing upon the subject;  the
Germans operate more frequently,  and at an earlier period than the British,
but on the other hand, they have fewer crotchet cases.  And I think it must
be admitted that until lately we have been too much afraid of the forceps,
and have  allowed  cases to become the subjects of craniotomy, which, at an
earlier period,  might have been safely delivered by the forceps.
  In forming our decision, there are several points  for consideration:
  1. The local circumstances of the case,  such as the position of the head,
space  in  the  pelvis,  complications,  etc.; these  constitute the principal
grounds of necessity for the operation, and have been enumerated.
  2. The general condition of the patient, and the presence or absence of
the symptoms  of a prolonged second  stage; if  present, their  amount,
urgency, rapidity of development, etc.
  Our great object in the  use of the forceps is to anticipate these formidable
symptoms, and to rescue the patient from the danger.   I think, then, that
as regards the mother  we  may conclude :
  1. That as these formidable  symptoms  are not  consequent upon a pro-
longed first stage,'therefore, before  the completion of the  first  stage of a
labor, that is, before the  os uteri is perfectly dilated, and  the membranes
broken, the use of the forceps cannot properly come into contemplation.
But I  would remark,  that  when the obstacle is  at the upper outlet, the
second stage virtually  commences  when the os uteri is fully dilatable,  as the
head cannot pass through it,  and the usual symptoms may arise if the labor
be sufficiently prolonged.
  2. That when the second stage has lasted so long as to  prove  the inade
1 Ramsbotham's Practical Observations on Midwifery, vol. i. p. 256. 
346
THE FORCEPS.
quacy of the natural powers, or at all events, so soon as the symptoms of a
prolonged second  Stage  make  their appearance  (quick pulse, dry tongue,
fever, etc.),  then we ought promptly to  interfere.   "A practical rule has
been formed, that the head of the child shall  have rested for  six hours as
low as the  perineum, that is,  in a  situation which  would allow of  their
application before the forceps  are applied, though the pains  should  have
altogether ceased during  that time."  The  symptoms, however, are  a surer
guide than the duration of the  labor merely;  some patients will show more
signs of suffering after six hours, than others  after twelve or sixteen.   Dr.
Collins observes : " Let it be carefully recollected, at  the same time,  that so
long as the head advances ever so slowly, the patient's pulse continues good,
the abdomen free from pain on pressure, and no obstruction to the removal
of the urine, interference should not be attempted, unless the child be dead."
With great  respect, I think this rule  defective : to a certain extent it  is true,
but it is not the whole truth, for there are  many cases which continue  exactly
in this state  until powerless labor sets in, and in  which, from the character
of the labor, it  may be certainly foreseen that these  symptoms  will arise,
and that the woman  will not previously deliver herself.   In all such  cases I
would maintain that the forceps should be used so  soon as we  feel justified
in coming to that conclusion.
   3. The life of the  child is a very important element for our consideration.
After the second stage has lasted a certain time, there is considerable  risk
to the child, and it may even die before the symptoms on the part of the
mother become very  formidable, though this is not generally the case.  This
condition may sometimes  be detected by the" stethoscope, the  action of the
heart becoming feeble and irregular.  In such a case, if no counter-indication
existed, it would be  our bounden duty to interfere for the purpose of saving
the child's life, provided the operation were  practicable.
                                Fig. 120.
Operation with Long Forceps.
  563. Method of operating.—When once we have determined upon the
propriety of operating, the operation itself is not very difficult; it requires 
THE  FORCEPS.
347
a thorough tactile knowledge of the pelvis, some manual dexterity, and
steadiness.  I shall first describe the application of the long forceps at tli3
brim, and then (the long or short forceps) in the cavity of the pelvis.
  I.  The long forceps.—These may be applied  either in the transverse,
oblique, or antero-posterior diameter of the pelvis.  If our object be com-
pression or a change of the  position, the antero-posterior diameter (fig.
120)  will be  the best;  but if necessary they may  be applied  in the trans-
verse, or still better in the oblique, diameter (fig. 121) of the brim.   In this
position, as there is more space, their application is more easy; but it must
be remembered, that in proportion to the  grasp we take of the head in its
longitudinal  diameter,  we diminish that diameter, but  increase the trans-
verse, and so may add to the  difficulty of the descent of the head.   There-
fore,  only sufficient force should be used to enable us to extract.   " When
about to apply the long forceps,  it is  to  be remembered that the  difficulty
exists at the  brim of  the pelvis, that the antero-posterior diameter, or that
from  the symphysis pubis to the  promontory of the sacrum, is diminished ;
in the application of  the instruments, therefore, care should be taken that
they be placed over the  head, in  such  a situation that they may occupy the
most  roomy  part  of  the pelvis,  which will be  its  lateral  diameter.  Iu a
natural presentation and situation, one blade of the instrument will conse-
quently be placed over the  forehead, the  other over the  occiput."1   Dr.
Simpson considers the  oblique diameter as the best, and  indeed  the  only
proper situation in which to apply the long forceps, at the brim,2 as in  the
accompanying plate.   (Fig.  121.)

                                 Fig. 121.
Operation with Long Forceps.
  The patient is to be placed on her left side (or on her back), close to the
edge  of the  bed; the forceps, warmed  and oiled, are to be within reach,

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

                                 Fig. 122.
Operation with Short Forceps.
applied we shall be quite as able to extract, but we must bear in mind the
observation made when speaking of the  long forceps, that  pressure in the
long diameter of the child's head increases its lateral or transverse diameter,
and so far augments the difficulty of its extraction.
  The bladder and rectum should be evacuated before the attempt is made,
and  the forceps warmed and  oiled, as already mentioned.  The patient  is
then to be placed near the edge of the bed, and after a careful examination, 
THE FORCEPS.
349
our decision formed as to the part to which the  instrument is to be applied.
One or two fingers  are then to be  introduced  into the vagina, during an
interval of pain, to guide the forceps and protect the soft parts.
   We must always be careful that " the point of the  instrument  be con-
stantly kept in contact with the head;  to effect which,  it 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."1
   The forceps must be introduced at first in the axis of the lower outlet, but
this  direction  must  be almost  immediately changed into that of the upper
outlet, or there will be danger  of wounding the posterior wall of the vagina,
The upper or anterior blade should be introduced first, and then  the lower
or posterior one.   When both  are  applied, they ought  to be opposite, and
if so, will easily lock; but if, on endeavoring to lock  the forceps, it should
be found that they do not  readily come together, they have not  been pro-
perly introduced : no force or violence  should be used to bring them toge-
ther, but the second  blade should be  withdrawn, and introduced afresh.
Great care must also be taken that the soft  parts,  or hair, are  not included
in the lock, as this 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, how-
ever, the head fit  tightly, and  more compression than merely  that which is
sufficient for extraction be  necessary, it will be useless ; the operator must
then regulate the  compression  with  his hand, and extract at the same  time.
" When the forceps are first locked, they are placed far backward, with the
lock close to, or just within, the internal surface of the perineum ; and they
can have no support backwards  except the very little which is afforded by
the soft parts.   The  first  action with them should therefore be made by
bringing the handles, grasped firmly in one or both hands,  to prevent the
instrument from  playing  upon  the  head of the child, slowly towards the
pubes, till  they come to a  full  rest.   Having waited  a  short  interval with
them in this situation, the handles must  be carried back in the  same slow
but  steady manner to the  perineum,  exerting, as they are carried in the
different directions, a certain degree of extracting  force ; and after waiting
another interval, they are again to be raised towards  the  pubes, according
to the situation of the handles."2  We must remember "that the force em-
ployed in extracting the  head be always  and steadily from  blade to blade,
but with intervals  resembling the labor pains, and constantly in the direction
of the axis of the  pelvis, till the occiput begins to emerge  from  under the
arch of the pubis, when the handles are  to be raised over the symphysis
pubis with the right hand,  while the left is  applied to strengthen and pre-
serve the perineum."3   I believe that the facility of extraction depends very
much in drawing the head  well down in the axis of the  lower outlet, in the
first  instance, and  then carrying it well  forward  under the pubic  arch, and
this, whether the forceps be  applied laterally or obliquely. The whole power
or force 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 tryiug a moderate degree  of force.
increasing it slowly and deliberately, according to the exigence  of each case
  When we thus employ the power we possess  gradually, steadily, at inter-
vals, and in the direction of the axes of the pelvis,  we must not  forget the
danger (in  some cases  at  least) from pressure or contusion.   Our guide in
   1  Osborn, Essays  on Parturition, p. 99.        2 Denman's Introduction, p. 281.
   * Osborn, Essays  on Parturition, p. 100. 
350
THE  FORCEPS.
this matter is the pulse, which rapidly rises  if injury be inflicted.   " If the
pulse be 120 or 130 before you commence operations, it  is clear that you
cannot, from counting the  beats, take an intimation whether the soft parts
have or have not sustained injury ;  but if, before the forceps be applied, the
pulse is under 100 in the minute, then should contusion be produced by your
efforts with the instrument, the rise of the pulse  will indicate  it.   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 com-
pletely round the  circle.   If you  find it below  100, no  serious  injury has
been  inflicted ; if  the  frequency is increasing, although it does not neces-
sarily follow that serious injury  has been inflicted, yet  the existence of con-
tusion becomes probable, and further  efforts must not be made without much
consideration."1
   When our efforts have been  so far successful, that  the  occiput emerges
from the lower outlet, if  there be pains, it is better to remove one blade (the
posterior one, when they are applied antero-posteriorly) of the forceps,  to
lessen the risk of laceration, and the perineum  should be carefully supported
by an assistant,  whilst the  operator uses the other blade as a tractor, if ne-
cessary.   If the head be high up in the pelvis, we must take care that the
usual half-turn be made as it descends, so as to  bring the face into the hollow
of the sacrum.
   In breech cases, when the head is detained, the operation is not very dif-
ferent ; the blades are to be passed up antero-posteriorly, or laterally, and
locked across the chin, or back of the head, and the extracting force applied,
gently, firmly, and at  intervals, not forgetting the  natural  turns, so as  to
bring the  face into the hollow of the  sacrum, if possible.
   565.  Difficulties. — " The  difficulty of applying  the forceps,"  says Dr.
Denman, "is most frequently occasioned by attempting to apply them too
soon:  or  passing  them  in  a  wrong  direction ;  or  by entangling the soft
parts of the mother between the instrument and the head of the child, against
all which accidents we are to be on our guard."
   1. The first  difficulty  we meet with is in  the  introduction of the blades.
There may not be space  enough, and if  we  find  this to be the case,  after a
fair and careful trial, we are not to persist at the risk of injury to the mother,
but craniotomy must be performed.
   When the head is pressed down  against the tuberosities of the  ischia,
there will  often be difficulty in passing the blades between them; and if th«
head cannot be raised up during an interval  of pain, the  forceps had bettei
be applied antero-posteriorly, or both blades being introduced posteriorly,
we may gradually slip  them to either  side.   I do not speak of the difficulty
of applying the forceps  when the  os uteri is rigid, because it should never
be attempted.
   2. As I have  already mentioned, there may be some difficulty in locking
the blades, and then  one of them must be withdrawn and reintroduced.   It
is  quite possible to deliver the child without  locking the blades, but there is
more chance of injury, and  the instrument is more apt to slip.
   3. The  extraction may be difficult, or even impossible.   The great value
of experience in such cases is, that it teaches us  how far we may carry our
efforts without injury.   Perhaps a little  more  compression, or a little more
force, may crown our efforts with  success, provided  that  it did not  exceed
safe limits.  But great care and caution will  be necessary, and if we find
our efforts fruitless after a fair trial, we shall then be justified in having re-
course to the perforator, nor will the patient  be the worse for the  failure
with the forceps, if the attempt have  been judiciously made.

            1 Blundell's Principles and Practice of Obstetricy, p. 505. 
THE FORCEPS.
351
   566.  The principal dangers to the mother are :
   1.  In the introduction of the blades, if it  be not effected in the axis  of
the upper  outlet, the vaginal parietes may be  lacerated, and if the cervix
uteri be not guarded by the hand, the blade  may be  pushed through it, or
it may be included between the end of the blade and the child's head.  Cases
of mal-practice illustrative of these dangers might  easily be quoted, but it
is sufficient for my purpose to allude to them as a caution.
   2. The soft parts'in the pelvis may be bruised or lacerated in the extraction.
   3.  The perineum may be lacerated.
   The dangers to the child arise :                  '
   1.  From want of care  in introducing the blades, by which the scalp may
be bruised or torn, or an ear cut off.
   2.  From excessive compression, by which  the  skull may be indented, the
bones fractured, or death  from pressure induced.
   Dr. Blundell has given a distressing  picture of the accidents which may
result from an  incautious  or maladroit use of the forceps.
   " The grand error you  are  apt to commit in  using  the  long forceps, is
force.  In violent hands, the long forceps is a tremendous instrument; force
kills the child, force bruises  the softer parts, force  occasions mortification,
force breaks open the neck of the bladder, force crushes the nerves ; beware
of force, therefore, arte non vi.   Other errors, too,  there are, against which
I beseech you to guard.   You may use the forceps without heed ; you may
try to use  it when the parts are rigid, and the  os uteri not fully expanded ;
you may attempt to apply it without knowing the position of the head ; you
may  oscillate  the instrument too extensively from side to side ;  you may
draw without intermission, instead of imitating  the  pains ;  you may close
the handles too forcibly by the  hand or ligature ; you may hurry the head
through the outlet;  you may neglect to throw the face towards the  sacrum ;
you may forget the  perineum ;  you  may fail to conduct the  head, when it
emerges, towards the abdomen and mons, by drawing it too much upon  the
perineum."
   567.  After-treatment. —The first symptom which will require our  atten-
tion, is the shock caused  by the operation.  If it  be great, a combination
of opium with ammonia 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.
   568.  It  is right here to notice some instruments which have been proposed
as substitutes for the forceps.   1.  Dr. Conquest  many years ago proposed
one, consisting of a loop  of thin whalebone,  fastened into a wooden handle.
The loop is easily introduced, and placed over the occiput or chin, and  he
supposes that sufficient extracting force may then  be exerted.   When placed
over the chin, it may, perhaps;  but on trial,  I found that  over the occiput
it had no purchase, but slipped immediately.
   2.  Dr. Simpson has invented a "sucker-tractor," consisting of a cup  of
vulcanized India-rubber, which is to be applied over the child's head, or a
portion of it, and to which is  attached a syringe,  for  exhausting  the air.
He has succeeded several  times, without injury to the child, but as yet  he
does not consider the instrument complete.  No doubt enormous force may
be exerted by it, and if it do  not  injure the  child,  it is certainly very safe
for the mother.
   3. Dr. Evans, of Chicago, TJ. S., has contrived an instrument consisting
of a band, with network and strings, which is to surround the forehead, and 
352
THE  FORCEPS.
embrace the head firmly, so as to allow of tractile force  being exerted.  It
is applied by two steel rods (something in the way that the ligature is  car-
ried around  a polypus by Gooch's canula),  which are  afterwards joined
together.1
  It is an ingenious instrument, but whether likely to supersede the forceps
in any case, I cannot tell.
  [Although  Dr.  Churchill avows his preference for "the long  or short
fo'rceps  with the single  curve," etc., he appears in reality not to  be at all
tenacious  on the subject of its  construction.   "The hand," he  remarks,
" that is to use the instrument  is of more  importance than the instrument
itself, of which it may be observed with truth, that 'that which is best ad-
ministered  is best.'"   In this  expression, we believe  that he inculcates a
serious error.
  A prudent and well-qualified  operator, it is true, may not do harm with
a bad instrument, but, on the  other hand, he may be  unable to accomplish
any good with  it, in cases where, with  a better constructed one, he would
succeed without difficulty.
  "I have repeatedly," says  Dr. Huston, in a  note to  a former edition,
" seen gentlemen of large experience in the art, completely foiled in  attempt-
ing to grasp the head  at  the upper strait, with a forceps having  only the
single curve, although when an instrument differently constructed was placed
in their hands they accomplished it very readily ; and I have myself delivered,
successfully for both mother and child, under the same circumstances, with, a
long double-curved forceps, after others had failed with  one without the
second curve, or of insufficient length."
  If the use of the forceps is to be confined to cases in which the head has
descended into the  cavity of the pelvis, resting on the perineum or protru-
ding at the os externum vaginae, then,  indeed, "the hand that is to use the
instrument is of more importance than the instrument  itself;" nor is it of
much importance what hand  it  is, if guided by the  common feelings of
humanity, so simple and easy is the  operation.   But when it is  important to
hasten the delivery  while the head remains above the upper strait, or is  still
engaged in it, as in convulsions, hemorrhage, some cases of prolapse of the
funis, aneurism, inability  of the female, from  feebleness,  to  sustain longer
the natural  parturient efforts, or when it is required to overcome  contrac-
tion of the brim to a degree not so great as to demand the perforator—in
such cases the kind of instrument we employ is of the  greatest importance.
The blades  should be adapted to the head of  the child,  the  shape should
correspond with the axes of  the pelvis, and the handles should  be  long
enough to allow the operator to obtain a secure hold outside and free of
the vulva, or success is not to be expected at the hands of the most dexterous
obstetrician.  British practitioners, we are aware, seldom employ the forceps
under the circumstances we have mentioned.   In this we think  they are
wrong,—they differ, certainly, from the practitioners of this country and of
Continental Europe.
  According to the rule for the application of the forceps, which, according
to Dr. Robert Lee,2 is  adopted by the  majority of English  practitioners,
every case in which the  unaided powers of the woman shall fail to make the
head "descend  so low into the  pelvis that an ear can be felt," will call for
the perforator !   The fruits of this practice may be learned from the fol-
lowing table, furnished by the same author:

             1 Rnnking's Abstract, vol. ii.  p. 275.
             2 [Clinical Midwifery, by Robert Lee, M. D., etc., p. l."j 
THE FORCEPS.
353
A  Comparative View of the Frequency of Forceps and Craniotomy Cases
                     in eleven Lying-in Hospitals.
Hospitals.	No. of Labors.	Forceps Cases.	Proportions.	Cranioto-my Cases.	Proportions.
Dublin, Clarke	10,199	14	1 in 728	49	1 in 248
Collins	16,654	27	1 in 617	118	1 in 141
Paris, Baudelocque	17.388	31	1 in 561	6	1 in 2898
" Lachapelle .	22.243	76	1 in 293	12	1 in 1854
" Boivin.	20,517	96	1 in 214	16	1 in 1282
Vienna, Boer .	9,589	35	1 in 274	13	1 in 737
Heidelberg, Naegele	1,711	55	1 in 31	1	1 in 1711
Berlin, Kluge .	1,111	68	1 in 16	6	1 in 185
Dresden, Carus	2,549	184	1 in 14	9	1 in 283
Berlin, Siebold	2,093	300	1 in 7	1	1 in 2093
  From this table it will be seen that those who relied most on the forceps,
had  the fewest occasions to resort to craniotomy, and vice versa.   Of the
extreme cases on each side, it will be  observed that Dr.  Collins, whilst he
employed  the forceps but once in 617 cases, resorted to craniotomy once in
141 cases  ; or nearly four and a half times as often as he did to the forceps.
Dr. Siebold, of Berlin, had recourse  to the forceps once in every 7 cases,
and to craniotomy but once in  2093 cases !  It is not difficult to imagine on
which side was the greatest mortality.   Whence arises this prodigious dif-
ference ?   Unquestionably from the different principles by which the prac-
titioners of these countries are guided.   As properly observed by Dr. Lee,
"if we compare the reports of  the principal Lying-in Hospitals  of Great
Britain, France, and  Germany,  and examine the doctrines inculcated by
the best systematic writers of these countries, it is impossible to avoid being
struck with the want of uniformity which prevails in all  that relates to the
operations of midwifery.   Although the cases of difficult parturition must
be nearly the same in every part of Europe, cases of instrumental delivery
are far more numerous in some countries and institutions  than in others, and
the method of operating is widely different."
   To the practitioners of this  country, the reports of the English Lying-in
Hospitals are of a most surprising character, especially when it is considered
that these Institutions are under  the supervision of men of the highest stand-
ing  in the profession.   The frequency with which many of the Germans
employ the forceps is in strong contrast with British practice, and is perhaps
scarcely more rational.
   The frequent occasion which  English practitioners find for a resort to
craniotomy appears to proceed  from the rules by which  they are  governed
in regard to  the use  of the forceps, and which  limit its application  to  a
comparatively  small number of cases.   Whether these  rules are deduced
from a consideration of the mechanical properties of the instruments  they
employ, or whether the instruments are constructed in reference to the ob-
 jects contemplated  by the rules, they certainly concur in  restricting the use
of this means of relief within much narrower limits than  either Continental
or American practitioners deem  necessary or proper.
   The sufficiency of the English  or almost any other forceps for the manage-
ment of cases  where the  head of the  child has  passed  through the upper
strait  is  admitted ;  but are they equally capable of useful application before
matters have advanced thus far ? The  application of the various shortfor-
ccps when the head of the child has not passed through  the upper strait, is
certainlv  out of the question.   The distance which it is necessary to pass
       23 
354
THE  FORCEPS.
the instrument within the  pelvis, and the almost impossibility of obtaining
by it a secure hold of the  head, renders it valueless.   The only exception,
if it really be one, is the forceps of Dr. Davis.   A very serious  objection,
however, to  this instrument is one that is common to all of its class,— the
blades are so short that, when introduced sufficiently far to embrace the head
in the upper strait, the lock is brought within the vulva.   This, beside  the
danger of injury to the soft parts of the mother, leaves to the operator a very
insufficient hold  of the handles for efficient action.   The great width of the
blades, too,  is an objection, perceived  by Dr. Davis himself;  he has endea-
vored to  obviate the difficulty by the  occasional use of one blade  formed
very narrow.
  These objections are made,  however, with  great deference,  as well from
the high character for skill of the  inventor, as from the fact that it is  the
instrument preferred by the Professor  of Midwifery in Jefferson College, Dr.
Charles  D.  Meigs.
  Dr.  Churchill  prefers "the long or short forceps, with the single curve."
There is certainly no advantage in the second  curve to the  short forceps; it
being only applicable in cases where the head  has descended into the cavity
of the pelvis ;  as there is in such cases but one strait to pass, an instrument
which corresponds in form with the axis of that one strait, is all that is re-
quired.   But it is widely different when the head is to be delivered from the
upper strait.  It must be borne in mind that the axes of the two straits run
in very different directions — that of the upper strait  being downward  and
backward, and of the lower, downward and  forward.  Now in order to
embrace the head in the upper  strait,  the instrument must pass through the
outlet  in the axis of the lower strait,  or nearly  so ;  and, consequently, it
must have a form corresponding, in a considerable degree, with the curved
line running through the axes of both straits, otherwise there will be excessive
pressure made upon the perineum by the instrument, and extreme difficulty
in adjusting it properly on the  head of the child.

                                  Fig. 123.
Axes of Pelvis.
  A glance at the accompanying cut will exhibit this better than any verbal
description.   A.  The sacrum.   B.  The coccyx.   C.  The pubis.   D. The
perineum.  Dotted line a, plane of the upper strait;  dotted, line 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 strait or its  axis ;
d, a similar  line,  extending  from the  middle of the sacrum through the os
externum vagina?, and marking  the axis of the lower strait.   The curved 
THE  FORCEPS.                        355
dotted line  between these straight lines, shows the course the head of the
child must take in passing through the  pelvis, and which  must necessarily
be traversed by the forceps when applied at the superior strait.
  If we are never to apply the forceps  but when an  ear  can be felt, and
"the head is resting on the perineum," there  is indeed little occasion  for a
long instrument; but what is to become  of  patients laboring under organic
affections of  the heart, hemorrhage,  convulsions, certain  tumors  of the
pelvis, slight contractions of  the  brim, great debility, aneurism,  hernia,
arrest  of the head from  want of proper rotation, etc. ?  ?s"o practitioner
should feel himself at liberty to stand by in such cases  and see his patient
sink into the grave without attempting delivery until  the  head rests upon
the perineum, or an ear can be felt;  nor should he dare to plunge the per-
forator into the fcetal head, without first  endeavoring  to save its life by the
use of the forceps.
  As to the ear as a guide, Dr. Rigby is perfectly right in  saying that the
position of the head should always  " be determined by the  direction of the
fontanelles and sutures, not by  feeling for the ear."  " The ear can  seldom
be reached  without  a good deal of  pain,  even  under the most favorable
circumstances."1
 _ The average  of the results of British practice, as  shown by their statis-
tics, is certainly creditable : this is owing, no doubt, in a great measure, to
the prudent avoidance of all  unnecessary interference.   But in shunning one
error, we not unfrequently fall  into the  opposite extreme ; and this would
appear to be the case with our brethren of England  and  Ireland.  If we
confine our examination to instrumental  cases, the comparison between  their
success and that of their neighbors is less flattering to them.
  The extreme  difficulty, not to say failures,  which Dr. Huston, of Phila-
delphia, experienced in operating with the  short forceps and  those with a
single curve, under the circumstances we  have just considered, induced him
many years  ago to attempt to supply what seemed to him a great deficiency
in the  various forceps in common use.  The forceps of Professor Siebold he
found to possess many advantages  over  any others that he  had met with,
and  he believed that with  some little alterations  it would  accomplish the
objects he had  in view.   The  annexed engraving (fig. 124) represents the
instrument.and its several parts, as  made by Wiegand and  Snowden, pretty
accurately.
  Width of the blade at a, one inch and five-eighths;  of the  fenestra, one
inch ;  separation of blades at  the  widest part  when properly locked, two
inches and a half (but this is increased  nearly a quarter of an inch  by the
manner in which the blades are'ground,  being concave on their inner  face,
and  convex  externally : by this arrangement the liability of the instrument
to slip off the head is lessened ;  length of the blades to lock at b, nine inches ;
length of the handles from joint at b, five inches.  The lock, which is exactly
like  that of the German instrument, is formed by a thumb-screw, c, which
is fastened into the male branch at  d, and is received  into  a mortise in the
female branch at e.   This mortise is countersunk, so that when the screw or
pivot is screwed down completely, the blades cannot be separated.
  The instrument of Dr. Huston is the same  length  as that  of Siebold's ;
the blades of the former are, however, longer than those of the latter, and
the handles, from the pivot, correspondingly shorter.   This brings the lock
more completely free from the  vulva when operating at or above the upper
strait; at the samp time, the shaft,  or narrow part of  the blade beyond the
pivot, constitutes iu fact part of the handle  equally effective with the handle
proper.  The fenestra of the blade is nearly double the width of that  of
1 [Rigby's System of Midwifery.] 
356
THE  F0RCEP8.
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 for-
ceps of Siebold.
                                Fig. 124.
Dr. Huston's Forceps.
  According to Dr. Huston, the objects gained by these modifications are :
  1. The blades being longer, the soft parts of the woman cannot be en-
tangled with the lock.
  2. The increased width of the fenestras avoids the thickness of* the instru-
ment being added to that of the head, renders  it less liable to slip off, and
lessens its weight.
  3. But the most important modification is in the increase  of  the second
or pelvic curve, by which the blades correspond better with the form  of the
pelvis, so that when  their extremities are in  the  axis of the upper strait,
their shafts pass directly through the axis of the  outlet.   By this  arrange-
ment, the instrument is more readily applied when  the head is high up, and
all undue pressure on the  perineum is avoided.  This form  of  the instru-
ment also enables the operator to  apply it when the patient is on  her back
on a mattrass, without bringing her down so low as to  have her limbs  off
the bed, which adds much to the comfort of the patient and the  decency of
the operation.
  From this description of the instrument it will be understood that it is
calculated, in  every case, to be passed along the sides of the pelvis.
  The following figures represents the forceps employed by Dr. Hodge, of
the University of Pennsylvania.  It is calculated, in a considerable degree,
to accomplish the same objects as the one employed by Dr. Huston.   The
eclectic forceps, as Dr.  Hodge calls his instrument, weighs one  pound and
one ounce ; being nine ounces lighter than  the French  forceps, as usually
manufactured by Mr. Rorer of this  city, and eleven ounces lighter than a
specimen of Dubois' forceps, made in Paris. 
THE  FORCEPS.
357
  The whole length of the instrument in a direct line from b to c is 1-6
inches.   From the joint a to  extremity b, 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

                                 Fig. 125.
Dr. Hodge's Forceps.
d, length of parallel shanks is 3 5..  From d  to c, the proper blades, in a
direct  line,  is  6  inches.   From c c,  the extremities,  to  e f,  the  greatest
breadth, 3*7 inches.
  The separation between the points c c, when the handles are in  contact,
is -5 of an inch.  From e to /, the greatest breadth when the handles touch,
is 2-5;  when  the separation  at e/is 35, the points c c are  separated to 2
inches.
  The breadth of the  blade is D8, slightly tapering to 17 near c c, the ex-
tremities.   The breadth of the fenestra is 11; the thickness of the blade is
■2 of an inch.
  The perpendicular elevation of the points c c, when  the instrument is on
a horizontal surface, is 34 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 was a few years since announced
by the late Dr. Henry Bond,  of Philadelphia.1
  At an early period of his professional  life it occurred to him that cases
are sometimes met  with, though not very frequently,  where, owing to the
p'osition or the form of the fcetal head, and its relation to the pelvis, it is
1 [American Journ. of the Med. Sciences, Oct. 1B50 ] 
358
THE  FORCEPS.
found impracticable to adapt the clams  to  the head  so as to lock the
branches, or to do so without  violent injury to the mother or child.
  Dr. Blundell very justly observes : " Unless the blades be elastic, absolute
adaptation can (I conceive) never be  obtained ;  for while the form  of the
instrument remains unchanged, that of the head itself varies."  " The lock
should be  loose,  so as to admit of a junction of the  blades, although they
may not be brought into exact apposition with each other;  for, in applying
them to the head, this adaptation cannot always be obtained."  For this
reason, he  says that Smellie's  lock (made loose) is decidedly the best.
  According to Dr. Meigs, if we fail to adjust the branches  accurately in
apposition, we either cannot  make them lock, or we lock them in such a
way that the edge of the  instrument contuses, or even cuts the part of the
scalp or  cheek on which it rests,  leaving a scar, or actually breaking the
tender bones of the cranium, while the other edge cuts the womb  or vagina
by its free  projecting edge.   In fact the forceps is designed for the sides  of
the head;  and if, under the stress of circumstances, we are compelled to 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.1
  Dr. Bond remarks, that  the difficulty  and the danger in such cases evi-
dently arise, to a great extent, from the want of an accommodating, rocking
motion, of  the  branches of the forceps upon each other, such as will allow
the depressed  ("cutting and contusing") edge to rise, and the elevated edge
to sink and come in contact and apposition with  the head ;  that is, that the.
blades may be adapted to the  head by varying from their usual relation  to
each other.
  In the  instrument,2 designated  in figs.  126, 127, 128, Dr. Bond  has at-
tempted  to supply  the desideratum just referred to, that is, to give the
branches of the forceps an accommodating rocking motion upon each other,
the extent  of which can be regulated at will, and which shall in no respect
lessen the power of the instrument.  The mechanism devised to obtain this
motion is very simple, not  liable to derangement, and it  may be adopted in
the construction of forceps of other forms than that here presented;  pro-
vided that  the pelvic curvature of the  branches does not take such a wide
sweep, as to throw the pivot far out of the direct line between £he handle
and the centre of the fenestras.
  The instrument of Dr. Bond does not differ, as a whole, from those  now
in use ; nothing connected with it except the lock, has any claim to novelty.
Its whole length is about  fifteen inches, and its weight about fifteen ounces.
The length of the  handle is six inches,  and that of the blade nine inches.
It might be made somewhat shorter and lighter without impairing its power.
  In fig. 126  the pivot is  seen of full size, the screw is of about double the
diameter and  nearly double the length of those in other instruments.   This
additional  strength is  necessary, because the bearing point  of the pivot is
not  immediately above the blade  in which it is inserted (as  in other instru-
ments), especially when this bearing point is elevated  so as to  give  the
blades a free rocking motion.   The additional length is required to give the
screw a firm lodgment, when  it is partly withdrawn  from  the blade.   The
thumb-piece is made to fit so  close upon the  female  blade, without resting
upon it, and is so thick and rounded,  that there can be no risk of injury

  1  [See "Obstetrics; the Science  and the Art," chap, xv., for much information and  ex-
cellent lessons on the use of the forceps.  We commend attention to the author's emphatic
inculcation of the idea, that " the forceps is the child's instrument."]
  2 [The instrument, from the manufactory of  Messrs. John Rorer  & Sons, of Phila-
delphia, is made of German steel,  and spring-tempered.] 
THE  FORCEPS.
359
should it ever happen to be brought into contact with the patient.   The
screw, when  well  made, will turn  so easily that the thumb-piece  may be
made much less prominent than it is here represented.  When the forceps is
used, the thumb-piece should be placed parallel  with the blades ; otherwise
it may interfere with the rocking motion.  Between the thumb-piece and the
Fig. 126.                 Fig. 127.                   Fig. 128.
Dr. Bond's Forceps.            Dr. Bond's Forceps,
screw, the pivot is of the form of two frusta of cones of equal dimensions,
united together at  their smaller diameters, forming an  obtuse angle  or
groove at their junction.  The base of that cone jojned to the screw projects
a little,  forming a shoulder, intended to  limit the  motion of the screw into
the blade.
  The notch in the female blade, made to receive the pivot, is so deep  that
the latter, in relation to the  edges  of the  branch, is nearly in  the middle ;
yet the  width of this branch,  opposite to it, is swelled out, so as to  give it
adequate firmness.   The width and the form of the sides  of the notch  are
accurately adapted to those of the pivot, and the bottom  of the notch termi-
nates in an edge, like the knife-edge  of  a balance, which is intended to rest
in, and bear upon, the angle or groove in the pivot.  On the under side of
the male blade is  seen a protuberance, finished  so as to present no salient
points.   It is a shield for the  extra  length  of the  screw.   When the pivot
is  screwed entirely down, the branches  have no  more  lateral  or rocking 
360
THE  FORCEPS.
motion than those of any other forceps, and in this condition, they will very
generally be used.  But by turning the  screw, so as to elevate the bearing
point, more or less freedom is given to the rocking motion, according to its
elevation ;  and this motion is effectually restricted within any desired limits.
When, by means of this free motion, the operator has been  enabled to grasp
the head,  he may sometimes change its  position, so that the clams may be
then adapted to the head, without the  obliquity at first necessarily allowed
to them by the elevation of the pivot;  and then,  if desirable, the pivot may
be screwed down, and  the  blades will become as fixed as  those of other
forceps."
   The blades of Dr. Bond's  forceps (figs. 127  and 128) resemble  nearly
those of Dr. Davis.   The shanks are considerably longer; the clams are
not quite so long ; the radius of their pelvic curvature a little less, especially
that of the outer limbs, so that it will be less  liable to be obstructed by the
promontory of the  sacrum, in passing  the instrument above  the superior
strait.   The fenestras are wider in their middle and posterior part than those
in most other forceps.   When the pivot is elevated, so as to allow the blades
their rocking motion, this width becomes especially requisite  in order to
secure a firm hold on the head, and to avoid the risk of their slipping side-
ways.   The space between  the blades is such, that, when  applied  to the
head, the  handles shall not be at a  distance from each other, awkward and
inconvenient to the operator.  From the pivot, the upper line of the shank
continues  forward, without any elevation or depression, to  the beginning of
the pelvic curvature ;  and the form and  the  relation of the shank  to the
clam are intended to be such as to interfere the least with the perineum.
   The pivot it will be seen (fig.  127) in these  forceps, is in a direct line be-
tween the handles and the centre  of the fenestrae.   This is  a point  of im-
portance in those cases where the rocking motion of the  blade may be re-
quired,  as it will cause feach limb  of the  clams to press with nearly equal
force, thus avoiding undue pressure upon any  one part of the head, and the
liability to slipping or displacement.
   "I am aware," remarks Dr. Bond, "that the first impression of some per-
sons, upon looking at the illustrations, will be, that the instrument is too
straight, that the pelvic curvature ought to be continued  into  the  shanks.
If the whole operation, or the most difficult and important part of  it, con-
sisted in passing the blades above the superior strait, narrow blades, with a
curve of a wider sweep, like  those of Professor  Siebold, slipping  in pro-
bably with rather more facility, would be preferable.  But as those here re-
presented can be passed above the superior strait with  facility, it seems to
me that what I have already said upon  the  importance, in  many cases, of
having the pivot in nearly a direct line between the handles and the fenestra,
furnishes a valid reason for adopting a model  not differing essentially from
that here presented."
   The remarks of Dr. Churchill on the "period of operating" with the for-
ceps, are highly judicious, and deserving of the  especial attention of the junior
practitioner.  They are the more satisfactory because they  inculcate sounder
doctrines, according to our view of the subject, than  are to be found  in the
writings of some of our late as well as older British authors, at least.
   When the difficulty exists " at the brim of the pelvis, it will be better in
all cases to apply the forceps in the transverse diameter."  If there be want
of space, it will be almost always in the  antero-posterior diameter, and on
that account there will be difficulty in passing the blades of  the forceps be-
tween the head of the child and the pelvis ; not only so, but it is nearly im-
possible to pass the posterior blade far enough, in consequence of the projec-
tion of the sacrum—if the instrument be straight, that is, without the second
curve, the extremity will be arrested by the upper portion of the sacrum, or the 
CRANIOTOMY.
361
shank of the blade will press very seriously against the perineum ;  in fact,
it cannot pass thus without  pushing this part back with  great violence, as
any one may see by looking at the vertical view of the pelvis represented in
fig. 123, page 354.
  In attempting to apply the instrument antero-posteriorly, there is always
danger of injuring the bladder and rectum, which alone is  a sufficient reason
for rejecting this mode of operating, if any other will answer.
  The only valid reason that can be discovered for applying the forceps an-
tero-posteriorly is, that the  pressure made  by the instrument in that case  is
upon the part of the head corresponding with the least diameter of the brim.
But if the blades  be made without pretty wide fenestras, their thickness will
be added  to that   of the head,  and will be  quite equal to all that will be
gained by the compression, if this be confined within the  limits compatible
with a proper regard for the safety of the child;  and if it is required the head
should be reduced more than this, the perforator should  be employed.   It
must be admitted  by all who have had experience in these matters,  that the
soft parts of the mother will bear as much compression as the brain  of the
child : if  this be so, where  the life of the latter is to  be preserved,  there is,
certainly, no reason why the necessary compression or moulding  of its head
may not be left to the influence of the resisting parts.  When this moulding
operation is left to the maternal parts, the compression is made exactly  at
the points where it is  needed, which can hardly  be  expected from  the arbi-
trary influence of  the  instrument.   We very much doubt the propriety of
employing  the forceps as a means of compressing the  head of the foetus,
unless, perhaps, when  the perforator is required.   It  should be resorted  to
only as a lever to  alter the  position of the head, or as a tractor to  aid in its
expulsion.   That  the  forceps should never be used as  a compressor, but
solely as a tractor, is strongly insisted upon by Professor Meigs.]
                        CHAPTER  XIII.

           OBSTETRIC  OPERATIONS.—5. CRANIOTOMY.

  569. The next  obstetric  operation we  have to consider belongs to the
second class, that is, where one  life is terminated to save the other; the
mother's  safety being secured by the destruction of her child, in cases where
both would be lost if no interference were attempted.  This is not an ope-
ration of election in any sense, but of stern and sad necessity ; neither have
we any choice which life we will  save ;  the child  cannot be  saved by any
means compatible with the  mother's safety, and therefore it  is destroyed.
As to the arguments for and against  the  morality of the operation, I  mu*t
refer my  readers to the Appendix to this  edition, where  I have endeavored
to investigate the question fairly  and fully.  I have seen too many difficult
cases to agree with Dr. Tyler Smith that  craniotomy can be abolished, but
it has always been my object that it should be restricted within the narrowest
limits.   Professor Scanzoni, no mean  authority, observes :  " From all we
have said,  we conclude, that as yet, we know of no means which will render
craniotomy useless.  It is an operation which, undertaken on good ground.-! 
362
CRANIOTOMY.
and  performed with address and  good  instruments, will save  many lives,
which otherwise would be sacrificed."
  The instruments (or part of them) employed in this operation are of great
antiquity;  and although they were originally proposed for the extraction of
dead children  only, yet this scruple had not the effect of saving the life of
the child, but merely postponed the interference until after its death.   This
conscientious  quibble  (refusing to destroy a  child, but  allowing  it to die)
was soon detected, and then the hook was used with living children, provided
that delivery were otherwise impossible.
  The class of cases to which it  was applied, doubtless, included a vast
number which were  subsequently relieved  by  the  forceps;  but there  were
still left a great many in which it was indispensable.
   Several  of  the ancients recommend  this operation.  Hippocrates advises
the breaking  up of the cranium,  and extraction  by the hook.  Moschion
advises embryulcia in those cases where  the fcetus cannot be  extracted by
the hands, and if embryulcia be insufficient, the exsection of the limbs and
body of the child.  Albucasis,  the Arabian physician, describes instruments
for compressing and breaking up the child's head, and others for extracting
it.   Of certain cases of difficult  labor, when the child is presumed to be dead,
Celsus remarks,  " Si caput proximum est,  demitti debet  uncus qui vel oculo
vel auri vel ori interdum etiam  fronti rectfe injicitur."
   In the Birth of Mankinde,  written  by Eucharius  Roslin, translated into
Latin about the year 1535, and into English by Thomas Raynalde, in 1634,
I find the  hook recommended to bring away dead children.   " If so be," he
says, " that it lie the head forward,  then fasten a hook  either upon one of
the eyes of it, or the roof of the mouth, or under the chin,  or on one of the
shoulders—which of those parts shall seem most commodious and handsome
to take it  out by, and  the hook fastened to draw it out very tenderly, for
hurting of the woman."   If the head be  too large, it is to be opened  with
 a sharp penknife, or broken in pieces.    He also recommends excision of the
 extremities, if they present (the child being dead), or evisceration, to facili-
 tate the delivery.
   Ambrose Pare's work  is dated 1579,  and it was  translated into English
 in 1634.   In it are given plates of different hooks for drawing out the child,
 and a knife for the excision of the limbs.
   From this  time we find the operation  recommended by every author, but
 the instruments underwent considerable  modification, and the class of cases
 in which they were used considerably decreased.  Of course this latter change
 was one of the consequences of the invention of the vectis and forceps.
   570. The following are the  principal  modifications of the instruments for
 craniotomy :  —
    1. Albucasis  describes a species  of forceps with teeth, which he terms a
 " misdach, or almisdach," for the purpose of crushing the head, and enabling
 it to pass.
   2. He also gives a plate of a single  and double hook, for extracting the
 child, and of a knife for cutting off the  head.
   3. Ambrose Pare contrived two  kinds  of blunt  hooks, and a double one
 with sharp points, for the extraction of the fcetus, and a knife for excision.
   4. Mauriceau invented an instrument which he called a "tire tete," con-
 sisting of a circular plate of steel, fixed  upon a rod.  The circular plate was
 to be introduced into the head (previously opened  by a scalpel), and being
  placed across the  opening, traction was to be made.   This instrument was
  never  much used, owing to  the difficulty of introduction, and its  feeble
  power when  introduced.
    5.  Sir  F.  Ould's "terebra  occulta" consisted of a sharp-pointed rod in-
  closed in  a canula or sheath,  and  retained by a  spiral spring at the lower 
CRANIOTOMY.
363
end.  When the handle  was pressed upwards, and the resistance of the
spring overcome, the point  of the instrument protruded a certain distance,
but was retracted when the pressure upon the handle was remoyed.  Its
application to the head was easy and safe ; but it must have been nearly use-
less, from the small opening it made.
  6. Dr.  Simpson,  of St.  Andrew's, invented an instrument, which he called
a " ring  scalpel," for opening  the skull.  It consists  of a loop  of  steel,
through which the finger is  to be passed, and from which protrudes a sharp-
pointed blade about an inch long, by which the  cranium was pierced.
  7. M. Mesnard described a crotchet which could be used either double or
single, and which was the original of the one in  present use.  He also  gives
a plate of a "perce-crane," and a pair of "tenettes a conducteur," that is,
craniotomy forceps.
  8. Dr.  Burton copied Mesnard's double crotchet and perce-crane" with
some slight  modification.
  9. M. Levret gives a plate of a single crotchet, which was arranged to fit
into a socket on the top of  another blade for the purpose of protecting the
mother, and rendering the purchase more secure.
  10.  Dr. Smellie recommended Mesnard's crotchet (single or double) ; but,
instead of the "perce-crane," he used a pair of strong scissors, with stops at
the shoulders to prevent the blades entering too far.  Denman abolished the
Fig. 129.                  Fig. 130.                   Fig. 131.
Hayn's Perforator.               Smellie's Perforator.                Crotchet.
cutting edge altogether, and added strength to the blades.   A spoon was
also used to evacuate the brain, but it is now very properly discarded.
  11.  Dr. Wallace Johnson published an  account  of his  instruments  for 
364
CRANIOTOMY.
opening the head and extracting the child.   I do not know that they have
ever been used by any other person.
  12. Dr. Aitken proposed a  flexible or living crotchet, which  could be
adapted to the convexity of the child's head.
  13. M. Baudelocque  recommended a very simple extractor, consisting of
a small piece of  wood, to the centre of which a ribbon was  attached.  An
incision having been made with a bistoury or "perce-crane," the bar of wood
was to be introduced and placed crosswise, and then extraction made by the
ribbon.
  14. M. Osiander has given a plate of an instrument for piercing the skull,
and  another for  extracting.   The  latter is the same as Smellie's  double
crotchet.
  15. Professors de Hayn, Vanhueval, Joerg,1 and  other  German practi-
tioners,  use a species of trephine  for  perforating the  head.   It has the
Fig. 132.                  Fig. 133.               Fig. 134.
Churchill's Crotchet.                     Holmes's Perforator.
advantage of occasioning no splinters, and of perforating the face as easily
as the skull.  The accompanying  plate is copied from M. Cazeaux's Atlas,
>»nd represents M. de Hayn's instrument.   (Fig.  129.)
1 Presse Med. Beige, Dec 31, 1818. 
CRANIOTOMY.
36 5
  16. Dr. Davis  has  invented  several species of crotchet, both single and
double,  as well as a pair of forceps  for breaking up  the  skull.   These are
well exhibited in  the fourth edition of his work.
  These are a few of the principal instruments which have been  employed
in the operation of craniotomy.  I have  not given a detailed description,
because most of them are discarded ; the instruments in general  use  being
a pair of scissors with  shoulder-stops,  as recommended by  Smellie, but
having a sharp edge  on  the outside  (fig. 130),  and a modification of Mes-
nard's simple crotchet (fig. 131).  I have found it an  advantage to  shorten
the points of the  scissors above the stops, and also the hook of the crotchet;
the latter of which  should be slightly cleft (figs.  132, 133).  Mr.  Holmes
and others have modified the latter, so that  in closing the handles we open
the blades (figs.  134, 135).  Further, I have copied plates of a knife for
Fig. 135.                     Fig. 136.              Fig. 137.
Holmes's Perforator.          Knife for Amputating Limbs.        Blunt Hook.
cutting off the head or limbs if necessary (fig. 136), a blunt hook (fig.  137;,
and Dr. Davis's bone forceps for breaking up the skull (fig. 138).
  Dr. Oldham  of  London has recently proposed  an instrument (fig.  139),
which I think likely to be useful.   It consists of a straight steel stem, fixed
into a wooden  handle, and  bent at an acute  angle at the other extremity,
the whole^being fourteen inches  long.  It can be inserted through the fora-
men  magnum into the  spinal canal, and thus obtain a purchase  when the
vault of the cranium  has been  broken  up.   Or it will serve  to steady the
head when it has been severed from the body, whilst the crotchet is applied.1
  From the inconveniences sometimes experienced with the crotchet, and to
1 Lancet, May 14th, 1853, p. 417. 
366
CRANIOTOMY.
avoid the risk of injuring the mother, craniotomy forceps have been em-
ployed by different individuals.
  Among the moderns, M. Mesnard has the credit of first inventing and
using this instrument, and since his time it has undergone various modifications.
  Dr. Haighton  used  a pair resembling the lithotomy forceps :  and since
his  time Drs.  Conquest and  Davis, Mr. Holmes, and others, have invented
Fig. 138.              Fig. 139.                 Fig. 140.
Dr. Davis's Bone Forceps.   Oldham's Instrument.          Craniotomy Forceps.
and described varieties of the instrument (fig. 140).  The object of each is
the same, viz., to avoid the risk of tearing the soft parts of the mother ; and
the principle of seizing the skull  between two blades, furnished with  teeth,
is also alike.
  Dr.  Zeigler of Edinburgh has invented an extracting  forceps (fig. 144),
which  must possess great power  from the grooved condition  of  its inner
surfaces, and from its figure is adapted to cases of contracted pelvis, when
the head has been  previously perforated.  Both blades are applied outside
the cranium, as other forceps ; but  by substituting for one of these blades
another with teeth (fig. 145),  a craniotomy forceps of the ordinary kind is
produced.1
  I am free to confess that I  do not like the craniotomy forceps, afthouo-h
I have tried them repeatedly.   They are by no means so  manageable as the
crotchet; and the interposition of the  hand of the operator will  always pro-
tect the mother from injury by the latter.
JEd Monthly Journal, May, 1849, p. 770. 
CRANIOTOMY.
367
  There is one case, however, in which these forceps may be more useful,
and  that  is, when the bones of the  head are extremely hard, so that it is
almost impossible to fix the point of the crotchet.
  17.  M. Baudelocque, Jr., has  invented  an instrument, which  he calls a
" cephalotribe," for the purpose  of crushing the head (fig. 146).  It con-
sists of a very  strong  pair of forceps, about two feet in length, the handles
of which are connected by a screw which pierces them, and which is turned
by a handle until the blades are so closed as to effect their object.   Velpeau
states that instruments somewhat similar have been formerly used by Assa-
lina, Osiander, Delpech,  Colombe,  etc.  M. Baudelocque  is said to have
used it three times successfully (and safely as regards  the  mother)  in  the
year 1832, and once again in 1834.   It is also said that M. Champion  has
tried it with success.   M. Cazeaux  speaks favorably of it in certain cases,
and with certain modifications ;x  but its appearance is so formidable, that I
doubt  if it could be used  in this country.  I am not aware that the attempt
has been made.
[Fig. 141.]             [Fig. 142.]        [Fig. 143.]
Dr. Meigs's Embryulcia Instruments.
  [Professor  Meigs uses the forceps and perforators represented in figs
141, 142, 143.  These forceps possess advantages over the ordinary instru-
ments for extraction  after perforation of the head, and are certainly safer
in unpractised hands than the crotchet.
   They are eleven inches in length ;  the gripe is serrated and the  sides of
the  mandibles are rounded, in order that they may not pinch any tissues
                  1 Traite" des Accouchemens, p. 585 Ed. Beige. 
368
CRANIOTOMY.
except those intended to be included in the bite, which, on account of the
seme, is very sure and strong.1]
  571.  The object of the operation  of craniotomy is to terminate the labor
with safety to the mother, in  cases where, from the disproportion between
the size of the fcetal head and the pelvis, a living child can neither be ex-
pelled by the  natural powers, nor extracted by the  forceps.   Such a case,
if left to nature (as it is called) will terminate fatally for both mother and
child ; consequently, although  the child is destroyed to facilitate the delivery,
and to save the mother, it  cannot be said to  be sacrificed, inasmuch as no
efforts of  ours could have insured its safety.

                Fig. 144.                           Tig. 145.
                             Craniotomy Forceps.

  The case presupposes, on the one hand, actual disproportion sufficient to
 prohibit the passage of the foetal head, even when compressed; and on the
other, that the distortion is not so great as to prevent the extraction of the
child when mutilated.
  Dr. Osborn states that when "the bones approach much nearer to each
other than three inches, it is utterly impossible  for a living child at full ma-
turity by any means to pass."2   He  fixes upon 2| inches as the diameter
rendering craniotomy necessary.   M. Alphonse Le  Roi  says that Z\, Dr.
Aitken 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.  Osborn re-
marks :—" Whenever there is a space  from pubis to sacrum, or from the fore
to the hind part of the upper aperture of the  pelvis, equal to an inch and
a half,  I am convinced it will be always practicable to extract a child by the
crotchet, after the head has been some time opened,  and the texture of the
child's body is  softened by putrefaction (as recommended above), and the

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

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

    i Dublin Journal of Med. Science, vol. x. p. 287.           * Ibid., Feb. 1859.
      24 
370
CRANIOTOMY.
the natural powers.  But in this case, it is assumed that the pains are suffici-
ently strong and frequent.
  3. When (as is frequently the case) the pains  are inefficient, or when the
state of the patient demands prompt relief, then we must not only evacuate the
brain, but add extracting force, by means of the crochet or craniotomy forceps.
  4. In some cases the distortion of the pelvis is too considerable to admit
the passage of the head, even when emptied of its contents ;  or the obstruc-
tion may result from the ossification of the bones of the  skull; in either case,
an extension  of the operation is necessary to complete the  delivery.   This
may be effected by breaking up the cranium with a small pair  of forceps,
resembling Dr. Davis's;  or according  to M.  Baudelocque, jun., by the use
of the cephalotribe.   It would require unusual  hardihood to venture upon
the latter instrument in private practice in this country.
  5. In these cases of distortion,  after the head has been extracted piece-
meal,  we may find it impossible to  bring away the  body of the infant.  We
must then use the perforator, for the purpose  of evacuating the contents of
the chest and abdomen, and afterwards  apply the crochet to extract the child.
  One or more of these modifications of the  operation will  be successful in
all cases  which  come within the limits already described.
  573. Statistics.—The positive  advantage  we obtain from embryotomy is
the safety of a large proportion  of the mothers, who, in addition to the
children, must have perished had  no aid been  afforded.  The children, of
course, are all lost.
  What  the  proportion of  success is,  I shall now endeavor to show;  but
previous  to  this  I shall adduce whatever evidence we possess to ascertain
the comparative frequency of the operation.
FREQUENCY OF  THE  OPERATION.
     a.  Among British Practitioners.
Date.	Authors.	i Total No. of Cases.	No. of Crotchet Cases.	References.
1781	Dr. Bland	1,897	8	Merriman's Synop. p. 333.
1787 to 1793	Dr. Jos. Clarke	10,387	49	Trans, of Assoc, vol. 1.
	Dr. Merriman	2,946	9	Synopsis.
1818	Dr. Granville	640	3	Report, p. 25.
1828, 1829	Dr. S. Cusack	701	5	Dub. Hosp. Reports.
1832, 1833	Dr. Maunsell .	839	5	Ed. and Dub. Jonr.
1829	Mr. Gregory .	691	2	Dublin Hosp. Rep., vol. 5.
1826 to 1833	Dr. Collins	16,414	79	Practical Treatise.
1834	Dr. Thos. Beatty .	1,182	3	Dublin Jour., vols. 8, 12.
	Mr. Lever	4,666	25	Guy's Hospital Reports.
	Dr. Beid	5,691	22	Ranking, vol. 4.
1835,37,38,39	Dr. Churchill .	1,640	11	Reports to June, 1840.
1838	Mr. Warrington . .	88	1	American Journal.
1829	Mr. Mantell .	2,510	3	Ibid.
1848 |	Drs. M'Clintock and"! Hardy . . /	6,634	52	Pract. Obs., p. 95.
1820 to 1827	Dr. Ramsbotham .	68,435	85	Obst. Med. & Surg. p. ,20.
1842 to 1844	Dr. Murphy .	467	2	Rept. of Univ. Col. Hosp.
	Dr. Storer	451	2	Amer. Jour., Oct. 1851.
	Dr. Adams	628	4	Ranking, vol. 4.
	Dr. Toogood .	1,135	6	Prov. Jour., vol. 8, p. 103.
	Dr. Copeland .	1,290	2	Crosse's Med., p. 12.
	Dr. Pagan	8,684	15	Glasgow Jour. July, 1852.
1847 to 1854	Drs. Sinclair and John- "I son . . /	13,748	130	Pract. Mid., p. 224.
	Dr. Hall Davis	7,302	9	On Difft.Parturition,p.271.
 
CRANIOTOMY.                        371
b.  Among French Practitioners.
Date.	Authors.	Total No. of Cases.	No. of Crotchet Cases.	1 References. i
1797 to 1809 1803 to 1811 1834 to 1843	Mad. Boivin . Mad. Lachapelle . Dr. de Belli .	20,517 15,654 2,739	16 14 39	Memorial, p. 337. Pract. d'Accouch., p. 500. Ranking, vol. 4.
c.  Among German Practitioners.
Date.	Authors.	Total No. of Cases.	No. of Crotchet Cases.	References.
1801 to 1807	M. Richter, Moscow	2,571	3	Velpeau.
1811 to 1827	( Moschuer and Kursak,") \ Prague . . /	13,329	4	Siebold's Jour., vol. 9.
1812	Dr. Siebold, Wurtzburg .	170	1	Ibid., vol. 1.
1818 to 1829	" Berlin	97	1	Ibid.. vol. 10.
1832	" Marburg .	155	1	Ibid., vol. 13.
1814 to 1827	Dr. Carus, Dresden .	2,908	9	Ibid., vol. 9.
1819	Dr. Ritgen, Giesen .	103	1	Ibid., vol. 6.
1825 to 1827	Dr. Kilian, Copenhagen .	2,350	4	Velpeau.
1794 to 1804	Dr. Henne, Prague .	500	1	Siebold's Journal, vol. 2.
	Dr. Naegele, Heidelberg.	1,411	5	Velpeau.
	M. Boer, Vienna	39,390	84	Die Geburtsh. Praxis.
1821 to 1825	Dr. Riecke	219,303	51	Velpeau.
1825, 26, 57	Dr. Kluge, Berlin .	809	8	Siebold's Jour. vols. 7, 9.
1825	Prof. Andre"e, Breslau	351	2	Ibid., vols. 7, 8.
1827	Dr. Kiistner, Bre'slau	176	o	Ibid., vol. 9.
1829	Dr. Adelmann, Fulda	57	1	Ibid., vol. 11.
1797 to 1837	Dr. Jansen, Ghent .	13,365	5	Med. Gazette, March 6, 1840.
1847 to 1849	Dr. Arneth, Vienna.	6,608	4	Die Geburtsh. Praxis, etc. p. 99. Ibid.
	M. Klein ....	35417	53	
	M. Bartsch	4,425	3	Ibid.
1821 to 1842	Dr. Ricker	304,150	143	Med. Times and Gazette, Oct. 11, 1856.
  Thus among British practitioners, we have 517 crotchet cases in 150,381
cases of labor— or about 1 in 291.
  Among the French and Italians, 69 crotchet cases in 38,908 — or 1 in
563f.
  And among the Germans, 386 crotchet cases in 646,645 labors — or 1 in
1675.
  Added together, we  have 835,934 cases, and 746 in which the crotchet
«vas used — or 1 in 1120^. 
372                        CRANIOTOMY.
RESULTS OF THE OPERATION TO THE MOTHERS.
Authors.	No. of Crotchet Cases.	Mothers died.	Authors.			No of Crotchet Cases.	Mothers died.
Dr. Smellie .	44	4	Drs. Sinclair and John- ") ston ... J			130	26
Mr. Perfect .	3	0 1					
Dr. Jos. Clarke	49	16	Dr. Storer			2	1
P. P . .	12	8	Dr. Beatty .			3	0
Dr. Granville	3	3	Dr. Churchill			11	1
Dr. Ramsbotham .	34	5	" P. P			20	0
Dr. Maunsell .	5	2	Mr. Warrington .			1	0
Mr. Gregory .	2	1	Dr. Pagan			15	2
Dr. Collins .	79	15	Dr. Siebold .			3	1
Dr. Lee, P. P . .	80	*4	Dr. Ritgen			1	0
Drs. M'Clintock and "1 Hardy . . /	52	8	Dr. Kluge			8	3
			Dr. Andre*e .			2	1
Dr. M'Clintock, P. P .	5	0	Dr. Kiistner .			2	0
Dr. F. Ramsbotham	60	6	Dr. Adelmann			1	0
Dr. Murphy	2	0	Dr. Arneth .			4	2
Mr. Cross, P. P . .	7	0	Dr. Ricker			123	35
    This table gives the mortality of 134 in 747 — or about 1 in 5|.
    At first sight one would expect  the mortality among the mothers to be
  less after the use of the crotchet than the forceps;  although the result of
  these investigations shows the  reverse to be the case, and Dr. M'Clintock,
  in  a very interesting paper, brought forward evidence to show this to be
  really the  case.   The  only explanation  I  can  give, is founded upon the
  natural unwillingness of every humane practitioner to destroy life—the con-
  sequence of which feeling,  is the delay of the operation so long as there is a
  hope of evading it.  This  delay, however, is unfavorable to the mother, and
,  when at length the operation is performed, although it may have been less
  severe than delivery by the forceps, yet her condition has rendered her much
  more susceptible of injury from it.  If we  separate the cases in the  table
  which occurred in private or consultation practice, we find the mortality
  very much less.  In consultation I have had recourse to craniotomy twenty
  times, and all the  patients recovered; in four  other cases  I was called in
  when the mother was past hope ; these I therefore omit.  Dr. Robert Lee
  has recorded eighty cases of craniotomy from disproportion, without com-
  plication, and although he was not  called to  some until much time  had
  elapsed, only four died.
     Dr. Joseph Clarke operated twelve times, and all the women recovered.
  Mr. Cross operated seven times, and all recovered.   Dr. M'Clintock, five
  times, and all recovered.
     This gives a result of 117 cases, and 4 deaths, or  1 in 29.
     574.  The  comparative advantages of the operation are very decided.  In
  the cases we  have  supposed, the forceps is useless, and  the  natural powers
  inefficient; if, therefore, embryotomy were  rejected  as  inadequate, the only
  alternative would be the  Caesarian section, the mortality of which is  much
  greater, for  1 in 2± of the mothers are lost; and 1 in 3£ of the children.
     It would,  however., be a serious omission  if I did not notice another alter-
  native operation, which, although not available  after labor has commenced,
  may supersede the necessity for embryotomy in  subsequent  pregnancies.   I
  allude to the induction of premature labour.  In all cases where pelvic dis-
  tortion  renders craniotomy necessary at  the  full  time, it becomes our duty
  to recommend the induction of premature  labor in subsequent pregnancies,
  at such  a period as shall, if possible, afford  a chance of life  to the  child, or 
CRANIOTOMY.                         373
    at least save the mother from a severer operation, and not merely to recom-
    mend, but to insist upon it.  No woman has a right to require us to destroy
    successive children,  when an  operation  like this can supersede  craniotomy.
    The mortality among the mothers  is very  small, and more than half the
    children are saved.
      575. So much for the positive and comparative advantages of the opera-
    tion.   I am not aware that  there  can  be any just objections against it, in
    suitable  cases ;  but undoubtedly there are most  weighty objections against
    employing it without  careful consideration  and consultation.   In fact, it
    ought to be deeply impressed upon  every practitioner, that he who destroys
    the child, without due evidence that it cannot be saved, and that this is his
    only resource for saving the mother, is guilty of murder.
      But it may be asked, when the responsibility is so serious, what evidence
    will be sufficient to satisfy a conscientious practitioner that he may not be
    committing a crime in his anxious endeavor to afford relief?   To this it
    may be answered :
      1.  That the continuance of strong labor pain for a certain time, without
    any advance of the head of the child, is so far evidence of a fixed obstacle to
    the passage of the child.                                               *
      2.  The failure  of a  cautious attempt to  introduce  the forceps will, to a
    certain extent,  demonstrate  the amount of  the  disproportion  between  the
    head and the pelvis ; and the failure of a careful yet firm attempt at extrac-
    tion by the  forceps (when the application has been effected), will prove that
    the disproportion cannot be remedied by compression.
      3.  A well-educated finger will enable us in most cases to ascertain whether
    the diameters of the pelvis are such as will allow of the passage of a living
    child.  And  even though this mode be uncertain, we have a means of cor-
    recting our  estimate,  by comparison  with the child's head, in opposition
    with  the  pelvis.  If the  natural efforts after several hours, or the forceps
    with a proper and safe amount of  compression and force, cannot bring the
    widest part of the head of the child through the narrow part of the pelvis,
    we may fairly conclude that the only resource is craniotomy.
      4.  The general condition of the mother will also aid our decision.  If she
    be much exhausted,  if fever be present, the uterus powerless, the life of  the
    child doubtful, and the success of the forceps dubious, we may shrink from
    inflicting  the double shock of an unsuccessful application of the forceps, and
    subsequent  delivery by the crotchet.  But these  cases are very rare ; they
    only happen when the patient has been mismanaged, and it requires experi-
    ence  and judgment to decide upon the  propriety of terminating them by
    embryotomy.
      A careful consideration  of  these  circumstances will, I think, enable us to
    arrive at a correct conclusion in an individual case ;  and as the responsi-
    bility incurred in the destruction of the infant may lead to timidity, it should
    also be remembered  that  hesitation  to act when the case is clear, involves a
    more fearful responsibility, by compromising the life of the mother.
     576.  The  cases in which  the operation is  demanded are those in which
I    the child  is dead, or  in  which the  character of the labor will involve its
    death, or in which  it cannot  be delivered alive  by any means compatible
    with  the  safety of the mother.  The limits of the operation are rightly
    restricted on the one hand by the extended use of the forceps, the induction
    of premature labor, and in certain cases by version ;  and on the other hand,
    by the employment of the Caesarian  section.   Within these limits, the cases
   suitable occur.
     1. "When  the  child is dead and the labor tedious.   But we must be quite
   sure  that the child be dead, before this is made the ground of interference.
   If the head be  putrid, and there is  space in the  pelvis, it is much better to 
374                        CRANIOTOMY.
use the forceps, as the bones and integuments of the skull give way so easily
under the crotchet, that it is  sometimes very difficult to extract the child.
I have seen the operation prolonged two hours from this cause alone.
  2. In some cases of convulsions, rupture of the uterus, etc., where imme-
diate delivery is necessary, and where the forceps cannot be applied, crani-
otomy must be  performed.
  3. In flooding cases, before the head  has passed through the os uteri, if
the cervix be dilatable, the child  may be thus delivered ; and this is pecu-
liarly desirable  when the  flooding is large and the child  premature.   Of
course it cannot be attempted when the placenta  covers  the os uteri, nor
must we have recourse to it  unless the woman is endangered by the he-
morrhage.   In these two latter classes of cases, the child dies in most cases
before we could possibly deliver it by any other means.
  4. In distortion of the pelvis, when  the antero-posterior diameter of the
brim is less than three inches, we  have  no chance of delivery  by the natural
efforts or by the forceps;  so that to save the  mother we must destroy the
child.
  5. When the transverse diameter of  the lower outlet is diminished to the
same extent by the approximation of the tubera ischii, if the forceps applied
antero-posteriorly are insufficient to move the head, we must have recourse
to craniotomy.
  6. When the  calibre of the  pelvis is diminished to  a certain degree  by a
fixed obstacle — as, for example,  a fibrous tumor, or  an  exostosis growing
from the bone  or periosteum,  it may not  be  possible for the natural efforts
alone, or aided  by the forceps, to expel the child.   In such cases it will be
necessary to lessen the head and apply the crotchet.  In these three latter
class of cases, the passage through the pelvis  may be so much diminished
as to render it necessary to break up the skull, or to eviscerate the child.
  7. In some cases of ovarian disease, where the tumor has formed adhesions
within  the  pelvis,  so as to prevent its being pushed above the brim, it has
been found necessary to lessen  the head, before the child could be extracted.
We are not, however, to decide upon this measure until the natural powers
have had a fair trial, as it sometimes happens, that in the progress of labor
the tumor is so much  displaced  as to allow of the  passage of  the  child.
Further, before sacrificing the infant,  we ought to ascertain whether the
contents of the tumor may not be drawn off, by passing a long trochar into
it.   If a small  quantity of fluid  escape,  it may allow of the  application of
the forceps, and so enable us  to save the child.   If, however, the tumor
prove to be solid and immovable, we must, as a "dernier ressort," have re-
course to the perforator and crotchet.
  8. When the child is hydrocephalic to such an  extent as to prevent its
entering or passing through the pelvis, whether distorted or of the natural
size, there can be no question of the propriety of opening the head.
  9. If an arm descend along with the head, the  diameters  of which cor-
respond closely to  those of the pelvis (whether the latter be of the usual size
or not), it may  be necessary to terminate the  labor by opening the head
  10. I have already alluded to a class of cases, where, from mismanagement  i
the patient has been allowed to continue  too long without help and in con-
sequence is  greatly exhausted, with fever, quick pulse,  delirium  etc   In
such cases the  patient  will soon  die if she be not assisted ;  and from the
unfavorable state  in which she is,  she cannot bear a prolonged  or very
painful  operation.  Now  if there be  sufficient space for the forceps  thev
ought to be preferred, and it would be very wrong to use the perforator •
but if this  be doubtful, and the  probabilities against our succeeding with
that instrument, then tl e  consideration of the  patient's  inability to  bear a
severe  operation may  in some cases  decide  us in  favor  of embryotomy 
                              CRANIOTOMY.                        375

  These cases, however, are but few, and they must be well marked, to justify
  our adopting at once such extreme measures.
     11.  In footling or breech cases, when the head  (separated or not from
  the body) cannot be extracted, we must evacuate its contents.
     577. The next question to be decided is the period of labor at which  the
  operation should be performed.
     1.  In all cases where the  diminution  of the pelvic diameters is  so great as
  to render it impossible that a living child can be born naturally or extracted,
  there can be no hesitation in recommending that the head should be opened
  at an  early period of the labor, say as soon as the os uteri is dilated or fully
  dilatable.  By this means we shall afford a chance of the completion of  the
  labor  by the natural powers, as  there can be no  objection to waiting a  few
   hours before extracting  the child.
     2.  When the distortion is less, we cannot be sure as to the result of  the
   natural efforts, and we must wait until it is evident that they are inadequate ;
   then an endeavor should be made to use the forceps, and if this fail, there
   should be no delay in the performance  of embryotomy.
     3.   These  observations will apply equally to the case of  morbid  growths,
   ovarian disease, etc., obstructing the passages.
     4.   In cases  of convulsions,  ruptured uterus,  etc., the time for the opera-
   tion  is  determined  by  circumstances connected  with  those accidents,  and
   which will be found laid down in the chapters on the subject.
     5   In cases where the child  is dead,  there need be no delay in  performing
   craniotomy as soon as the  delay in the labor renders it desirable.
     [In the first volume  of  the Transactions of the Obstetrical Society of
   London, published  1860, there is a very elaborate and highly interesting
   paper by  Dr. W. Tyler Smith, " On the Abolition of Craniotomy from  Ob-
   stetric Practice in all Cases where the  Foetus is Living and Viable."
     It  is upon the extension and development  of three  great conservative
   measures — the  use of  the forceps,  turning, and induced labor—that Dr
   Smith insists the diminution and abolition of craniotomy must mainly depend.
     "Although," he remarks, " I would contend for the abolition of craniotomy
   in the case oi living children, as a rule of practice, believing firmly that it  may
   always be avoided if we properly develop the whole of the resources  at our
   command, I am not so Utopian as to expect that cases will not occasionally be
   met with in  practice, in  which  perforation of the living child will not only be
   necessary, but a positive duty.   Cases will occur of deformity overlooked, of
   impaction from delay, and swelling of the soft parts, of malpositions and  mal-
   presentations unrectified, and  other forms of dystocia, in which such a point
   of difficulty has been reached, that  either the mother or the child  must be
   sacrificed.  Under  such circumstances, it would be the bounden  duty of the
   accoucheur to craniotomize rather than allow the mother to perish.
      " But I believe that  such deplorable contingencies need never occur, and
   that cases of this kind,  when they do happen, ought to be considered as de-
   pending on  some error  or neglect, and to be held only as exceptions to right
   practice.   Nothing will tend  so much to diminish or prevent such cases, as
»   the establishment of the non-necessity of craniotomy as the rule of practice.
   Considering the various means at our disposal in the way of preventing the
   necessity for craniotomy, I do not hesitate to express my strong conviction
   that, as the rule, craniotomy in the case of the living and viable  child  should
   be abolished, and that if all the resources of obstetrics, in the way of preven-
   tion, management, and alternative  treatment,  were properly wielded, the
   necessity for the operation  would  never  occur.   There is no  department
   of medicine in  which, looking to what has been already done, there is more
   reason to be proud and hopeful for  the future,  than obstetrics."
      After referring to the fact that, in  London, previously to the year 1670, 
376                         CRANIOTOMY.
the deaths from child-birth, was 1 in 39, whereas it is now rather less than
1 in 200,—showing that two centuries ago, more than five women were lost
in child-bed where  but one now perishes, Dr. Smith remarks, that, " look-
ing to the  results obtained by the most successful practitioners, there are
good grounds for expecting that the  deaths from child-birth may ultimately
be reduced to less than 1 in 1000.   No class of cases admits of improved
management  to a greater  extent  than instrumental labors, and of these
craniotomy cases are by far the most fatal."  If the facts and arguments
adduced by him are of any value, Dr. Smith believes that they show that
 ' the diminution or abolition of craniotomy must greatly diminish the loss
of maternal, as well  as of fcetal life.   Rightly  considered,  the interests of the
mother and child rarely if ever come into collision.   With the one exception
of high pelvic  deformity, it may be laid down  as a moral axiom in obstetrics,
that the treatment which most certainly assures the safety of the child, is
also the safest for the mother."]
  578. Mode of operating.—It is not  absolutely necessary for the opera-
tion that the os uteri should be fully dilated, though it is  a great advantage,
and greater care will be required when  this dilatation has not taken place.

                                Fig. 147.
                             Use of the Perforator.

  The rectum and bladder are first to be evacuated;  the patient is then to
be. placed on her left side,  with the hips over the edge of the bed and an
assistant beside her, to fix and steady the abdomen                '
  One or two fingers of the left hand are then  to  be introduced into the
vagina,  and their extremities fixed upon that part of the head of the child
which is to be perforated.  Contrary to ancient practice, this should  never 
«
                            craniotomy.                          377

be the sutures, because after the opening is made in that situation, the bones
collapse and close it.   Having  determined upon the situation, the perforator
is to be passed along close to the palm  of the hand  and the inside  of the
fingers, so as to avoid injury to the soft parts of the mother.
  Having arrived at the point of insertion into the skull, guided and guarded
by the fingers of the operator, the perforator is to be pressed firmly forwards
with  a semi-rotatory motion, until it pierce the bone  (fig. 147) ; it is then
to be passed in up to the shoulders, and the handles are to be separated by
an  assistant as widely as possible (fig. 148).   The  cutting  edges  of the
scissors are then to  be placed at right angles with the first incision,  and
again separated, so as to make a crucial incision.  This being  effected, the
perforator is to  be  passed into the skull, the  brain thoroughly broken up,
and the medulla oblongata  cut across.  The scissors are then to be with-
drawn, and the  first part of the operation is complete.
Fig. 148.
Use of the Perforator.
  The left hand is again  to  be introduced, as a guide  and guard to the
crotchet, which should be passed into the cranium for the purpose of com-
pletely breaking up the brain.   When this object  is attained, if we wish to
terminate the operation at once, the crotchet may be fixed on the outside or
inside of the head; the former was  adopted by the older practitioners, but
the latter is recommended generally  at present  (fig. 149).  In some cases it
is useful  to employ two crotches — one internally and the other externally.
The scalp should be carefully folded over the  edges of the  bones, in order 
37 8
craniotomy.
to prevent injury to the passages, and then extracting force must be gradu-
ally and  steadily applied during  the pains, or at intervals, in  imitation of
them, in the axis  of the outlet through which the head is passing : the left
Fig. 149.
Application of the Crotchet.
hand  remaining in  the vagina, and two  fingers, being placed on the head,
opposite to the insertion of the crotchet, both for the purpose of steadying
it and of preventing mischief, if the instrument should slip.   If the  part  of
the skull in which the  crochet is fixed give  way, we must  obtain  another
purchase.   The amount of force, and its continuance, will depend of course
upon the resistance to the passage of the child ;  but if, after a certain time,
no progress be made, in order to avoid contusion of the soft parts of the
mother, it will be well to break up  the  skull with the forceps adapted  for
that purpose  (fig. 138).   The perineum must be  carefully guarded, and care
must be taken that no injury be inflicted by the spiculae of bone.
   After the head is extracted, the body generally follows without much diffi-
culty ; but should this  not be the case, we must have recourse to eviscera-
tion.   The scissors must be plunged into the chest, and the contents broken
up: the crotchet hooked upon the ribs, and traction exerted.  The  contents
of the abdominal cavity may be evacuated in a similar way, and after this
we shall generally be able to extricate the child.
   If the craniotomy forceps  be  used, one blade must be .passed  into  the
skull, and the other on the outside, and sufficiently far to  secure a firm hold
(fig. 150) ; the blades then being closed, the operator must draw down firmly,
yet gently, and at intervals.
   In the plate I have placed the instrument on the forehead of the child,
in order to show its application ; as  a general rule, however, we would seize 
craniotomy.
379
the occiput with them, unless there be special reasons for preferring some
other part.
  579. The principal difficulties of the operation are as follows :
  1. If the bones of the skull be very firm, it is not easy to perforate, and
the point of the scissors is very apt to slip.   This can only be avoided by
great care and steadiness.
  2. A similar state of the bones will offer a serious obstacle to the insertion
of the point of  the crotchet;  but a little perseverance will in most cases

                                Fig. 150.
Application of the Crotchet.
overcome it.   The fingers of the left hand placed on the outside of the skud,
will render it still more easy.
  3. The extraction may be difficult.  If the narrowing  be  not too great,
the difficulty may be overcome by steady force ; but if such a degree as may
be exerted with impunity do not move the head, we must then break up the
skull, as already stated.
  580.  The dangers to which the  patient may be exposed in this operation
are more serious than when the forceps is used.
  1. The perforator may slip, and the vagina or uterus be wounded.
  2. The hook may slip, or the bone in which it is fixed may suddenly give
way ; and if the hand of the operator be not interposed, a severe, or even
fatal rent may be inflicted.
  3. The perineum may be  lacerated by the injudicious exertion of extract-
ing force.
  4. From the condition of the patient, she generally suffers more from the
shock to the nervous system, than in the  operations previously described.
  5. There is also greater danger  of subsequent  inflammation of the womb
or vagina, with perforation  of the bladder,  especially if much  force have
been necessary.
  After-treatment.—The nervous  shock will be best remedied by quiet,
small doses of opium, and moderate stimulation. 
380
CRANIOTOMY.
  The state of the vagina and uterus  should  be carefully watched,  and
vaginal injections of warm water used occasionally.
  If any  symptoms of  inflammation  arise, they must be  met promptly by
the appropriate remedies,—venesection, leeching, calomel,  and opium, etc.
  In other respects, if the  patient go on well, she must be treated as after
natural labor.
  [Cranioclasm.—Dr. Simpson, of Edinburgh, has proposed, in cases where
labor can  be accomplished only by a reduction of the size of the child's head,
an operation which he  denominates cranioclasm.  He  believes it to be an
easier, safer, simpler, and shorter operation than the ordinary one of crani-
otomy, and one which, inasmuch as it  is  adapted to dislocate and break up
the bones  composing the basis of the cranium, diminishes to a much greater
extent the size of the child's head, facilitating thus, its passage  through a
very contracted pelvis, in which case  alone is the breaking  up of the head
justifiable.
  In the performance of cranioclasm the instruments required are, 1, a per-
forator, to  open the head (fig. 151),  and 2,  a cranioclast,  to break down
the skull, and extract the head through the pelvis (fig. 152).
Fig. 151.
Fig. 152.
The Perforator.
The Cranioclast.
  The perforation of the head is effected in the same manner and according
to the same rules, precisely, as in the operation of craniotomy.
  The perforator  used  by Dr. Simpson  is so constructed that the blades
can be separated by the simple approximation of the handles.  As this can
be done witn one hand, the other is left free to guide and guard the point of
the instrument, rendering the assistance of another practitioner or a nurse
unnecessary.   The ends of the handles  are  kept apart, during the  passage
of the point through the skull, by means of a hinged bar, which allows of the
ready approximation of the handles, and consequent separation of the blades,
without it being necessary for the operator to stop, after the instrument has
pierced the skull, to  remove the straight solid bar which,  in Naegele's per-
forator, is used to keep  the extremities of the handles asunder.  Dr. Simp-
son has also, usually had the instrument  made with  an angled indentation
at the base of each of its cutting edges or sidet.  These lateral indentations 
CRANIOTOMY.
381
prevent the point and edges from readily slipping out of the skull when the
instrument is opened,  an accident which has sometimes  happened under the
use of the common form of the perforator or perforating scissors.
   The cranioclast is of the usual  length and weight  of the guarded crani-
otomy forceps employed in British practice — being about 13 inches long,—
5^ inches from the tip to the middle of the button joint; its outer blade,  at
its broadest point, one inch, and its inner blade, of course, somewhat narrower:
and the exterior of the length of the fenestra of the outer blade, about three
inches.  It is a kind of forceps with  a movable button  joint, so as to allow
the instrument to be introduced either in a  fixed form with the blades con-
joined, or each blade separately, like the  common midwifery forceps.   The
inner or smaller blade is solid and convex,  and serrated on the side by which
it fits  into the concavity of the other larger fenestrated blade.   Both  have a
slight curve to  enable them to be adapted to  the curved form  of the bones
of the cranial vault.  The concave surface of the outer fenestrated blade,
and the convex surface of the  inner solid  blade, are serrated with relative
transverse ridges and grooves, so as to make the hold of the instrument as
perfect as possible without the fear of lacerating the included tissues.
   In using the instrument, the smaller solid blade is first introduced, through
the opening made by the perforator in the vault of the skull, very deeply into
 the interior, and then the other, or fenestrated blade, being passed over the
 occiput outside the  scalp, the two are made to lock, after they have been
 pushed in this position as far down over the occiput as they can be made to

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

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

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

 OBSTETRIC  OPERATIONS. —6.  THE CESARIAN  SECTION, OR  HYS-
                              TEROTOMY.

  581.  So far, I think, our investigations have fully borne out an observa-
tion  made in a former chapter, viz., that obstetric  operations  formed an
ascending series—each one exceeding the other in importance and danger;
and that whilst no two  could be compared  in terms of equality, the value of
each was shown by its alternative, which is always one  of greater danger.
Thus the  mortality  of premature labor  is less  than  its alternative, the
crotchet;  that of the forceps less than the crotchet; and we shall now see
that inasmuch as  when it is employed  early,  the safety of the mother  is
nearly secured, the danger of embryotomy  to her is far less than that  of the
Caesarian section.   This operation is indeed the dernier ressort of midwifery.
Preferable as it is  to the certain death of both parties, it is far more  serious
in its consequences than any other operation.   It comes under the class of
operations already noticed, in which the life of mother  and child are  neces-
sarily more or less compromised.
   It  is of very ancient date, being  known  to  the  Greeks, and  called
votepotopotoxiri, or i/x^piosxxr;; but J believe  by them only employed after the
death  of the  mother.  From the  circumstances of several remarkable per-
sonages having entered the world in this way, it was deemed fortunate to be
so born—a royal  road, in short, to  distinction.  Pliny has recorded that
Scipio Africanus was thus extracted.   He  says, " Auspicatius enecta  matre
nascuntur, sicut Scipio Africanus prior natus."   He is not correct, however,
in stating that Scipio was the first thus  brought into this world ; Claudius
Ccesar,  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  " Caesares,"  on the
authority  of Pliny, Festus,  Pompeius,  Solinus, etc.   " Quia  caeso  matris
utero in lucem  prodiscunt."  Caeso Fabius, who was three times consul, was
thus extracted.  Julius Caesar  is also stated to  have  been brought into the
world bv means of this operation, although it is an error to state that the
name Caasar was given to  him on this account, inasmuch as he inherited it
  1 [Clinical Lectures on the Diseases of Women,  by J Y. Simpson, M. D., London Med.
Times and Gazette, May 8, June 9, I860.] 
384
THE CAESARIAN SECTION,
from his father.  Among the ancients, persons thus born were  considered
sacred to Apollo, to which Virgil alludes in the lines—

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

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

                       1 A New System of Midwifery, p. 272.
          25 
386
THE CAESARIAN  SECTION,
sometimes impossible to introduce the hand;  or from large excrescences or
glandular swellings, that fill up the vagina and  cannot be removed ; or from
large cicatrices in that part and at the os uteri, which cannm be separated;
in such emergencies, if the woman is  strong and of  a good habit of  body,
the Caesarian operation is certainly advisable,  and ought to be performed ;
because the mother and child  have  no  other chance to be saved, and it  is
better to have recourse to an operation which has  sometimes succeeded,
than leave them both to inevitable death."1
   The operation is described by almost all authors, both English and Con-
tinental, but with considerable  difference of opinion, both as  to its useful-
ness and the cases to which it is applicable1.   I shall not,  however, occupy
the reader with further detail, but again refer him to  my researches on Ope-
rative Midwifery for those minute particulars which  would be misplaced here.
   582. After this  short sketch, we may proceed to  consider the operati'on
itself, its object, and the means for attaining it.
   The objects of this very formidable operation  are of extreme  importance.
   1. To afford a chance of escape to the mother, and of life to  her offspring,
in cases where  the child cannot be extracted through the  natural passages
by any means  at our  command, or in cases when the extraction,  if com-
pleted,  would  be  almost  certainly fatal to the  mother.   As to  using
it as an ordinary substitute for craniotomy, the proposal is simply absurd.
If the reader will turn to the appendix, he will find  the question investigated
at length.
   2. To extract the child so promptly, as to afford it a chance of life, when
the death of the mother has taken place suddenly.
   3. To relieve the mother from the risk of fatal inflammation, owing to
the presence of the fcetus in the abdominal cavity acting as  a foreign body.
   583. The nature  of the operation by which these objects are  to be effected
is simple, viz., that  of  cutting through the abdominal and uterine parietes,
so as to come  at the child, and then  removing the  entire contents of the
uterus, and closing the external incision by sutures and sticking-plaster.
   But though so simple, it is most dangerous.  Wounds of the peritoneum
of the simplest kind,  though not necessarily and  invariably fatal, are very
frequently so.   In most cases, inflammation of the serous membrane  has
followed, and in very many it  has terminated in death.   There is  another
source of danger.   If  the  wound in the uterus should not be  completely
closed by its  contraction,  hemorrhage  to a  fatal  amount, from  the uterine
sinuses,  may occur, though it is not so frequent as was supposed by the
earlier writers.   This appears to have been the  cause of death in the cases
related by Dr. Cooper and  Mr. Thompson.
   The formidable nature of the operation, however, only makes it the more
necessary to ascertain clearly the grounds upon which it  is justifiable.   It
is sufficiently evident,  from what has been already stated, that the  older
practitioners  performed it unnecessarily; this  is proved, I say, by the fact
that the same woman bore  children afterwards without assistance.   Now,  it
is an established axiom in midwifery, that the mother's life is not to be com-
promised in order to save the  child.   A  certain amount of risk may be
fairly incurred, but  beyond this, the  safety of the  mother is to be secured,
because that is in our power, and if necessary,  the child sacrificed, because
it cannot certainly be  saved without  sacrificing the mother.  In no cases  •
where the  mother's security can be  so  purchased, can  we be  justified in
having recourse to  the  Caesarian section;  but there are  cases 'on record,
where the pelvic outlets are so narrowed by distortion, that  a mutilated child
could not be dragged through.  In  Mr.*Thompson's case, the antero-pos-
terior diameter of the upper outlet was only fths of  an inch. In Dr. Cooper's

                      1 Midwifery, vol. i. p. 239, 6th ed. 
OR  HYSTEROTOMY.
387
second case it was 1|, and the transverse diameter of the lower outlet only
t an inch.   In Dr. Young's case, the antero-posterior diameter of the upper
outlet was  If inch.   In a skeleton in Dr. Hamilton's possession it was only
fths of an inch.   In  one of Dr. Hull's cases (Ann Lee)  the conjugate
diameter, taken from the symphysis pubis to the projection  of the sacrum
was If inch, and  from the acetabula to the projection of the sacrum, lT9gths
inch on each side.  In the  other case (Isabel Redman), the passage was
narrower, though the deformity was different.   " Out of 80 cases, the opera-
tion was  necessitated by  narrowness of the antero-posterior diameter of the
pelvis in  G2.
                  Thus it was      1   inch in  1 case.
                                   1^   "  in  8 cases.
                              1| to 2    "  in 23   "
                              2  to 2i   "  in 25   "
                              2£to2|   "  in  5   ul

  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 1-g-  inch antero-posterior  diameter, by 3  transverse, as
the smallest space  through which a child, after evacuation of the contents
of the cavities, and the breaking up of the  cranium, could be extracted by
the crotchet;  but others have deemed this impossible.   Certainly great risk
of injury to the  soft parts  of the mother would be incurred by the  force
necessary to drag the fcetus through so small a space, not quite, perhaps,
but nearly  equal to that resulting from the Caesarian operation.  Moreover,
there are cases on record by Drs. Shekelton and M'Clintock, in which a child
was extracted through a pelvis  whose diameter was  about that fixed  upon
by Dr. Osborn, and the mothers died, one immediately, and the other within
twenty-four hours.   In such cases, I  agree with Dr. Murphy, that the risk
of the Caesarian  section  would  be less for the mother, and we should give
the child a chance.
  I  should, therefore,  conclude that when,  from  any cause, the antero-
posterior diameter of the  upper outlet, or the transverse diameter of the
lower, is not fully 2j inches, there is  no possibility of delivery "per vias
naturales," with safety to the mother, but that we must have recourse to the
Cicsarian section.
  [Dr. Meigs believes that the operation may be demanded in different dia-
meters in different cases, and that it is impossible to fix  a minimum diameter
through which a female may be delivered.   In diameters of  an inch or an
inch and a half  the Caesarian section is of  course inevitable.  Dr. Meigs,
however, would not hesitate to recommend  it in a pelvis the diameter of
which ranged from two to two and a half inches,  where the patient is in im-
minent danger of sinking, while in another and less pressing case—with the
same  pelvic dimensions — where the  patient had sufficient strength left to
bear the  operation of craniotomy, he would as certainly advise the latter in
preference  to  the Caesarian section.   Dr. Meigs relates  a case where the
diameter of the pelvis was not beyond two inches, in which he delivered by
embryotomy on two occasions,  and  in which the Caesarian  operation was
subsequently performed  twice, successfully as to both mother and child—no
chano-e in the condition of the pelvis  having taken place in the meantime.]
  584. Statistics.—But it may fairly be asked, what chance does so serious
an operation afford to either mother or child ?  The only mode of answering
this question is by adducing the evidence on record.  The following tables
contain a  list of British and American  operations,  successful and unsuc-
cessful.
                    i Yelpeau, Traite" des Accouch., p. 4-17. 
I. UNSUCCESSFUL CASES.
  3
  4
  5
  6
  7
  8
  9
 10
 11
 12
 13
 14
 15
 16
 17
 18
 19
 20
 21
 22
23
1737
1773
1769
1773
1774
1774
1774
1775
1777

1794
1798
1795
1798
1799
1800
1813
24	1817
25	1821
26	
27	1820
28	1821
29	
Operator or Authority.
Mr. R. Smith, Edinburgh
Professor Young
Dr. White, Manchester
Mr. Wood, Edinburgh
Mr. Thompson, London
Professor Young
Dr. Cooper, London  .
Mr. Chalmers, Edinburgh
Mr. John Hunter
Mr. Wliyte, Glasgow
Mr. Atkinson, Leicester
Mr. Clarke, Wellingborou
Dr. Hull, Manchester
gh
Dr. Hamilton,  Edinburgh
Mr. Kay, Forfar
Mr. Wood, Manchester
Mr. John Bell, Edinburgh
Mr. Dunlop, Rochdale
Mr. Wood
Dr. Kellie, Leith
Mr. Kinder Wood
Dr. Wallis
Barlow and Cort
Barlow and Dugdale.
Dr. Henderson, Perth
Dr. Radford, Manchester
Patient's Name.
Paterson
Martha Rhodes
Eliz. Foster.
Eliz. Clarke.
El. Hutchinson

Isabel Redman
Ann  Lee
Jean Douglass

El. Thompson
Susan Holt .
H.Rheubotham
Ann Hacking
Mrs. Ridgedale
Mrs. Lowe  .
Mary Ashwell
Mary Nixon
Hours
  in
Labor.
7 days
24 hours
 2 days
12 days
 8 days
 3 days
12 hours
10 days
 2 days
 3 days
24 hours
48 hours
18 hours
34 hours
19 hours
moll, ossium
moll, ossium

moll, ossium

malacosteon

 distortion
tumor
distortion
Results
  to
Mother.
died
CO
oo
References.	
Smellie's Mid., vol. iii. p. 42	3.
MS. Lectures.	
Hull's first letter.	
Ibid.	
Med. Obs. and Enq., vol. iv.	p. 261.
MS. Lectures.	
Ibid., vol. v. p. 218.	
Hamilton's Outlines, p. 339.	
Med. Obs., vol. v.	
Hull.	
Hull, p. 67.	
Mem. Med. Soc, vol. v.	
First Letter, p. 162.	
Ibid., 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. Journal, vol	vi. p. 346.
Ed. Jour., vol. viii., p. 11.	
Med. Chir. Trans., vol. vii. p. 264.	
Med. Times and Gazette,	March 12,
1858.	
Barlow's Essays.	
Merriman, p. 317.	
Ibid.	
Ed. Journal, No. 146.	
Ibid.	
Pamphlet, 1849.	
 
II. UNSUCCESSFUL CASES —CONTINUED.
Date.
HO	1848
31	1851
32	1843
33	.
34	1853
35	1854
36	1856
37	1856
88	1858
39	1858
40	
41	1820
42	1829
43	
44	1834
45	1841
40	1843
47	
48	
49	
50	1845
51	1847
52	1849
53	1850
54	1848
55	1848
50	
1850
Operator, or Authority.
Dr. Merriman  .
Dr. Shipman  .
Drs. Cyrus Falconer and Goodman
Dr. Radford   .
Dr. Waller
Dr. Simpson   .     .    .
Mr. Humphrey     .    .
Dr. Clay  ....
Dr. Murphy
Dr. R. Greenhalgh  .
Drs. Douglass and Vanvalsah
Dr. Crichton
Dr. M'Kibbin,  Belfast
Mr. Ward
Dr. Montgomery, Dublin .
Mr. Ross, Invergordou
Dr. Elliott, Waterford
Mr. Whitehead, Manchester
Mr. Braid
Messrs. Bailey and Hardy
Mr. Lyon, Glasgow  .
Mr. Skey, London   .
Mr. Campbell,  Disburn
Mr. Nimmo, Dundee
Dr. Shipman, U. S.  .
Dr. Sannerman
Dr. West, London
Dr. Oldham, London
Patient's Name.
Betty Wilcock
Williams
Hours
60 hours
6 days
5 days
17 hours
48 hours
12 hours
14 hours
17 hours
Cause.
tumor
distortion
fib. tumor
moll, ossium
     a
   tumor
     it
 distortion

     n
 exostosis
fib. tumor
  tumor
distortion
 tumor
distortion
 tumor
distortion
Results		Results
to		to
Mother.		Child.
died		saved
	<	dead
	t	saved
		twins") saved /
		
	'	saved
	<	dead tt
	< <	saved
	t	dead
	t	saved
	t	dead
	t	tt
	t	alive
	i	dead
doubt'l		alive
dead		dead
	t	saved
d	ed t i t t	dead saved dead saved dead
Amer. Jour., vol. xviii. p. 122.
Amer. Jour. N. S., vol. vi. p. 264.

Assoc. Jour., Jan. 19, 1856.

Med. Times and Gazette, vol. xxvii. p.
  20G.
Brit. Med. Jour., 1854, p. 1066.
Ibid., 1856, p.  779.

Dub. Jour., No. 6, 1859.
Med. Times and Gaz., May, 1858.
Amer. Med. Journal.
Ed. Jour., July, 1828, p 53.
Ibid., Nov.  1831, p.  352.
Lancet, Mar. 28, 1840.
Dub. Jour., vol. vi. p. 418.
Ed. Monthly Jour., 1842.
Letter to the Author.
Ranking, vol. vii. p. 330.
Ed. Monthly Jour., Dec. 1845.
Ranking, vol. v. p. 293.
Ibid., vol. x. p. 330.
Ed. Monthly Jour., Sept. 1850.
Amer. Med.  Jour., July, 1849.
Lancet, July 13, 1850.
Med. Times, Feb.  22, 1851.
Ibid. 
TI.  SUCCESSFUL CASES.
No. 1	Date.
	1739
2	1793
3	1822
4	1827
5	1827
6	1833
7	1835
8	1837
9	.
10	
11	1845
12	1847
13	1849
14	
15	1850
16	1841
17	
18	1856
19	1858
20	1851
21	1845
<)0	1851
23	1851
Operator, or Authority.
Mr. Barlow
Mr. Cellen, New York
Dr. Richmond, Ohio, Amer.
Mr. Knowles, Manchester
Mr. Greaves, Rockingham
Mr. Gibson, New York, Amer.
Ditto and Fox .
Dr. Fox  .
Dr. Wright
Mr. Goodman, Mancheste
Dr. Henderson, U. S.
Dr. Radford   .
Dr. Coltman
Dr. Travis, Tenn.
Dr. Jeter, Georgia
Dr. Thornton,  Dewsbury
Mr. James Hawkins
Dr. Oldham
Dr. Brodie  Heron
Dr. W. II. Merriman
Mary Dunally, Midwife
Patient's Name.
Alice O'Neal

Jane Foster
Mrs. Sankey
Mrs. H
Anne N—
Mat. T
aigh
12 days

 5 days
5 days


5 days
3 days
Cause.
distortion
distortion
exostosis
same patient
2 days
dis. of sacrum
  distortion

   scirrhus
Results
  to
 Child.
dead
saved
saved
putrid
saved
dead

  it
saved

  t<
dead
References.
Ed. Medical Essays,  vol. v.  part 1, p.
  439.
Med.  Rec. and Res.,  p. 154.
New York Journal, March, 1823.
Western  Medical Journal,  November,
  1827.
Trans, of Prov. Ass., vol. iv.
Lancet, 1833-4, p. 148.
American Journal of Medical  Science,
  May, 1835.

Lancet, March 28, 1840.
Ibid., 1833-4, p.  148.
Ranking, vol. vii. p.  239.
Ibid., vol. v. p. 293.
Prov. Medical  and  Surgical  Journal,
   August 22, 1849.
Ranking, vol. x. p. 212.
N. Orleans Medical and Surgical Jour-
   nal, November, 1850.
Med. Exam., September, 1850.
Southern Medical and Surgical Journal,
   March, 1851.
Lancet, March 28, 1857.
Medical Times aud  Gazette, May 8th,
   1858.
 Lancet,  vol. ii. p. 226, 1851.
 Amer. Jour. N. S., vol. xii.  p. 386.
 Ibid., vol. xxxi. p. 507.
 Ibid. 
OR  HYSTEROTOMY.
391
     Thus in British and American practice, out of 79 cases, 23 mothers were
  saved and 56 lost, or more than two-thirds.
     Out of 77 cases where the result to the child is mentioned, 44 were saved
  and 33 lost, or nearly one-half.
     In addition, I have collected from foreign authorities 371 cases, out of
  which 217 mothers recovered and 154 died, or about 1 in 2^}   Out of  189
  of these cases where the result to the child is given, 139 were saved and 50
  lost, or nearly one-fourth.  Taking the entire number, which amounts to 450,
  we find that 230 mothers  were  saved  and 210 lost, or about 1 in 2 ;  and
  that out of 315 children, 211 were saved and 104 lost, or about 1 in 3|.   M.
  Figuiera collected 790 cases, of which 424,  or nearly one-half, were fatal to
  the mothers.
     In Nassau, Dr. Ricker  says, that in 311,409 cases, there were 12 cases
  of Caesarian section,  2 mothers and 7 children were saved.
     As  to the value of each  case, that must depend  upon the reporter.  I
  have not felt it my duty to exclude any which are related upon definite
*  authority—my endeavor throughout has been to ascertain  that authority as
  far as possible, and to  avoid repetitions.   For  so much  I am  responsible,
  * aud I trust I shall be found correct.  It may, however, be objected to this
   catalogue of operations, that many of the cases occurred in the " dark ages"
   of midwifery and may perhaps have been exaggerated or invented.   Sup-
   pose that  we admit  this, and only take those which have occurred  since
   1750, this calculation  gives 321 operations, from which 149  mothers re-
   covered, or more than one-half,  and by which 130 children were saved, and
   57 lost, in 182 cases where the result is mentioned.
      Dr. West has collected 409 cases, of which  251 (considerably more than
   one-half) proved fatal to the mothers, 237 children were saved.
      Dr. Arneth mentions that Kayser has collected and analyzed 338 cases,
   of which number 210, more than half, proved fatal to the mother;  86 of the
   children were either  dead born or perished soon after birth.
      585.  Further: 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 we find five, six, and seven times with-success.
      This  is shown in the following table :—

     1 I do not mean that  so many mothers were saved from death by the operation, but
   that they were saved from the effects of the operation.  No doubt, many were  really
   saved from death, which could not have been otherwise avoided; but we have proof that
   many could have  been  delivered by other means, inasmuch as they afterwards bore
   children naturally.
     In 11 cases recorded in foreign journals since my tables were constructed,  I find that
   six mothers were saved and five lost;  eight children were saved and three lost. 
392
THE  C.ESARIAN SECTION,
No.	Date.	Operator or Au-thority.	Patient or Place.	Opera-tions.	Children Baved.	Result to Mothers.
l7		—Guillet		6 times	6	saved.
\ 2	: :}	Le Noir and Le-brun	.	3 times	3	recovered.
3		M. Jobert	.	twice	1	k
4		M. Peyronnie		"		"
5	, .	M. Sommius	his own wife	7 times		(<
6	• •}	A Surgeon atl Paris J	his own wife	5 times		a
7		.	...	3 times		a
8			At Aucois	6 times		tt
9		Count Nessan	.	7 times		it
10	1775*-9	M. Lambron	...	twice		a
11	1797")				'■'■\	recovered twice—
12 13	1801 [ 1805 J	Mangold and 1 L. Mautz /	.	3 times		died after 3d.
14	17971 1806/	M. Bacqua	—Gabery	twice		recovered.
15	17961 1810 f	Rhode and 1 Sommer /		u		k
16			• .			
17 18	1802 » 1805/	Lorinzer	Groger	it		<(
i 19	/18051 17-14/	M.le Maistre 1 d'Aix /	—Fauve	3 times		do. died after 3d.
20	1313,'15	Dr. Charmeil	...	twice		recovered.
21	f 1817 1 \ 1819/	M. Locher	.	(<	■ '■}	recovered once— died 2d time.
22	1821,'26	M. Merrin	—Viandes	it		recovered.
23	1823	M. Bosch	. .	it		u
24	1823, '25	M. Schenck	. .	a		CI
1 25 1	1805, '07 f 1826,1	M. Dariste	Martinique	it		((
i 26	\ 30,32 V I 39 J	M. Michaelis	—Adawetz	4 times		(«
27		Dr. Zwancke		, ,		
28	•	Weidemann, 1 Michaelis j		4 times		recovered.
29	(<	it		# #		
30	. .	Dr. Boowin		twice		recovered.
31	.	M. Gardey		a		»
32	f 18251 \ 1826 /	Dr. Schmidt		tt	'■'\	recovered once— died 2d time.
33	J 1824 \ \ 1826 f	Dr. Engletrum	Amsterdam	"{	2 \ saved (	recovered once— died 2d time.
34	1833,'35	Dr. Bouvin	• • ■ .	tt		recovered.
35	1832, '38	Dr. Kilian	.	tt		<<
36	/1837 \1843	"	.	ce	. .	a
37	/1840 \1844	Dr. Mesten-1 hausen /				
			• •	it	• •	tt
38	-f 1846	Drs. Bach 1^ and Stolz /	.	tt		n
39	• «	Dr. Wieckel	• • .	thrice	. ,	n
  M. Stolz has also published a case in which he performed the operation
twice with success.1
  [Professor Stolz, of Strasburg, has reported not merely one, but six cases,
in which he has  performed the Csesarean section.   In four of these cases

     » Med. Circular, Aug. 22, 1855, p. 89 ; Ed. Med. Journal, Aug. 1855, p. 179. 
OR  HYSTEROTOMY.
393
both mother and child were  saved by the  operation, but in the  other two
the child only ]
  Dr. Simpson mentions that, when he visited Bonn, he saw a woman upon
whom  Kilian  had operated three times successfully, and who was  looking
forward to a fourth operation,1 which my friend, Professor Retzius, of Stock-
holm, informs me has since been successfully performed.
  [Professor Gibson, formerly of  Philadelphia, operated twice  on the same
patient, and both times successfully for mother and child.2]
  Dr. Decoene has recently  performed hysterotomy in a case  of ruptured
uterus, for the purpose of removing the children (there were twins) from a
woman on  whom he had  formerly performed Caesarian  section.   She re-
covered the more recent as well as the former  operation.3
  586.  After a Careful examination of the cases on  record, it appears that
a certain amount of success  has  attended  the operation, and that  modern
improvements have rather increased  the number of recoveries ;  so that I
think we may fairly conclude, that as so  many women  have recovered from
the operation, it does afford  a chance to both mother and child, and that
therefore we  may be justified in having  recourse  to it;  but that, as the
danger is much greater  than from  any other operation, we should not be
warranted in performing it,  if there were a  prospect of success by other
means.
  This, then, constitutes the  sole  advantage of the  operation, that  in cases
where we cannot deliver the patient with  safety by any other means, and
when,  consequently, both mother  and child would inevitably die, we  may
afford each a chance by performing the Cossarian section.
  It has no comparative advantages, being itself the  ultimate  standard by
which  the other operations are to  be estimated, and which are valuable, in-
asmuch as they afford a means of  escape from this more formidable one.   In
this point of view I must not omit noticing one which, although  not avail-
able in any case to which we  are  called  at the time of labor, may prevent
the necessity of a second operation.  I allude to the artificial induction of
premature labor,  or  of abortion.  Whenever the diameters of  the pelvis
are so reduced as to render the extraction of  a mutilated fcetus impossible,
or even hazardous, I conceive that it would be grievous neglect of duty not
to  propose this alternative ;  nay, more, I  really think we have a right to
insist upon it; for surely, it can hardly be  expected that a conscientious
medical man will consent to destroy child after child, or to subject  mother
and child to the fearful risk of the Caesarian section,  when a means of avoid-
ing it is in his power.  It is  true that by this operation the child may be
lost, but the mother will, in all probability, be saved;  and the  bare chance
of saving the child by Caesarian section, can  never compensate for the  ad-
ditional risk to the mother.
  [It is very certain that nothing can justify  a resort to the Caesarian sec-
tion in  any case in which there is a fair prospect of the labor  being termi-
nated with safety to the  mother, either by the  unaided  powers of the uterus,
or by instrumental assistance.  Formidable as  the operation must be viewed
under all circumstances,  modern statistics have shown us, nevertheless, that
when it is  resorted to early in  labor, it is attended with less  danger than
was formerly ascribed to it,  and  that it affords  a chance in a considerable
number of cases, for the escape of both mother and child  from the almost
certain death which must happen to both if it  were omitted.]
  587.  The disadvantages of the operation  will be easily gathered from
what has been  said ; they are mainly, the great risk of  hemorrhage or  of

  i Edin. Monthly Journ., July, 1S50.    2 [Amer. Journ. Med. Sciences, May, 1838.]
  " Med. Times and Gaz., May 21st, 1853, p. 630. 
394
THE CiESARIAN  SECTION,
fatal peritonitis to the mother, and the small chance afforded to the child ;
these constitute the  objections to the operation.
  That these  are very serious  objections cannot be denied, nor that they
would  be insurmountable, had  we any other mode  of delivery.   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 ac-
coucheur, that his  patient, after  recovering  from the Caesarian  operation,
should bear children without assistance.
  [We are informed by M. Castel, that in a case  which occurred in one of
the French hospitals, the Caesarian  section being determined on, some delay
took place in accommodating with seats the crowd of students who had as-
sembled to witness the operation : during the time thus occupied the female
was  delivered naturally.  M. Gomelle  states that at the  hospital of M.
Dubois, a small  woman, who had five  times submitted to the Caesarian  sec-
tion, was delivered  naturally the sixth time.]
  588. The cases suitable for the operation are not very numerous.
  1. When the pelvis is so  distorted from  any cause that the diameter of
the upper or lower  outlet is  reduced to an inch and a half  or two inches, it
may be considered  impossible to extract a mutilated fcetus;  or, if possible,
it must be with so much force as  to entail the death  of  the mother.   The
operation is equally necessary under these circumstances, whether the child
be alive or dead, aud it may also be required (in consequence of mollifies
nssium) after several children have been born naturally.
  2. Morbid growths from the periosteum, which offer  a fixed and perma-
nent and increasing obstacle, may so much reduce the calibre of the passage
as to render this operation necessary.   This was  the case with the patients
of Dr. Montgomery and Dr. Shekleton.  But before we decide upon the ne-
cessity for this mode of delivery, we must be quite sure that  the obstacle
can neither be displaced nor reduced in volume ; aud this can  seldom be
determined until labor commences.  On  the other hand,  we must remember
that all  tumors  increase, however  slowly, and that, therefore,  the patient
having been delivered "per vias naturales" in one labor, is no proof that
she may be in the next.
   3. In  some cases of  ruptured uterus, when delivery is imperative, but im-
possible  "per vias naturales,"  Caesarian section has been recommended.  It
appears to me that  the additional risk from the operation renders its pro-
priety very questionable.
   4.  The operation has been performed successfully in cases of extra-uterine
foetation, where  the continued presence of the fcetus in the abdominal  cavity
threatened the mother's life.
   5.  In case of the  sudden death of the mother, the Caesarian section may be
performed for the  purpose  of  saving  the infant.   Successful cases are on
record;  and one recently  by  Mr.  Harlay,  in  Edinburgh.1  Of course  the
operation will h e useless, unless the woman have  arrived  at that period of
pregnancy when the child is "viable."   It will also be in vain if much time
have elapsed after the death  of the mother.   Dr. Jackson,  however, re-
covered  an infant half  an hour after the death of the mother.
   6.  If,  towards the end of pregnancy, the uterus  be wounded extensively,
 Dr. Hull considers  the Caesarian section necessary.
   7.  Authors have mentioned other cases to which the operation was appli-
1 Edin. Monthly Journal, July, 1850. 
OR  HYSTEROTOMY.
395
cable, as in occlusion to the vagina, scirrhus uteri, etc.   But these hardly
appear to be adequate grounds  for so serious an operation.
  589. The best period for the performance  of the operation appears to
be at the commencement of  the labor, provided  there be no doubt of its
necessity.  The strength  of the woman is then  unimpaired, and she can not
only support the operation better, but has greater prospect of escaping sub-
sequent  inflammation.   It is  supposed, and  I think not without foundation,
that the  ill success which has  attended the operation in this country is partly
owing to the late period at which it has been undertaken.
  In Mr. Thompson's  case, it was performed 24 hours after the commence-
ment of labor ; in Dr. Cooper's, 12 hours ;  in Mr. Chambers' case the labor
had  lasted 12 days; in Dr. Hamilton's,  more than 2 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 Donally, 12 days;  in  Mr. Barlow's case, 5 days.  Dr. Hull pro-
poses to operate as soon  as the os uteri is dilated,  and before the membranes
burst.  De Graafe advises  the operation  to be performed just after the
rupture of the membranes, and the commencement of the expulsive pain.
  590.  Method  of Operating.—Having  determined upon the  necessity,
and  the proper period for the  operation, the next subject for consideration
is the best mode  of performing  it.   Very little  alteration has taken place iu
this respect since the earlier writers.
  The  bowels and bladder are to be evacuated, and the patient placed on
her  back, upon a table covered by a mattress.  Her fortitude must decide
upon the necessity for restraint, and  its amount, if chloroform  be not used.
  Before commencing the operation  it will  be proper to ascertain  (by the
stethoscope) the  situation of the placenta, or, at least, that it be  not in
front.  The incision through the integuments must then be  made, either
vertically, through the linea alba — obliquely, on the outside  of the rectus
muscle — between that muscle  and the spine — or horizontally, beneath the
umbilicus.  The  latter is the  best if  the  patient be deformed.  It should be
about eight or ten inches in length, and when vertical, it may be commenced
a little  above the umbilicus, and terminate near the pubes.   This  incision
 should  divide the parietes of the abdomen down to the peritoneum, which is
then to be cautiously punctured, and a director, or the finger, inserted into
 the  wound, so as to avoid injuring the intestines, and the peritoneum divided.
 The uterus will  now be exposed, and an incision must  be made into,  but
 not through its parietes, of the same length as that through the abdominal
 parietes.  This incision must be cautiously deepened, until the membranes
 are  exposed.  A slight  opening must then be made in them, and some of
 the  liquor amnii  removed, by small pieces of sponge.  It has occurred to me
 that this  might  most readily be effected by a  syringe.   The object in view
 is to prevent effusion  into the  abdominal cavity.   By Lauverjat and others
 we  are recommended to rupture the membranes previously.  The opening
 is then  to be enlarged, and the infant withdrawn,  the funis  tied, and  the
 placenta and membranes removed.
   The  remaining liquor amnii, with any blood  which may have escaped,
 must be removed from  the  cavity  of the  uterus, and the operator should
 make sure that the os uteri is  pervious  for the escape of the lochia.   No
 sutures are required  in  the uterus : as it contracts, the wound  will be
 reduced to about 1| to 2 inches in length, and the lips will come into appo-
 sition,  if it  be healthy.   It  is  only in cases where  they do not do  so, that
 there is anything to fear from   hemorrhage.   When the uterus is diseased,
 the wound does  not close perfectly,  and of  course, union cannot take place.
   The abdominal cavity is next to be lightly sponged, to remove any blood
 which may have escaped, and then,  the  intestines being  retained "in situ" 
396
THE CAESARIAN  SECTION.
by an assistant, the lips of the external wound are to be closed by so many
sutures  of  silver or iron wire as may be necessary.   Dr. Monro, of Edin-
burgh, advised "that in performing the Caesarian operation, we should  be
careful that the viscera be exposed as little as possible ; and that the^ sides
of the wound  should  be kept contiguous by a greater number of stitches
than  are commonly employed in wounds, in order to exclude the air from
the cavity of the abdomen."  In addition to the sutures, straps of adhesive
plaster may be applied, and over all I would suggest Dr. Macartney's water
dressing.   The patient must then be  placed in bed,  and the  utmost quiet
observed.   Stimulants will probably  be necessary  during and after  the
operation ; and when  the  patient is settled in bed, an opiate may be given.
  As a variation  from this mode of operating, I may mention  Dr. Aitken's
suggestion of performing  it " while the parts  are immersed in tepid water,
so as to exclude the air," and so, perhaps, diminish its fatal effects.  I  do
not know that this plan has ever been tried.
  M. Roubaix, in an elaborate essay on this subject, lays down the following
objects at which we are to aim  in performing the operation :  1, to prevent
the entrance of air into the peritoneal cavity and uterine sinuses ; 2, to pre-
vent the effusion of blood and liquor amnii;  3, to make the incisions in such
a manner that union by first intention may be encouraged as far as possible;
4, to take  precaution against inflammation of neighboring tissues ; 5, to
perform the operation at a favorable time.1
  591.  The difficulties of the operation  are not great.   With  a little care,
we  may avoid that part of the uterus to which the placenta is attached, and
which is the most vascular, as the stethoscope, previously applied, will indi-
cate  whether  it is situated  anteriorly  or  not.   Caution will  also avoid
wounding the child when dividing the uterus.
  In approximating the lips of the external wound, the intestines are some-
times troublesome, and it is of importance not to include any of them, as that
would add  the dangers of  strangulated hernia to the unavoidable risk of the
operation.
  The principal dangers of the operation are—
  1.  Hemorrhage, from the incomplete closure of the wound in the uterus.
  2.  Strangulation of a loop of the intestines, either in the wound of the
uterus, or  in the external wound, although due attention will avoid this
danger altogether.
  3.  Subsequent inflammation of the uterus and peritoneum.
  The patient may die of  the shock within a few hours, or her strength may
be exhausted by hemorrhage into the  abdominal cavity; but if  she  survive
for a day or two, her death will then probably be owing to inflammation.
  592.  Subsequent treatment.—The most incessant care and attention will
be  required.  The  water-dressing should be continued, and it may be as
well to administer small doses of calomel and opium.   On the  first appear-
ance of inflammation at the edges of the wound, leeches should be applied
along it, and if there be tenderness, a considerable number should be applied
over the abdomen, and repeated if necessary, and the doses of calomel and
opium increased.

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

         OBSTETRIC  OPERATIONS. —7.  SYMPHYSEOTOMY.

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

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

  Persons were not  wanting to applaud  the inventor  and his operation,
which was characterized  as "the result of inspiration," and several practi-
tioners in France  and Germany followed his example. 
398
SYMPHYSEOTOMY.
   M. Sigault himself operated on four other women, one of whom died, ant
 several of the children.  He seems, indeed,  to have become less confident in
 Its safety and efficacy;  for he refused to perform it unless there was a space
 of 2^ inches in the short diameter ; and before his death, in such a case, he
 recommended the Caesarian section.   "It was soon found, however,  not to
 merit the high encomiums  bestowed upon it.   Every operation was  found
 to have  its victim, although it  was several times performed  upon women,
 whose  pelves were  either not  at all, or very slightly  deformed, and who,
 either before or after the operation, were delivered without any extraordinary
 assistance—a convincing proof that the operation had been,  in these cases
 at least, unnecessarily resorted to."1
   In 1778, he published a " Discours  sur les Avantages de la Section du
 Symphyse du  Pubis," in which he examines the usual means  of assisting
 difficult labors,  and  concludes by stating his reasons for preferring Symphy-
 seotomy to the  Caesarian section.
   The first persons, I  believe, who investigated the propriety and efficacy
 of the new operation in this country, were Dr. W. Hunter, Mr. Hunter, and
 Dr. Denman.   The former published the result of his inquiries in the Lon-
 don Med.  Obs.  and Enquiries.   " The women of Great Britain," says Dr.
 Osborn, " are therefore*under considerable  obligations to the late Dr. Wm.
 Hunter, who, from an accurate mensuration of those pelves where the Caesarian
 operation  had  actually been  performed in  this country, and of others still
 smaller, preserved in his museum, has  demonstrated the  futility  of the sec-
 tion of the  symphysis as a succedaneum for  that operation, or as a certain
 means of preserving both the mother and child."  He suggested a combi-
 nation of the Sigaultian operation with craniotomy, as affording the mother
 a better chance than the Caesarian section.  But, as Dr. Osborn remarks,
 "Prof. Guerard's case is exactly in point, and confirms  by experiment what
 was to be  expected ct  priori.   The child's head  in that case was opened,
 after the division of the symphysis had been performed;  but  the professor
 was, notwithstanding, foiled in every attempt to deliver, both by the forceps
 and the crotchet; and the event in the end  proved fatal to the mother."2
   The next writer  who notices the  operation is Dr.  Leake, who,  in  his
 work  on the Diseases  of Women, 1781, has a few pages upon  this opera-
 tion, of which he is inclined  to  judge favorably, though with  caution.  He
 answers some of the objections urged  against it, but admits that more ex-
 perience was required.
   The operation was performed in the  year 1782, for the first and last time
 in this  kingdom, by Mr. Welchman,  of Kington, in Warwickshire.   The
 child was putrid, and  the mother died ; but Mr.  Welchman thinks that her
 death was not caused  by the operation.3
   Dr. Osborn,  in his  Essays on Midwifery, 1783, gives a good historical
% sketch of the operation, and  after a very careful examination into the  merits
 of it, he arrives at the conclusion that "no  circumstances whatever, real or
 imaginary, can ever render it a warrantable operation."
   Mr. Dease, in his Observations  in  Midwifery,  1783, disapproves  of the
 operation.   He says, it was "of worse consequence than the Caesarian ; as
 it subjected  the woman to all the dangers,  of the latter,  without the  same
 advantages of saving the child."
   Dr. Hamilton, Sr., in his  Outlines of the Theory and Practice of Mid-
 wifery, 1784, doubts the efficacy of the  operation, and points out  its hazard.
   Dr. Aitken, Elements of Midwifery, 1784, says that the operation maybe
 nseful " when about half an inch of addition  to  the short diameter (of the
 pelvis) is sufficient to allow delivery."
    1 Hull's Second Letter, p. 94.           2 Essays on Midwifery, pp. 282, 323.
    3 London Med. Journal, 1790.   Hull's First Letter, p. 138. 
SYMPHYSEOTOMY.
399
  Dr.  Hull,  in his First Letter, 1790, points out the inadequacy  of the
operation ; and in his Second Letter enters more fully into the history of
it, and shows that the combination of symphyseotomy with craniotomy (first
proposed by  Dr.  Hunter, and repeated by Mr. Simmons) is worse than the
Caesarian section.
  Dr.  Denman, in his Introduction to Midwifery, objects  to the operation,
except, perhaps, in a case where the life of the child (it being alive)  was of
such immense importance to the  nation, that the  mother might fairly run
the risk.
  By every modern British writer the operation is denounced, and is not
likely ever to be again attempted in this country.
   The contagion of  enthusiasm spread rapidly among the French, though
some more cautious  and  philosophical writers held aloof, and others de-
cidedly disapproved  of  the  new operation. .  It  has  not, however, even in
more modern  times, been  so completely discouraged as we might have ex-
pected from  the results of the cases in which  it  has  been employed.   The
last case performed in France was by M. Masleur, at Lagemont; the space
gained admitted  one finger between the divided  symphysis; and the neces-
sity for the operation may be judged by the fact that, after recovery, the
patient bore  a living child naturally !
   The operation  has been performed in Italy.   It has also been modified
by Prof. Catolica, after  the suggestion of Desgranges and Champion.  In-
stead of dividing the symphysis, the ossa pubis were cut  through, nearer
their juuction with the ossa ilia, and by this means a positive increase in the
antero-posterior  diameter was gained.   M. Galbiati performed this opera-
tion in 1819, and it proved fatal.
   In Germany, it was at first highly extolled ;  but the general opinion after-
wards was unfavorable  to its  utility.  Indeed, it would  be  astonishing to
find any candid man who could resist the evidence afforded  by  the cases in
which it has been tried.
   594. Statistics.—49 cases have been recorded : of  these 16  mothers
died, or  about 1  in  3 out of  40 cases; the child was  born alive in  11, and
dead in 19, or 1 in 2.
   I shall not give these  cases in detail, but a slight analysis may show more
fully the slight ground the advocates of the operation had for exultation.
   1.  It was performed unnecessarily in four cases, as was proved by a sub-
sequent natural delivery.
   2.  Without any cause in one case, the patient having borne children natu-
rally, and there being no deformity;  and  in another,  where there was suffi-
cient space.
  '3.  Without the possibility of benefit from it in one case, where the an-
tero-posterior diameter was only If inch.
   4.  Although 33 mothers recovered, 10 children were lost, 14 saved, and 1
much injured.  Of 7 nothing is stated.   Of  the 16 mothers who were lost,
5 of their children only were saved;  9 were dead, 1 much injured, and of 1
nothing is  stated.  So that,
   5.  In  the latter case, 16 mothers were sacrificed to save 5 children.
   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 incon-
tinence of  urine ; 3 had  prolapsus  uteri.   In one, the bones  of the pelvis
exfoliated, the cervix uteri and posterior part  of bladder  were gangrenous;
and several were  endangered by the operation, whilst of a great number no
details are given.
   We shall now examine the merits of the operation  a little more minutely.
   595. The object of the operation is to increase the  short diameter of the
pelvis, by the enlargement of the arch formed by the ossa ilia and pubis, so 
400
SYMPHYSEOTOMY.
as to allow of the passage of the child in cases "where it must otherwise have
been extracted through an artificial opening ; and by this means afford  a
greater chance of life both to the mother and child.
  596. The 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 syn-
chondrosis; so that, if the latter were anchylosed, the operation would fail
altogether.
  Again, it must be remembered, that owing to the posterior situation of
the sacro-iliac synchondrosis, the space gained will be mainly in the oblique
diameter of the  pelvis;  next to this in the transverse, and least of all in
the antero-posterior diameter.   But it is from the last-mentioned diameter
being too  short that the difficulty exists, and therefore upon the amount
gained in it, depends the successful  issue of the operation.
  The entire question turns  upon this point.   If  by the separation of the
ossa pubis so much space be gained as will make up the difference between
the sacro-pubic  diameter in a deformed pelvis,  and the same diameter in
an  ordinary one, then the operation  is, at  least mechanically, adapted to
the object in view.
  Hence it is very  important to ascertain  as nearly as we can, how much
may thus be added to the antero-posterior diameter.  We know from Sigault
and Le Roi's case, that the ossa pubis may be separated four inches : how
much will this increase the short diameter ?   Dr. Bentley, in his  Disserta-
tion, quotes the  experiments of Ripping of Paris, and Lobstein  of Stras-
bourg, in support of the conclusion that the utmost  gain by the operation
is four lines in the  short diameter, and Dr. Aitkin says half an inch,
  I feel satisfied myself that half an inch  is the very utmost that can be
gained, except by such violence as  would be utterly unjustifiable.   But then
Dr. Leake observes that the head will press into the opening, and " it will
therefore follow that as much of the occiput, or hind head, as is intruded into
an  aperture at the pubis  of two inches and a half, so much precisely will be
the space gained by this  operation,  and  superadded to the short  axis of the
pelvis from sacrum  to pubis, which  will  be  equal to the enlargement from
side to side — the circumstances here contended for."   This is undoubtedly
ingenious, but not quite correct, inasmuch as the long diameter of the head
at the upper outlet corresponds with  one of the oblique, and not with the
sacro-pubic diameter; so that the  occiput would  correspond pretty nearly
with the acetabulum, and the tuber  parietale with  the interval between  the
ossa pubis.   In  this situation, no part of the head could  pass through the
opening unless the operator  changed its position.  Further, Dr. Osborn has
justly remarked, that this pressing  into the opening would be at the expense
of so much injury to the bladder and soft parts  as would render the opera-
tion unjustifiable.
  597. The advantages of the operation, as  enumerated by its  supporters,
are :
  1. That it substitutes  an  operation of less danger for the Caesarian sec-
tion ;  but this, we have seen, is not true, for  although one in three of the
mothers only are lost by it (rather  less  than by the Caesarian section), yet
those who  recover  are liable to accidents which  fully counterbalance this
slight advantage.
  2. That it affords a better chance of  saving the child ;  but we have seen
►hat only one-half of the children were saved, whilst by the Caesarian section,
more than two-thirds were preserved. 
SYMPHYSEOTOMY.
401
   3.  That it is a less painful operation.   This is true as regards the period
 of operating, but if the period of convalescence be included, with the se-
 quelae which occasionally occur with each, I should doubt the fact.
   4.  The  section of the pubis which allows the child to be born by  the
 natural passage, carries not with it those ideas of cruelty which the Caesarian
 operation does, where the patient is, as it were, embowelled  alive.   This is
 very plausible but very false humanity.
   598. The objections against the operation are to my mind unanswerable,
 although some that have been put forward  as  such have been refuted by
 experience. ^ It must be remembered that the operation is contemplated for
 those cases in which the Caesarian section would otherwise be necessary.
   1.  For these cases the operation is inadequate.   In a former chapter, we
 have seen that  the Caesarian  operation  ought not to be performed in  any
 case where  the antero-posterior diameter is more than two inches, inasmuch
 as the delivery can be accomplished by a less hazardous method.   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 ascer-
 tained that a living child cannot pass through a pelvis whose short diameter
 is less than 3 inches; consequently, the Sigaultian  section cannot  avail in
 these cases, unless craniotomy be superadded.   But  the mortality of the two
 would be greater than that of the Caesarian section, for 1 in 3 of the mothers
 would be lost, and all the children, by the combined operations ;  whereas
 by the latter, although 1 in 2£  of the mothers are lost, more than two-thirds
 of the children are saved.
   2.  Even  if the  space gained would secure the delivery, the mortality of
 mothers and children would not justify its  preference  to the Caesarian section
 —especially if we take into account the sequelae.  These  objections appear
 to me quite conclusive  against the  operation; but as  others  have been
 adduced, it may be as  well to enumerate them.
   3.  The cartilage of the symphysis may be ossified; which will render  the
 operation impracticable, even after it has been commenced.
   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 synchondrosis may be ruptured past remedy.
   8.  The divided cartilages may not unite.  Experience, however, has shown
 the groundlessness of this objection.
   9.  The admission of external air may excite inflammation.
   These latter objections have, of course, a certain weight, but hardly suffi-
 cient to prohibit the operation, if it were  adapted to the  cases for  which it
 has been proposed.
   But there is another class of cases for which it would seem at first  sight
 more  suitable, and which, indeed, appear to have  been contemplated  by
 those who recommend  its. performance, where the antero-posterior diameter
 of the upper outlet is three inches.  I mean those cases where the difficulty
 is  too great for the forceps, and  in which, as we have seen, craniotomy is
 necessary.   Here the gain  of  half an inch might enable  a  living child to
 pass.   But  the operation  is objectionable in these cases,  because of  the
 results;  for independent  of the ill consequences to those who recover,  we
find that one in three of the mothers die,  and only half of the children  are
sa^ id ; whilst, although  all the children  are  sacrificed by craniotomy, only
one in five of the mothers  die.   And it must  also be borne  in mind, tha'
       26 
402
SYMPHYSEOTOMY.
these results of craniotomy have occurred under more unfavorable  circum-
stances than those of the Sigaultian operation.
   599.  From  these considerations, I trust that my readers will agree with
me in the following conclusions:
   1. That the Sigaultian operation is undeserving of the encomiums passed
upon it, inasmuch as it offers no increased chance  of safety to the mother or
child—the statistics of the  cases in which it has been  tried having shown
that one in three of the former, and one-half of the  latter are lost;  besides
that in  those of the mothers who recover, much inconvenience is experienced
from the consequences  of the operation.
   2. That it  is perfectly  inadmissible as a  substitute for  the Caesarian
section, because  the utmost  space  gained by it would  not permit the child
to be born alive in any case in which the Caesarian operation  ought to  be
contemplated; and if the child must,  in addition, be destroyed, the combined
mortality of the  mothers and children would then be far greater than from
the Caesarian operation.
   3. That it is  equally inadmissible as a  substitute for craniotomy alone,
in cases where the forceps are  inadequate, because the consequences to the
mother are more serious from it than from craniotomy.
   600.  If, as  I believe, these  conclusions are correct, I need- only add an
account of the mode of performing the operation, not  as a  model, but  to
complete  its history.   Perhaps the best mode of doing this is to give the
account of one of M.  Sigault's cases, abridged by Dr. Osborn.  " Mons.
Sigault,  with a  common bistoury, cut through the integuments and linea
alba, beginning the  operation at the upper and central part of the symphy-
sis pubis ; then introducing  his forefinger as a director,  he cut through the
ligaments and cartilage ; immediately upon the  completion  of which, the
two ossa  pubis, with a peculiar noise, spontaneously separated two inches
and a half; this  was demonstratable,  for M.  Le  Roi laid  his  four fingers
into  the opening.   M.  Sigault immediately introduced his hand into the
uterus,  broke  the  membranes, and brought  down the feet.   M.  Le Roi
accomplished the delivery.   The whole operation, both section and delivery,
was finished in five minutes.   The child was  born alive.  A ligature was
passed round the body of the mother, to keep the pelvis firm.   The  patient
having no bad symptoms, was left till  the  next day, when every circumstance
continued favorable ; she had passed  her urine voluntarily twice, there had
been no hemorrhage, and she had suffered little pain."
  Having entered thus fully upon the  operations proposed for the relief of
the previous classes of unnatural labor, we may now resume the considera-
tion of the remaining deviations from natural labor. 
MAL-POSITION AND  MAL-PRESENTATION OP  THE CHILD.  403
                       CHAP TER XVI.

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

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

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

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

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

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

                                   Fig. 158.
Face Presentation—Second position. 
106          MAL-POSITION  and mal-presentation
604.  Statistics.—Frequency.
a. British Practice.			b. French Practice.		
Authors.	Total No. of Cases.	Face present.	Authors.	Total No. of Cases.	Face present.
Dr. Jos. Clarke	10,387	44	Mad. Boivin .	20,517	74
P.P.	3,847	7	Mad. Lachapelle	15,652	65
Dr. Merriman	2,947	10	M. Ramboux .	491	3
Dr. Granville .	640	1	M. Dubois	10,742	30
Dr. S. Cusack	701	3	Dr. de Belli .	2,739	17
Dr. Maunsell . Mr. Gregory .	839 691	7 2			
					
Dr. Thos. Beatty .	1,184	4	c. German Practice.		
Dr. Collins . Dr. Lever	16,414 4,666	33 24			
					
Dr. Reid	5,691	25	MM. Moschner \ and Kursak j Dr. Carus	12,329	122
Drs M'Clintock and Hardy	| 6,634	14		2,557	24
Dr. F. Ramsbotham	48,996	162	Dr. A. E. v. Siebolc	I 1,003	10
Dr. E. Murphy	467	7	Dr. E. C. v. Siebolc	I 494	4
Dr. Metcalf .	300	1	Dr. Kilian	9,392	122
Mr. Crosse	1,394	5	Dr. Merrem .	157	1
Mr. Earle	4,320	4	Dr. Naegele .	115	4
Birmingham H.	650	13	Dr. Kluge	799	6
Mr. Rose	600	1	Dr. Brunatti .	100	2
Mr. Bailey	2,819	15	Dr. Adelmann	57	1
Mr. Watson .	800	14	Dr. Jansen	13,365	15
j Dr. Copeland .	1,290	7	Dr. Arneth	6,608	40
j Dr. Bliss	771	8	Prof. Schwerer	21,804	50
. Dr. Pagan . .	8,684	6	Wurtzburg Hospita	1 637	10
Mr. R. U. West .	2,106	10			
Mr. J. Thompson .	3,300	6			
Drs. Sinclair and 1 Johnston /	13,748	40			
Dr. Hall Davis	7,233	110			
  Thus in British practice, out of 141,259 cases, there were 567 face presen-
tations, or 1 in 249 ; among the French, 50,141 cases, and 189 face presen-
tations, or about 1 in 265^ ; and among the Germans, 69,417 cases, and 411
face  presentations, or about 1 in 169^ ; the whole  giving 1167 face presen-
tations in 260,817 cases, or about 1 in 223^ cases.
  As to the mode of delivery,  and results to mothers and children, I cannot
make out a regular table, but must content myself with such scattered notices
as I  have been able to obtain.   Mr. Giffard relates 4 cases; 1 was delivered
naturally, and 3 with the forceps; neither mother nor  children were lost.
Dr.  Smellie gives 19 cases; 3 delivered naturally, 5 by  version, 4 by the
forceps, and  5 by craniotomy; 3 mothers and  11  children were lost.  Mr.
Perfect relates 8 cases: 1 delivered naturally, 2  by version, 4 by forceps,
and  1 by craniotomy ; none of the mothers, but 2  of the children were lost.
Dr.  Jos.  Clarke performed craniotomy twice in his 44  cases;  all the rest
were delivered naturally.   Dr. Ramsbotham has recorded 3 cases :  2 de-
livered by the forceps, and 1 by craniotomy; all the children were lost, 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.
All  Dr. Pagan's 6 cases were delivered naturally ;  all the mothers recovered,
and 5 of the infants were saved.  All Mr.  Thompson's cases, mother and 
OF  THE CHILD.                        407
child, recovered.1   Drs. Johnston and Sinclair lost 6 children, and 1 mother
died of peritonitis.2   Dr. Hall Davis lost 8 children.3
  Of Madame Boivin's  74 cases, we are informed that  41  were delivered
naturally, 14  by version,  and 2 by craniotomy, but  nothing is said of the
mortality.   Of Madame Lachapelle's 65 cases, 41 were delivered naturally,
20 by version, and 4 by the crotchet; 7 children are stated to  have been lo'st.
  Of 80 cases under the  care of Dr. Boer, of Yienna,  all but  one were
delivered without assistance ; in that one case the forceps were used.   None
of the mothers suffered, and 3 or 4  of  the children only were lost.   Of Dr.
A. E. v.  Siebold's 10 cases, 6  were delivered by the forceps.   Of the 40 cases
related by  Dr. Arneth, all were delivered by the natural powers ;  3 boys
and  2 girls  were  lost.4
  Thus,  so  far as  our data  go, out of 384  cases, 248 were  delivered natu-
rally, and 77 required artificial assistance {i.e. 42 versions, 20  forceps, and 15
craniotomy).  In 190 cases where the result  to the mothers is given,  3 died,
or 1 in 60; and  of 256 children, 19 were lost, and 15 destroyed,  or about
1 in 7.
  It is worthy of remark, that the  mortality among both mothers  and chil-
dren is greatest when assistance was given ;  for of Dr. Collins' 33, M. Boer's
80, and  Dr. Arneth's 40 cases, delivered naturally, none of the mothers, and
but  12 of the children  were lost.   These notices show also the change of
opinion  as to the necessity for assistance.
   [" I have treated," says Dr. Huston, in a note to a  former  edition,  " seven
cases of  face presentation; four were delivered with the forceps, one with the
vectis, and the others without  assistance, the children  being small.  The
mothers all recovered, but two  of the children  were still-born."   We have
seen nine cases of face  presentation ;  four of them were delivered without
assistance.   In these cases the mother  had a favorable recovery, and  the
children were born alive and  did well; three were delivered with the vectis;
the  mothers all  did well, one of the children was still-born, but recovered
under the use of appropriate means, in the remaining two cases the applica-
tion of the forceps was found to be necessary to accomplish delivery.  In both
the children were still-born; one was subsequently resuscitated, but the other
perished.]
   605. Causes.—It is  very difficult to  assign correct causes for  this mal-
position.  It maybe owing to some shock—coughing, for instance,  or sud-
den uterine action, just before the  head takes up its  permanent position at
the brim.
   Dr. Simpson attributes  mal-position and  mal-presentations generally to
the following causes :—
   1. Prematurity  of the  labor: parturition occurring  before the  natural
position of the fcetus is established.
   2.  Death of the child in utero ; or, in  other words, the loss of the adaptive
vital reflex actions of the  fcetus.
   3. Causes altering the  normal shape  of the  fcetus or contained body, or
causes altering the normal shape of the uterus or containing body,  and thus
forcing the fcetus to  assume,  in its reflex movements,  an unusual  position in
order to adapt itself to the unusual circumstances in which it happens to be
placed.
   4. Preternatural presentations are occasionally the result of causes physi-
cally displacing  either the whole fcetus  or  its  presenting part,  during the
latter  periods of gestation or at the  commencement of labor.
   606. Diagnosis.—"The presentation  of the face," says Dr. Denman, " is
  1 Glasgow  Med. Journal, July, 1855, p. 130.          2 Practical Midwifery, p. 75.
  » On Diff. Parturition, p. 274.
  * Die Geburtsshiilfliche Praxis,  etc., zu Wien.  Von Dr. F. H. Arneth.  1851,  p. 45. 
408         MAL-POSITION  and mal-presentation
discovered by the general inequalities of the presenting part, or by the dis
tinction of the particular parts, as the eyes, nose, mouth, or chin.  There is
no very great difficulty in making out this  presentation before tumefaction
takes place :  but afterwards  it may be  mistaken for the  breech, unless we
are very careful.  The bridge of the nose  will be the best guide, as  being
prominent, firm, and unlike any part of the breech.   The eyes or mouth may
be confounded with the anus, and the malar bone with the tuber ischii.
  607.  Symptoms.—The only effect  which a face presentation has  upon
labor is to retard the second stage, but not  to such an extent, or very rarely,
as to give rise to unfavorable symptoms.  The resistance to be overcome is
greater, because the bones of the face and  base of the cranium which pass
the first through the brim, cavity, and outlet are incompressible, and because
there is not the same power of adaptation ; but the  impediment only calls
forth more energetic action on the  part of the uterus, and we perceive that
the progress of the labor, if slow, is still evident.   The suffering, of course,
is more severe, as well as more prolonged.   The child when born is a fright-
ful object in most cases;  one eye closed, and  the  half or the entire of one
cheek swollen, red, and contused ; but these injuries speedily pass away, and
in a day or two the  face assumes its ordinary aspect.  I should mention,
that if a rough and careless examination of the presenting part be made in
these  cases,  the eye  may  be seriously damaged, or even destroyed.   The
mortality amongst the children is rather more than in head presentations,
but less than in any other mal-presentation.
  If, as is very rarely the case, the delay should be excessive, the symptoms
of powerless labor will be developed, and will call for  prompt relief.
  608.  Treatment.—Formerly, when this mal-position was regarded as an
unnatural  presentation,  it was held  necessary or  advisable to  deliver the
patient by art without loss of time, as appears from the statistical results of
the operation.   M. Portal  appears to have been  the first  to  suspect that
nature might  be adequate to the delivery,  and Deleurye concurred in this
opinion.  M. Boer, in 1793, objected to any interference ;  and of late years
it  has been  established  as  a rule, that assistance is unnecessary merely on
account of the mal-position.   If there should be any disproportion between
the size of the head and the pelvis, or the pains should become inefficient, or
accidental complications occur, then of course we must have recourse to the
mildest form  of assistance.   If within reach,  the  forceps will  probably be
the best instrument.
  In  ordinary cases we  must keep up the courage  of  the patient, and exer-
cise all our own patience and kindness until the delivery be effected.
  If there  be a difficulty in  establishing respiration, after the birth of the
child   as from the cerebral  congestion  there  may be, the cord must be
divided, and  an ounce or two of blood allowed to  escape, previously  to
applying the ligature.  The child's face may be fomented with a decoction
of chamomile flowers or poppy heads, and afterwards bathed frequently with
a spirit lotion.                                              ^    J
  •609  2.  The forehead  towards the arch  of the  pubis—When
describing the  mechanism of parturition, it was stated, when the head pre-
sents in the third or fourth position, it ordinarily changes into the second or
first in its passage through the pelvis, but  that occasionally this change of
position does not take place, and  that the  head then passes down through
the lower outle  with the  forehead turned  obliquely under  the arch of the
pubis.   When there the head may be forced equally down, if there be room
presenting the  longitudinal diameter (a little modified) to  the antero-pos-
terior  diameter of the lower outlet, or the forehead may remain stationary
at the pubis whilst the posterior part of the head sweeps over the perineum
  610.  Statistics.— Frequency.                                l 
OF  THE CHILD.                       409
Authors.						Total No. of Cases.	i Forehead to Pubis.
Dr. Bland......						1.897	5
Dr. Merriman						2,947	44
Dr. Granville .						640	2
Dr. Cusack						303	2
Dr. Maunsell						849	7
Dr. Collins .						16,414	12
Dr. Storer						440	1
Mr. Crosse						1.394	26
Dr. Toogood						1,135	8
Dr. Metcalf						300	1
Dr. Pagan						8.684	31
Mr. R. U. West						2,106	59
Mr. J. Thompson						3.300	28
Drs. Johnston and Sinclair						13.748	20
  Thus, in 4*3,367 cases, the face was turned to the pubis 156 times, or about
1 in 278.
  As to the result to the child; of  50 cases where the result is specified, 9
were lost.
  611. Causes. — It is not easy to explain why the  ordinary 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 produce
similar effects, but they are not so easily detected.
  612. Diagnosis.—The mal-position will be detected by the  flatter shape
of the forehead, which does  not fill up the arch of the pubis so well as the
posterior part of  the  head ; and especially by the situation of the fonta-
nelles, the larger one being anterior, and the smaller one posterior.
  613. Symptoms.—The effects of this mal-position upon labor in its second
stage are by no means serious;  in  ordinary cases it  causes some delay at
the latter part of it, and calls  for more expulsive force; but the effort is
successful, and the child is  expelled.  If, however, the pelvis be narrower
than usual,  it may offer a considerable impediment, as a  larger diameter is
presented to the lower outlet than in the usual position.   I have seen a few
cases in which the impediment,  though so slight,  was  sufficient to  cause
mischievous delay even in women who had borne children before, and whose
pelvis was perfectly well formed.
  The effect upon the  child is generally of no moment, unless  the pelvis be
so deficient  as to require an operation.
  614.  Treatment.—If the pelvis be not smaller than usual, assistance will
rarely be necessary;  and, if we  suspect a narrowing, still  sufficient  time
must be allowed to prove whether the relative disproportion be such as $e
natural agents can overcome.   If it  be  not, then, after a due and  careful
estimate of  the  obstacle,  we must determine whether  there is room for the
application  of the forceps, or whether the  only  alternative is craniotomy.
In some few cases the  forceps may be necessary from  a failure of the uterine
power.   The time for operating  must be determined  by the amount of the
obstacle, and the symptoms present.
  615.  Mal-presentations.—Having taken the presentation of the  head
as a  type of natural  labor, we must include  the presentation of any other
part of the body under the class of mal-presentations.  If we were to follow
implicitly Baudelocque, and other foreign authorities, there is scarcely any
part of  the  body  which may not  present; but Denman, Lachapelle, aud 
4 10         MAL-POSITION AND  MAL-PRESENTATION

Naegele consider that such regijns as the back, loins, belly, neck, etc.,
constitute the presenting part.

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

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

                              i 
412          MAL-POSITION and mal-presentation
turns itself then (and frequently during the course of a single pain, by whu
it is fully expelled) from the side completely forwards, and then to the opp^
site side, so that the anterior surface of the child,  which for instance in tl

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

                                Fig. 162.
Breech Presentation — Second position.
  618. The second deviation is thus described by Naegele.   " It sometimes
happens, in presentations of the nates, that the head does not rest with the
chin upon  the breast; but  the occiput, as in  those of the face, is pressed
against the nape of the neck ;  in this case the passage of the breech through
the pelvis,  according to  which species of nates presentation it may be fol-
lows in the manner already described, as far as the head ; this, with the
occiput depressed on the nape of the neck, enters the superior aperture with 
OF  THE CHILD.
413
the vertex corresponding  to one or other ilium of the mother, and in pass-
ing through it, and pressing  lower into the cavity of the pelvis, the vertex
gradually turns more and  more backwards, so that when the trunk is born,
the arch of the cranium is directed to the hollow  of the sacrum, and the in-
ferior surface  of the under jaw to the internal one of the symphysis pubis
The passage through the inferior aperture  takes place in the following way,
viz , whilst the under  jaw presses with  its inferior  surface against the  os
pubis, the point of the occiput, with the vertex,  followed by the forehead,
sweeps first over the perineum."  Thus bringing the occipito-mental diameter
of the head into a position with the  antero-posterior diameter of the outlet
   619.  Thus,  as I observed in speaking of the passage of the head, whether
we consider the ordinary or  extraordinary adaptation of the  diameters in
breech  presentations,  we  see  at  once the  admirable way in which  the ar-
rangements are calculated to  provide for the passage of the child  with the
least possible  waste of space; and it may convince us that in far more  cases
than we should & priori suppose, nature is adapted  to the fulfilment of the
functions of parturition;  and interference, when injudicious, is more likely
to impede than to further her efforts.
   620.—Statistics. —Frequency.
a. British Practice.			b. French Practice.		
Authors.	Total No. of Cases.	Breech present.	Authors.	Total No. of Cases.	Breech present.
Dr. Bland	1,897	36	Mad. Boivin .	20,517	373
Dr. Jos. Clarke	10,387	61	Mad. Lachapelle	15,652	349
Dr. Merriman	2,947	78	M. Ramboux .	491	4
Dr. Granville .	640	2	M. Dubois	10,742	391
Edin. Lying-in- 1 Hospital |	2,452	17	Hotel Dieu, Paris . M. Mazzoni .	280 452	3 5
Dr. Cusack	701	14?	Dr. de Belli .	2,739	44
Dr. Maunsell . Mr. Gregory .	416 691	6 14			
					
Dr. Collins .	16,414	212	c. Germa	i Practice.	
Dr. Beatty . Dr. Lever	1,182 4,666	28 59			
					
Dr. Reid	3,250	79	M. Richter .	2,571	48
Mr. Warrington Mr. French .	110 89	4 2	Moschner and "1 Kursak J	12,329	125
Dr. Churchill .	1,525	35	A. E. v. Siebold .	1,944	44
Drs. M'Clintock "I and Hardy /	6,634	101	E. C. v. Siebold	1,165	18
			M. Kilian	2,350	125
Dr. Storer	440	5	M. Naegele .	1,411	76
Mr. Crosse	1,394	25	Dr. Merrem .	299	14
Mr. Earle	4,320	41	Dr. Henne	555	6
Mr. Rose	600	9	Dr. Kluge	1,074	27
Mr. Bailey	2,819	14	Dr. Carus	2,908	43
Dr. Bliss	771	15	Dr. Brunatti .	295	6
Birmingham Hosp. .	650	17	Wurtzburg Hospital	637	18
Dr. Metcalf .	300	3	Dr. Theys	28	1
Dr. Toogood .	1,135	11	Dr. Adelmann	53	2
Dr. J. Lee .	850	5 -	Dr. Arneth	6,608	113
Mr. K. Watson	800	11	Prof. Schwerer	21,804	97
Dr. Copeland .	1,290	13			
Dr. Pagan . x	8,684	131			
Mr. R. U. West .	2,106	27			
Mr. J. Thompson .	3,300	18			
Drs. Johnston 1 and Sinclair J	13,748	309			
					
Dr. Hall Davis	7,233	93			
 
414
MAL-POSITION  AND MAL-PRESENTATION
  Thus in British  practice,  breech presentation  occurred  1363 times  in
91,651 cases, or about 1 in 67i; in French  practice 1169 times in 50,813
cases, or about 1 in 42|; and in German practice 793 times in 54,794 cases, or
about 1 in 66^; the entire number of breech presentations being  3325 in
197,318 cases, or about 1 in 59J.
  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	5 4 73
Dr. Beatty Mr. Lever					28 59	12 30
Dr. Churchill .					35	14
Drs. M'Clintock and Hardy					80	34
Dr. Metcalf .					3	0
Dr. Storer					5	0
Dr. Arneth					113	19
Mr. J. Thompson . Drs. Johnston and Sinclair1					18 258	5 84
Dr. Hall Davis					93	18
  Thus, in 1148  cases  of breech  presentations, 337  children were lost, or
about 1 in 3^.
  621. Diagnosis.—The breech of the child is distinguished by its round-
ness and softness, by the cleft between the  buttocks, by the anus and by
the organs of generation ; and it would seem unlikely that it should be mis-
taken for anything else.   Yet it may be confounded  with  a face  presenta-
tion which has  advanced slowly, and where there is much swelling ; to  the
touch there is really a great similarity, but in the latter we have the bridge
of the nose obliquely across the-os uteri, and in the former the more or less
movable coccyx may be felt close to the anus, and  joining  the broader and
firm sacrum.    This  will also  distinguish  it from  a shoulder presentation,
which might be mistaken for one of the tubera ischii.
  The discharge  of meconium  is  of very little value, as it occurs in head
presentations, although  in the latter case Dr.  Collins remarks, " it comes
away in a more fluid state, and has not its natural appearance, being mixed
with the discharges from the uterus and vagina;" nor is it found on the end
of the finger  after examination.
  622. Symptoms.—The duration of the labor varies a good deal; in some
cases, it  is concluded as quickly as if the head descended, in  others  it is
more tedious  ;  there is  more  delay  when the arms are stretched  upwards
than when they are down by the side.  There is also  delay in the expulsion
of the head, owing to the incompressibility of the base of the skull, which is
the first to enter,  and its being less able to adapt itself to  the  brim.  It is

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

                                Fig. 163.
Breech Presentation — Extraction of Head.
position "  This  manoeuvre, when dexterously executed,  will generally ex
tncate the head with ease and promptitude, if the patient have had children
In these cases it is peculiarly necessary that  pressure should be applied over
the uterus from the time  that the  chest is expelled, in order to secure the
regular expulsion of the after-birth.
  624. But if the uterine power should fail (as in powerless labor), or anv
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  TnE CHILD.
411
of the child may be fractured.   After the breech is born, we may extract by
grasping the body of the child, covered with a napkin ; and let me impress
upon my junior readers, that extracting force,  to  be successful (not to say
safe) must always be made in  the axis of the brim or outlet,  at whichever
part the resistance may be.
   In  some cases, however, the head is not so easily extracted, and I per-
fectly agree  with Dr. Collins,  that " should there be  any considerable ob-
struction to the  getting  away of the head,  we  are by no means justified in

                                 Fig. 164.
Presentation of Inferior Extremities.
using violence; the soft parts of the mother will be sure to suffer from such
a mode of proceeding, and on the child's part, nothing is to be gained, as-n
is destroyed by pressure  on  the funis, continued during the time the ordi-
nary efforts  have been diligently but unsuccessfully  employed  for its  de-
livery."  If the pulsation  in the cord have ceased, " the only safe plan  under
these circumstances will be to lessen the head by means of an opening made
behind one or both ears."  If the  pulsation be good, it will be right  to try
the forceps, provided they can be introduced without difficulty; but we must
remember that we cannot in these cases  gain  much space by compression,
because we grasp the base of the skull
  625.  2. Presentation of the Inferior Extremities.—Under this head
I include  presentations of one or both of the knees  or feet, as  the former
are alwavs converted into footling cases as the labor advances.  In point
of frequency they stand next to breech presentations.
  626.  Mechanism.—Adopting Naegele's arrangement, we shall make but
two divisions of this mal-presentation.   1.  When  the toes are directed
backwards, and 2, when the toes are  directed  forwards.  The former is the
more frequent, and both correspond to the two classes of breech  presentations.
  As we  should expect,  the  feet, meeting with no resistance to  fix them,
are liable  to change their position during their descent, until  the hips enter
the brim, which they do  precisely as was described in breech  cases (§ 6171
In  fact, in its further progress the case is  identical  with breech cases,  and
the description already given will serve as well for footling cases,  on  which
account I  need not repeat it.
  The expulsion  of the body of the child may be more rapid, owing  to the
absence of the additional bulk of the thigh when doubled up on the abdomen,
but it is just so much the  less  safe for the child.
       27 
418           MAL-POSITION AND  MAL-PRESENTATION




                                   Fig. 165.
Presentation of Inferior Extremities.
627.  Statistics.—Frequency.
a. British and American Practice.			----------------------_—.—_--------------1 b. French and Italian Practice.		
Authors.	Total No. of Cases.	Pres. of ! Infr. Ex. 1	Authors.	Total No. of Cases.	Pres. of Infr. Ex. 242 247 3 1 32
! Dr. Bland Dr. Jos. Clarke Dr. Granville . 1 Dr. Merriman j Ed. Lying-in Hosp.. Mr. Gregory . ! Dr. Maunsell. 1 Dr. Beatty Dr. Collins . 1 Dr. Lever \ Mr. French . j Dr. Churchill. Drs. M'Clintock and 1 Hardy 1 Dr. Murphy . 1 Dr. Storer Mr. Crosse Mr. Earle Birmingham Hosp. . Dr. Bliss Dr. Metcalf . Mr. Rose Mr. Bailey Dr. Toogood . Dr. J. Lee. Dr. Copeland . Dr. Pagan Mr. R. U. West . 1 Mr. J. Thompson . Drs. Johnston and 1 Sinclair J Dr. IIrill Davis	1,897 10,387 640 2,947 2,452 691 839 1,182 16,414 4,666 89 1,525 | 6,634 467 440 1,394 4,320 650 771 360 600 2,819 1,135 850 1,290 8,684 2,106 3,300 13,748 7,302	18 184 3 40 8 7 21 15 187 29 1 22 38 6 2 6 40 2 8 4 7 29 3 13 10 113 29 8 181 44	Mad. Boivin . Mad. Lachapelle M. Ramboux . Dr. de Belli .	20,517 15,652 501 2,739	
			c. German Practice.		
			Moschner and "I Kursak J M. Richter A. E. v. Siebold . E. C. v. Siebold . Dr. Kilian Dr. Carus Dr. Kluge Dr. Brunatti . Dr. Theys Dr. Adelmann Dr. Arneth Prof. Schwerer	12,329 2,571 2,059 947 2,350 2.908 1,074 295 21 53 6,608 21,804	82 30 25 11 8 23 17 3 2 2 59 119 !
 
OF THE  CHILD.
419
  Thus in British practice, we have 93,749 cases, and 935 presentations of
the inferior extremities, or about 1 in 100^.
  In French practice, 45,409 cases, and 524 presentations of the inferior ex-
tremities,  or about 1 in 86|.
  In  German practice, 53,019 cases, and  372 presentations of the  inferior
extre   ities,  or about 1 in 142^.
  Alto ether 192,174 cases, and 1831 foot or knee presentations, or about
1 in 105.
  The following table shows the mortality among the children :—
Authors.	Footling Cases.	Children lost.	Authors.	Footling Cases.	Children lost.
Mr. Giffard .	23	13	Mr. Gregory .	7	3
Dr. Smellie	9	3	Dr. Beatty	15	10
Mr. Perfect .	11	6	Dr. Collins .	187-	73
Dr. Jos. Clarke	184	62	Dr. Lever	29	16
Dr. Ramsbotham .	2	1	Dr. Churchill .	22	10
Dr. Merriman	40	6	Drs. M'Clintock \ and Hardy j	25	i 5 1 |
Edin. Hospital	8	2			
Dr. Arneth	59	11	Mr. J. Thompson .	8	0
Dr. Metcalf .	4	2	Drs. Johnston 1 and Sinclair j	127	59
Dr. Murphy .	6	1			
Dr. Storer	2	2	Dr. Hall Davis	44	18
  This gives a very large mortality, 303 children being lost  out of 812, or
about 1 in 2^.
  628.  Symptoms.—The first circumstance in the labor which excites our
suspicions of its being unnatural, is very often the early rupture of the mem-
branes, and the large quantity of liquor amnii which escapes,  and on making
an examination, we discover the absence of the head  blocking up the brim,
although we may not be able to make out the presentation.  As the labor ad-
vances one or both of the feet or the knees descend through the os uteri, some-
times with the toes pointing downwards, but more frequently bent up towards
the tibia.   An examination at this period will enable us to form a diagnosis.
The labor  proceeds gradually, and the hips descend  into  the pelvis; then
the chest,  shoulders,  and  the head, precisely as described  in  breech pre-
sentations,  and with the same evolutions and adaptations.
  Danger to the mother can only  arise from  a prolongation of the second
stage, or injury to the passages, and there is little risk of either so long as
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 presentations—viz.,  the inadequate
dilatation of the passages.   The child passes through as a wedge, and each
succeeding part  being  wider than  the preceding, has to effect dilatation
sufficient for  itself, and  that at a stage when time is of great value from the
pressure to which the child is exposed.   The breech, with the  legs turned
up, is certainly less bulky than  the head, and therefore prepares badly 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 prolonga-
tion of the  pressure upon the  funis is the explanation of the increased
mortalitv.
   629.  Diagnosis.—Footling presentations, when high up in  the pelvis, 
420
MAL-PRESENTATION OF THE  CHILD.
may be confounded with presentations of the hand ;  and if  one foot only be
down,  the heel may be mistaken for an elbow.   However,  a little care will
enable us to distinguish them.   For instance, the foot is longer and the sole
flatter  than the hand ;  the toes, are shorter, and more equal in length than
the fingers, and the great toe does not separate from the others, as the thumb
does from  the  fingers.  The presence of the heel,  with  the ankle-bone  on
each side, is quite different from the  hand and wrist.   Tracing  from the heel
along  the sole  of  the foot  to  the toes, will,  of course, distinguish the heel
from the  elbow.  In an examination, the knee may be distinguished from the
elbow, for which it may in some degree be mistaken, Naegelfe  remarks, in
that it is thicker,  that it has  two prominences, and  a depression  between
them ;  while on the other hand, the  elbow, which  is thinner, presents to the
feel between the two prominences a  projection in which it seems  to end.
  630. Treatment. — In every particular, the treatment of breech presen-
tations applies to footling  cases, except that I think there is rather more
temptation to pull down the child at an early period, because of the greater
facility for so doing; but, from what I have said,  it must be evident that it
is more necessary that the labor should be let alone.   There can  be no oc-
casion  to interfere until the pressure upon the funis  is felt, i. e., until  the
umbilicus is visible, and then the risk to the child  must decide  upon whether
assistance is to be  given or  not.  The same method  must be adopted for ex-
tricating the arms, and for facilitating the expulsion of the head :  and in the
more difficult cases we have the same remedies at command.
  631. 3. Presentation of the superior extremities.—In almost all cases
of this kind, it is the shoulder  which primarily presents, and afterwards  the
arm  prolapses;  occasionally however we find the hand at  the beginning of
the labor at the os uteri,  and more rarely the elbow.
  In all cases the back of the  child  either looks forward  towards the abdo-

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

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

other observers—for example, M. Boer, Dr. Mitchell,1 Dr. Dyce,2 and  Mr.
Crosse.8
  i Charleston Med. Journ., May, 1850.     * Edin. Monthly Journal, May, 1850, p. 437.
  » Cases in Midwifery, p. 105. 
422
mal-presentation  of the  child.
  That there is another and more common  mode  in which the evolution
takes place is certain, for I have seen it from  beginning  to end, and for the
true explanation of which we are indebted to  the accurate observation and
ingenuity of my friend, the late Dr. Douglas, a distinguished practitioner of
this  city, in an  essay  published in 1811, from which  the  following  short
description is extracted.   Before its  expulsion, the situation of the  fcetus
"resembles the larger segment  of a  circle;  the head  rests on  the  pubis
internally, the  clavicle presses against the  pubis externally, with the acro-
mion stretching  towards the mons veneris (fig. 168) :  the  arm  and shoul-
der are entirely  protruded, with one side of the thorax  not  only  appearing
at the os externum,  but partly without it:  the lower part of the same
side  of the trunk  presses on the perineum, with the breech either in  the
hollow of the sacrum or at the brim of the pelvis, ready to  descend into it
(fig.  169) ; and by a few further uterine efforts the  remainder of  the trunk,
with the lower extremities, is expelled (fig.  170).  And to be more minutely
explanatory of this ultimate stage of  the process, I have to state that the
breech is not expelled exactly sideways, as the upper part of the  trunk had
previously been ;  for,  during the progress  of that  pain  by which the  evo-
lution in completed, there is a twist made, about the centre of the curve, at
the lumbar vertebra?, when both buttocks, instead of the side of one of them,
are thrown against the perineum, distending it very  much ;  and immediately
after the breech, with the  lower extremities, issues forth ;  the  upper and
back part of it appearing first, as if the back of the child  had  originally
formed the convex, and its front the concave side of the curve."
Fig. 170.                               Fig. 171.
                            Arm Presentation.

  Thus the head and the shoulder depressed in the pelvis are fixed, and the
remainder of the body doubled up, is, inch  by inch, forced  into the pelvis,
and through the external parts, until all below the  arm is expelled, leaving
the case to be .terminated as a breech or foot  presentation  (fig. 171).  a! 
SUPERIOR  EXTREMITIES.
423
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.
Douglas, is therefore more suitable than  that of "spontaneous  evolution."
An essential condition of this extraordinary  effort of nature, is the relative
disproportion of the fcetus and pelvis; either the fcetus must be smaller, or
the pelvis larger than usual, to permit it.  The accuracy of Dr. Douglas's
explanation has been proved by the observations of Dr. Gooch and  others.
I can also add  my testimony, having some years ago had an opportunity of
witnessing the entire process.
   It sometimes happens in arm presentations, when  the  child, is  small and
the pelvis large, and especially with premature births, that  the  child is ex-
pelled double.  Dr. Dyce describes a case  in which  the  shoulder and but-
tocks were brought down nearly together, the arch formed by the body look-
ing downwards.1
   I have seen the reverse more than once, and I think it is the more common,
i.  e.,  where the body doubled is  protruded, the extremities, back, and head
being above.
   632.—Statistics.—Frequency.
a. British Practice.				a. British Practice.		
Authors.		Total No. of Cases.	Pres. of Sup. Ex.	Authors.	Total No. of Cases.	Pres. of Sup. Ex.
Dr. Bland		1,897	8	Mr. Earle	4,320	34
Dr. Jos. Clarke		10,387	48	Mr. Rose	600	3
Dr. Merriman		2,947	19	Mr. Bailey	2,819	7
Dr. Granville .		640	1	Dr. Toogood .	1,135	3
Ed. Lying-in-Hosp.		2,452	4	Dr. J. Lee	850	3
Dr. Collins .		16,414	40	Mr. K. Watson	800	11
Mr. Gregory		694	4	Mr. J. Thompson .	3,300	5
Dr. Cusack		701	5	Drs. Johnston 1 and Sinclair J	13,748	60
Dr. Maunsell		839	4			
Dr. Beatty		1,182	4	1 Dr. Hall Davis	7,302	25
Dr. Lever		4,666	12			
						
Mr. Mantell		2.510	4	i		
j Dr. Churchill		1,525	9	b. Frenci	*i Practice.	
Drs. M-Clintock"» and Hardy J		6,634	26 29 4			
				Mad. Boivin .	20,517	80
Dr. Reid		5,691 650		Mad. Lachapelle	15,652	68
Birmingham Hosp. .				M. Ramboux ...	491	4
Di. Murphy .		467	-	Dr. de Belli .	2,739	37
Dr Copeland . Mr. Crosse		1,290 1,394	4 3	Wurtzburg Hospital	637	3
  Thus in  British practice it occurred 382 times in 96,454 cases, or about
1 in 252^ ;  and in French practice, 192 times in 40,036 cases, or about 1 in
2081.  Altogether 574 times in 136,490 cases,  or about 1 in 208^.
' Ed. Monthly Journal, May, 1850, p. 433. 
424
mal-presentation of the  child.
--------------------						--------- Delivered by	
Authors.			Presentation of Superior Extremities.	Mothers	Children		
				lost.	lost.	Version.	Crotcht.
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	V	2	4	
Dr. Maunsell			4		4	2	
Dr. Beatty	.		4	■' 1	4	4	
Mr. Lever			12	3	8		
Dr. Churchill			9	0	5	' 9*	
Drs. Hardy and M'Clintocl		£	26	2		19	' 4*
Dr. Murphy			2	.	2 '		
Mr. J. Thompson			5	1	5		
Drs. Johnson and Sinclair			42	3	28	'25'	
Dr. Hall Davis ....			25		15	20	' 2'
  The second of the preceding tables is intended to show the mortality to
both mother and child, so far as it is mentioned by the author : where it has
not been recorded, I have left the space blank; but if either died, I have so
specified.   I have thought it worth while, also, to add  some columns show-
ing the different modes of delivery practised.
  From this  record we  find, that out  of 314  cases of presentation of the
superior extremities, 175 children were lost, or rather  more than  one-half.
Out of 282 cases, 30 mothers were lost, or nearly 1 in 9.
  633.  Symptoms. — Labor with  this mal-presentation is, as the statistics
show, extremely dangerous  to  the mother and child, and especially as the
remedy involves a very serious  operation.   Dr. Rigby  has  given a graphic
picture of a case of this kind when unassisted : " After  the membranes have
burst, and discharged more  liquor amnii  than  in  general when the head or
nates presents, the uterus contracts tighter around the child, and the shoulder
is gradually pressed  deeper  in the pelvis, while the pains increase consider-
ably in violence from the child being unable, from its faulty position, to yield
to the expulsive efforts  of nature.  Drained of its liquor amnii, the uterus
remains in its state of contraction even during the intervals  of the pains ;
the consequence of this general and continued pressure is,  that the child is
destroyed from the circulation  in the placenta being interrupted, the mother
becomes exhausted, and inflammation  or rupture of the uterus and vagina
are the almost unavoidable results."
   On  the part of the mother, so long as the labor is virtually in the fir^t
Btage, the symptoms are perfectly natural and favorable; but after the second
stage  (marked by voluntary effort and change of cry) has lasted for some
time, then we have 111 detail the symptoms  of  powerless labor, exactly as  I
have described them; but with a difference  in the results  owins to the
mechanical obstructions offered by the mal-position  of  the child • and I re-
gard these cases as the most striking illustration of the fact I have'repeatedlv
pressed upon the reader's attention —viz., that the development of unfavor-
able symptoms is owing to the stage  at which the delay occurs, and not to
the kind of impediment; for here we find that the same  symptoms arise from
a purely mechanical impediment on the part of the child, the uterine system 
superior  extremities.                  425
being in perfect integrity, as we found to result from inefficient pains, from
tumors in the soft passages, or from deformity of the pelvis.
  634.  Diagnosis.—Our first suspicion will probably arise from finding, on
examination, that we are not able to reach the presentation; this, of course,
proves nothing ;  but it ought to induce a very careful investigation, and we
may find the os uteri very little  dilated,  and suffering comparatively little
pressure during each pain, or the  hand may be  felt protruding through the
undilated os uteri.   The high situation  of the presentation (if it be  the
shoulder) renders it  difficult to ascertain the part which is descending.   We
may derive confirmation of  our suspicions from  finding the bag of the mem-
branes  protruding, of a conical or elongated form, and evidently not cover-
ing the head.
  When the shoulder  has  descended a little, we may be able to reach the
axilla, and we  shall  find that the  shoulder is rounder than the elbow,  and
has not the condyles of the  humerus, so that this will decide the point for us.
  The hand may be mistaken for the foot;  but  its shortness, the length of
the fingers,  and the  divarication of the thumb, will enable us to distinguish
it.   The situation of the thumb, and the aspect of the palm of the hand, will
mark whether it is the right hand or the left.
  635.  Causes. — This mal-presentation has been  attributed to irregular
early contractions«of the uterus, to  irregular distention, to obliquity, etc. etc.
They may possibly have some such effect; but  I  think all the explanations
as yet offered are insufficient.  Dr. Rigby concludes:—" We may, therefore,
state that the causes of arm or shoulder presentations are of two kinds, viz.,
when the uterus has been distended by an unusual quantity of liquor amnii,
or when, from  a faulty condition  of the  early pains of labor, its form has
been altered, and with  it the position of the child."
   636. Treatment.—As (with very few  exceptions) the labor is impracti-
cable, we have nothing to expect from the natural efforts except an increase
of difficulty, it becomes our  duty to interfere promptly in  every case.   Should
the mal-presentation have been detected before the rupture of the membranes,
and before  the os uteri is fully dilated, we may  wait for a time to allow of
as complete dilatation as possible ;  nor is  there any risk so long as the mem-
branes are  entire.   But if they have given way, we ought not,  and if  the
os uteri be  fully dilated (whether the membranes  be  entire or not)  we must
not wait  a  moment, but proceed to deliver by  turning.  When  the  liquor
amnii has not escaped, there is  seldom any difficulty, but after that  event,
we generally find the uterus more or less strongly contracted upon the child,
and in  proportion to this contraction is the  difficulty.  If the uterine action
be  very intense, the  operation may be impossible without risk of rupturing
the  uterus ;  and in  such cases, instead of proceeding-at once to turn,  a dose
of tartar emetic or opium, or a combination of both,  may be given, so as to
moderate or suspend uterine action, and admit of the introduction  of  the
hand.   If the pulse be quick and strong,  venesection  may be beneficial.
I have already given the details of the operation of  turning.
   [Dr. Churchill, in his recommendation of bleeding in the cases referred to,
does not exhibit that  decision which the importance and efficiency of the
measure would seem to demand.  When, in cases where turning is demanded,
the waters are evacuated, and the uterine  contractions so strong as to render
the  operation difficult and dangerous, there is no remedy equal to free blood-
letting, pushed  even ad deliquium, a full dose of laudanum being given, at
the  same time, to prevent any undue reaction.   If the practitioner is prompt
and skilful, he may effect the turning before the relaxation produced by the
bleedino- shall have  passed  off.  It is unnecessary in  these cases to lose time
by  searching for both  feet, as delivery can be accomplished equally well by
bringing down only  one, while the risk to the child is less.  If, however, the 
126
mal-presentation  of the  child.
child be dead, or there is much hemorrhage, it will be proper to seize and
bring down both feet, with the view of accomplishing  the  delivery more
rapidly, provided always both  can be gained  without much delay or dif-
noulty.]
  Should  these  measures  fail, and version  be  impracticable, we must open
the chest of the child, and eviscerate ; after which it may be extracted by
the crotchet.   "Several writers," says Dr. Collins, "recommend, in  difficult
cases of this nature, the separation of the child's head, so as to bring the body
away by the presenting arm, and afterwards deliver the head by the crotchet;
this  we would condemn, unless we  failed in our efforts,  by breaking  down
the thorax, which is very  unlikely, if the operation be properly performed,
and the pelvis not extremely under size.   We  once  saw a delivery  effected
as above described, and the  greatest difficulty was  experienced in the ex-
traction of the head ;  it was necessary to  introduce the hand to bring it
into the vagina, and then it had to be  lessened before it could be removed."
  637. But, it will at once be asked, what  practical  application can be
made of our knowledge of the occurrence of spontaneous expulsion ?  I am
afraid not much.  I am satisfied that we ought not to wait for it in any case
in which  turning can  easily be accomplished, because, if it did not  occur
(and, according  to Dr. Douglas, it does not occur above once in ten  thou-
sand labors), the operation will be  rendered tenfold more* difficult, from the
greater depression of the child, and more energetic action of the uterus ;  it
would, in fact, be exchanging a comparatively easy and  not very dangerous
operation  for a very difficult one, in- which  the risk to the mother would be
great, and the death of the child certain, provided this rare phenomenon did
not occur.   I think, however, that  in such a  case as Dr. Douglas  has de-
scribed, we may venture upon a little delay, to afford a chance of  sponta-
neous expulsion.  " If the arm  of the  fcetus," says Dr. Douglas, "should be
almost entirely protruded,  with the  shoulder pressing on the perineum ; if a
considerable portion of its thorax be in the hollow of the sacrum, with the axilla
low in the pelvis ; if, with this disposition, the uterine  efforts be still powerful,
and if  the thorax be forced sensibly lower during the pressure  of each suc-
cessive pain, the evolution may with great confidence be  expected."
  [Dr. M. B. Wright of Cincinnati, in an essay which appeared a few years
since, and to which a  gold medal was awarded by  the Medical Society of
the State  of Ohio, has presented a strong  plea in favor of cephalic version
in cases of arm or shoulder presentation.   He maintains  that it may be per-
formed whenever turning by the feet  is practicable, even, indeed, when this
cannot be effected, and with  greater safety  to mother  and child.   There
cannot, we think, be any doubt as to the possibility in certain favorable cases
of arm or shoulder  presentation — when the head of the fcetus is small and
the pelvis large —of cephalic version, particularly in the manner practised
by  Dr. Wright,  being  effected ;  and whenever such is the case there is un-
questionably a greater probability of the child being saved than when podalic
version is  resorted to.  In complex and complicated cases of shoulder pre-
sentation, however,  though not absolutely impracticable, cephalic version  is
always attended with  great difficulty, and is as replete with danger to both
mother and child as turning  by the  feet.  To such cases it is altogether
unadapted.   Even  under the most  favorable circumstances  we  are  to
recollect  that  after the mal-position  of the  head  has been'rectified by
cephalic version, notwithstanding  the pain and risk to which the female has
been subjected, the delivery is still to  be effected by the regular contractions
of  the uterus —by a  "labor" that may,  for  all  we know, be sufficiently
tedious and painful to produce an  amount of exhaustion as shall require  to
insure the safety of the patient, a resort to  instrumental delivery -—hence  it
is evident that, under all  such circumstances  as indicate the necessity for a 
superior extremities.                   427
speedy termination of the labor,  podalic is invariably to be preferred to
cephalic version.]
  As the minute details  of management are the same  in natural and un-
natural labors, I have not thought it necessary to repeat them, but refer the
"eader to the chapter on  that subject.
  638. 4. Compound presentations.—From an untoward position  of the
body or extremities of the child, one or more parts may come together tc
the os uteri; in some cases  merely adding  to the  bulk to  be transmitted
through the passages without altogether preventing it,  in others  rendering
interference necessary for the delivery.   For instance :—
  1.  The hand or arm may present with the head, of  course adding to its
size, and perhaps, if  the pelvis be small, prohibiting its entrance into the
passage.   As a general  rule, the hand or arm  is stretched out  or placed
along the side of the head, descending with it or before it; but Dr. Simpson
has met with a case in which the fore-arm was placed across the back of the
head and neck, at once increasing  the bulk  and opposing a projecting ob-

                                Fig. 172.
Compound Presentations — Hand, Foot, and Funis.
struction which caught upon the brim of the pelvis.   He brought the hand
downwards and forwards : but the pains proving insufficient, and the child
getting weak, he delivered by podalic version.1   Nor is this compound pre-
sentation without danger if the uterine action be violent.   Dr. James Gray
has related a case in which the hand, presenting with the  head, was forced
through the walls of the vagina  and rectum.2  Such cases, however, are
very rare.  Compound presentations, as Dr. Merriman has observed, rarely
occur except when the pelvis is large.   In  the cases recorded, by Drs. Jos.
Clarke, Collins, and  Jansen, no example  is mentioned:  and in those of
Mesdames  Lachapelle and  Boivin only three, i.e.,  three  cases in 75,903"
deliveries.  For which reason, if it be discovered early, a cautious attempt
should be made to replace  the arm  above the  head, so as to allow it to
descend; but, above all  things, we must be cautious neither to draw  down

  1 Ranking's Abstract, vol. ii, p. 263.      2 Edinburgh Monthly Journal, Jan., 1851 
4 28
COMPOUND  PRESENTATIONS.
the hand nor to displace the head, as either may convert a simple manageaoxe
case into an arm presentation.                                           f
   If the arm cannot be replaced, the case must then be treated as oneoi
relative disproportion ; perhaps a little time and extra uterine action (wnicn
is  generally exerted, as we have said, in  proportion  to  the  demana ior ix;
may suffice : if not, and the delay should excite unfavorable symptoms, we
must first see if the forceps are applicable, or version, and, as a last resource,
if  all others fail, we must  lessen the  head.   I prefer the forceps to version
because of its inferior mortality as regards both mother and  child ;  and
version (when  possible) to the crotchet, for the same reason.
   2.  The feet and hands may present, or one  of each, and in  these cases
it  not unfrequently happens that the cord prolapses (fig. 172) from the upper
outlet not being filled by the presenting part.
   In such cases, it is evident  that one or other extremity must descend and
give the character to the labor, making it an arm or footling case.
°  Now it is exactly for the determination of this question that 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 presentation, and to be
managed accordingly.  But I must repeat my caution, that the greatest care
is  necessary, first, not to  mistake a  hand for a foot, and, secondly, not to
favor the descent of the hand  and arm by the mode  of examining.
   Prolapse of the cord increases the danger to the child, and may (according
to the rules laid down) require us to hasten  the labor,  if the pulsations be
weak and the woman have previously had children.
CHA PTER  XVII.
         PARTURITION. —CLASS II.  UNNATURAL  LABOR.
              ORDER 6.  PLURAL BIRTHS. —MONSTERS.

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


640.  Statistics.—1.  Frequency.
42 9
a.  British Practice.
Authors.
Dr. Jos. Clarke
Dr. Merriman .
Dr. Granville .
Edinburgh Hospital,
Dublin Hospital
Dr. Maunsell
Mr. Gregory
Dr. Beatty
Dr. Lever
Dr. Reid .
Mr. Warrington
Dr. Churchill .
Drs. M'Clintock and Hardy
Dr. F.  Ramsbotham
Dr. Murphy
Dr. Storer
Mr. Crosse
Mr. Earle
Mr. Rose
Mr. Bailey
Mr. AVaddington
Dr. Toogood
Dr. J.  Lee
Mr. K. Watson
Dr. Copeland
Dr. Adams
Dr. Pagan
Mr. R. U. West
Mr. J. Thompson
Drs. Johnston and Sinclair
Dr. Hall Davis
Total No.
of Cases.
 10,307
  2,947
    640
  2,452
129,172
    839
    691
  1,182
  4,666
    580
    110
  1,640
  6,634
 48,996
    467
    451
  1,394
  4,320
    600
  2,819
  2,159
  1,135
    850
    800
  1,290
    628
  8,587
  2,106
  3,300
 13,748
  7,302
Twins.
  184
   39
    9
   31
2,062
   13
   12
   18
   33
    9
    3
   25
   95
  536
    3
    5
   17
   53
   10
   41
   19
   12
    9
   18
    9
   10
   95
   23
   25
  233
   69
Triplets.
 3
 1

 2
29
Quadru-
b.  French Practice.
Mad. Boivin  .
Mad. Lachapelle
Hotel Dieu, Paris
M. Mazzoni
Dr.  de Belli   .
20.357
15,481
   280
   452
 2,739
154
165
  4
  9
 34
c.  German Practice.
 Dr. Henne
 Dr. Richter
 Moschner and Kursak
 A. E. V. Siebold
 Dr. Riecke
 Dr. Kluge
 Prof. Andre*
 Dr. Theys
 Dr. Brunatti
 Dr. Adelmann
 Dr. Jansen
 Dr. Hoffman
Dr. Klein
Dr. Bartsch
Prof.  Schwerer
Dr. Arneth
Gebarklinik
Wurtzburg Hospital
1,214	1		
2,571	52		
12,329	165		
1,409	20		
219,303	2545	34	
809	15		
176	5		
55	4		
99	2		
56	1		
13,365	157	1	
6,139	98		
35,084	325		
4,383	42		
21,804	250	1	
6,527	81		
39,121	445	3	
637	31		
 
430
PLURAL BIRTHS.
  So far as these numbers go, we find among British practitioners, m 257,935
cases, 3431 cases of twins, or about 1 in 75 ;  and 43 cases of triplets, or 1
in 556H.   Among the French practitioners,  in 39,409 cases, 336 cases ot
twins, or about 1 in 108; and 6 of triplets, or 1 in 6568.  Among  German
practitioners, in 369,080 cases, 4239 cases  of  twins,  or about 1 in 87 ;  and
38 of triplets,  or about 1 in 9765.   Taking the whole,  we have 666,424 cases,
and  8006 of twins, or 1 in 83 ; and 87 cases of triplets, or 1  in 7443.
  I have formerly  quoted the comparative frequency in  different countries
stated by M. Quetelet.
  [Dr. E. Von  Siebold gives1 an account  of the twin births which have
occurred at the Grottingen  Midwifery Institution since its establishment.
These amount to 89  in number, occurring in 7139 births, which had taken
place between the years 1792 and 1859 — making  1 twin case in every 80
births.   According to Yeit's statistics, the proportion in Prussia is 1 in 89;
in Wirtemberg,  1 in  86 ; and in Saxony, 1 in 78.   The proportion has been
found to vary greatly in different towns.  Kiirschner in  his Thesis  sets it
down as 1 in 158 at Naples, 1 in 126 at Palermo, 1 in 118 in Lunenburg, 1
in 110 at Marburg, 1 in  96 at Hamburg, 1 in 88 at Berlin, 1 in 86 at Leipzic,
1 in  85 at London, 1  in 84 at Paris, 1 in 74 at Vienna and Wurzburg,  1 in
68 at Dresden, 1 in  62 at Heidelberg, 1 in 72 at Prague, 1 in 75 at Phila-
delphia, 1 in 57  at Dublin.]
  2.  Mortality.
Authors.		Twin	Children	Triplet	Children
		Cases.	lost.	Cases.	lost.
Mr. Giffard.....		14	9	1	
Dr. Smellie		8	2	2	
Mr. Perfect		7	7		
Dr. Jos. Clarke .		184	282	3	
Dr. Ramsbotham		15	9	2	4
Dr. Granville		9	4		
Dr. Collins ....		240	' 58	4	4
Mr. Gregory . . .		12	16		
Dr. Beatty		18	8		
Dr. Lever ....		33	6		
Dr. Jansen .		157	16		
Drs. M'Clintock and Hardy		95	19		
Dr. Arneth.		81	8		
Dr. Hoffman		98	38		
Mr. J. Thompson		25			
Drs. Johnston and Sinclair .		233	85'		
Dr. Hall Davis .		69	9		
  Thus, out of 1298 cases  of twins (t. e., 2596 children), 636 were lost, or
about 1 in 4; and out of 12 cases of triplets (i. e., 36 children), 11 were lost,
or 1 in 3.
  This  mortality, however,  which is very large, must be qualified by allow-
ing for the great number of children whose death could not be attributed to
the labor.   Dr. Jos. Clarke had 43 still-born ; Dr. Collins had 54 premature
labors among the twin cases, and 12 cases  of the birth of a  putrid fcetus
Drs. Johnston and Sinclair record 27 cases of putrid foetus.
  The mortality to the mother in twin cases has been computed as 1 in 20 •
in Dr. Collins' cases it was  1 in 34: in Drs. Johnston and Sinclair's it was
1 in  23.   I regret that,  from the imperfection of the records, I cannot o-ive
ample statistics on this point.                                        b
> [Monatsschrift f. Gebtirtskunde, Bd. xiii.] 
PLURAL  BIRTHS.                       43]
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..... Dr. Collins..... Dr. Lever ...... Dr. F. Ramsbotham .... Drs. M'Clintock and Hardy Drs. Johnston and Sinclair .	184 240 33 536 95 233	47 73 11 171 38 76	68 67 11 183 22 58	71 97 11 182 35 99
	1,321	416	409	495
  Thus we find that twin children are most frequently of opposite sexes, and
that twin males are more  common than  twin females.   From Dr. Collins'
record,  I may state, that  of his twin male  cases  23 were dead (1 putrid),
and that of these 23,13 were the first-born children ; of the female twins, 11
were dead (4 putrid) ; and of the twins  of opposite sexes, 22 were lost (7
putrid),  of which  15 were boys and 7  girls.   Drs. M'Clintock and Hardy
state that "of the 190 children, 171 were born alive; viz., 85 first-born, and
86 second-born.  Of the entire number of children, 111 were boys, of whom
58 were  first-born, and 53 second-born ; 79 were girls, of whom 37 were first-
born, and 42 second-born ; 101 boys were born alive, viz., 52 first-born, and
49 second-born ;  70 girls were born alive ; viz., 33 first-born, and 37 second-
born; 10 boys were dead born, viz., 6 first-born, and 4 second-born ; 9 girls
were  dead born, viz.,  4 first-born,  and 5 second-born;  5 of these females
were putrid."1   Of Drs. Johnston and  Sinclair's 233 cases in  466 children,
in 76 cases both were boys; 133 were born alive, 14 still-born, and 5 putrid ;
in 58 cases, both were females, 106 were born living, 6  dead, and 4 putrid.
In 99 cases they were  of opposite sex; 58  of the male  children were alive,.
9 dead, and 5 putrid ;  89 of the girls were alive, 6  dead, and 4 putrid.2  This
is important, since from it we  learn that there is more  danger to the boys
than the girls, and  particularly when there are twin cases of opposite sexes.
  From  the reports of the same authors, the presentations, placed in order
of birth's, were as follows: —
	Both Head.	Head	Head	Both Breech.	Breech	Breech	Both
Authors.		and	and		and	and	Foot-
		Breech.	Foot.		Head.	Foot.	ling.
Dr. J. Clarke ....	16		25	2	6	1	3
Dr. Collins ....	103	30	25	8	25	9	5
Dr. Lever ....	15	i	5	2		1	
Drs. Johnston and Sinclair	125	44	• •	19	26		1
Authors.	Foot and Head.	Breech and Elbow.	Head and Arm or Shoulder.	Face and Head.	Head and Face.	Foot and Hand.	Foot and Breech.
Dr. J. Clarke .... Dr. Collins .... Dr. Lever .... Drs. Johnston and Sinclair	10 19	1 ' 9*	5 2 10	1	1	1	1 1
1 On Midwifery and Puerperal Diseases, p. 239.    2 Practical Midwifery, pp. 273-4. 
432
PLURAL  BIRTHS.
   Dr. Collins thus states the mortality of his different presentations : when
 both were head presentations, he  lost 24  (4 putrid), when .the head  and
 breech (i. e., the first child with the head, and the second with the breech)
 presented, 2 of the former and 5 of the latter were lost;  when the head  and
 feet, 2 of the former and 3 of the  latter; when the feet and head, 4 of the
 former and 2 of the latter;  when  the  breech and the head, 1 of the former
 and 6 of the latter;  when both were footling cases, 2 were lost; when the
 breech and feet, 3 of the former and 2 of  the latter were lost.
   This confirms what I have elsewhere stated, that the less the passages are
 dilated by the presenting part, the greater the mortality amongst the children,
 because  of the  delay in the transit of the remaining parts of the body of the
 child.
   [According to Von Siebold,1 in a series of 35 cases of twins attended by
 Osiander between  the  years  1792 and 1822, the head presented  in both
 children  19 times, the head  and breech 6 times, the  head and feet  4 times,
 the  breech and feet, twice.  In one case the feet presented in both children,
 and in another case, the breech.   In one case, one child presented the head
 and the  other  the shoulder, and in one case the position was not accurately
 ascertained.
   In the 35 cases — 70 children, 28 were delivered without interference,  the
 remaining 42 being removed by the forceps, turning, or extraction by the feet.
   In a series of  54 cases of twins attended  by Von Siebold himself, in con-
 junction with Mende, between the  years 1823 and  1859, the head presented
 in both  children  22 times, the head and breech 11 times, the head  and feet
 10 times, the head and shoulders  5 times,  breech of both  children twice,
 breech and feet twice, the feet once, the breech and shoulder once.
   Of the 108 children born in these 54 cases, 83 were delivered without in-
 terference, and  25 by the forceps, turning, or extraction by the  feet.
   In 87  of the  entire number of cases, 2 boys were born in 28, 2 girls in  17,
 and  a boy and girl in  42; there being 99 boys and 77  girls in 178 children.]
   Dr.  Simpson has  investigated the subject of the  alleged infecundity of the
 female in twin births of males and females.   He concludes " 1. That in the
 human subject,  females born co-twin with males are, when married, as likely
 to have children  as any other females belonging to the general community.
 2. That when they are married and become mothers, they are, in respect to
 the number of their children, as  productive  as other  females.   3. That the
 same law of fecundity of the female in opposite-sexed twins seems  to hold
 good among  all  our uniparous domestic animals,  with the exception of the
 cow alone."2
   641. Symptoms. —The first, second, or third child  may present naturally
 or unnaturally,  and  in that respect the course of the labor will resemble that
 of similar cases with single children.  But  it is generally remarkable that
 the progress of the  first child is slower than we should have expected • for
 on examination,  there  appears no  want of space, and  the pains  may be
 strong.   This I suppose arises from the pressure  of the entire uterus not
 bearing directly upon  the child which is  to  pass first, but at least as much
and  primarily upon  the second child.  The pressure upon the  second child
causes  it  to press down the first child ; but in this transmission of force much
power is  necessarily lost, and  thus  it is that we find very gradual progress

WnerZafie^nvI5thSKnding,that  thG painS are S°od a"dthe space ample.
When the first child is born, whatever suspicions may have been previously
entertained are  changed into certainty, unless in the case of a smafl blighted
fetus;  for, upon  placing the  hand upon the abdomen, the uterus is felt
near y as  large as at first  and the child may be detected through its parietes
  After the birth of the first child,  there is an interval of rest  varying from

   1 [0pera citat3             2 Edinburgh Med. and Surg. Journal, No. 158. 
PLURAL  BIRTHS.
433
ten minutes to some hours;  nay, instances are on record of days and weeks
interveninff before the birth of the second child.  Of 212 cases related by
Dr. Collins, in which the interval is accurately marked, in 38 it was 5 minutes;
in  29, 10 minutes ; in 45,15 minutes ;  in 23, 20 minutes ; in 30, half an hour;
in  5, three  quarters of an hour ; in 16, 1 hour; in 8, 2 hours; in 3, 3 hours;
in  5, 4 hours ; in 1, 4^ hours; in 3, 5 hours ;  in 2, 6 hours; in 1, 7 hours ;
in  1, 8 hours; in 1, 10 hours; and in 1, 20 hours.  Thus in by far the larger
number the uterine action was resumed within half an hour.  Dr. Merriman
refers to three remarkable cases : in one the second child was retained four-
teen days after the first;  in the  second, it was  retained  six weeks; in the
third case,  the woman was delivered  of twins, and  two days afterwards of
two more boys.   Drs. M'Clintock and Hardy have noted that in 3 cases the
interval was 5 minutes;  in 9,  10 minutes;  in 10,  15; in 11, 20;  in  2,
25 ; in 13,  30 ; in  1, 40 minutes;  in 4, 1 hour ; in 3, 1^;  in 1,  2; and in 1,
2^  hours.   Drs. Johnston  and Sinclair found that the average duration  of
labor when both twins were males was 10^ hours, and  for primiparae 14|
hours ;  when both were female,  94 hours, in primiparae,  14  hours ;  when
male and female, a little more than 12 hours, with primiparae, nearly 23^ hours.
   After this interval, whatever it may be, the pains return; and if  there be
nothing unusual on the part of the child, the labor is completed in less time
than with the first child, because of the previous dilatation of the passages.
For the same reason, when the second child presents with the breech or foot,
the mortality is less than usual.   Dr.  Denman remarks, " the most fortunate
presentation of the second child in a  twin case  is certainly with the inferior
extremities, because it may in this position be  extracted without injury or
difficulty, and if  assistance  be required, this may be given with safety and
convenience."
   There is one important point to be borne in mind—viz., that the more
quickly the two labors succeed  each  other, and the more rapidly they  are
terminated, the more probability there is of collapse afterwards,  whether
there be hemorrhage or not.  I have seen a lady placed in very great peril
from this cause, without any unusual  loss.  I rather think, also, that there
is  more danger of hemorrhage, but of that I am not quite certain.   On this
account the  medical  attendant  should not leave the  patient for some time
after all is over.
   642.  Treatment.—Whether  the first child present with the  head or any
other part, it is to be treated exactly according  to  the rules heretofore laid
down, just as if it were a single birth ; and so,  as far as  the labor is con-
cerned, must the  second child ; thus,  if the first be a natural labor and  the
second a mal-presentation, we need not interfere with the first, but assistance
may be necessary with the last child ;  or the first may be a mal-presentation
requiring assistance, and the second a natural labor needing none.  For  the
reason  already stated, viz., the  diminution of direct uterine force, it occa-
sionally happens that the first child has to be delivered by the forceps.   The
rules laid down for the  employment of that instrument apply equally to these
cases, but  it is even more necessary that no undue delay should take place.
   So' far we must act according to  the nature of the case.   But suppose
that the uterus do not resume its action  after the ordinary interval, are we
still to leave all to nature ?  It is clear that, if  the  passages be allowed to
recover from the former distension,  there will be  more  trouble with  the
second child, especially if it be a mal-presentation ; and  that there must be
a risk  of hemorrhage so long as the uterus  remains uncontracted ; and it
would seem  that delay involves  danger  to the second  child.  For these
amono- other reasons, opinions have varied as to the necessity of interference,
aud a* usual, the  practice has ranged from one  extreme to the other; some
havin»- advised instant delivery to obviate these dangers, and others, finding
that in  many cases left to nature no  evil has followed, recommending that
             28 
434
PLURAL BIRTHS.
we should abstain from all interference.   Dr.  Denman advises ns to wait for
four hours, "if there  be  no cause for delivery sooner."   Dr.  Ramsbotham
two or three hours, Dr. Burns about an hour.   Dr. F.  Ramsbotham agrees
with Denman.  Dr. Campbell suggests that  ergot should be given before
we attempt to extract the child.   The rules laid down by Dr. Collins appear
to me extremely judicious;  he advises a middle course, " as soon as the first
child is born, a binder should be applied so as to make  gentle pressure  upon
the abdomen; we should not leave the house until the  second child is deliv-
ered.   If we find, after the  lapse of half an hour, that the membranes of the
second child still  remain unbroken, they may be punctured with advantage,
with the  view of exciting uterine action,  as  the soft parts having been so
well  dilated by the passage of the first, no bad  result can ensue.   This
expedient in some instances will be found not to succeed ; and in such cases,
when we do not observe any progress made in the course of two hours after
rupturing the membranes, the best mode of proceeding will be  to pass the
hand cautiously into the uterus, and bring down  the  feet.   There will be
but little  difficulty  experienced  in this  operation, the parts being  in so
relaxed a state.   When  the  head has made  any considerable descent  into
the pelvis, the forceps will be the best means  of affording assistance.   It is
very rarely, however, that we are  called upon to effect  delivery by either of
the latter methods; yet experience has shown that the second child is very
likely to  be still-born if left longer than two or three hours unassisted."
  There  are  circumstances, as Dr.  Merriman has justly observed,  which
would  negative any delay in the  delivery of the second child : as, for ex-
ample, 1, when artificial aid has  been required with the first child ; 2,  when
the second child presents preternaturally; and 3, when the labor is compli-
cated with convulsions, hemorrhage,  etc.
  Any deviation from normal labor with  the  second child is to be treated
according to the rules laid down,  without regard to its being a twin case.
  643. With regard to the placenta of the first child ; unless it  come  away
quite easily, I believe that in all cases it is better to leave it until after the
birth of the second child, as its removal might excite uncontrollable flooding.
After the birth of the second (or  third) child, the binder is to be tightened,
and pressure or friction made upon the uterus, and when  we find it disposed
to contract, then we may draw down (in the  axis  of the upper  outlet) first
one cord, and if that do  not  yield, the other, or both together, so as to aid
in the  expulsion.   But  it  must  be remembered that, after the  delivery of
plural children, the uterus is less disposed to renew its  exertions, and there-
fore a longer interval must  be allowed : and that by the detachment of the
placenta a much larger  surface of bleeding vessels will be exposed  and
therefore, that we  should  avoid  their forcible separation by traction' and
should be particularly careful to secure the due and  permanent  contraction
of the uterus afterwards.   It will probably be safer and wiser in  these  cases
to give a moderate dose (ps.) of the ergot of rye immediately after the
birth of  the last  child.   "In twin cases," Dr. Collins observes  "when it
becomes  necessary to remove the placenta,  we should  be careful not to
withdraw our  hand from the uterus, until both be separated, at  the  same
time waiting for uterine action, so as to induce as  perfect a contraction of
this organ as practicable: a point of most vital importance."  The shock
to the nervouy system is generally greater than after natural  labor and in
some cases it is very severe, amounting to collapse, as in the case'I  have
mentioned: this will justify the exhibition of stimulants and opium and it
demands extreme quiet and care.                             ^   '      l
  The  management of twin cases applies equally to triplet and quadruplet
cases ;  especially the care recommended as to the placenta          <""pieii
  Dr.  Denman states that "it is a constant rule to keep patients, who  have
borne one child, ignorant of there being another, as long as it can possibly 
monsters.
435
he 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 that she will
soon give birth to a second;  and this may be coupled with a congratulation
on the fortunate progress of the labor so far ; and an assurance that she will
have but  little more pain to bear, and that the case presents no features
calling for anxiety."
   644. I have hitherto spoken  of twin  cases in which one of the children
only presented ; but it has occasionally happened that both bags of mem-
branes have ruptured, and an extremity of different  children descended, at
the same time.  Thus, the late  Dr. Fergusson, of this city, has published a
case in which the head of one child  and the foot of another presented to-
gether. ^   The midwife drew down the  leg, and so jammed the  head  and
breech in the  pelvis together.    However, the pains being powerful, expelled
the natural presentation first, and the other afterwards.   A similar case is
recorded  by Mr. Alexander,1  and  Mr. Allen relates one2 in which the  two
heads occupied the pelvis together ; and both were naturally expelled.  Dr
Murphy3 mentions a case in which the heads of twins were jammed in the
pelvis  together ;  and my friend,  Dr. Christie, of Aberdeen, has related to
me a similar case, in which the feet of the first child presented, but the head
of the second descended into the pelvis in advance of the  head of the first.
He  succeeded, by pushing up the  head of the  first child,  in liberating and
pushing  back the  head of the second, after which the labor was speedily
terminated.   Dr.  F. Ramsbotham mentions having  been  called  to a case
when a right and a left  foot  belonging to different children presented ; he
pushed up one and  extracted  by the other,  and both  children were born
living.
   Such cases are  no  doubt very  puzzling at first, and may excite some
anxiety as to  the result; but it  may be remarked, that the descent of a foot
with the  head proves that the pelvis is unusually large,  and in all the cases
it appears that the pains were very powerful.   It would, therefore, be right,
if we could not push up  one of  the presenting parts, to give fair play to the
natural powers, and only upon  conviction of their inefficiency to  lessen the
bulk of  one child.  If  the head  of  the footling case were within reach, it
would be better to operate upon it, as the child's life will have  already been
compromised  by the pressure upon  the cord, whilst the other child has in-
curred little or no danger.  In such a case as Dr. F. Ramsbotham's, we must
of course adopt a  similar line of practice, pushing up one leg and drawing
down the other, until the breech be engaged in  the upper outlet.

   645.  II. Monsters. — All that is obstetrically important relating to this
subject may be comprised in a few words.  As  far as we are concerned, we
may divide all these deviations  from  normal formation into monstrosities by
defect and excess, those  from  disease, and the cases where two children arc;
conjoined.  The only practical  point involved is their relation in size to the
pelvis ;  consequently with those by defect we have nothing to do, as there is
no  difficulty in  their transit through  the pelvis.  Monsters from excessive
development of different parts likewise come under the class of which we are
treating, just so far as their bulk is rendered disproportionate to the pelvis.
   646. The  principal diseases  which render  the  child disproportionate to
the passages are hydrocephalus and  ascites.  ^Neither are very uncommon,
    1 Edin. Med. and Sure:. Journal,  1822.           2 Med.-Chir. Trans., vol. xii
    8 Lectures on Parturition, etc, p. 274. 
436
monsters.
and most practitioners  must have met with cases of them.   When a child
affected witb hydrocephalus presents at the brim the entrance may^be: effected
with difficulty, or it may be  quite impossible : the head being nearly incom-
pressible   On examination, therefore, we find that, notwithstanding good
Fig. 173.
                              Hydrocephalus.

pains, in well-marked  cases, the head does not even  dip into  the  pelvis;
that no advance whatever is made by the uterine pressure (fig.  173).   The
head  feels  full and tense during a pain, but during  an interval the fluid
gives way under the point of the finger.  The bones of the head are uncon-
nected, and  give the impression of being loose in  the scalp.  If the labor
were left to nature, we should, after due time, have  all the bad symptoms of
a prolonged second stage.   The diagnosis is obscure : if we ascertain the pel-
vis to be of the usual size, and still  find that the great bulk of  the head is
above the brim, and cannot descend, the  case is clearly one of great dispro-
portion, and it is  equally plain that the excess is on the part of the child;
in such circumstances,  if the bones are loose and  the head flaccid during an
interval, it will be fair to suppose the case one of hydrocephalus, especially
if we find the pulsations of the fcetal heart have ceased.
   I need not say  that the diagnosis will be much more difficult if the  feet
present, although the same principles of treatment apply equally, first having
established the impractibility of delivery, from relative disproportion.
   647.  In ascites, there is much less obscurity, the head having been expelled, it
is easy to see that the  difficulty arises from the distention of  the  abdomen of
the child, and a careful examination will, in  most cases, distinguish between
ascites and  tympanites.   In the latter case, the air is seldom limited to the
abdomen, but the  face and chest will be found more or less puffed.1
   M. Depaul has  published a memoir upon distention of the fcetal bladder,
as an impediment  which he seems to think more common than simple  ascites.
He recommends puncture of the bladder through the abdominal parietes as
the only remedy, and after birth an attempt to  remedy the original defect
which occasioned  the  retention.2  A case of difficult  labor  from enormous
enlargement of the kidneys is on record,3 but as far as I know, it is the only  one.
             1 Ed. Med. and Surg. Journal, vol. xvii. p. 561.
             2 Banking's Abstract vol. ii., 266, from L'Union  MeVlicale.
             3 British and Foreign Med. Chir. Review,  Oct. 1856, p. 557. 
monsters.
437
   64b. Double monsters are very rare, and may create great difficulty in the de-
 livery, although there are cases on record of the children having been born
 alive.  Dr. Burns quotes several such : " In the seventh volume of the Nouv.
 Journ. p.  164," he says, "is a case where two children were born at the full
 time, united by the inferior part of the belly, from the centre of which came the
 cord.  The vertebral columns almost touched at the lower part.  The two chil-
 dren, who were of different sexes, lived, we are told, twelve days, but nothing is
 said of the labor.   In the Bulletin  for  1818, p. 2, two children, who  were
 joined by the back of the sacrum, are stated to have been born, and lived till
 the ninth  day.  The first  child presented the head, but the midwife could
 not well tell how the second got out.   There is another case, at  page 32, of
 a woman who, after many days of labor, bore a monster double in its upper
 parts.  The  spinal column was united from  the sacrum to the top of the
 dorsal vertebrae, then  the cervical vertebrae divided to form two necks.   The
 midwife finding the head to present along with the cord and a hand, tried to
 turn, but  could  discover nothing  but superior extremities.  She therefore
 let her  alone.   The head  was afterwards expelled, but neither  nature nor
 art could deliver the body.  M.  Ratel  finding the head and two arms almost
 separated from the body, cut  these parts off, then introducing his  hand, he
 found another head, turned the child, and brought away the whole mass.
    There is a skeleton in the Royal College of Surgeons  of  Ireland  of a
 double monster, the children being joined  by the lower part of  the sacrum,
 and I believe they were  also born  alive.   The  Siamese twins  are another
 instance of the kind ; and two similarly joined were in the possession of the
 late Dr. Montgomery.
    649.  Treatment. — I have already stated the general principle by which
 we are to be  governed in all these cases.   Whenever the monstrosity adds so
 much to the  bulk of the child as to render the delivery impracticable by the
 natural powers alone, or assisted by the forceps, we must lessen the bulk.
    In cases of hydrocephalus there need be no hesitation, if the head be not
 too large  to pass ; no interference is required whether the  child be alive or
 dead; but if it be so large that  it cannot pass, we  have  no choice but to
 perforate.  In the majority of cases the child is  dead before the operation.
 The ground  of the operation  is the  mechanical impediment  to delivery, and
 the death of the child will justify an  early interference.  The operation is
 very easy ; but  should  the operator not have suspected  hydrocephalus, but
 disproportion from another cause, the sudden rush of water may alarm him
 lest he should have perforated the bladder.   In footling cases the head must
 be perforated behind the ears.
    When the body cannot be extracted, owing to  the distention by air or
 water, relief  may be afforded by plunging the perforator into the body.
    As to the  double monstrosity, Dr. Burns remarks very truly:  " The gene-
 ral principle of  conduct must be, that, when the impediment is very great,
 and does not yield to such force as can be safely exerted by pulling that part
 which is protruded, a separation must  be made, generally of that part which
 is protruded, and the  child  afterwards turned,  if necessary.   Unless the
 pelvis be greatly deformed, it will be practicable to deliver even a double
 child by means of perforation of the cavities, or  such separation as may be
v expedient, and the use  of the hand, forceps, or crotchet, according to cir-
 cumstances.   A great degree of deformity may render the Caesarian opera-
 tion necessary."
    I may add, as a caution to my junior readers, that the  destruction of a
 monster after birth  (no  matter how great  the deformity)  is punishable as
 infanticide. 
438
PROLAPSE  OF  THE FUNIS.
                     C HAPTER  XVIII.

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

  650. Having fully considered natural labor where the agents or elements
of parturition are equally balanced ; and unnatural labor, where the abnor-
mal deviation is dependent upon some deficiency or irregularity in the power,
the passages, or the child, we shall now  pass on  to  the third class, or com-
plex labor, of which, as I observed before, the  characteristic peculiarity is
not anything in the mechanism of labor,  but consists in some accidental com-
plication.   The  labor  itself  may  be  natural or unnatural, but  more fre-
quently the former than the latter:  however, with the consideration  of the
labor (except as connected with the complication) we have nothing to do.
  Prolapse of the Funis  Umbilicalis. — The first complication I shall
describe is prolapse of the funis, either alone or along with the presenting
part; and  occurring either at the commencement or during the course of
the labor.
  This accident has no influence whatever upon the progress'of the labor;
but a very serious one upon the life of the child,  and any interference which
may be advised is for the purpose of rescuing it from peril.
  651. Statistics.—We may form some  idea  of the frequency of its oc-
currence, and of  the result to the child, from the following table: —
  1. Frequency.
British Practice.			French Practice.		
Authors.	Total No. of Cases.	Prolapse of Funis.	Authors.	Total No. of Cases.	Prolapse of Funis.
Dr. Bland Dr. Jos. Clarke Dr. Merriman Dr. Granville . Ed. Lying-in-Hosp. Dr. Collins . Dr. Cusack Dr. Maunsell . Mr. Gregory . Dr. Beatty Dr. Lever Dr. Reid Mr. French . Dr. Churchill . Drs. M'Clintock "1 and Hardy j ' Dr. Bliss Dr. Metcalf . Mr. Rose Mr. Bailey Dr. J. Lee . Dr. Copeland . Mr. J. Thompson . Drs. Johnston and "1 Sinclair J Dr. Hall Davis	1,897 10,387 2,947 640 2,452 16,414 398 839 691 1,182 4,666 3,250 89 1,525 6,634 771 300 600 2,819 850 1,290 3,300 13,748 7,302	1 66 8 1 3 97 5 2 7 6 6 16 1 7 37 1 2 2 9 2 5 3 98 • 19	Mad. Boivin . Mad. Lachapelle M. Mazzoni .	20,357 15,652 452	39 41 18
			German Practice.		
			M. Richter . A. E. v. Siebold . Dr. Voigtel . Dr. Jansen . M. Bartsch . M. Klein Dr. Arneth	624 492 29 13,369 4,425 5,490 6,608	4 2 1 86 16 55 33
 
PROLAPSE  OF  THE FUNIS.                 439
  Thus, in British practice it occurred 404 times in 84,991 cases, or about
I in 210^; in French practice, 98 times in 36,546 cases, or about 1 in 373 ;
and in German  practice, 197  times in  31,037 cases, or about  1  in 162f.
Taking the whole together, we  have 152,574 cases, and  699 examples  of
prolapsed funis,  or about 1 in 218.
  The risk to the child may be estimated from the following table : —
  2. Mortality.
Authors.		Cases of Prolapse.	Chil-dren lost.	Cord replaced	Nat.	Delivered Version.	by Forceps.
Mr. Giffard Dr. Smellie Mr. Perfect Dr. Jos. Clarke Dr. Merriman . . . Dr. Ramsbotham Dr. Collins Dr. Cusack Mr. Gregory Dr. Beatty Mr. Lever Dr. Churchill . Mr. J. Thompson Drs. Johnson and Sinclair Dr. Hall Davis . Mad. Boivin Mad. Lachapelle Dr. Voitgel Dr. Jansen Drs. M'Clintock and Hard Mr. Roberton . Dr. Metcalf Dr. Bartsch Dr. Klein . Dr. Arneth	?	21 6 4 66 8 1 97 5 7 6 6 7 3 98 19 39 41 1 86 37 22 2 16 55 33	17 2 3 49 4 1 73 5 4 4 2 5 2 42 9 9 7 38 25 15 2 4 20 11	2 'l4* ' 5' 5 27 11	61 ' l' ' 6'	15 5 4 1 16 4 26 12 1 46 2	5 9 13 13 ' 6' 3 2 | 9
  Here we find that out of 722 cases of prolapse, 375 children were lost, or
more than one-half; a  larger mortality than we find  in any other order of
practicable labor.
  It must always be remembered, when speaking of the results of this acci-
dent to the child, that in lying-in hospitals many of the cases do  not  seek
admission till some time after the occurrence, when the chance  of a safe de-
livery is diminished; and  some not until the cord has  ceased  to pulsate.
Twenty-two such cases  occurred out of the seventy-three unfavorable  ones
Dr. Collins has recorded ; in eleven of Drs. M'Clintock and Hardy's,  and
twenty-one in Drs. Johnston and  Sinclair's report.
  652.  Causes.—Many circumstances have been assigned as likely to cause
or to favor the occurrence of  this complication.
  1  'Mal-position of the  child. —Smellie, in his plate of  this accident,  has
represented the child lying across the uterus, with the umbilicus at the upper
outlet  and the cord hanging down in the cavity of  the pelvis ; and Froriep
regards this as an exact  explanation.  After a careful examination of the
cases I have  seen, and a tolerably extensive investigation into those recorded
by authors, I can find  few, if  any, facts in support of this view, and must,
therefore, attribute  the  explanation rather to Smellie's ingenuity than to his
observation.
  2. It would appear that a small child  with a large quantity of the liquor 
440
PROLAPSE  OF  THE FUNIS.
amnii, by allowing the head  of the  foetus  to  move away from the brim  of
the pelvis during the latter months, will favor the  escape of a loop ot the

 T'The sudden rupture of the  membranes, and the forcible rush of a
large quantity of the liquor amnii, may have  a similar effect, and especially
when aided by an untoward position in the mother, as occurred to a patient
of mine who was standing up when the membranes suddenly ruptured.

                                Fig. 174.
                             Prolapse of the Funis.

  4. It will be favored by a presentation of the feet or knees, as they do not
fill up the upper outlet;  and even where the cord does not descend at the
commencement of labor, it may  before the  breech  enters  the  pelvis.   In
short, if the presenting part do not block up the os uteri, the  cord, being
specifically heavier than  the  liquor amnii, will be apt  to prolapse, as Mr.
Roberton has observed.1   M. Naegele is not correct,  however, in stating
that it occurs most frequently in footling cases.
  5. M. Naegelk adds irregular shape, or irregular action of the uterus,
as an occasional cause.
  6. Excessive length of cord forms undoubtedly an important element; but
it requires other conditions also, since in the cases of cords of from thirty-six
to fifty four inches long, which I have noticed, no prolapse occurred.
  7. I  may state, from my own observation, that I have found, in several
cases of prolapse, that the placenta was situated low down  near the  cervix
uteri, and, in some few others, that the funis was  inserted into the lower
edge of the placenta.
  There are cases,  however, which are  not attributable to any  of these
causes.
  I have already mentioned a case in which prolapse was prevented  by  the
coiling  of the cord round the neck of the child.
   653.  In all cases  of prolapsed funis, the child is in the utmost danger
from the moment the upper strait of the pelvis :is filled by the part of  the
child descending, in  consequence  of the pressure upon the cord, just as in
footling cases.   The effects of this pressure are in proportion to the  time it
is continued, if the cord be not partially shielded from it by its situation.
1 Phys. and Dis. of Women and Mid., p. 339. 
                       PROLAPSE  OF  THE FUNIS.                 441

  There are but few cases in which the child escapes safely when  the  labor
is left to the natural powers.  In those in which  I have seen this happy
result, the pelvis was very large, the child of a moderate size, and the pains
very violent, so that the  second  stage of labor occupied but a very short
space of time.  The same result will obtain in those cases where the cord is
shielded from pressure by being  lodged in the  angle at the junction of the
sacrum and ilium.   The  chances will be  still greater, if the  patient have
previously borne five or six children.
  654.  Treatment. — The means to be adopted will depend entirely upon
the state of the prolapsed cord.   Should it exhibit marks of putrefaction,
or be without pulsation, it will be useless to interfere, because hopeless as
regards  the life of the infant, and the labor may be allowed  to  terminate
naturally, or be  terminated by  craniotomy if  there be any undue delay.
Capuron advises us not to interfere  at once, even  though the cord should
pulsate, but rather to  wait until the  pulsations  become feeble.  It will cer-
tainly be desirable  that the os uteri should be as much dilated as possible ;
and if we discover the prolapsed cord before the rupture of the membranes,
it will be well to postpone their rupture until that  object be effected.
  Various modes of management have been  proposed.
  1.  We are advised to push the  cord upwards, beyond the  brim of the
pelvis,  and there to retain it with one or two fingers, until the upper  outlet
be  filled by the descending head.  This  would seem easy and certain, but in
practice it is not so; for the pains which  force down the head, force down
the cord also ;  and besides, there is  some risk of displacing the head.   This
re-position is still  more  difficult, if any other part than  the head  present.
On  the  whole, I  believe I may say  that it rarely succeeds.   Dr. Arneth
states, that in the Vienna Hospital, the  funis was generally carried over and
beyond the head of the child, and lodged in the hollow of the neck ;  and
that of  forty cases in his own  practice and that  of Klein and Bartsch in
which this plan was adopted, thirty-eight of the children were born alive.1
  2.  It  has been proposed to return the cord, and  to hook it over the limbs
of  the  child.   This may also succeed, but it is a very difficult and  a  some-
what dangerous operation ; and  I am inclined to agree with Dr. Burns, that
" if the  hand is to be introduced so far, it is  better at  once  to turn the
child."2 It is but right to add, that Sir R. Croft succeeded twice in this way.3
  3.  Various mechanical expedients have been contrived for retaining the
cord when replaced.   Thus, enclosing the cord in a leathern bag,  and push-
ing it beyond the head of the  child,  was  recommended by  Mackenzie ; *
attaching the cord  to  the extremity  of a canula, by Ducamp ;  or  of a cath-
eter, by Dudan ;5 the  reductor, by Aitken ;  a thin elastic flat rod of steel,
by  Dr. D. Davis ;6 and a modification  of some of these contrivances  was
suggested by Champion, Favereau, and Guillon.* Dr. Harris, of Philadelphia,
returned the cord above the knees in a  breech  presentation, and  the child
was saved.
  4.  Osiander, Busch, Hogben, and Hopkins, propose to retain the  cord by
introducing a piece of sponge after its replacement.
  5,  Dr. S. Merriman has twice  succeeded  in  saving the infant,  not by re-
turning  the cord, but  by placing it in the  angle formed by the junction of
the sacrum and ilium,  where it is in  a  great measure shielded from pressure.
  [" Many various methods of repositing the  cord, or putting it  back into
the  womb, above the fcetal head," remarks Dr. Meigs,8 "have  been pro-

  i  Die GeburtshUlfliche Praxis, etc., p. 138.     2 Principles of Midwifery,  p.  433.
  »  Merriman's Synopsis,  p. 99.               4  Merriman, p.  99.
  5  Revue Med., 1828. vol. iii. p. 502.
  6  Elements of Operative Midwifery,  1825.  p. 170.
  » Velpeau, Traite" des Accouchemens, p.  342.  Ed. Brux.
  s  [Obstetrics; the Science and the Art, 2d ed.] 
442
PROLAPSE  OF  THE  FUNIS.
posed ; they have mostly been found ineffectual, the cord being apt to fall
down again, even after it had been put into the proper place.   I have never
yet had an opportunity to try a method which I beg leave to propose to my
readers, and which is as follows : Take a piece of riband  or tape, a quarter
of an inch wide 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
supported on the end of the catheter or womb-sound.   Let the catheter be
now pushed up  into the womb, beyond the fcetal head  ; it  will carry the
secured portion of cord with it, and the catheter being withdrawn, the tape
is left in the uterine cavity, where no harm can be occasioned by its presence.
If required, several such tapes could be secured round the cord, and all of
them fixed on the end of the same catheter, and pushed at the same moment
far  up within the cavity of the womb."]
  If we determine to try the preceding plans, or if the advance of  the head
preclude  any attempt at re-position,  or, lastly, if the cord come down during
labor, we may increase the chances of safety by applying  the forceps and
hastening delivery, as soon  as the head is within reach.
  6. Dr. Gaillard  Thomas,  of New York,  has proposed a modification  in
the re-position  of the funis, so simple and so  in accordance  with common
sense, that one only wonders that none of us ever thought of it before.1 He
recommends that the woman should be placed  on  her hands  and knees,  so
as to reverse the inclined plane formed by the cavity of the uterus and pelvis ;
and to have in our favor the influence  of gravitation.  In  this position,  if
the membranes  be not broken,  it is possible that the loop of the cord may
slip above the head spontaneously.  If the cord have  descended, the hand
is to be introduced into the vagina, and the cord passed  above  the  head,
and the  same position to be maintained for a few pains.   In  two cases  in
which he tried it, no part returned prolapsed, and the  head  coming forward,
he had no further trouble with the cord.
  7. If the patient have had  children before, and if the pelvis be roomy,
and the soft parts well dilated, perhaps  the best chance  for the  child  is  in
turning,  particularly if there  should  be a mal-presentation.  But as this
operation is not without hazard to the mother, we should accurately esti-
mate the favorable or unfavorable probabilities as regards the child, before
we attempt it.   Dr. M'Clintock  has recently showed that while  more  chil-
dren are  saved  by this than by any  other method, the  risk to  the mother is
not so great as has been supposed.
   Madame Boivin turned the child in 25 cases, and used the  forceps  in  13
out of the 38 cases she has recorded, and saved 29 children.   Madame La-
chapelle, in 23 cases, used the  forceps 13 times, and version 10 ; 17 children
were saved.  In one case, Dr. Collins saved the child by returning  the cord
and retaining it by the hand in the vagina ; in another, by enclosing  it  in
a  linen bag, returning it, and retaining it there by introducing  a piece  of
sponge.                                                    °     •
   Should the  delivery have been completed within  a short  time  after the
cord has ceased to pulsate, it will be  our duty to employ for some time the
usual means for resuscitating the child; so long  as the heart  beats ever so
faintly, there is hope.
» Transactions of the New York Academy of Medicine, vol. ii. part 2, p. 21. 
RETENTION OF THE  PLACENTA.               443
                        CHAPTER  XIX.

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

  655. In  the  definition of natural labor I  included the expulsion of the
placenta  "in due time ;" and when speaking  of the third stage I mentioned
that Dr.  Clarke found the average  interval between the birth of the child
and  expulsion  of the after-birth was twenty minutes ; and that out of  654
cases observed by myself, in 622 it was expelled within a quarter of an hour ;
from these  data I remarked, "we may conclude with the highest authorities,
that in natural  labor the placenta ought to be expelled within an hour or an
hour  and a half, and that when the interval exceeds  this, the  case fairly
comes under the order of 'retained placenta.'"
  There  is, however,  an exception to the  stringent application of this rule,
and that is when, from  the length  of the labor or its abnormal  character,
the uterus  has been over fatigued,  so that it does not so soon  resume its
contractions.   There is no reason to  suppose the uterus  exempted  from
fatigue in  proportion to  its exertions, any  more than any  muscle of the
body; and when it has been so fatigued, we do not find that it requires and
takes a longer interval of rest than usual, and that after this has  elapsed, it
contracts again, and expels the  remaining  contents.   In estimating the
interval which ought  to elapse before we  interfere, we must, therefore, take
into consideration the peculiar kind of labor and probable amount of fatigue,
and allow a certain variation accordingly.
  Some  writers have recommended that  the placenta should never be ex-
tracted except  in case of hemorrhage;  but it  was found,  that if left to
nature, it  was  occasionally retained until it putrefied  and excited  uterine
inflammation;  for this reason, others recommended its immediate  extrac-
tion ; but the truth appears to lie between the two  extremes.  We  do not
interfere when  the  uterus  is adequate  to the  expulsion,  but when  we are
convinced that its efforts are suspended or inadequate, we extract it to avoid
the risk  of hemorrhage or inflamation of the  uterus.
  [Much,—almost all the difficulty which occurs in respect to the  delivery
of the placenta in cases of natural  labor, originates, we are persuaded, from
mismanagement — either the improper administration of ergot with the view
to accelerate labor, hurrying the birth of the shoulder and trunk, by manual
interference, after the expulsion of the head,  or the neglecting to secure the
prompt and regular contraction of the uterus, and the early removal of the
placenta lying  loose in  its cavity, subsequent to the  birth  of the child.   The
common direction to  wait, after the child is born, from an hour to an  hour
and a half, for the spontaneous expulsion of the placenta, before any attempt
is made to remove it, has been productive of no little mischief.   With Dr.
Meio-s, we  believe that there cannot and ought not to be adopted any  fixed
rule°in respect to the period that should elapse before proper measures are
taken to secure the  extrusion  of the placenta from the womb.   The only
thing to be kept in mind is that the placenta must be got rid of at as  early
a period as practicable, there being no security for the patient while it re-
mains   There is no  good  reason  why, after the  child is born, the practi-
tioner should wait patiently for a renewal of labor  pains in order that the
expulsion of the placenta may be effected.  His chief care should  be  to have 
444
RETENTION OF  THE  PLACENTA.
the uterus rid of the latter as early as this can be effected with a due regard
to the safety  of the mother, in  order that prompt, regular, aud permanent
contraction of the  organ may take place.   If within a  reasonable time,
under the diligent employment  of abdominal frictions and  gentle  pressure,
the placenta is not expelled from  the uterus, the practitioner has then good
reason for concluding that its retention is caused by something unusual,  and
should at once  proceed to ascertain  its exact nature, in order that  the
proper means may be employed to overcome it.]
   656. Definition.—I would,  therefore, define cases of retained  placenta
to be those in which the uterus  does not, after a due interval of rest, detach
or expel the  placenta,  and  which, consequently, require to be extracted.
This interval may be  fixed at  an hour or thereabouts, for ordinary cases;
but,  on  the  one  hand, more  time may  be  required  if the fatigue have
been excessive, and, on the  other, prompt interference will be necessary
if hemorrhage supervene.
   657. Statistics. — The  following  table will enable  us to  estimate  its
frequency, causes, and,  in some  measure,  its consequences.
Authors.	Total No. of Cases.	Retained Placenta.	Inertia.	Irregular Contrac-tions.	Morbid Adhesion.	Mothers lost.
Mr. Giffard Mr. Perfect Dr. Jos. Clarke Dr. Ramsbotham Dr. Granville . Edin. Hospital. Dr. Cusack Dr. Maunsell . Dr. Collins Dr. Reid . Dr. Beatty Dr. Lever . . Dr. F. H. Rams-1 botham / " Dr. Toogood Dr. Lee . M. Riecke A. E. v. Siebold Drs. Johnston 1 and Sinclair /	10,387 640 2,452 701 416 16,414 3,250 783 4,666 68,435 1,135 850 219,303 238 13,748	24 19 21 27 7 6 22 2 66 32 1 37 403 24 5 188 57	3 2 2 37 1 22 1 21	7 14 5 1 5 19 9	11 3 '24 10 'l5 . 5 27	3 4 5 10 6 1 6 1 4
1 ?romn  V* Wears'that in 343>6?0 cases, it occurred 881 times, or about
I in 390.   In 243 cases, when  the result to the mother is given, 40  died or
about 1 in  6;  but much allowance must be made for this excessive mortality
owing to mismanagement on the part of midwives before an accoucheur is
called in   The immediate cause of death is generally hemorrhage

nl,oentfl ^SElS T ^t™' ~ ^ ^"^ CaUSeS °f ™^{™ of the
  ffaA   = L Inertia of the uterus; 2. Irregular contraction of the uterus ;
aud 3.  Morbid adhesion  between the uterus and placenta.   These we shal
consider separately, with their treatment.
  1. Inertia,  of the uterus .-I have already stated that the contractions
which expel the child generally detach the placenta, and often  partial yexpe
it but it may be unaffected by them; in this state  it will, of  course  remain
until the occurrence of uterine action.   But cases not unfrequently occTrn 
RETENTION OF THE PLACENTA.
445
which  the uterus remains quiescent after expelling the child, owing some-
times to the length and severity of  the labor, and sometimes, apparently, to
a peculiarity of uterine constitution ; in other words, to a cause unknown.
Now, if in such cases the placenta be entirely adherent, no evil consequences
will result for some time ; there is,  of course, the risk of a partial separation
occurring, and a secondary risk from decomposition if it remain long enough :
but there is no immediate danger.  On the other hand, if it  be  partially or
wholly detached,  and lying in the uterus, the separation will have  exposed
many large vessels, and the absence of uterine contraction permits the un-
controlled escape of blood, so that, in these cases, there  is generally more
or less flooding — it may be, even to a fatal  extent:  therefore,  in  addition
to the  more  distant danger, which  these cases share in  common with the
former, there  is immediate danger from hemorrhage, of the most urgent kind.
If the hand be placed upon the abdomen, the uterus is felt large and flabby,
without any of the firmness which  is  its characteristic in a state of active
contraction.
  659.  Treatment.—The  promptitude  of  our  interference depends en-
tirely upon the presence or absence of flooding.   If there be great hemor-
rhage, the placenta must  be instantly removed, either by traction by the
cord, or by the introduction of the hand.   There is one exception to this
rule, however, and  that is when hemorrhage has occurred to such an extent
that the patient  has fainted, and is almost moribund :  in  this case a very
little additional loss may be fatal,  even so little as may occur on removing
the placenta; but as for the present it is arrested by the syncope, we may
postpone the operation until  the patient rallies a little, taking  care not to
wait until the hemorrhage return.   " If there have  already been  hemor-
rhage  so profuse as to  occasion  danger," says Denman, "and the  common
consequences of loss of blood, as fainting and the like, have already followed,
the placenta  ought not then to be extracted, nor the patient disturbed, nor
any change made, till she is somewhat recovered from her extreme debility:
as the danger would be thereby increased, and the patient  die, during, or
immediately  after  the  operation, as  I have seen and known  in  several
instances."
  There may, however, be no flooding : and in some cases it might be pos-
sible to remove the placenta by a steady pull at the cord, but to  say nothing
of the risk of breaking it, we should be only exposing the patient to a risk
of hemorrhage by withdrawing  the placenta whilst the uterus was  relaxed.
The best plan is  first to try and excite the uterus to contract by  friction and
pressure upon the  abdomen, and then to draw by  the  cord steadily and
firmly.  If the uterus still remain inert, we are recommended by M. Mojon,
and  some continental practitioners, to inject the  umbilical vein with cold
water, so  as to stimulate the uterus by the impression  of cold.  I have men-
tioned this, but I should fear  that there would be risk of exciting inflammation
by it.   I have, however, repeatedly given the ergot of rye in such cases, and
with the best effects ; when successful, it brings on uterine contractions, and
causes the spontaneous expulsion of the after-birth, at the same  time that it
effectually guards against hemorrhage.   If it fail, we have no resource but
to extract the placenta by the hand, an operation never to be lightly under-
taken, as  it is one  of the most dangerous, in consequence of the frequency
with which it is followed by inflammation.  It should be performed very gently
and deliberately.   The fingers, formed  into a cone, are to be introduced in-
to the  vagina and os  uteri, in the axis of the outlet  and brim, guided  by
the funis, and so  gradually up to  the placenta, which may be grasped by its
inner surface, as  Hamilton  and  Burns recommend,  or the finger  may  be
gently insinuated between it and the uterus, so as to peel it off very carefully 
44 6
RETENTION OF THE  PLACENTA.
and gently.   Great care must be taken, on  the one hand, not to injure the
surface of the uterus, and, on the other, to remove the whole of the placenta ;
and having done this, the detached mass should be grasped, and the uterus,
which by the operation will be excited to action, allowed  to expel both  it
and  the  hand.  By so doing, we shall secure its contraction,  and  guard
against  hemorrhage, and meanwhile external pressure should be exerted by
the other hand, and maintained by compresses and the binder.  This opera-
tion should never be performed without clear conviction of its necessity.  I
perfectly agree with  Dr. Denman, who observes, that although " it is often
mentioned as a slight thing, yet I am  persuaded  that every person who at-
tends to the consequences of the practice will think it of importance, and
that, if possible, it always ought to  be  avoided.
  After the  operation, we  must remain some time with the patient, to be
sure that the  uterus  does  not again relax, and  hemorrhage ensue, giving
ergot of rye if there be the least threatening,  and for some time  watch
carefully lest inflammation should set in.
  660. 2. Irregular contraction.—After  the  delivery of the child  in  ordi-
nary cases, the uterus closes  equably over the after-birth, pressing it on all
sides and forming a globular tumor in the abdomen.   There are occasional,
though  rare exceptions, however, to this equal  contraction, in  which the
uterus contracts unequally, and yet forcibly, and so far from effecting the
expulsion of the placenta, which is the principal object of its contraction, it
is thereby effectually retained.  This irregular contraction sometimes follows
natural  labor, but more frequently labor with mal-presentation or instru-
mental delivery, and  it is  attributed (not without justice,  I think, in  some
cases) to the action of the ergot of rye.1
  There are three kinds of irregular contraction which may be briefly no-
ticed :  1.  The  first  is seldom noticed in  books,  and yet it  is of  frequent
occurrence.   It appears to consist in a contraction of the fibres of the
cervix uteri  to a greater degree than of those of the body and fundus.  If
the hand  be placed upon the abdomen, the uterus is to a certain degree,
but not firmly,  contracted, whilst, if the finger be  passed into  the os uteri,
the cervix is found  to be hard and contracted, and the cord when pulled
does not give.   The placenta  is sometimes  adherent, but more  frequently
partially or wholly detached, and a portion  of it may often be felt in  the os
uteri.   In common with the other varieties of irregular contraction  there
is sometimes hemorrhage, but frequently none at all, and  the necessity for
interference chiefly arises from the indisposition of the uterus to rectify the
irregularity  and  expel the after-birth.   The globular tumor,  moderately
contracted, the narrowed os uteri, and the firm retention of the placenta,
even when partially or wholly detached, will distinguish these cases from all
others.
   2.  The second irregular contraction is  that which has received the name
of "hour-glass contraction."   The fibres  around the body  of the uterus are
thrown  into a state of permanent contraction, the remaining portion being
only in  a state of moderate  action, giving to the uterus something  of the
figure of an hour-glass, and dividing its cavity into two  unequal chambers
an  upper and  a lower, in  the  former of  which the placenta is mainly  or
entirely  contained.   It may be  entirely  adherent,  or partially or wholly
detached, though seldom  the  latter.   Occasionally there is hemorrhao-e
This variety of irregular contraction has  been attributed to the too  rapid
passage  or extraction of the child ; to a  lingering  labor with women  of an
irritable  constitution, and  to  the  partial  action of ergot.  Dr.  Douo-las

            1 Hasbrouck, New York Journal of Med., Nov. 1853, p. 334. 
RETENTION  OF  THE  ILACENTA.
447
thinks  that  hour-glass contraction rarely or never occurs without morbid
adhesion of the placenta.   Drs. Campbell and F. Ramsbotham  deem it a
very rare  occurrence.  It is very seldom that we can discover any irregu-
larity of form in  the uterus  by placing  the hand on the abdomen, and, in
consequence, the  diagnosis is very obscure, until the hand be introduced for
the purpose of extraction.
   3. The third irregularity is a preponderating contraction of the circular
fibres of the uterus, throwing the organ into the  shape of a long cylinder,
so that it feels narrower than  usual;  and instead of a globular  tumor just
above the pubis,  it is  often  felt reaching  up above the umbilicus, and  in-
ternally it may be difficult to reach to the fundus.   As in  hour-glass con-
traction, there is  not always flooding, and the causes are probably the same.
The diagnosis  is  aided, however, by the shape of the uterus, although it is
often sufficiently  obscure.
   661.  Treatment.—The first variety of irregular contraction can generally
be remedied without the introduction of the hand.  Steady and firm traction
should  be made  by the  cord in the axis of the  brim, and  maintained  for
some time without relaxation, at  the  same time that very firm  pressure is
made over the uterus, and towards the pelvic cavity; this in  many cases
overcomes the spasmodic action,  and  the placenta is rather suddenly re-
leased.   If it fail, one or two fingers introduced within the os uteri may be
sufficient, as they may be able  to seize a portion of the after-birth, and so
aid in  the traction.   I have  seldom found it necessary to do more than this ;
but of course if it do  not succeed,  the  placenta must be extracted by intro-
ducing the  hand  carefully and  gently, as before described.

               [Fig. 175.]                          [Fig. 176.]
Hour-glass Contraction of the Womb.          Removal of adherent Placenta.
  In the second and third form of irregular contraction, traction by the cord
is quite ineffectual, so firmly is the placenta grasped.  We can only wait, there-
fore, until we are satisfied that it will not be separated and expelled naturally,
and cannot be withdrawn by the cord, and then at once proceed to extract
it.  The introduction of the  hand is  to be effected in the way already de-
scribed, until we arrive at the  contraction, which is to be overcome by gentle
but steady pressure of the points  of the fingers gathered into a cone ;  and
when we reach the placenta, we must remember to detach the whole, and to
allow the hand to  be expelled by the uterus.   In the hour-glass contraction, 
448
RETENTION OF  THE PLACENTA.
*he lower chamber is so complete, and the contraction so close, that persons
have suspected that the aperture through which the cord was traced was, in
fact, a laceration :  a little patience  and perseverance,  however, will show
the true state of  the  case, and besides, although  the  child often escapes
through a laceration into the abdomen, it  is very rare  for the placenta to
do so.
  [When hour-glass contraction is ascertained to be present, no reasonable
hope can be entertained of a spontaneous expulsion of the placenta ; to wait,
therefore, for such an occurrence is a mere loss of time.   The proper course
is for the accoucheur to proceed at once to overcome the contraction of the
uterine fibres, and  deliver the placenta by manual interference.]
  Opium and venesection have both been recommended for the relief of ir-
regular contraction ; but I quite agree with Dr.  Ramsbotham that both are
objectionable.
  Let me again impress upon my readers  the necessity of great care to  se-
cure the regular, equal, and permanent contraction of the uterus afterwards.
  662. 3. Morbid adhesion of the placenta to the  uterus. — Many of  the
diseases of  the placenta to which I have heretofore referred, may occasion
adhesion between its outer surface and the inner surface of the uterus.  Thus
inflammation may  end  in the effusion of lymph connecting the two, or in  in-
duration.   Again, the  adhesion  has  apparently been affected by calcareous
or scirrhous deposition.  The space  occupied by the adhesion is generally
limited.
  This accident is  manifestly the  result of disease during  pregnancy, ana
has no relation *to  the kind of labor.  It is much more dangerous than
irregular contraction, because the uterine action generally detaches more or
less of the placenta; but the adhesion retaining the mass in the uterus, prevents
its contraction and the  closure of the bleeding orifices of the uterine vessels.
We find, therefore, more or  less  flooding, sometimes to an enormous extent.
Almost  the only exceptions  are the few cases where the adhesion is very
extensive, and the detached  part small.
  The diagnosis is in  almost all cases impossible, until  the extraction is
attempted :  a strong suspicion will be excited, however, by the occurrence of
uterine contraction, without extrusion of the after-birth.  The previous his-
tory of the  patient may in some degree confirm these suspicions;  if she have
suffered much pain in  some fixed parts of the uterus  during pregnancy, it
may have resulted from inflammatory action.  Whenever  we see a patient
suffering thus, we  should always ascertain by the stethoscope whether it is
in the situation of the after-birth, so that  we may be prepared for  the con-
sequences at the time of labor.
   663.  Treatment. — As we cannot be sure that the  retention  arises from
adhesion, we must  only have recourse to the usual preliminary means and
finding them ineffectual, to extraction.   The hand is to  be introduced in  the
usual manner, and on trying to separate the placenta, we shall discover that
some part  of it is closely adherent, as it were amalgamated with the uterus
It would be extremely wrong to use violence in endeavoring to detach  it •
if therefore, we cannot easily effect this, it is better to peel off the placenta
all round up to the adhesion, and  then to separate the loose part from  the
adherent portion close round the adhesion, leaving the latter in the uterus
to soften and come away with the lochia.   In  a case of Dr Smellie's in
which he removed the indurated and adherent portion, the patient died'of
hemorrhage ; and several similar cases are on record
   It cannot be denied  that danger may arise from the'decomposition of what
 remains ; but we have no means of  avoiding it, except by care afterwards
 If the discharge be very offensive, vaginal injections of tepid milk and water 
FLOODING.
449
should be used twice a-day, and  any symptoms of inflammation promptly
treated.
  664. The extraction  of the  placenta  may be rendered  necessary by the
rupture of the cord, inasmuch as we can afford no assistance ;  but it is by
no means so easy, as we lose the guide it affords us into the os  uteri and to
the situation of the placenta.   In such a case, of  course, we must first try
fairly what the natural  powers, stimulated by friction and ergot, will effect,
and if they fail, the hand  must be introduced  with greater caution, and the
placenta very  gently sought for, and detached  in  the usual manner.  Once
more let me repeat the necessity of removing all  the placenta, for a small
portion left behind may render all our exertions fruitless as to the result.
  I  have deferred the  consideration of  the treatment of the hemorrhage
until the next chapter,  as I preferred limiting this chapter strictly to the
management of retained  placenta;  the  two chapters should, therefore, be
taken together.
                        CHAPTERXX.

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


  665. There  is no  deviation from the ordinary course of labor so trying
to the medical attendant as flooding;  not only on account of the imminent
danger;  but from the sudden and rapid progress of the attack, and the im-
possibility of waiting for  assistance.   Nothing can  preserve our calmness
and presence of mind under such circumstances, but understanding the sub-
ject  clearly  beforehand,  and  being perfectly  prepared for meeting  each
variety of the accident with its appropriate treatment.
  I have already spoken  of the hemorrhage  accompanying abortion, and it
remains now for us to consider those forms of flooding which occur just pre-
vious to or during labor and  afterwards.  During the  last month of gesta-
tion  and at the commencement  of labor, patients are exposed to two forms
of hemorrhage, differing  in their causes, but depending upon the situation
of the  placenta.  The first has been  called  " accidental hemorrhage," be-
cause it arises from a  partial and accidental separation of the placenta, which
occupies its usual situation ; and  the second  is justly termed " unavoidable
hemorrhage," because the placenta, being placed partially or wholly  over
the os uteri, the dilatation of this will unavoidably separate the after-birth,
and  give rise to hemorrhage: as Naegele has observed,  " the  very action
which nature uses to bring the  child into the world is that -by which she
destroys both it and its  mother."  After delivery, flooding may occur to any
extent, and from various causes.
  Each of the  varieties of hemorrhage will  require  a separate  and careful
consideration.   But  first  let us ascertain their frequency and mortality, as
far as possible.
       29 
450
FLOODING.
666.  Statistics:—
		4h						a> aJ		?, ^	to
Authors.		O — a 0	be C £ C £	.a 0	c c a	3l ask ii	<	If 2-2 0 a >* 2 * 3	0		h Of O
		H		S	£ C		1	P-a	s	K M	1
Mr. Giffard			35	6	14 1			. 19	5	5	
Dr. Smellie		.	34	13	16 6			3 24	8	3	2
Mr. Perfect			18	6		7 8		2 6	3	0	1
Dr. Bland .		1,897	9	3							
Dr. Jos. Clarke .		10,387	24	5	10 10			4 4	1	10	
Dr. Merriman .		2,947	32	1	14 21			4	1	5	
Dr. Granville		640	2			1		2			
Dr. F. Ramsbotham		49,996	350		135 !			. 83		108	
Edinburgh Hospital		2,452	31	' 3		1		I 2	i	28	i
Dr. Collins		16,414	131	12	1	7 13		2 11	2	107	8
Dr. Cusack		701	15			6				5	
Dr. Maunsell		839	110	' i				5	i	6	i
Dr. Beatty		1,182	6	1				4	0	2	1
Dr. Lever .		4,666	51	4		r 16		. 13	2	35	2
Mr. French		89	5					1			
Dr. R. Lee			47	10		. 24	L	t 23	6		
Dr. Reid .		3,250	52			. 22		3		27	
Mr. Warrington		110	4		' ]	L . .		2		2	
Dr. Churchill .		1,640	25	' 6	(	) 3	' (	) 1	6	21	
Drs. M'Clintock and Hardy		6,634	93			29	t.	I 8	3	56	7
Birmingham Hospital		650'						4	1		
Mr^ Earle ....		4,320						22			
Mr. Rose ....		600	20			18		2			
Mr. Bailey		2,819	61			56		5			
Dr. Toogood		1,135	21					1			
Dr. J. Lee.		850	11					4		7	
Mr. Watson		800	27						2		
Dr. Copeland .		1,290				5		2			
Mr. J. Thompson		3,300	13	3	t			5	2		
Drs. Johnston and Sinclair		13,740	105	10	41	*81	4	24	6	33	2
Dr. Hall Davis .		7,300	234	2	16	23	c	11	2	39	1
Dr. Richter		624	5					5			
A. E. v. Siebold		730	9	2	1			3	2	6	6
Dr. Voigtel		29	1	0	1			1	0		
Dr. Jansen		13,365	11			4					
Dr. Bartsch		4,383						11	6		
Dr. Klein ....		11,410						15 1	2 1		
Dr. Arneth		6,527						9			
  From this table we find that in 163,738 cases, hemorrhage occurred 1338
times, or about 1 in 122; out of 782 cases of hemorrhage, 126 mothers were
lost, or about 1 in 6; out of 944 cases,  288  children were  lost, or about

  Further, out of 218 cases of accidental hemorrhage, 32 proved fatal  or 1
in 6 ; out of 261 cases of unavoidable hemorrhage, 71 provedTtal or nZhr

aboufl'Cll0^ °' ^ "^ °f ^^ ^ ™^T^°k™%
  667.  1  Accidental Hemorrhage.-In  these cases, as I  have said the
placenta is in its  ordinary situation ; it may be at any part  of the uterine
parietes except the cervix, as then the case would come  under the ckss of
unavoidable hemorrhage.    The immediate cause  of the flooding ?<,+£
separation of some portion of the placenta from the womb and the laeJ™
tion  of its vessels; as these cannot be closed by the uterine contrSn" 
FLOODING.                          451
because the uterus is full, of course the blood  is poured  out freely.   The
amount of the loss is said to be in proportion to  the  extent  of the surface
exposed, and, perhaps, in many cases this may  be true, but there are strik-
ing exceptions : fatal hemorrhage may take place from  a space not more
than an inch square.   In some rare cases, a portion of the centre of the
placenta is detached, and a cavity formed which is filled with blood, but a3
it issurrounded with adherent after-birth, of course none escapes externally.
Or it  may extend beyond  the placenta, and be  retained by the  adhesion
of the  membranes or other causes.   "In such  cases," Dr. Burns  remarks,
" the effusion is accompanied  with  dull internal  pain at the spot where it
takes  place.   This pain is something like colic, or like the  pain attending
the approach of the menses.  The part of the  womb  where the extravasa-
tion takes place,  swells  gradually, and  in  a short time the  uterus  feels
larger.  If the quantity  be considerable, the size  increases, the uterus is
felt to be firmer and tenser, as well as larger, the strength diminishes, and
some faintings may come on.   In course of time,  weak, slow  pains are felt;
but if  the  injury be  great, these decline  as  the weakness increases.  They
may or may not  be attended  with the discharge of coagula from the  os
uteri."  The hemorrhage, in fact, is  at first internal, and generally, though
not always, becomes  external.   Dr. Burns suggests that  in some cases  the
bleeding may be the result of the separation of the decidua, and a laceration
of the vessels running to that membrane  from the inner coat of the uterus,
and not from a separation of the placenta.
   668. Causes.—Violent shocks, such as blows, falls, etc.,  may have the
effect  of detaching a portion  of the placenta, and in  some cases, a very
slight  shock will be sufficient;  I was called to a case in which it was effected
by a hearty fit of laughter.   Besides these causes, fatigue, over-exertion,
violent straining  at stool,  lifting heavy  weights, excessive  action of the
utero-placental vessels, disease of the placenta,  general plethora, spasmodic
action of that portion of the womb to which the placenta is  attached, may
be equally effective.  Dr. Burns  observes, " we  sometimes find that extra-
vasation is produced by an increased action of the uterine vessels themselves,
existing as a local disease.  In this case, the patient  for some  time before
the attack  feels a weight and uneasy sensation about the hypogastric region,
with slight darting pains about the  belly or back."  It  may also occur in
the course of labor, the  placenta being  partially detached  by the uterine
action, and may even prove fatal.
   669. Symptoms.—The exciting cause  may be  instantly  followed by the
discharge,  or preceded  by general and local uneasiness, dull pain and aching
in the  belly and back ;  and if the hemorrhage be retained, by rigors,  tension,
and weight in the abdomen, and by faintness.  When the flooding is  internal
during labor, none may escape until after the expulsion of the child or pla-
centa,  as occurred with a patient of mine ; and  the characteristic symptoms
are gradual diminution or cessation  of the pains, with fainting, which may
possibly be mistaken for symptoms  of laceration, but differing from this
latter accident in the gradual cessation of the pains, and  the  absence of re-
cession of the head.   At  length, with  or  without a pain, the dischage
commences, 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 discharge
is arrested ; but after she has rallied, it again  recurs, and the syncope  is
repeated.   The surface is blanched and covered with cold sweat, the coun-
tenance sunk,  with dark circles around the  eyes, the  pulse becomes weak,
quick,  and  fluttering.  If the flooding  be not arrested, all these symptoms
increase;  the  sight becomes dim, there is a ringing  in  the  ears,  frequent
sighings, intolerable restlessness, uneasiness, jactitation, and death; preceded 
452
FLOODING,
by fainting or convulsions.  The fatal result is not  always in Fop0 ]*£"  =
the amount of hemorrhage ; in certain constitutions or in certain conamons,
a comparatively small loss will end fatally, whereas in others a mucn larger
loss will be borne with impunity.
  Labor pains may come on at some period of the discharge, or tney may
be entirely absent;  a good deal will depend on the period of pregnancy at
which the complication occurs.   If they do, it will be observed  that during
a pain the hemorrhage  is arrested, but that  it returns on the cessation ot
the pain.                                         ...   ,^    i,   e    i
  If an internal examination  be made, the os uteri will  seldom be  lound
dilated, unless there have been  pains for some time, but the cervix  is  gene-
rally softened and relaxed by the hemorrhage ; and what is of great import-
ance, in most cases we can pass the finger within the os uteri sufficiently to
ascertain the presence of the  membranes, and that no  part of the placenta
is within reach.
  As regards the child, this complication is most dangerous ; if the hemor-
rhage be excessive it is almost always still-born.
  670. Diagnosis.—The diagnosis of accidental from unavoidable hemor-
rhage is of extreme importance, inasmuch  as the  treatment  of the two is
essentially different.  There are four points in which the two varieties differ
remarkably, and  which  will enable us to distinguish  them.   In  the first
place, we can generally make out some definite external cause for accidental
hemorrhage, and its occurrence is accidental and irregular, whereas in una-
voidable hemorrhage the only exciting  camse is the expansion of the cervix,
and the time of its first  occurrence  has  a  certain degree of  regularity.
Secondly, in accidental hemorrhage the discharge takes place freely, during
an interval, but is at once arrested by a pain during its continuance ; but in
unavoidable hemorrhage the discharge which continues also  during  the
intervals, is greatly increased during the pains.  Thirdly, in cases  of acci-
dental hemorrhage, the os uteri is free, closed by membranes  only, and  the
cervix is of equal thickness all  round ; whereas  in placenta prsevia the  os
uteri is  more or less covered by the after-birth, or if it only reach to  the
edge of the cervix, the latter is felt to be considerably thickened at that part.
  Lastly, in many cases we  may ascertain the situation of the  placenta by
the stethoscope, and its presence in  the body or" fundus of the  uterus will
decide the case to be one of accidental hemorrhage.
  I have already stated that weakening or cessation of pains, fainting, sense of
distension, are the characters of internal hemorrhage,  with the absence of
any other cause calculated to produce these symptoms.
  671.  Treatment.—The  indications of management must be drawn from
the period of pregnancy, the state of the os uteri, and amount of discharge.
  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 discharge
is not profuse.   In such a case the patient is not in immediate danger • and
as prompt delivery would be difficult,  it may be well to temporize  and see
how far we can arrest the discharge.   For which purpose the patient should
be placed in bed on a hard mattress, and very lightly covered with bed-clothes •
the temperature of the room should be reduced very low, and nothing but
cold drinks allowed.  Enemata of cold water exert a very powerful control
in such cases.  The plug may be used (according to the restrictions formerly
laid down), inasmuch as the uterus being full, there is little dano-er Gf  inter
nal hemorrhage to any extent.   The best plug  is  cotton woof which mav
be most easily introduced  through a  cylindrical speculum ; but we may use
common tow, or one or two silk handkerchiefs ; and the  object will not be
attained unless the vagina be quite filled.
  Internally we may give the acid mixture,  with a large proportion of acid • 
FLOODING.
453
for instance, half an ounce of dilute sulphuric acid to six ounces of infusion
of roses, an ounce to be taken every hour.   To  tell  the truth, I  think it is
more highly estimated than it deserves.  Lead, in large doses (gr. x. Acet.
Plumb. 2dis horis), has been recommended :  Dr. Conquest speaks favorably
of it.  It may be combined with opium, or either may be given separately.
I have no doubt of the beneficial effects of  opium, either in large  doses (gr.
ij.) or  (gtt. Ix.  Trae.  Opii), or repeated small ones.  I have  also seen the
Tinct.  Cannabis Indicae exert very  beneficial influence.
  Large drinks of  cold water alone, or with the addition of  the nitrate of
potash, seem beneficial.   Of course the patient cannot be allowed to sit up,
or to leave her bed, and it is an advantage to  free the bowels by enemata
of cold water, as involving less effort in the evacuation.
   672. There are many cases in which, under this treatment,  the discharge
is diminished, and the patient carried to her full time in safety; but in others
it will  fail, either on account of the increase of the discharge or because the
pains  of labor are  brought on.  In  these  cases, as well  as in those where
the amount of discharge  is great from the beginning, another line of treat-
ment is practised which would  be very doubtful  in the former  case.   I have
said that the discharge is observed  to  cease during a pain, and the reason is
simple.  During a pain, the placenta is pressed by the contents of the uterus
on the one hand, and against the  bleeding vessels on the other, and by its
pressure as a tourniquet, the flow of blood is arrested.  An observation of
this fact led  to  the inference, that if the liquor amnii were evacuated, the
pains would be quickened, the pressure increased and rendered more  perma-
nent, besides that the labor would be sooner terminated.   As  Dr. F. Rams-
botham has  remarked, " the vessels of the uterus are diminished in size by
the contractions  of the uterine parietes: the open  orifices  are in a degree
plugged by the parietes being brought into closer and stronger contact with
that portion of the  placental mass disunited from the  uterine surface; and the
pains are usually increased in frequency and power by the  augmented stimu-
lus impressed upon the os uteri."   Moreover, in cases of large flooding, we
need not anticipate the usual delay  in  the dilatation  of the os uteri; for, as
I have mentioned, the hemorrhage softens the cervix uteri, and prepares it
to yield easily to the  pressure of the head.   In  these cases,  therefore, when
the flooding is profuse, and the danger imminent, the membranes should be
ruptured by the finger or a female  catheter.  Soon  afterwards, we find the
pains increase, the  flooding diminish, and the labor advance.
   For the clear understanding of  the principles  of this practice, and the
cases to which it is suited, we are mainly indebted to the late  Dr. Rigby of
Norwich, who published his valuable essay on Uterine Hemorrhage in 1775,
although  the plan was first recommended by Julian Clement and  Puzos.
That it is very successful we have  the testimony of many authors, as Den-
man, Baudelocque, Merriman, Ramsbotham, Blundell, etc.  Dr. Rigby suc-
ceeded by it in  64 cases, without having  occasion to turn the child.   Dr.
Merriman in 30 cases.  Dr. F. Ramsbotham in  23 out of 25 cases.
   Some writers, as  Hamilton, Burns, Stewart, etc., have opposed the evacua-
tion of the liquor amnii on the following grounds : 1, that by  it gestation is
suspended : 2, that  it is not certain  to bring on labor in time to avoid danger :
and, 3, that it may not arrest the hemorrhage, and if not, we  must turn and
deliver under more disadvantageous circumstances.   The first objection is
true, but of no  value, unless the others be true also ;  for if the operation suc-
ceed, and save the  woman's life, which is in danger, the shortening of gesta-
tion is of no consequence.  The second objection,  though contrary to the
general opinion, is  better  founded ;  for although, where there are pretty good
pains, they increase  after rupture of the membranes, especially if ergot be given,
yet if  there be  little or no uterine effect before the membranes are ruptured, 
454
FLOODING.
pains may not come on and  the  hemorrhage may prove fatal.   I saw one
example of this, and on post-mortem examination, the head of the child was
found filling the brim, and the uterus filled with blood.   The third objection
I think hardly holds good, if the pains have been good before rupturing the
membranes ; for most likely the pains will increase ; and if not, there will be
but little more difficulty in turning.
  673. I should  say, then, that if there be decided pains and dilatation, or
good pressure upon the os uteri, that we may safely give an ample dose of
ergot, and before the loss has been excessive, rupture the membranes for the
purpose at once of  arresting the hemorrhage and hastening the labor.   But
if there be no uterine effort, or very slight  pains, it would  be  dangerous
practice to rupture  the membranes.   If you remember that the uterus is so
filled that external hemorrhage cannot  take place to a  very great extent,
you  will  see that by plugging the vagina thoroughly, all external  hemor-
rhage can be stopped.   If so, is it not better to do that, and gain time until
an  effort  be made to excite uterine action ?  Besides, we often find  that
when we succeed in thus arresting the hemorrhage for a time, on the remo-
val of the  plug (which ought to be done every day) it does not return.  After
filling the vagina thoroughly, therefore,  I would advise that half-a-drachm
of powdered ergot  should  be given every three or  four hours  for a time,
until uterine action is fully excited, and then, if the hemorrhage return, we
shall be justified in  rupturing the membranes.   If  this fail, or in  place of it,
we ought to try the effect of  galvanism, by which Dr. Radford succeeded in
cases in which there was no uterine action and a rigid and undilated os uteri.
Drs. Haeniger and  Jacoby, Mr. Cleveland,  Mr. Dorrington,1 Mr. Wilson,2
and  Mr. Clarke,3 have also found a favorable result from its employment.
If this fail, or be counter-indicated, then we  must adopt the  plan recom-
mended (without any definite notion of the nature of the case) by Ambrose
Pare, Guillemeau, etc. etc, viz., introduce the hand and bring down the  feet,
thus terminating the labor.    The operation will be facilitated by  the relaxa-
tion produced by flooding, and though more dangerous for the child, if the
mother's safety demand it, must be done.
   The child may be premature, however, the os uteri not sufficiently dilated,
or there may be other reasons why this operation is objectionable, although
immediate delivery is called for ;  and in such cases, as the os uteri is generally
soft and dilatable to a certain extent, and  the  child dead, I have found "it
the best plan to perforate the head and extract with the crotchet.   The  opera-
tion is not difficult,  nor is there any risk, if the operator  be careful to pro-
tect the point of the perforator, and afterwards to  extract slowly, cautiously,
and at intervals.
   In the  case of internal hemorrhage occurring during the progress of the
labor, the  treatment will depend upon the stage of the labor, and  the amount
lost, judging by its  effects.   If the patient be in danger of sinking, and the
os uteri dilatable, but the head within the uterus, there can be no  doubt that
we must deliver by turning ;  but if  the loss  be moderate, we may perhaps
afford to wait until the head descends into the cavity of  the pelvis ;  and in
all cases where it is within reach of the forceps, they ought to be used for
immediate delivery, if the case be mechanically suitable.  But  little hesitation
need be felt on account of the child  in deciding upon  the mode of delivery
as it is lost in almost every case of excessive hemorrhage.
   674  By a judicious application of the suggestions I have made, we shall
be able to temporize beneficially in  cases where no  pains exist,  or perhaps
to carry on the patient to her full time ;  or if there be pains, or  we succeed

      JProv. Med  and Surg. Journal, March 11th, 1846, p. 105.
       Ibid. April 29th, 1846.         3 Dublin Hosp. Gazette, March 1st, 1848. 
UNAVOIDABLE  HEMORRHAGE.
45b
in exciting  them, then, by one or other of these  methods, we may almost
always succeed iu terminating the labor without incurring an additional loss
of blood, and if that have not been excessive previously, the mother may be
saved.   As  we have seen, nearly one in  three are lost.   There is danger to
the child in  proportion  to the hemorrhage, and additional danger if we are
obliged to turn.
  There are cases, however, to which we are called after alarming flooding
has continued for some time,  and although we succeed  in  delivering the
woman, she  may die afterwards from loss of blood.   In  such  extreme cases,
and such only, transfusion, as recommended by Dr. Blundell, seems to be the
only resource.  It has succeeded in fourteen cases on record ;  but it has also
failed  many times.   It is performed  by means  of a syringe and tube; a
small tube is inserted into the median or other vein of the woman's arm, and
blood from  a healthy person is taken  up by the syringe, previously warmed,
and after expelling all  the air from  the  instrument, its  pipe  is passed into
the small tube, and  the blood very slowly forced in.  If the lips or eyelids
of the  patient quiver, or the respiration become more difficult, we must stop,
or death may result.   If her countenance and pulse improve, we may con-
tinue.   In  this manner blood  to the amount of sixteen or eighteen ounces
may be gradually injected, if necessary ;  although  a  much less quantity may
save the patient.   Great care must be taken that the instrument be clean,
and of a proper temperature, and that the blood be healthy and fluid.
   Two additional  successful cases  have been recently published  by Mr.
Wheatcroft.1
   675. In all these cases, a liberal but  judicious allowance of stimulants is
necessary;  but in regulating the amount, we must not forget that the subse-
quent  reaction will be somewhat in proportion.
   As  to the placenta, it is very often expelled immediately after the  child,
and if it be not, it will be much better to extract it, and secure a firm con-
traction of  the uterus, than to allow the hemorrhage to  continue.
   After the delivery is completed,  the  stimulants  must  be  continued,  if
necessary, or chicken broth may be substituted for them.  Notwithstanding
the danger  of suspending uterine action, I  have seen so much benefit from
small doses  of laudanum combined with ammonia, that I have no hesitation
in recommending its exhibition.
   The utmost watchfulness  will be needed  to suppress any return of the
hemorrhage, and to enable us to guard  against  any subsequent attack; for
it should always be borne in mind that hemorrhage is by no means a  guaran-
tee against  inflammation afterwards.

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

                i British Medical Journal, April 10, 1858, p. 290. 
456                          FLOODING.
believed that it had originally been situated  different y, ^t  had been
tached and  fallen down.   Paul Portal  first spoke of it as adhering^to tnis
part, in consequence of which he was obliged to deliver by art.   Lriudiu,
Fig. 177.
Placenta Prsevia.
Levret, Roederer, and Smellie  were also cognizant of this fact, and  they
seem  to  have been  aware of the mode  in which the  hemorrhage was pro-
duced, and of its inevitable occurrence.   But it is undoubtedly to Dr. Rigby,
of Norwich, that the profession is indebted for the full and clear elucidation
of the subject.   Time, which is the great test of merit,  has only confirmed
the truth of his observations, and illustrated the value of his essay.
   677. The cause  of the hemorrhage  is evidently the separation  of the
placenta  from the cervix uteri, and the exposure of the mouths of the  torn
vessels;  and this separation  is effected and increased by the uterine contrac-
tions dilating the os uteri.
   Dr. Simpson  considers  that the source  of the hemorrhage  is, mainly at
least, from the placenta, and that it is venous in character;  in this I cannot
agree with him.   I  am sure  I have as frequently, at least, noticed the blood
to be arterial as venous, and this  observation  has  been recently confirmed
by Dr. Mackenzie,  of London, whose  experiments  appear  to me to prove
satisfactorily that, though some blood may escape  from the separated por-
tion of the placenta, by far the principal portion is from the uterine vessel.1
Dr. Barnes also considers the uterus to be the source of the blood.
   678. Symptoms.—The first discharge  is usually about three weeks before
labor commences,  coincident  with  the  commencement  of  the  process of
dilatation already noticed.   The amount of the discharge varies  but in
general it is not excessive in the first  instance, nor is  it accompanied  with
pain.   After its cessation, the  patient rallies ; but in a  week or two it re-
turns, perhaps in greater quantity, and again ceases, thus continuing fif uot
interfered with, or if premature labor do not come  on) until the  full terra
1 Association Journal, Dec. 23d, 1853, p. 1127. 
UNAVOIDABLE  HEMORRHAGE.
457
With the first sensible contraction of the uterus, the flooding comes on more
profusely, and is observed to increase during each pain.   Thus it would go
on until death supervened before delivery in most cases, if no assistance were
afforded.   I say in most instances, because there are some cases on record
in wrhich the placenta was  forced through  the os uteri before or along with
the child,  decidedly the happiest natural  termination.  The  first case on
record, I believe, is that by F. Lossius, in his Observ. Medicinal., 1672, p.
380, obs. 24, in the following words : " tandem secundiam ante partum ex-
cluserat, non tantum fcetu sed et matre salva."  I am indebted to my friend,
Dr. Aquilla Smith, for this early example.  Besides this, Smellie and  Lee
have  recorded  three ;  Ramsbotham five ;  Hamilton two;  F.  Ramsbotham
two;   Baudelocque, Perfect, Chapman,  Merriman,  Barlow,  Collins,  and
Maunsell, one;  etc., etc.
   Thus far the symptoms are alike (supposing the head to present), whether
the placenta be  situated entirely or partially over the os uteri  or only down
to its margin ;  but the difference is detected on making  an internal  exami-
nation.  In the former case, the os uteri is felt to be closed by a thick, soft,
spongy mass, firmer than a clot, and  not breaking down under the  finger,
through which  the presentation cannot be felt;  in the second, this spongy
mass  stretches over a portion only of the os uteri; its edge can be distinctly
felt, and  also  the  membranes covering the  remaining  portion  of  the os
uteri, through which we may be able to detect the presentation ;  whilst in
the third case the os uteri is closed by  the membranes only ;  but some por-
tion of the cervix is found to  be much thickened, whilst the  rest is of the
usual thickness; in  the latter case,  after delivery, the perforation in the
membranes is found close to the os uteri.
   I should mention that in  some cases where the placenta covers  the os
at the beginning, it is found to extend only partially over the orifice when
dilated.
   If the feet present,  with only a  partial  implantation  of the placenta, or
with it coming to the  margin of the  os uteri  only, they may  pass through
the os uteri; and although  the detachment  of  the placenta will increase
with the dilatation, yet the flooding will be arrested  by  the pressure of the
body of the child upon the placenta.    This may be considered as  the most
favorable presentation in " placenta praevia," because it saves the introduc-
tion of the hand to turn the child.
   The effects of  the hemorrhage upon  the mother, are  precisely as before
described,  but produced more rapidly, and more speedily fatal.
   679.  Diagnosis.—The sudden and apparently causeless occurrence of the
first hemorrhage, the increased  discharge  during a pain, and  the detection
of the placenta, partially or wholly covering the os  uteri, or descending to
its margin, are  the  distinctive characteristics  of  placenta praevia; in acci
dental hemorrhage, as before observed, there  is generally some assignable
cause, the  discharge is arrested  during  a pain, the os uteri is closed  by the
membranes, and  the placental murmur can generally be heard away from
the os uteri.
   There may occasionally be  some doubt as to whether the os uteri be
closed by a clot or by the placenta ; but the former is less firm, and is easily
broken up  by the finger, and we may often feel the adhesion of the placenta
to the cervix within the os uteri.
   680.  Treatment.—If we are called on the occasion of the first or second
hemorrhages, and find that the discharge has not been great,  and that the
term of pregnancy not being complete, the uterus is not in action, we may
try palliative treatment, as previously  recommended (§671), perfect  quiet,
rest on a hard  bed, a' cool  room, and light clothing, with cold and acid
drinks, enemata of cold water, small doses  of  opium, and the plug if neces- 
458
FLOODING.
sary.   The bowels must be gently freed.  It is hardly necessary to say that
in no form of uterine hemorrhage is venesection admissible.
   But  the hemorrhage may be so profuse as to  demand interference, or n
not  so at first,  it will  become so  immediately  on the commencement  01
labor;  and, from the nature  of the case, there is no hope of a natural ter-
mination, unless  the pains  be so violent as to force away the placenta before
the child; and as we need not wait for it, nor for the occurrence of uterine
action, the  only  question is whether the os uteri  is  in such a condition as to
admit  the passage  of the hand without risk of laceration.   If not, which
will  probably be the case if gestation be not completed, we  must wait, and
fortunately, in the plug well applied, we possess a means of control over the
discharge, for in this variety there is absolutely no danger of internal he-
morrhage.   When we have thoroughly plugged the vagina, we may give
any  hemostatic  remedies  we  please, and  on removing the plug,  we  must
ascertain whether the os uteri is more yielding, and either replace the plug,
or turn, according  as we find, just  as was  advised by M. Leroux, in 1776.
"Very often, as in a case I saw lately, the flooding does not  return, and if
the placenta  only partially cover the os uteri, labor may  come on  and ter-
minate naturally.
   But  if, on examination,  we find the  os  soft, yielding, or dilated, there is
no occasion to delay, and  the best  plan is to terminate the labor before the
woman's constitution has suffered greater damage.
   The  hand is to be passed in the usual way into the vagina, in  the axis of
the lower outlet,  and its direction immediately changed into that of the brim,
which will bring the points of the  fingers near  to the  os uteri, into which
they are  to  be  gently yet firmly  insinuated, and then  passed between the
placenta  and cervix,  on that  side  on which we  believe the  placenta to  be
narrowest, until  it  arrive at the membranes,  which  must be pierced,  and the
feet found and brought down.   Some writers", Smellie and Mohrenheim,  for
instance, have proposed to perforate the  placenta, instead of passing the
hand between it and the uterus; this is by no means  easy, and  appears to
me extremely objectionable.   When the body of the child is in the pelvis,
it will  act as a tourniquet, and the flooding will cease ;  nevertheless, it is
well not to  delay the delivery, as  internal  hemorrhage might occur.  The
mode of completing it I have already  described: it is rarely that a child is
saved.
   In placental presentation, even more than in accidental hemorrhage, it is
desirable to extract the placenta if it do not follow the child immediately,
and the same care and watchfulness will be  necessary to secure a good per-
manent contraction, and to guard against subsequent hemorrhage.  Pressure
above  and over the uterus should  be made with compresses and the binder,
and if  there be much  draining, cold must be applied to  the vulva, and ergot
or cold enemata administered.
   681. It is an advantage if the foot present, even when the placenta covers
the os  uteri, because the operation of turning is rendered easier ; but when
the os  uteri is  only partially covered, this  is still  greater, because by rup-
turing the membranes we  facilitate the descent of the feet, and have only to
seize them in the vagina and  extract the child
   When the placenta reaches only to the  margin  of the  os  uteri  the case
is truly one of  unavoidable  hemorrhage;   bu!  yet it  admit of thesane
treatment as accidental hemorrhage, no matter what  be X presentarion
temporizing  if  that be necessary,  but if there be pains, after rLturing  the
membranes, the pressure of the head whilst dilating the os uteri wiU  doe
the  mouths  of  the  bleeding vessels with  the  placenta,  and so arrest  the
rieno^J b   f ClUl(VS eXpelled"  This T ha™  fou^  ^  repeated eVpe!
nence, and therefore, when we are certain of the case, and pains are present 
                   UNAVOIDABLE  HEMORRHAGE.                459

our duty is limited in  the first instance to evacuating the liquor amnii;  but
if this fail, we must turn and deliver the child.
  682.  Such has been hitherto the mode of proceeding recommended by
practitioners of the highest authority;  it remained for my learned and in-
genious friends, Dr. Radford and Prof. Simpson, to propose another, which
at first sight is remarkable mainly for its boldness, but which  Prof. Simpson
has supported with his usual research, and which is  at present the  subject
of controversy.
  I have already stated (§678) that the placenta is sometimes expelled be-  -
fore the child, and that the mother  is not always  lost in these cases.   Now,
it  appears  that these instances  are  not so rare as  was supposed.   Dr.
Simpson has collected  56  published cases, and he has been  furnished with
74 unpublished  ones  (130  in all), in which the  placenta was either expelled
or extracted first, and he finds that in all, 10 women died, or about 1 in 13:
and of 110  cases the  infant was born dead  in 73, or 69 per cent, and alive
in 33, or 31 per cent., i. e., nearly every third child was saved.  In placenta
praevia, under ordinary management, 1 in 3,  or thereabouts, of the mothers
are lost, and more than half of the  children.
   Taking this as the basis of his  proposal, Dr.  Simpson advises  us in cer-
tain cases to substitute extraction of the placenta for turning the  child.   In
 justice to the Professor, it must be  remembered that he does not intend that
this plan should in every case supersede either the rupture of the membranes
or turning the child.
   Dr. Lee, of London, who  has entered into controversy with Dr. Simpson,
has objected to the  proposed  plan :—1. That the mortality, under the or-
dinary treatment, as  stated by Dr.  Simpson and me, is exaggerated ; but he
is far from having proved this.   2.  That it was never practised by the older
accoucheurs; but this would be  equally an  objection  to  any improvement.
 3.  That the child must inevitably be sacrificed; this would be a very serious
 objection, if the mortality among the children in the  ordinary mode of treat-
ment were  small, but it is so  great that it is an insufficient argument on
 which to reject the operation.
   The probability of hemorrhage after the extraction of the placenta would
 most likely occur to  any one as an  objection ;  but Dr. Simpson  states  that
 "in 19  out of  20 cases in  which it  has happened, the attendant hemorrhage
 has either been at  once arrested, or it has become  so much  diminished as
 not to be afterwards  alarming."  This Dr.  Simpson attempts to  explain by
 the supposition that  the bleeding proceeds almost entirely from the placenta,
 and not from the uterus.  But Dr. Lee contends, and I  think correctly,
 that it escapes from the uterine sinuses laid  bare by the detachment of the
 placenta.   Dr.  Ashwell  advocates  this  view,  and,  with  others of high
 authority, decidedly  oppose  Dr. Simpson's plan of extraction.
   683.  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 neces-
 sity of interference, and is not restrainable or restrained by milder measures
 (such as the evacuation of the liquor amnii), but at the same time  turning
 or  any other mode of immediate or forcible delivery of the child is especially
 hazardous or impracticable, in consequence of  the undilated or undeveloped
 state of the os uteri,  the contraction of the pelvic passages, etc.  Or, again,
 the death,  prematurity, or non-viability of the infant may not require us to
 adopt modes of delivery for its sake, that are accompanied  (as  turning is)
 with much  peril to the mother,  provided we have a simpler and safer means,
 such as  the detachment of the placenta, for at  once commanding  and re-
 straining the hemorrhage and  guarding the life of the parent against the 
460
FLOODING.
dangers  of its  continuance.  Hence, as  I have elsewhere  stated, I believe
that the suppression  of the flooding, by the total detachment of t;be^pla-
centa, will be found the proper line of practice in severe cases of unavoidaoie
hemorrhage, complicated with an os uteri so  insufficiently dilated ana un-
dilatable as not to allow of version being performed with  perfect safety to
the mother ;— therefore, in  most primiparae, in many cases in which placental
presentations  are (as very often happens) connected with premature labor
and imperfect  development of the cervix  and  os uteri;  m labors  super-
vening earlier than the seventh month ;  when the uterus  is too contracted
to allow of  turning;  when the pelvis or  passages  of the mother are organi-
cally contracted;  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 immediate peril of life, to be submitted to  the  shock
and dangers of turning or forcible delivery of the infant.   This enumeration
is far from comprehending  all the forms  of placental presentations that are
met with in practice ; but it certainly includes  a considerable proportion of
the  cases of this  obstetric complication ;  and among  them,  all, or almost
all,  of the  most  dangerous  and  most difficult  varieties  of unavoidable
hemorrhage.  In adopting the  practice, one  error, which  I would strongly
protest against, has been committed in some instances.   Besides  completely
detaching and withdrawing the placenta, the child  has been subsequently
extracted by direct operative  interference.   If the  hemorrhage  ceases, as
it usually does, upon the placenta being  completely separated, the expulsion
of the child should be subsequently left  to nature, unless it present  prefer-
naturally, or the labor afterwards show  any kind  of  complication which of
itself would require operative interference under any other circumstances.
Both to detach a placenta  and extract a child would  be  hazarding a double,
instead of a single operation."
   Dr. Radford states that the  placenta ought never to  be detached in such
cases, unless, " 1.  The danger to the woman is so great from  exhaustion as
vto render the ordinary  plan of delivery, by  turning the  child,  hazardous.
2. When there exists  some obstacle to the extraction of the child, either from
distortion in the bones of  the pelvis, or tumors connected with it, or  in its
cavity, but  connected with the soft parts.   3. When  the child is dead."
Subsequently, he protests against the operation until the cervix and os uteri
will allow the introduction of the hand, as that "is  the only instrument by
which the placenta should  be detached; indeed, I hesitate not to say, that
it cannot be safely and effectually separated by any other means.".
   Dr. Edwards thus  sums up the cases  in which  this practice seems admis-
sible.   1. When the  patient is of so weakly and delicate a constitution, that
loss of blood to any great extent would be attended with present danger and
subsequent  injurious  effects.  2. When  the child is well  ascertained  to be
dead.  3.  In cases in which the powers  of life have been excessively lowered
by the hemorrhage, and the os uteri remains firm and unyielding   4  In
cases in which, although the os uteri is dilatable, the powers of life would be
unequal to the shock  of turning.  5. In primiparas,  when the soft parts are
so contracted that they would be liable to be bruised  or torn  in turning
 6.  In contracted pelvis.                                               °'
   684. We shall now examine in detail the practical value of this operation in
the cases proposed, so far as our facts will  permit, and assuming the correct-
ness of Dr Simpson's statistics.   The  rates  of mortality, by the ordinarv
treatment, I believe to be  about one in  three  of the  mothers,  and sixty-five
per cent, of the children, according to a statement of Dr. Lee's,  quoted bv
Dr. Simpson, t. e., of  course,  taking  large  numbers.  According  to Dr
 Simpson, when the placenta has been first expelled  or detached, the  mor
 tahty is one in fourteen of the mothers,  and sixtv-nine per cent, of the chil 
UNAVOIDABLE  HEMORRHAGE.
461
dren.  So far there appears to be  an important  advantage gained by the
new method, but it will be found, on  further inquiry, that there are great
difficulties, if not insurmountable objections to it.
   1. There appears to me  great practical difference between the placenta
being expelled first, and extracted first, although Dr. Simpson  makes none,
but  includes both equally in his statistical table.   The former is the result
of vigorous  uterine action : the latter mayor may not be accompanied by it;
and I think there is much force in the doubt expressed by Dr. Barnes, as to
whether the results would  be  as favorable in cases of detached as of ex-
pelled placenta.  The 17 cases quoted from Dr. West by Dr. Simpson, are
much too few for proof.  Dr. Radford has given two tables, the first of 41
cases, and the second  of  14 cases, in which the placenta was separated and
detached by the hand, and of these 5 mothers were lost, or 1 in 11, and 7
children saved, or  1 in 8.  Of 20  no  information is given.   We must re-
member that  in the one case there  is  no irritation, no force applied to the
cervix and os uteri, in the other there must be.
   2.  This distinction   between detached  and expelled  placenta alters the
ratio of mortality among the children fearfully.   Dr. Simpson has recorded
in  his tables, but one case of  the child being born alive, when the interval
after the expulsion or  extraction of the placenta was more than 10 minutes ;
and 16 of the 17 children, in the cases  quoted from Dr. West were lost.  If
any attempt be made  to save the child by artificial delivery, this will be to
"incur the hazard of a double operation," and will defeat the object of Dr.
Simpson's proposal.
   3.  In Dr. Simpson's first table, of 47 cases, with an interval after the ex-
pulsion or extraction of the placenta of from ten minutes to ten hours before
the birth of the child,  I find that delivery was completed by art in 18 cases,
in 14 of them by turning.   In  the second table, of 21 cases, where the inter-
val was  less than ten minutes,  in 7 cases by turning,  and in one by eviscera-
tion.  In the third table, of 27 cases, where the child came with the placenta,
or followed immediately,  there are  5 cases of turning, and  1  of extraction
recorded.   In the fourth table, of 27 cases, where  the interval is unknown,
delivery was effected by  turning in 15 cases, by the forceps  in 2, and by
decapitation in one.
   From this it appears that in a very large proportion of cases (46 cases in
119), artificial delivery was necessary, in many, no doubt, from mal-presenta-
tion ;  but still, in these cases, detachment of the placenta alone would have
been useless, in many injurious; nor, if the operation were performed before
the dilatation of the os uteri,  could the mal-presentation have always been
ascertained.   Again, we find that delivery by art was more frequent, accord-
ing as the interval  after the separation of the placenta was prolonged, and
I  should suppose,  although Dr. S. does not  mention it  in his tables, that
the interval would  be much greater in cases where the placenta is extracted
than where  it is expelled, and,  consequently, that the probability of a second
operation being necessary would be greater in such cases, which would con-
stitute another important difference  between these two classes of cases, or,
as Dr. Simpson admits, wrould  double the hazard.
   Of 41 cases given by Dr. Radford,  "in 18 turning was performed, in 6 it
is  presumed to have been so, in 1 the child was drawn by the presenting leg,
16 were terminated by  the natural efforts, 1 by the vectis, 1 by the perforator
and crotchet."   In table 2d, of 14  cases, 2 were  terminated by the natural
efforts, 10 by turning,  2 by the forceps.
  4. The first class of cases in which Dr. Simpson thinks this new method
advisable, is where  the hemorrhage is  excessive, and  the  os  uteri undilated
and  undilatable.  Now, although it is evident that so  long  as this state
continues ^fortunately it  is rather the exception  than the rule), turning is 
462
FLOODING.
impracticable, I confess I do not see how the placenta can be easily or safely
detached.   I put out of the question using any instrument but the finger for
this purpose, for  I  quite agree with Dr. Radford that any other would  be
extremely hazardous to the mother under such circumstances.   And I concur
with him that "in those cases of unavoidable hemorrhage  which occur before
the expansion of the cervix uteri, it would be quite impossible to force the
finger  along the cervical canal, and reach  the edge of  the placenta, so as
entirely to detach it; and  in those cases which occur at  the latter part of
pregnancy, or beginning of labor, with a rigid os uteri, it appears to me to
be out of the power of the operator, with the finger alone, to reach so far
as the  edge of the placenta."  It must also be borne  in  mind  that  Dr
Simpson's favorable rate of mortality does not apply to  this class, as there
are no statistics of  such cases.
   5. "In premature labors, with an undeveloped os uteri,"there will be the
same difficulty in detatching the placenta,  whether the  child be viable or
not, and we  are  in  the same ignorance  of  what would be  the result to the
mother.
   6.  In a great number of the. cases in Dr.  Simpson's tables (23 in 91), as
we have seen, the presentation was abnormal, of the shoulder, arm, or hand
and head, and  in such  cases artificial delivery must take place, and it may
be a question whether, if we first merely removed the  placenta, on account
 of the exhaustion of the mother, we should not thereby increase the difficulty
 of turning at a subsequent period.
   7. In the cases  mentioned by Drs. Simpson, Radford, and Edwards, of
 distortion of the pelvis,  or tumors  in  the  soft parts offering an obstacle to
 the extraction of the child, the new operation would  not  be exactly an
 alternative, but a substitute, as version would be out of the question in  most
 instances, and the doubt remains whether it could be effected if the obstacle
 were great.  If it could,  it might facilitate the use of  the  perforator and
 crotchet.
   8. In cases  of extreme  exhaustion, where the mother is  unable to  bear
 the shock of turning or any additional  loss of blood, if the os uteri be dilated
 or dilatable, and the circumference of  the placenta within reach—as the
 hemorrhage is said to cease after  the  removal of the placenta—the opera-
 tion may be admissible for  the  purpose  of gaining  time,  even with the
 chance of artificial delivery afterwards.
   9. In cases  where the flooding  is considerable, the presentation natural,
 and the pains strong (the cases in which the  placenta is sometimes expelled
 before the child), there seems to be no  objection to arrest the hemorrhage
 by the removal of the placenta, leaving the conclusion of labor to the natural
 powers, either alone or stimulated by galvanism, as Dr. Radford has  pro-
 posed.^   To those two classes the results of Dr. Simpson's statistics almost
 exclusively apply.
   I have thus examined with care  this very difficult subject, and although I
 would be far from  pronouncing dogmatically upon  it, I  feel bound in duty
 to state, that except in the cases  I have mentioned, I  could not  consent to
 substitute the new  method of treatment for the old, and  even in those  cases
 I would recommend the very utmost caution.
    685.  Dr. Robert Barnes has  proposed another mode  of treatment based
 upon  some  very ingenious views.1  He  has divided the uterus into  three
 zones;  the lower  one,  the cervical,  being the only portion  of the uterus
 narrower than the child, is the  only part dilated by the process of labor, and
 therefore the  only part from which the placenta will be detached by that
 process.   So much of the placenta as may be within this zone will and may

   \rh,e .J^8'010^ and Treatment  of Placenta Praevia, being the Lettsomian Lectures
 on Midwifery for the year 1857. 
UNAVOIDABLE HEMORRHAGE.
463
be detached, but any portion beyond it will not be so necessarily.   So far,
1 think, he is right.   Again, we know, as I have already mentioned, that if
the hemorrhage be arrested, it does not always return, from which Dr. Barnes
infers that a renewed hemorrhage is always the result of a new detachment
of a portion of the placenta.   Carrying this view into practice, Dr. Barnes
proposes that the cervical portion of  the placenta should be detached, with
the hope that the hemorrhage will cease  and not return.   He does not ad-
vise this plan  for all cases, and  the cases  in which he  has tried it are but
few.  I must refer my readers to his able  work for fuller detail; all I will
say at present  is, that I rather doubt the fact of an old detachment giving
rise to no renewed bleeding, and  fearing that the artificial detachment of the
adherent after-birth might give rise  to a severe additional flooding, I should
be afraid to run the risk,  especially as by the plug, and,  when suitable, turn-
ing, we have a mode of prompt delivery by which any great increase of
hemorrhage  may be  avoided.  Without denying that it may be suitable in
some cases,  I  should hesitate in recommending it until further experience
shall have tested its merits.
   [" Messrs.  Simpson, Radford, and the  other gentlemen  who advocate
the new  method  in placenta praevia,"  remarks Dr. Meigs,1  "very  earn-
 estly recommend the prompt separation of the whole of the placenta ; and
 they are persons whose  opinions are  justly to  be  esteemed of the greatest
 weight; but notwithstanding the profound  respect with  which I receive any
 statement  of theirs, I cannot but think that in any case  in which it is possi-
 ble to detach the whole  of the placenta, it  would be  also possible to intro-
 duce the whole of  the hand, and thus commence at once  the operation  of
 turning, which ought to  be esteemed as the essential indication of treatment
 in placenta  praevia,  and  which the  earlier  it  is done, so much the greater
 chance does it give  both of rescuing the child and saving the woman from
 fatal losses of  blood."
   Before the Obstetrical Society of London  Dr. Robert Barnes read a paper,
 April 6th, 1859, giving the history of fourteen cases illustrative of the physi-
 ology and treatment of placenta  praevia.  The following series of therapeu-
 tical deductions he believes to be sustained  by the result of these cases.
    " 1.  That inflammation of the uterine structures, particularly of the cervix,
 is especially likely to supervene upon delivery attended by placental presenta-
 tion ; and that the danger of this complication is  increased by the forcible
 dilatation and contusion of the  vascular cervix, caused  by the introduction
 of the hand, or by the extraction of the child.
    " 2.  That the greatest amount of flooding generally takes place at  the
 commencement of labor, when the os is beginning to expand.  That the os
 is always, from its being near  the seat of the placental attachment, highly
 vascular, and  is frequently, at this stage, very rigid.  That any attempt to
 force the hand through  this structure, at  this stage, either for the purpose
 of wholly detaching  the  placenta, or of turning the child, must be  made at
 the risk of injuring the womb; and that the dragging the child through the
 os when in this condition—even  when  it has not been necessary to pass the
 hand into  the  uterus—is  a proceeding affording slender  chance of life to the
 child, and dangerous to the mother.
   "3.  That the entire detachment of the placenta is not necessary to ensure
 the arrest of the hemorrhage ; and that, therefore, it  is not necessary either to
 wholly detach the  placenta before the birth of the child, or, in cases uncom-
 plicated with  cross-presentation, to proceed  to forced  delivery with a view
 to wholly  detach the placenta after the birth  of the child.
   " 4.  That, since the dilatation of the cervical portion of the womb must
> [Op. cit.] 
164
HEMORRHAGE  AFTER DELIVERY.
take place in order to give passage to the child, and since, during the earlier
stages of this necessary dilatation, hemorrhage is liable to occur, it is desir-
able to expedite this stage of labor as much as possible
  " 5  That in  cases where labor appears imminent, with considerable flood-
in jr  whilst the  os internum uteri is  still closed, the arrest of the flooding
and  the  expansion of the  os  may be favored by plugging the vagina, and
especially the cervix; by the  use of ergot; by the stimulus  of galvanism
to the uterine muscles, or by the method, recommended by Professor Braun,
for bringing on labor in puerperal convulsions.
   " 6  That since a cross-presentation, or other unfavorable position of the
child at the os  internum uteri  is apt to impede or destroy the regular con-
tractions of the uterus, which are necessary to the arrest  of  flooding, it is
mostly desirable in cases complicated with unfavorable  positions of the child,
to deliver as soon as the condition of the os uteri will permit.
   " 7. That, in some  cases, the simple use of means to excite contraction
of the uterus,  such as ergot,  rupturing the  membranes, the administration
of a purgative, or the employment  of galvanism, will suffice  to_ arrest the
hemorrhage.
   " 8. That, in some cases where it  is observed that the os uteri has moder-
ately expanded—namely, to the size of a crown-piece,  or less,—the placenta
being felt to be detached from the cervical zone, and the hemorrhage having
ceased, it  is not necessary to interfere with  the course of the labor, now
become normal.
   " 9. That, at the critical period, when the total detachment of the placenta,
or forcible delivery are dangerous or impracticable operations, the introduc-
tion of the index finger through the os, and the artificial separation of that
portion of the placenta which lies within the lower or cervical zone of the
uterus, is a safe and feasible operation.
   " 10. That the  artificial detachment of all that portion of the placenta
which adheres  within the cervical zone of the uterus will at once liberate the
 os internum uteri from those adhesions which impede its equable dilatation ;
and by facilitating the regular contraction of this segment of the uterus,
 favor the  arrest of hemorrhage, and  convert a labor  complicated with pla-
 cental presentation into a natural labor."1
   For a very full report of the statistics of placenta praevia, so arranged as
 to present as far as possible  their true bearing upon the  several questions
 involved in a consideration of the  proper treatment of the  accident, with
 direct reference to the safety  of the mother and  child, the reader is  referred
 to  the Prize  Essay of Dr. I.  D. Trask,  contained in the 8th vol. of the
 Transactions of the American Medical Association, page 593.]
   The necessary stimulants and support must be afforded, as in accidental
 hemorrhage, and if the  patient be  extremely sunk  and exhausted,  we may
 have recourse  to transfusion.

    686.  3.  Hemorrhage after delivery. —A certain amount of  blood is
 always lost after delivery, nor is this injurious ;  and it is only when it is so
 great as to produce an impression upon the constitution and the pulse that
 it is to be considered as flooding.   Of course, in  all cases it escapes from the
 mouths of the vessels, exposed by the partial  or  entire  separation of the
 placenta, not  being closed by firm uterine contraction.
    It sometimes, but rarely, takes place when an interval elapses between the
  expulsion of the head and body of the child, but much more frequently after
  its birth, before or after the expulsion of the  placenta.   The presence of a
  olot or a  polypus in the uterus may also give rise to it.
1 [Transactions of the Obstetrical Society of London, vol. i., 1860, p. 83.] 
secondary  hemorrhage.
465
  The hemorrhage after the expulsion of the placenta may be the result of
want of contraction of the uterus ; but there are severe and even fatal cases
which are caused by a limited rupture of the cervix.
  Dr F H. Ramsbotham has recently published a series of very interesting
cases, in which hemorrhage co-existed with severe  after-pains, owing, appar-
ently, to the presence of a firm coagulum in the uterus, which it failed to expel.
The remedy consists in introducing the hand and removing the coagula.
  I have, in the last chapter, spoken  fully of retained placenta and its treat-
ment, which I shall not now repeat, but shall confine myself to the treatment
of the hemorrhage, whose effects are similar to those already  noticed.
  687.  Treatment.—Let us suppose, therefore, that the placenta has been
extracted or expelled, but that the flooding is not arrested.   The first object
isto produce  a firm and persistent  contraction ; and  to  effect this, whilst
with one hand we firmly grasp the uterus, with the other cold is to be sud-
denly applied to the genitals by means of cloths dipped in cold water.  The
advantage of  grasping the uterus  is, that we thereby secure an artificial con-
traction, as it were, until the means employed effect a real one.
  Ergot may be given at the same time, and in no case is it more beneficial.
Cold  enemata and  cold drinks are also valuable  auxiliaries.   If these fail,
we  may pour cold water from a height upon  the abdomen, and the shock
will generally succeed in rousing  the uterus into action.  Dr. Tyler Smith
succeeded, as a last resource, by injecting iced water into the uterus,1 in two
cases; and  Mr. Chavasse, of Birmingham, speaks highly both of the success
and safety of  the'practice.2  Compression of the  aorta is said to be effectual
in some cases.  It was introduced by Saxtorph,  and has since been recom-
mended  by MM.  Lentin,  Chailly, and  others.    Dr.  Radford recommends
galvanism.   When  all has failed, Dr. Gooch recommends the introduction
of the hand into the uterus, for the purpose of exciting it to  contract by  the
irritation.   I have no doubt of its success, but it is more hazardous than  the
other means I have  mentioned.
  The internal remedies advised  in  the  other forms of hemorrhage (as lead
and opium) are equally suitable to this,  whether primary or secondary. The
restorative treatment is likewise the same.
  In all cases where,  after  a  previous labor, the  patient has suffered from
hemorrhage, I am in the habit of giving half a drachm of the ergot of rye,
immediately after  the birth of the child, and repeating it if  necessary.   By
this means  I  have rarely failed to protect the  patient  against a repetition
of the accident.  It is right to mention  that so far from flooding affording
the patient any immunity from subsequent inflammation, I  should say that it
is not very  rarely  followed by such an attack.

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

  i  Lancet, Julv 7th, 1840. vol. ii. pp. 6, 693.  .          2 Ibid., Dec. 29th. 1849.
  s 1 linve been'niuch indebted to a valuable and learned essay on this subject by my friend
Dr.  M'Clintock.  in the Dublin Quarterly Journal for May. 1851. to which I beg to refer
much <>f my readers as may be anxious for further details than 1 have given.
  *New York Annalist, Oct. 1st, 1848.
        30 
466
SECONDARY  HEMORRHAGE.
 Dr. Fergusson 1 on the  13th.1  Dr. Roberton has  given 14 cases ;  in  1 it
 occurrecf on the 7th, in 2 on the 9th, in 2  on the 10th, in 1 on the 11th, in
 1 on the 12th, in 2 on the 14th,  in 2 on the 16th, in 1 on  the 19th, in 1 on
 the 22d, and in 1 on the 27th day after delivery.  In 5 of the cases there  was
 but a single attack;  in  the  remainder  the  hemorrhage recurred.2   In  Mr.
 Campbell's case it was on the 14th day.3
   689.  Causes.—The causes are various.   The  retention  of a portion of
 an adherent placenta, after an operation for its removal;  the formation of
 a firm  coagulum, which the after pains are  not sufficient  to expel;  the
 relaxation of the uterine contraction within a limited period ; local or general
 disturbance of the circulation ; constipation, according to Moreau ; disorder
v of the  liver, according to Dr. Ayre ; inflammatory  ulceration  of the  cer-
 vix, according to Dr. Bennet; polypus uteri, inversion, disease of the body
 of the  uterus, a minor degree of laceration, and thrombus  of the  cervix
 uteri.
   Any of these causes  may  give rise to very serious hemorrhage  at an  un-
 certain period after delivery,  and  the most important point for the attendant,
 when summoned, is to  ascertain to which of these causes it is attributable.
 The size of the uterus will assist us in deciding the question of the retention
 of the  placenta or a clot, and  in most cases some light will  be thrown upon
 the matter by a careful internal examination, added to the  previous history.
 After all, in many cases it is  only by the "method  of exclusion" that we
 can arrive at a conclusion as  to the nature of the case.
   It does not appear that the attack is frequently fatal,  except when it is
 complicated with organic disease.  Of  Dr.  Collins' cases, four died, one of
 rupture of the uterus, one of sloughing of the  vagina, and  two from  the
 effects  of the hemorrhage.4  Of  Dr. M'Clintock's cases, two died, one from
 the effects of the hemorrhage, and one  of uterine phlebitis.5   None of  Dr.
 Roberton's cases  proved fatal; but he  relates two from the practice of his
 colleagues,  Mr. Windsor and  Mr. Clough,  and   quotes one from Madame
 Boivin, which ended unfortunately.6
   690.  Treatment. — Having decided upon the nature  of the case,  the
 treatment  is not difficult.   The  application of cold  externally, or enemata
 of cold water, and  ergot, are, perhaps,  the most valuable  means, and  the
 latter will facilitate  the expulsion of any portion of the placenta, if loose, or
 of a clot.
   ["Iced-water may be injected  into the bowels,  a quart at once, which  is a
 favorite remedy  of my highly esteemed and judicious colleague, Professor
 B. R. Palmer, who  informs me that it has never failed in his hands to excite
 uterine contraction and arrest the bleeding."7]
   Dr.  M'Clintock speaks highly of the plug, but it must be combined with
 pressure over the uteres, to guard against internal hemorrhage.
   ["To attempt," remarks Professor Miller, of Louisville,  Ky., "to control
 hemorrhage from an empty and flaccid uterus,  by plugging  the  vagina, is
 highly  hazardous.   We may, it is true, prevent  the issue  of blood by  this
 expedient, but we can have  no assurance that it  will not continue to pour
 from the vessels, and collect in the uterine cavity, until life is exhausted.   It
 is  better to contend with an open  than a lurking enemv —let the blood
 therefore,  have an  unobstructed  channel;  we  can,  then,"the  more clearly
 discern our patient's danger —which it  is folly to hide from our eyes —and
 Khali be incited to more earnest efforts to save her from impending death."8]

   \?r6^  ^ ^ t ueC^Snept 1?5°- •  21>hys- and Dis- of Wo™en and Med., p.  365.
    Med. Gaz., Oct  26th 1849, p. 732.    «Prac. Treatise on Midwifery, etc., p. 158.
    Prac. Obs. in Midwifery, etc., p. 236.   eDis. of Women and Midwifery p. £65-
     Henry M.ller M. D., of Louisville, Ky. Principles and Prac. of Obstetrics.!
   B [Principles and Practice of Obstetrics.] 
CONVULSIONS.                        467
  Tincture of the Indian hemp, the oxide of silver, spirits of turpentine  and
a blister to the sacrum,  are all valuable remedies.
  In cases of disease, ulceration, polypus, etc., a selection of these remedies
may be used.for the purpose of arresting the hemorrhage ; but other treat-
ment will  be necessary for  those cases, which I have detailed in the volume
on Diseases of Women,  and need not repeat here.
  Inversion of the uterus, and  its treatment, will also be found in the same
volume.
  Mr.  Slyman proposes an elastic bag introduced into the uterus,  and filled
with cold  water or air, so as to make pressure.1
                        C HAP TE R  XXI.

           PARTURITION. —CLASS III.   COMPLEX  LABOR.
                       ORDER 4.  CONVULSIONS.

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

   692.  1.  Hysteric  Convulsions.—This variety is confined  to the period
 of  gestation,  and is  more frequent during the early  months than  subse-
 quently.   Females of a nervous or  hysterical  constitution  are the  most
 obnoxious to the attacks.
   Causes.—Want  of sleep, or excessive fatigue, may give rise to  hysteric
 convulsions, or they may be caused by disordered digestion.
   693.  Symptoms.—The attack is generally preceded by a tightness about
 the throat, by sobbing,  or repeated attempts at swallowing.   The patient
 then becomes still and motionless, or may roll about from side to side.  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.
                       1 Lancet, Jan. 13th, 1849, p. 37. 
468
convulsions.
  The paroxysm may be a  single occurrence, or return after a time, with
the same phenomena.                                                ,
  It does not  generally influence  the  progress of gestation, though I have
seen premature labor take place during the paroxysm.  The mother's health
may be rendered  rather more delicate, but it is not seriously compromised
by the disorder.                                      ,     .      .. ,  ,,
   694  Diagnosis.  1. J?Vom epileptic convulsions.—The body is but slightly
contorted;  there is no complete  insensibility; there is no frothing at the
mouth  nor biting the tongue, nor stertorous breathing ;  and after the fat is
over, the patient recovers her usual state—the reverse of all which symptoms
occur in epileptic convulsions.
   2  From apoplectic  convulsions.—In  these the  patient loses conscious-
ness and voluntary motion at first, and ultimately all motion  ceases ;  this is
not the case in hysteric convulsions ;  besides which, in the latter the breath-
ing is not stertorous, and the patient soon recovers.
   695.  Treatment.—If the pulse be quick (which is not ordinarily the case),
or the head ache, venesection may be practised,  or a few leeches be applied
to the forehead ;  but this is rarely necessary.  In most cases, antispasmodics
combined with diffusible stimuli (valerian or assafcetida, with  ammonia), will
relieve the patient.   Volatile alkali, held to the nostrils, is useful; or cold
water dashed  upon the face.
   When the  paroxysm is over, a moderate dose of opium may be given ;
and,  after a sound sleep, the patient will  find herself nearly restored.  The
stomach must be attended to.  Tonics may be  given if necessary, and ape-
rient medicine.
   696.  2. Epileptic Convulsions.—This variety is by far more  frequent
than either of the others.

   697.  Statistics.—Frequency.
Authors.				Total Number of Cases.	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
Dr. Mantell .				2,510	6
Dr. Churchill .				600	o
Drs. Hardy and M'Clintock				6,634	18
Dr. F. H. Ramsbotham .				68,435	67
Mr. Earle				4,320	8
Mr. Rose				600	2
Mr. Bailey				2,819	11
Dr. Toogood .				1,135	1
Dr. J. Lee				850	2
Mr. K. Watson				800	4
Dr. Copeland .				1,290	8
Dr. Arneth				6,527	13
Mad. Boivin .				20,357	19
Mad. Lachapelle				38,000	61
Mr. J. Thompson .				3,300	6
Drs. Johnston and Sinclair				13,748	63
Dr. Hall Davis				7,302	5
i					
 
CONVULSIONS.
469
Thus we nave 34? cases of convulsion  in  214,663 cases of labor, or 1 in
about 618|.
  On the whole, the mortality is considerable, though  probably much  less
so than formerly.  Jacob states that in his time scarcely any survived.   Dr.
Parr, in his Med. Dictionary, that six or seven out often die.   Dr. Hunter,
that the greater proportion were lost.
Authors.				Cases of Convulsions.	Mothers lost.
Mr. GifiFard .... Dr. Jos. Clarke . . , Dr. Ramsbotham Dr. Maunsell . Dr. Churchill . Dr. Mantell . Drs. Hardy and M'Clintock Dr. F. H. Ramsbotham . Mr. J. Thompson Drs. Johnston and Sinclair Dr. Hall Davis.				4 8 14 2 1\> 36 26 4 30 1 2 6 13 43 13 20 13 6 63 6	2 2 5 0 6 8 10 2 6 0 0 2 3 3 4 3 2 0 13 0
  Thus, out of 328 cases, 70 mothers were lost, or about 1 in 4^.
  Women of all temperaments may be attacked, but it is more common, as
Dr. Collins has remarked, "in strong plethoric young women with their first
children; more especially in such as  are of a coarse make, with short thick
necks."1  Dr. Ramsbotham has stated that "women with large families are
equally or perhaps more liable to be assailed."   This, however, is not borne
out by numerical investigation, for of thirty-six cases related by Dr. Merri-
man,  twenty-eight were with first children.  Of Dr.  Ramsbotham's  own
cases, more than two-thirds were with first children ; of  Dr. Collins' 30 cases,
29 were with first children; and of Dr.  Johnston and Sinclair's 63 cases, 49
were primiparae.
  698. Causes.__Various and  very obscure have been the explanations of
the causes  of puerperal convulsions.  Dr. Locock thus  enumerates them :
"The immediate  causes of puerperal convulsions  are often very obscure.
They  appear sometimes to depend  upon  a  loaded state of the brain ; at
other times the brain appears to be influenced by distant  irritation, either in
the uterus or digestive organs;  and, again in some  cases, puerperal convul-
sions are induced  apparently by a peculiar irritability of the nervous system
It has been remarked, that there has been a greater disposition to puerperal
convulsions in those patients who have been in early life subject to convulsive
attacks, particularly of  an epileptic  character;  and also in those who have
suffered similarly in former labors, and have omitted those measures usually
employed as precautions.   That the uterine organs are in some way particu-
larly implicated, is evident from the convulsions being of a character which
may be said to be peculiar to the state of either pregnancy or parturition."
i Prac. Treatise on Midwifery, p. 199. 
470                        CONVULSIONS.

"The immediate attack  may be brought on  by a loaded or disordered
stomach, or by  food, however small in  quantity, of an indigestible kind
Some substances (shell-fish for instance) have been found very frequently to
induce convulsions in the puerperal condition, when at  other tames they may
have been  taken by the same  individual  with perfect impunity   A sudden
frio-ht, afflicting intelligence, or any unexpected or depressing mental emotion
may excite  the paroxysm ; hence it has been long remarked, that unmarried
women  are more particularly likely  to be sufferers  from convulsions, from
the shame  and  distress under which  their children are usually born.   The
violent straining caused by labor  pains, from the disturbance of the frame
by the earlier uterine contractions, causing a temporary rush of .blood to the
head, will sometimes bring on convulsions."1
  The application of Dr. Marshall Hall's theory, however, by Drs. Thomp-
son, Murphy, and Tyler Smith, has  thrown much light upon the  matter.
The former gentleman insists that no injury to the cerebrum or  cerebellum
can cause convulsions, so long as the  true spinal system is not involved, in
which Dr.  T. Smith  agrees  with  him.   He then states that the proximate
cause of puerperal convulsion consists  in a morbid irritation  of the  true
spinal system, and more especially of the medulla  oblongata, propagated to
it from  the mucous surfaces, through the incident nerves of the excito-motor
system.2
   Dr. Murphy3 enumerates,  among the proximate causes, morbid irritation
of  the  uterus from hyperaemia or anaemia,  and morbid irritation of other
organs, and regards the whole as a beautiful illustration of the reflex nervous
function ; the peripheral nerves that supply the affected organ rapidly com-
municating their irritation to  the spinal system, which, as an excito-motor
centre,  radiates the irritation over the whole  of the voluntary muscles, and
the muscles of respiration.  Even the involuntary muscles,  as the uterus and
heart, do not escape.
   Dr. TylerNSmith, in his admirable work, has entered into a most elabo-
 rate investigation of the causes of convulsions  : after  which he observes :—
 " In conclusion, to give a summary of the whole subject, the true puerperal
 convulsion can only occur when the central  organ of this system, the spinal
 marrow, has been acted on  by an excited condition of an important  class
 of its incident nerves, namely, those passing from the  uterine organs to the
 spinal centre, such excitement depending on pregnancy, labor, or the puer-
 peral state.  While the  spinal marrow remains, under the influence of either
 of these stimuli,  convulsions  may occur from two  series  of causes ; those
 acting  primarily  in the spinal marrow, or centric causes ;  and secondly,
 those affecting the extremities of its incident nerves ;  causes of eccentric or
 peripheral origin.

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

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

   1 Cycl. of Pract. Med.  Art.: Puerperal Convulsions.
   2 Essay on the Epileptic form of Puerperal Convulsions.  Ranking, vol. viii  d  313
   4 Lectures in Med. Gazette, Jan. 1849.                              ' 
CONVULSIONS.
471
  3. Irritation of the incident spinal nerves of the rectum.
  4. Irritation of the ovarian nerves.
  5. Irritation of the gastric and intestinal branches of the  pneumogastric
nerves.
  6. Irritation of the incident spinal nerves of the bladder.
  1. As probable causes maybe enumerated, irritation of the cutaneous nerves
of the mammae, and of the hepatic and renal branches of the pneumogastric.
  " Though the subject distinctly admits of this division, several causes may
act together, and centric and eccentric causes may be in operation at the
sametime.. Ihave  made no attempt at a division into predisposing  and
exciting, proximate  and remote causes, as other authors have usually done,
because it is evident that a cause which, in one case, is the exciting or proxi-
mate, may, in another, be the predisposing or remote cause."1  Subsequently,
Dr. Tyler  Smith endeavors to explain the operation  of the causes, and to
trace  the gradual progress from  the slight commencement up  to  the com-
pletion  of the convulsive paroxysm : but the investigation, though able, and
full of interest, is too long for quotation, and I must refer my readers to his
work, with an assurance that  tjie perusal of the whole will abundantly repay
them.
  Among  the most common exciting causes are  usually enumerated intem-
perance in eating  and drinking ;  mental emotion ;  fright,  as in  the case
related  by Denman, of a lady who was  going on a party of pleasure, and
whose carriage broke down ;  she was near the time of her lying-in, and was
very  much frightened,  though she received  no  apparent injury.   When
she fell into  labor, this was preceded  by convulsions, in which  she died
undelivered.2
  Mr. Robbs has related a case3 in which  the  convulsions seem to have
been owing to the irritation of worms ;  at least, they ceased on the expul-
sion of  two large lumbrici.
  Atmospheric  influence, according to  M. Duges,4 appears to have some
peculiar effect in producing  the disease, so that it assumes the character of
an  epidemic.   This is  confirmed by the observation  of Dr. Ramsbotham,
who observes:—"I  have  repeatedly  remarked,  amotig the numerous pa-
tients of the  Royal Maternity Charity, as well as among others to whom I
have  been  accidentally called, that  several cases  have occurred soon after
each other.  Whether this fact ought to be attributed  to mere chance, or to
the agency of some general principle upon the female system,  I must leave
to others to  determine in  future ;  but I  am inclined  to suspect that it  may
be  ascribed to the latter principle.   And here I may be allowed to observe,
that I have witnessed the occurrence of several cases during warm weather;
at a time when  the clouds  have been charged with electric fluid ; when at-
mospheric  appearances have threatened a thunderstorm, and when, perhaps,
they have  ended in one."5   And most practitioners will probably have had
occasion to remark the occurrence of several cases about the same time, as
if they depended upon some  general cause.
   699.  In considering the exciting causes of the disease, we  cannot over-
look the condition in the urine.   Hamilton6 and Demanet7 first stated  that
puerperal  convulsions were  liable to  be preceded by anasarca,  and their
observations  were  confirmed by the highest  authority.  Dr. Simpson  and
Dr. Lever8 were the first to connect this dropsy with  that condition of the
kidney  which  gives  rise to  the secretion of albumen, and since their time,

  i  Parturition and Obstetrics, p. 306.    2 Introd. to Midwifery, p. 429.
  s  Med. Gazette.  Sept. 21st. 1849.      * Diet, de MeU etdeOliir. Prat., vol vi. p. 541.
  5  Pract. Obs. in  Mid., vol. i. p  250.     6 Duncan's Annals of Med., vol. v. p. 313.
  7  Recneil PeViodique de la Societe" de Me"d., vol. ix. p. 110.
  8 Guy's Hospital Reports, 1843. 
472
CONVULSTONS.
 the researches  of  Cahir and Rouchut, Rayer, Depaul, Cazeaux, ere, have
 confirmed and extended their observations.   That in a large proportion of
 cases of convulsions there  is albuminuria, with or without anasarca, there
 can  be  no doubt; but, on  the  other hand, albuminuria may occur without
 convulsions, and convulsions without albuminuria.   For example, Dr. Blot1
 found albumen in the urine of 41 pregnant women out of 205, and chiefly
 in primiparas;  and Dr.  Litzman2 examined the  urine of  131 females, 79
 during  pregnancy, 80 during labor,  and 80 after delivery;  albumen  was
 present in 37, and absent in 95 ; of the 37, 26 were primipara.  What is
 the exact relation between the two is difficult to  say precisely.  I believe,
 with Dr. Simpson, that they both stand in the relation of effects of another
 cause, viz., " a pathological state of the blood, to  the occurrence  of which
 pregnancy may some  way dispose ;3  or  it  may be that  the excretion of
 albumen so discomposes the equilibrium of the component parts  of the blood,
 that in  their disproportion  they give rise  to these peculiar morbid effects.
 This seems to be the opinion of  Dr. Braun,4 who terms the disease "TJraemic
 Eclampsia," from " TJrasmic  intoxication of the blood," and he  considers it
 analogous to the first  stage of Bright's disease.   Frerichs  has  pointed  out
 the altered condition of the blood in  pregnant women, viz., the increase of
 water and  of fibrin, diminished  quantity of albumen, diminution of the red
 and increase of the white corpuscles, as a subordinate cause.
   Dr. Cormack has published an excellent paper on the connection between
 renal congestion and  puerperal convulsions.5  He considers that  in  many
 cases the latter are the toxicological results of non-elimination of the  ex-
 cretfonsof the blood,  and that in the greater majority of  cases this non-
 elimination depends upon renal  congestion, caused by  the  pressure of the
 gravid uterus.
   Many  authors have  assumed  the previous occurrence of epileptic, as a
 predisposing cause of  puerperal  convulsions, as I did myself  in  the previous
 editions of this work,  but I am induced to think this very doubtful    In the
 work from which I have quoted, Dr. Tyler  Smith observes that " the sus-
 pected affinities between epilepsy and puerperal convulsions deserve attention.
 It would seem a, priori, that  epileptics, or persons  who have been subject to
 convulsions during infancy, would be far more liable than  others to attacks
 of convulsion during the puerperal state.   It would also seem probable that
 patients  suffering from puerperal convulsion should  become subsequently
 liable to  epileptic attacks.    But experience does not positively support
 either of these probabilities."6  In a more  recent publication he mentions
 that in fifty-one pregnancies occurring in fifteen epileptic subjects, only two
 had puerperal convulsions,7 and the experience of Drs. Hardy  and M'Clintock
 confirms this view.
   Of those cases of severe epilepsy before marriage which have  come under

 lUTin^TlZ7 WaS there fJ attaCk dudnS  Sest^°"  or  parturition ;
 whilst in the numerous cases of puerperal convulsions  I have  seen I have
  There'Ts T "   ^ ?* COnvulsions ^™* ™ the absence of pregJancy
time  oT^tT°aVn8^l011 -f °rd °f Pen'°dical convulsions during  the
time  of gestation only.   « The wife of  a citizen of  Ferrara, twenty years of

  iti; let^z::^0^and th?mother °f th-e chiw;-> ~ s^
o  ^TZtZnltP7 rhefVe/ Sne conc^ed, and sustained  a paroxysm
of that malady once a  fortnight  during the whole  of her gestation ; bat as


  3EdU'Z^^S.l^> p 369
Or* Sr^cT't: °J ^k,^ ,Parturition' ^ Childbed.  Translated by
  5 Lancet^ April 13th' 1850   ^^ Uttle ™\* Which T b<* to refer ^ ™**rl
  ' Med. Gazette, 1849, vol ix p  i074          Parturition and Obsterics, p. 323. 
CONVULSIONS.
473
soon as she was delivered, the  disease left her.  Its occurrence, therefore,
was always to her a sign that she had become pregnant."1
  I have seen a case something like this.  A lady was attacked by convul-
sions  of an  epileptic character the  first time she conceived, and they were
repeated at the moment of quickening.   She  escaped an attack during her
second  pregnancy,  but was seized  at the  moment of conception  the  third
time.    She passed  through her labor without the least threatening of con-
vulsion.
   700.  Symptoms.—The symptoms  of epileptic convulsions  resemble very
closely, if they are  not identical with, those of ordinary epilepsy.  In the
majority of cases there  are  certain  premonitory symptoms.   The patient,
for some time previous, suffers  from pain in the head, giddiness, confusion,
ringing noise in the ears, obscure vision, temporary loss of sensation, rigors,
nausea, or even vomiting.  The face is flushed, and  the eyes injected.   Dr
Hamilton, senior, mentions as peculiar, an intense pain in the forehead ; and
Dr. Denman, a severe pain in the stomach, and  these, he  thinks, are the
worse kind of cases.   Osiander has  noticed a tumid state of the hands and
face preceding the  attack.   Most practitioners are familiar with a dropsical
swelling of the face alone, or  face and  upper extremities, which  is not un-
commonly followed by convulsions, and which we  may regard undoubtedly
as a precursory symptom, if the urine be at the  same time albuminous.  In
some few cases,  however, there are  no precursory symptoms ; the patient
has no  warning until the moment before she becomes insensible. The " aura
 epileptica" is seldom felt.
   As the attack approaches,  these  symptoms  are  aggravated ;  the  pupils
 become dilated, the face more  injected, the eyes fixed, and the patient loses
 consciousness.
   During the attack, the face  is swollen, of a dark red or violet  color, and
 distorted by spasmodic contractions ; the eyes are  agitated, the tongue pro-
 truded, and  the under jaw repeatedly closed with force, so as to wound the
 tongue.  A quantity of froth  is ejected  from the mouth, which is generally
 drawn more  to  one side  of the face than the other.  The muscles  of the
 body are thrown into violent and irregular action;  the limbs  are jerked in
 all directions, and  with such force that  it is  sometimes difficult to keep the
 patient in  bed.    The  respiration  is at  first  irregular, and being  forced
 through the closed teeth and the  foam at the mouth, has a  peculiar hissing
 sound  ; it subsequently becomes nearly suspended.   The pulse is quick, and,
 at the  beginning, full and hard, but afterwards small and almost impercep-
 tible.  The  body  participates in  the purple  color  of the face.   The urine
 and faeces are often passed involuntarily.  This terrible paroxysm, however,
 is not  of very long duration.   After a period varying from five  minutes to
 half an hour, the convulsive movements  become less violent,  and gradually
 subside ; the countenance is less distorted, and assumes a more natural and
 placid appearance ; the eyelids close, the respiration becomes more regular,
 though still sibilant, and the circulation is restored, the pulse becoming more
 perceptible, though still very quick; the patient  rests quietly in bed,  and
 the paroxysm has terminated  for the time.
    During the interval,  the patient's condition  is very variable.   She may
 partially'recover consciousness, so as to recognize persons  around her, and
 to be aware of something extraordinary having happened, without knowing
 what  and without being able  to express herself clearly.  In other cases the
 return of intelligence (but without recollection) may be complete until the
 approach of the next fit, accompanied with great weakness,  headache, and
 confusion   These are the more  favorable  cases.   Others,  again, remain  in
i Comm. by Lanzoni, Ephem. Germ., dec. ii. an. 10, p, 160. 
474
CONVULSIONS.
a state of total insensibility, almost approaching to coma or asphyxia, with
sibilant or stertorous breathing,  and without muscular  motion,  or with a
restless throwing about of the body and extremities.  This calm is, however,
of no very long duration ;  it may be half an hour,  or two hours, but sooner
or later  the paroxysms return, to be succeeded by an interval which in its
turn gives place to a paroxysm.   I have known as many as eighteen parox-
ysms  occur in twenty-four hours.
   701. The urine, as I have already mentioned, is in the large majority of
women, albuminous.   Dr.  Lever  remarks, " I have carefully examined the
urine in every  case of puerperal convulsions that has since come  under my
notice, both in the Lying-in Charity of Guy's Hospital and in private prac-
tice, and in every case but one, the urine  has been found albuminous at the
time of the convulsions."   And this has been confirmed by Simpson, Sabatier,
Legroux, Richelot, Blot, Mascarrot, Braun,  and others. More  recent re-
searches  have  thrown a good deal of light upon the occurrence of this renal
affection.   De Villiers and Regnault1 observed it as early as the sixth month ;
Litzmann not  till the eighth.  The most characteristic symptom  is dropsy
of the hands,  arms,  and  face;  but dropsy  does not necessarily  co-exist.
" The quantity of albumen is usually very conspicuous, and increases as the
time of delivery approaches.   In proportion to the intensity and duration
of the morbid  process in the kidneys, are found casts of the uriniferous tubes
in greater or  less  quantity, the  epithelium lining  them being  sometimes
normal,  sometimes  in a state of fatty degeneration.   In the milder cases,
the tube casts  are often  found just at delivery, or soon  after.  Careful ex-
amination will probably,  in all cases, detect a not inconsiderable  diminution
of the urine."2  Dr. Cormack and Dr. Litzmann  attribute  the  albumen  to
mechanical  pressure  upon the kidney, by  the  enlarged uterus  producing
congestion of  that organ, and they adduce as an  argument the greater fre-
quency of albuminuria in  primiparae.   Neither regard it as the consequence
of granular degeneration ;  and  certainly, the temporary character  of the
phenomenon is not consistent with structural disease.   Dr. Seyfert attributes
it to the disturbance of  respiration and circulation.   According to most
observers, the  albumen disappears within a short time;  often  forty-eight
hours after delivery.
   The termination of the attack varies in different patients ; some remain
in a state of half-stupor and great exhaustion for hours or days, and gradu-
ally recover.    Other patients become maniacal, and  may even remain so for
a long time, and ultimately recover.   I  had a  patient who  remained  in  a
state of  mental derangement for several months before she was  restored to
health.  In a  few cases the patient continues comatose, and gradually passes
into a state resembling apoplexy, and dies.
   It is not always, however, that the recovery is complete.   Sometimes the
patient lies apoplectic, or in a state  analogous ;  or she is deaf,  or blind,  or
incapable of  speaking, or both  ; or the limbs  are paralyzed.   In fine, it
seems as if the sensorium had received some permanent injury,  the corres-
ponding parts of the body suffering in consequence.3   Cases of  partial  or
complete paralysis are recorded by Lever, Simpson, and others,  as a termi-
nation of convulsions.*
   702. I have already mentioned that convulsions may attack the patients
either during  pregnancy, at the time of parturition, or after delivery.
   It will be necessary to say a  few words upon  its occurrence  at each  of
these periods.
   703. Pregnant women are  more especially  obnoxious  to this disease

   i Arch.  G6n. de MSd. 1848.  Eecherches sur les Hydropisies chez les femmes enceintes.
   I As^ciahon Journal, Jan. 21st, 1853. p. 64.       3 Blundell's Obstetricy, p. 638
   Churchill s Dis.  of Women.  Chap. Paralysis in Childbed. 
CONVULSIONS.
475
during the latter two months of gestation, though it may occur at an earlier
period, and at irregular intervals.   The nearer the patient  is to her con-
finement, the greater the risk of an  attack, on account of the extreme dis-
tention of the uterus, and its increased irritability.
  Although  the beginning of  labor  may  not be  detected, either by an
internal or external  examination at the outset of these attacks, yet during
its continuance labour may commence  and  run a natural course.  In such a
case, the fits will be found synchronous with uterine  contractions, though not
recurring with each.
  In many cases, however, the uterus  remains perfectly quiescent, and  ges-
tation  may be carried on for a time  longer.   In almost all cases the child is
still-born, often putrid;  but whether its death preceded  the  convulsions, or
resulted from them, is not easily determined.   When the former is the case,
may we not attribute the convulsions to the dead child acting in some  sort
as a foreign  body ?   Dr. Ramsbotham observes, " When the result proves
thus satisfactory, the convulsions seldom return ;  but the woman rarely com-
pletes  her full period of gestation.   The  process  of labor commonly com-
mences within the space of a few days ; sometimes within that of twenty-four
hours.  Its progress is as regular and  natural as if no previous derangement
had taken place ;  but the child  is too  frequently still-born, and occasionally
shows  marks of approaching putrefaction."1
   [Instances occur of convulsions happening at each succeeding pregnancy,
and persisting until abortion takes place.  This is one of the greatest afflic-
tions  that can befall the married female.   " I  have witnessed," says Dr.
 Huston, in a note to a former edition, "the attack  twice in  the same lady,
 with only an interval of three months, both times terminating, as remarked,
in abortion.   She was a remarkably delicate woman,  of great nervous im-
 pressibility.   During the attacks she  had no frothing at the mouth, nor
 stertorous breathing, but after recovery,  was unconscious of all that had
 passed.  She was  bled freely at the  commencement of the  first attack, be-
 cause  of pain  in the head, and had a tedious recovery;  the  next time,
 she wras  put under  the use of excitants,— sinapisms, wine  whey, camphor,
 morphia, etc.,—and recovered rapidly.  The symptoms were very similar in
 both attacks : as the more  prominent of the convulsive phenomena subsided,
 those  of  a hysterical character,  such as  crying, laughing, etc., became more
 prominent."]
   The labor runs a natural course generally, and  in a fair proportion of
 cases  the mother recovers tolerably well, though there are startling excep-
 tions,  as  in the following instance : "A lady, in the end of her pregnancy,
 was seized with convulsions;  her attendant  was sent for, and decided that
 there  was no indication of labor, and that  a stay was unnecessary.   The
 midwife  left the house, and  returning early the  following  morning, the
 patient was  found dead ; the  child, too, the birth of which no one seems to
 have suspected, lay lifeless  beneath  the clothes."2
   When convulsions occur at the commencement of labor, it might naturally
 be attributed, in some cases at  least, to mal-presentation of the child ; but
 this is not the case.   Mal-presentation is  observed very rarely in  cases of
 convulsions.
   704. During labor, the return of the paroxysm  takes  place at  the com-
 mencement  of a labor pain, although not with every pain.  There is  a
 greater expression of suffering from  the uterine contraction than  from the
 convulsion.   The  symptoms  I have  described appear to be more intense
 when  the attack conies on during labor than during gestation.  The uterine
 contractions do not appear to be impeded by the  fits;  the  labor generally
               i Eamsbotham, Pract. Obs.  in Midwifery, p. 641, note.
               * Blundell's Obstetricy, p. 641, note. 
476
CONVULSIONS.
runs a natural course in the usual time, if not terminated by art; neither ia
it necessarily fatal to the infant, although there is great danger.
  It is remarkable, and not easily explicable, that after the convulsions have
ceased, and the labor is over, there is a great  tendency to  abdominal  in-
flammation, adding fearfully to the mother's risk.   Denman, I believe, was
the first to point out this fact, which Dr. Collins and others have confirmed ;
and which should be remembered in the treatment.
  705.   When the patient is  attacked by convulsions after delivery, they
generally occur from two  to four hours  after the birth of the child, some
times  later.  There can  be little hesitation  in  attributing them to  some
injury received  by the  brain or nervous system during labor,  though  we
may not be able to  specify the particular mischief.   It does  not, however,
depend upon the length or difficulty of the labor; they occur as  frequently
after  natural labor.
  The loss of blood at the time of delivery does not necessarily prevent
the occurrence  of the fit, though it adds to  the danger by the debility it
occasions.
  Duges  considers cases  of convulsions after delivery to be more tractable
than  any others,  whilst Dr.  Ramsbotham  states exactly the contrary.   I
Bhould say that the  cases  where the  convulsions occur during  labor, and
continue  afterwards,  are  the least manageable;  next to these the attack
during labor only ;  then, those after delivery;  and lastly, the most favor-
able are those which  occur during gestation.
   After recovery from the consequences of the  attack, the patient may
enjoy her usual health, and her subsequent pregnancies do not appear to
be  very liable to similar attacks.
   706. Morbid Anatomy.—In  the majority of cases, a post-mortem  ex-
amination affords but little information.   In many  instances there is  no
deviation whatever from the healthy state of the  brain,1 in others, according
to Braun, we find anemia, cedema, and diminished consistence.  Sometimes
the vessels of the brain are turgid with blood ;  and in other cases there is
a quantity of serum effused on the surface and base of the brain, or into  the
ventricles.  The heart  is  generally flaccid  and  empty, and the lungs of a
pale  color.   Some fluid is occasionally found in  the pleura, or pericardium.
Traces of inflammation have also been discovered in the peritoneum.  In a
few cases the  spleen is unusually large and the kidneys  congested.   Dr
Braun states that they may exhibit one or other stage of the three forms
of  Bright's disease.  He  has given  a very minute account of the appear-
ance to  be observed, but it is too long for insertion, and 1  must refer  the
reader to his work.
   707. Diagnosis. —1. From hysteric convulsions.—In the attack I have
just described, there is a total  loss of consciousness,  great muscular action,
frothing  at the mouth, frequent recurrence of  paroxysms, and incomplete
restoration or total  insensibility during the intervals.   In hysteric  convul-
sions, on the contrary, the patient scarcely loses  consciousness, exhibits only
moderate spasmodic action, has no frothing at the mouth, does not suffer from
a frequent recurrence of the fits, and recovers shortly  after each.   The sob-
bing, sighing, weeping, and screaming of the hysteric convulsions  are also
peculiar to it.
  2.  From apoplectic  convulsions.—In  epileptic convulsions,  the whole
body is thrown into violent spasms, which are  repeated, with intervals  of
quiescence, and often of  partial return of sense.  The breathing is rather
sibilant than stertorous, and the muscles preserve their tone even  during  the

  !  Bouteilleux, Thesis, Paris,  1816.  La Chapelle, Traite* des Accouch., vol. iii. p.  23.
Cruveilhier, Distribution des Prix  a la Maternite", Paris, 1838, p.  31.  Baudelocque,
Thesis, p. 65.  Ciniselli, Ann. Univ. di Med , vol. kix. p. 472. 
convulsions.
477
intervals ; whereas in apopletic convulsions, the spasmodic movements occur
at the commencement, and are not repeated ;  sense and sensibility are totally
lost, the breathing is stertorous, and the muscles lose all power, so that the
arm when raised, and allowed to fall, does so like that of a person recently
dead.
   708.  Prognosis.—On the whole, the  mortality is  considerable, though
probably much less so than formerly.   Jacob states that in his time scarcely
any survived.   Dr. Parr, in  his Medical Dictionary, that six or seven out of
ten die.  Dr.  Hunter, that the greater proportion were lost.   And we have
found that about one in four and a half are lost.
   709.  Treatment.—The  division  of convulsions into sthenic and asthenic
is of great value as regards  the treatment.   When the patient is pale, exsan-
guined, and weak, it is clear that much caution must be used in abstracting
blood.   Of course it may be advisable, but our main reliance must be upon
counter-irritation to  the head and neck, cold in moderation, calomel, opium,
and, I believe, upon anaesthetics.   In the sthenic form, when the head is hot,
the face flushed, and the  pulse  full, firm, and frequent, as soon as possible
after the convulsion, the first thing to be done is to take away blood from
the arm or temporal  artery, largely, and in a full  stream.   If the paroxysms
continue, this may be repeated.   Denman took  forty ounces and Blundell
seventy ounces of blood from a patient under these circumstances.  We are
not to be deterred from a free use of the lancet by the absence of immediate
relief—the benefit is rather in the ultimate and early recovery of the patient,
than in the immediate  arrest of the paroxysms.   " The quantity likely to
suffice for the relief  of  a case of only  threatened convulsions might amount
to between twenty and thirty ounces;  but if the convulsions are supposed to
have been  long established, or to  have taken place very suddenly, the prac-
titioner would have  to take away perhaps  thirty or forty ounces of blood, or
even fifty, in cases of great intensity of the symptoms. The rule should be,
that the pulse must  be reduced into a state of  mellowness and softness be-
fore the arm is allowed to be tied up.   In a few extreme cases, in  which the
author  has from time to time been consulted, he has considered it necessary
to order a second bleeding, after the lapse of two  or three hours subsequently
to the former one.  But he has never, that he recollects, recommended for
the second bleeding the abstraction of more than fifteen ounces of blood."1
Another good effect from  venesection is  the prevention  of the abdominal
inflammation, to which we have seen that the patient is exposed subsequently.
If there be  any objection  to repeating the  venesection, leeches may be ap-
plied ;  or if the  patient be sufficiently quiet, the nape of the neck may be
cupped.  Dr. Braun is strongly opposed to bleeding in  anasmic eclampsia,
as not  only having no good effect,  but as producing irreparable injury.
    [There can be no doubt that, under the  circumstances described by Dr.
 Churchill, the employment  of blood-letting to an  extent sufficient to produce
a decided'effect upon the pulse, is  strongly indicated in  the commencement
of the attack of puerperal convulsions.  It acts beneficially by relieving the
surcharged condition of the cerebral vessels, moderating the severity of the
pressure to which they are subjected  during the convulsive paroxysm, and
thus diminishing the danger of rupture and effusion; it, also, removes the
counter pressure from the medulla oblongata. While, however, blood-letting
is often a sufficient  remedy for simple convulsions depending upon a turgid
condition of the blood vessels of the brain and of the medulla  oblongata
and spinalis, no  little judgment and  discrimination  are  required, not only
to keep it within safe  bounds in the cases in which it is indicated, but to
detect those circumstances  under which it will be more likely to prove mjuri-
i Davis's Obstetric Medicine, vol. ii p. 1027. 
478
CONVULSIONS.
ous than beneficial.   Ip *ases of puerperal convulsions occurring in delicate
anaemic females, no  matter what may be the character of the symptoms by
which they are  attended, blood-letting—even one copious bleeding, but espe-
cially repeated  bleedings—would tend to rather augment than to relieve the
frequency and violence of the paroxysms.   With the great majority of prac-
titioners in the management of puerperal convulsions, as has been properly
remarked by Dr. C.  A. Lindsley,1 to  bleed is the rule,  absolute and im-
perative — no  matter what is the condition of the  patient.  No effort is
directed to  discover  any  existing cause of  spinal irritation and  to resort
to the  appropriate means for its removal —whether indigestible  food in the
stomach, unaccumulation of hardened faeces in the bowels, or of urine in the
bladder.  The  condition of the uterus and the state of the  vascular system
and its contents are alike overlooked.   The rule is absolute—to bleed boldly
and fearlessly.   Such rank and rash empiricism is altogether inexcusable —
under its influence  it is very  certain that blood-letting has been  practised
under  circumstances where  it should have been entirely  avoided, and  that,
in cases where within  proper limits it was called for, it has been carried to a
most injurious excess.
   "It  would  appear," Dr.  Lindsley remarks,2  "that  after the circula-
tion is reduced, either by proper depletion,  or from   any  other cause,
to somewhat below par, blood-letting  acts no  longer as  a sedative, but be-
comes itself a most certain irritant of the spinal marrow.   The continuance
of convulsions,  therefore, is not a reliable indication for further bleeding ; but
the state of the circulation in the interval of the fits, is the only proper crite-
rion, regard being had  to the different effects of an engorged and  an empty
state of the spinal vessels."]
   A strong purgative (calomel and jalap, for  example) should next be ad-
ministered,  as from the free evacuation of the bowels great benefit is gene-
rally derived;  and it may also excite  uterine contractions, and hasten the
delivery.
   [Numerous observations, as is well remarked by Dr. Lindsley,3  attest the
fact that large  accumulations in the stomach or intestines, whether of  food,
of faeces, or the presence of worms or of foreign bodies,  may excite convul-
sions in the puerperal  female in consequence  of  the irritation they induce
being  transmitted to the  central organ by reflex action.   Whenever, there-
fore, such offending matters are found to exist, their prompt removal is  obvi-
ously demanded. But the manner in which this is done is important.  There
can be but little difference between irritating drugs and irritating faeces, and yet
the most drastic purgatives are often administered,  with the effect too often of
only thus changing one cause of irritation for another.  It is but fair to pre-
sume that copious injections of water simply, would be quite  as effectual, and
vastly  safer, inasmuch as  they are  more rapid  in  their effect, and  leave
nothing to irritate the intestine after their mission is  accomplished.   If
necessary, their action  may be assisted by the  addition of castor oil or tur-
 pentine.  If an overloaded stomach or undigested food  is  suspected  to be
the cause of the convulsive paroxysms, an emetic of sulphate of zinc should
be administered.   If the patient,  however, is plethoric, venesection should
always precede the  emetic, to guard against  any injury from the increased
distension of the cerebral vessels during the act of vomiting.
   Mr. Vines mentions  an instance  of puerperal convulsions in  which, after
resisting for two days all the usual remedies,  including the delivery of the
child,  the paroxysms  ceased immediately upon  withdrawing from the bladder
 five and a half pints of turbid and  highly ammoniacal urine.   This case
    1 [Proceedings Connecticut Medical Society, A. D. 1858.1        2 fLoc. citat.1
    » [Op. citat.] 
CONVULSIONS.
47 9
shows the necessity of attention to that condition of the urinary bladder in
all cases of eclampsia.]
  The head may then be shaved, and cold lotion or ice applied.   Denman1
^peaks highly of cold affusion.   He says, " On a patient in convulsions who
aad been bled, and for whom many other means had been fruitlessly used, I
determined to try the effect of cold water.   I  sat down by the bed-side, with
a large  basin before me, and a bunch of feathers.   She had a writhing of
the body, and other indications of pain, evidently occasioned by the action
of the uterus before the convulsions ;  and when these came on, I dashed the
cold water in her face repeatedly, and prevented the convulsions.   The effect
was astonishing to  the bystanders,  and indeed to myself.  On the return of
the indications of pain, I renewed the use of the cold water with equal suc-
cess ; and proceeded in this manner until the patient was delivered, which
she was without any more convulsions, except  once when  the  water was
neglected.
   [Dr. Lindsley,2 also,  suggests the  application of cold water to the head
Applied in a continued stream, it is adapted to lessen the distended state of
the cerebral  blood vessels, and thus  relieve the counter pressure upon the
medulla oblongata.   In the form of douche it would tend to excite an inspira-
tion, and thus dilate  the glottis.   When the cold water is applied along the
spine it should be continuous — the intermittent  application  excites instead
of allaying irritation.]
   A warm bath has  been  recommended, but besides that its value is doubt-
ful, it would  in most  cases be* very  difficult to  administer it.
   After the lapse of some time, the head and nape of the neck may be covered
with blistering plaster, as counter-irritation will materially further the restora-
tion of the patient.
   When, after copious bleeding and purging,  the attack is somewhat subsi-
ding, it has been recommended to give an opiate.   Considerable difference
of opinion has existed upon this point, owing,  I think, to the different parties
not specifying with sufficient accuracy the time at which it should  be admin-
istered, and the cases suitable for  it.   Under  the circumstances I have  men-
tioned,  it seems  to be the opinion  of the highest authorities that it may be
of service.   Dr. Collins remarks, " Many of  our best writers  have actually
condemned the use of opium in convulsions, stating it to be most injurious —
some even  destructive.   Ample experience has convinced me that it is not
only harmless, but  highly  beneficial in those  cases  where  the fits continue
after delivery.   And I should hope the cases adduced will prove satisfac-
torily that it is  also useful under  many  other circumstances,  when  proper
steps had been previously taken.   Its combination  with tartar emetic, and
and occasionally with calomel, is most advantageous."  Calomel, given  so as
to affect the  constitution, has  been  found beneficial.  Dr. Collins speaks
very highly of tartar emetic with opium, in doses sufficient to produce nausea,
but not vomiting.   " In every severe case of  convulsions, after having car-
ried into effect the ordinary mode of treatment, as  bleeding freely, acting
briskly on the bowels with calomel and jalap,  and at the same time adopting
the means  usually  had  recourse to for protecting the patient during a pa-
roxvsm  I endeavored to bring her under the influence of tartar emetic,  so
as to nauseate effectually,  without vomiting.   With  this view,  a tablespoon-
ful of the following mixture was given every half-hour :—
                          Aquae Pulegii,  ^viij.
                          Tartar Emetici, gr.  viij.
                          Tinct. Opii. gtt. xxx.
                          Syr. Simpl. 31J.
                                             M.
           1 Midwifery, p. 435.                        2 £0P- fiitat] 
480
CONVULSIONS.
  " In some cases the quantity of  tartar emetic used wis only four  grains
to an eight-ounce mixture ;  and in others, the quantity of opium was some-
what increased."
  It will be necessary to insert a wedge of leather or wood  between  the
teeth, to prevent injury to the tongue, and also to remove everything  out of
the way, by striking  against which  the patient might hurt  herself.  [A roll
of linen or  muslin answers as well as leather, and is much better than wood;
besides, it is always  to  be  obtained at the moment when  wanted.]   This
treatment applies  equally to convulsions occurring before, during, or after
labor — except that  in  the latter case venesection must depend on the state
of the patient.
  710.  Very recently it has been proposed to administer.anaesthetics, so as
to produce insensibility, in  hopes, at the same time, of  calming  the convul-
sions ; and certainly so  far as we  can fairly judge from the cases on record,
it appears  a most valuable  and  successful remedy.  Dr.  W.  Channing, of
Boston, U. S., has used ether in ten cases ;  six mothers recovered  and three
children, a larger proportion than  when ether was not  used.1   Mr. Turner,
of Mansfield, administered chloroform in a case of convulsion after delivery,
with perfect success.   When given  on the approach of a fit, it arrested it at
once.  The patient recovered.2   Dr.  Keith gave it in convulsions occurring
during pregnancy.   It quieted  the  fits, and when labor came on, the patient
was  placed completely under its  influence, and kept so until delivery.   She
recovered well, and with no  recurrence of the attacks.3  In a case related by
Mr.  Morris it was equally beneficial.4  In a case which  occurred at Gosport,
the inhalation was continued for three hours, after the patient had had thirty-
three fits, and the success was complete.5   Dr. Shekleton, the late master of the
Dublin  Lying-in Hospital, has  tried it in  nine cases ; in five the convulsions
were completely arrested, and  in four they were lessened  in  intensity and
frequency.6  Mr. Bolton had  recourse to it after bleeding  and opium had
failed, and  with  great success.7  I  have  tried it  in  several cases with  great
benefit.   Dr. Braun  tried it in sixteen  cases, all of which  recovered com-
pletely.
  711.  The next important question is, whether we are to interfere with
the progress of  gestation or parturition.
  I believe it is  the general opinion, that, until labor sets in naturally, inter-
ference  would be injurious ;  so  that in convulsions during gestation, we have
nothing to do with the uterus, but must confine ourselves  to the treatment
of the convulsive disease, and it  is more especially useful if we have to  de-
liver artificially.
  If the attack  take place at the commencement of the labor, some practi-
tioners have been anxious to hasten the operations of nature by manual dila-
tation ;  but this has  been abandoned, and very properly, as likely to increase
the convulsions,  without advancing the  progress  of delivery.8   Belladonna
has  been applied  to the cervix  uteri, for the purpose of dilatation, but  I
should doubt its  utility, and dread its poisonous effects.9  The older writers,
with some  moderns, have proposed  incision of the cervix, but the risk would
outbalance any benefit to be derived from so " heroic "  a remedy.  But sup-
posing the os uteri to be dilated  or dilatable, are we then to proceed  to de-
liver by art ?  This question has been much debated, and opposite opinions
have been advocated.   Some advise instant interference,  and others  no  in-
terference at all.10  The true plan seems  to be to avoid both extremes.  We

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

   713. 3. Apoplectic Convulsions.—This variety  seldom or never occurs,
 except towards the termination or after the conclusion of labor.   Dr. Burns,1
 indeed, mentions its  occurrence  at the commencement  of labor, and MM.
 Morithon2 and Menard3 at the  sixth month of pregnancy.
   Causes.—It is evidently  caused by the stress  upon the  cerebral vessels
 during the labor pains.
   It is very  probable that anxiety of mind may predispose to the attack ; at
 least in  one case I saw this appeared to be the case.
   714.  Symptoms.—In many cases the patient suffers from  pain and throb-
 bing in the head for some days previously ;  but in others  there  are no pre-
 monitory symptoms.
   Generally speaking, during the labor the patient complains of headache ;
 and during the  second stage the face may be observed  to  be much  flushed,
 and the eyes injected.
   Strictly speaking, there is but little  convulsion;  the body and extremities
 are agitated or thrown about for a short time, and then the patient lies in a
 comatose state.  There is little  or no distortion of the face,  and  no frothing
 at the mouth.   The muscles become flaccid and powerless ;  the respiration
 is stertorous; there is no return  of intelligence,  and rarely any repetition of
 the paroxysm, though such cases have  been recorded.   The pulse is full and
 slow, and  the pupils in some cases dilated, in  others contracted, but in all
 insensible  to light.
  In almost  all cases the condition of the patient remains unaltered  until
 death; but there are a few cases, answering, I presume, to the congestive
 apoplexy of Abercrombie and Lallemand, where our timely aid is successful,

 ^eedilyweir  reC°VerS ^ ""* "^ 5 &nd' * ^ eve be taken, is

rellw tt^'woV^ • °an giVG aiettGr illustrati™  of this disease than by
relating the two following cases.  For the first I was indebted to my friend
S    /b  ASt°Qi Jt appearS t0 be a simPle case  of apoplexy from Ton-
ftta  hed   I  ZZZZY " thG PraCt!CG of a dispensaVto which I was
attacned   1  quote  them  from  a report I published  some  years ao-o in thP
Medical Gazette : " Catherine Costello, aged eighteen  years aM nine°months
of low stature and corpulent figure, complained first  of severe headache  or
Wednesday,  January 2d, 1833.   The  pain was more violent than  any  of

  1 Midwifery, p. 527.     * Trans.  Med., vol. v. p. 162.      3 ibid., vol. iv. p. 241 
convulsions.
483
the kind she had  ever  experienced.   Sickness of the stomach set in nearlv
at the same time, and she continued throwing up green bilious matter durino-
the entire day; the bowels were confined for four days; the face and ex-
tremities were much swelled, which commenced two  days  before, and con-
tinued gradually to  increase as the headache  became more intense.   She
wanted  about seven weeks to complete the usual term of utero-gestation.  I
[Dr. Aston]  was sent for in the evening; she was walking about the room,
but suffered most acutely;  the face was swelled to such a degree as almost
to hide  the eyes, and her  speech was somewhat thick.   The motion of the
child  had not  been felt all  day.   As  she had an objection to bleeding, I
omitted it for the present, and  directed some opening  medicine to relieve
the bowels; and  having given  the requisite  directions, I left her; but in a
few hours her husband  came for me  in all haste, requesting my immediate
attendance, as she had had a  fit, and appeared to be in a dying  state.
Upon further inquiry, I was told that the pain in the head got much worse,
when suddenly the eyes became fixed, the face distorted, convulsive motions
ensued,  and ended with stertor, which must have been of short continuance,
as no such symptoms  existed when I visited her a short time  afterwards,
although she  was unconscious of anything that happened until  after vene-
section, which I immediately performed to the extent of eighteen or nineteeu
ounces,  from  which she experienced almost instantaneous relief.  The heat
of skin was  much  greater than natural;  thirst  extremely  urgent;  pulse
pretty  frequent,  but inclined  to  hardness; after venesection it  became
quicker;  shortly  after,  slower and softer, until it gradually came down to
the natural standard.  From this  time  all the  symptoms subsided, and she
was delivered January 5th, and  recovered well."
   " Mary----, set.  30, was attended  in her  first confinement by a pupil of
the Wellesley Dispensary, on Monday, November 20th, 1832.   The  labor
was natural, and terminated within the usual period.   She complained of
severe headache during her labor, and seemed sleepy towards the conclusion.
After asking some question of the attendants, she  settled to sleep;  some
irregular motions of the limbs were noticed by those in the room, but nothing
further, until her breathing became loud and heavy, when, as they could no\
rouse her, I was sent for.   I found her perfectly insensible; pupils fixed ano
contracted ; breathing stertorous ;  heat of head but little increased ;  abdo-
men distended with flatus; muscles perfectly flaccid ; pulse firm, and tol-
erably full.   The usual remedies were tried, but unsuccessfully, and she died
during the night.   A post-mortem examination was permitted, and we  found
great effusion of blood, filling both  ventricles.   A  quantity of serum also
was found at the base  of the skull.   On further  inquiry, I learned that she
had been  the victim  of seduction and desertion, and  that she had  suffered
from depression of spirits and severe headaches  for some weeks before her
confinement."
   715.  Pathology.—The brain may be found  greatly congested, but with-
out any effusion ; but this I believe to be rare.
   There maybe  great effusion  of serum, which  by  its pressure will  cause
symptoms of apoplexy.
   More frequently, blood is poured out into the ventricles, into the substance
of the brain,  or at its base.
   Cases of this kind have been noticed by  Denman, Targioni, Marchais,
Lachapelle, Leloutre, Schedel, Velpeau, etc.
   716.  Diagnosis.—The entire  and  persistent insensibility, the absence of
repeated paroxysms with their accompanying symptoms, will at once enable
us to  distinguish  apoplectic from epileptic or  hysteric convulsions.
   It is  not easy to distinguish  that form which arises from congestion from 
484
lacerations  of  the
that caused by effusion, the chief difference being  in  the  intensity of  the

Syl?170rTREATMENT —The most active  antiphlogistic  measures should  be
instantly put into requisition;  a  large  quantity of blood should  be taken
from the  arm, jugular vein, or  temporal artery, and repeated if necessary.
This is the more  requisite, as it is from the effect of  bloodletting that we are
mainly to look  for the distinction between  apoplexy from congestion, and
apoplexy from effusion.   If no relief whatever be afforded, the case may be
regarded  as nearly hopeless; but if the patient be at all benefited, the head
should then be shaved, and ice  applied.
   After a short time  a large  blister may be applied to the head or  neck, and
a brisk purgative given.
   These remedies will generally  afford relief in those cases which are susceptible
of  it and they may be modified or  repeated as circumstances  may require.
   Should this variety occur during labor, and the uterine action be suspended,
it will be desirable to deliver the patient as speedily as possible, so as to
save the child ; and for  this purpose, if the head be within reach, the long
or short forceps  should be applied.
CHAPTER  XXII.
          PARTURITION. —CLASS III. COMPLEX  LABOR.
                     ORDER  5.  LACERATIONS.

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

  1. Rupture op the uterus. — This formidable and very fatal accident
has long been known to practitioners in midwifery.1
  It is not, however, confined to the time of parturition  but, may  occur
during gestation, or at a more advanced period of life.
  719.  Statistics.—The following table will indicate the frequency of its
occurrence.
Authors.					Total No. of Cases.	Cases of Rupture.
Dr. Jos. Clarke......					10,387	8
Dr. Merriman .					2,947	1
Dr. M'Keever .					8,600	20
Dr. Collins					16,654	34
M. Pacaud					4,180	2
Dr. F. H. Ramsbotham .					68,435	13
Dr. Toogood .					1,135	4
Mr. K. Watson					800	3
Drs. M'Clintock and Hardy					6,634	9
Drs. Johnston and Sinclair					13,748	17
  'I would recommend to the attentive perusal of the reader, a most valuable monograph
on this subject by Dr. J. D. Trask, Amer. Journ. of Med. Sciences, Jan. and April, 1848 
UTERUS  AND  VAGINA.
485
Making a total of 111 cases in 133,520 patients, or about 1 in 1203.
Dr. Burns says that it occurs about once in 940 cases.
It rarely occurs with first children.
Of Dr. Jos. Clarke'	s cases —
1 was the 2d pregnancy.	
1 "	3rd
2 "	4th
1 "	7th «
1 «	8th
1 «	9th
Of Dr. M'Keever's	cases—
4 had 2 children.	
5 " 3	"
4 » 6	it
2 " 7	a
2 » 8	a
1 " 9	a
Of Dr. Collin's 34 cases —
        6 were 3d  pregnancies.
2 '	' 4th
2 <	' 5th
5 " 6th	
1 '	' 8th
1 '	' 9th
2 «	' 10th
2 « 11th	
Of Dr. Ramsbotham's cases—
        2 were 2d pregnancies.
        1  "   4th      "
        3  "   7th      "
Of Dr. Collins' 34 cases —
        7 were 1st pregnancies.
        6  "    2nd
  Dr.  Cathrall's case was a 1st pregnancy.'
  Dr.  Simms' patient had had several chil-
dren."
  Dr.  Hooper's case was the 4th pregnancy.3
  Mr. Kite's,*   "    «   2d     »
  Dr.  Frizells,5 "    "   7th     "
  Mr. Powell's,6 "    "   1st     "
  Mr. Birch's  cases  were the  3d  and  4th
pregnancies.7
  Mr. Partridge's case was the 7th preg-
nancy.8
  Thus, of 75 cases, 9 occurred in the first pregnancy; 14 in the 2d ;  13 in
the 3d ;  and 37 in the 4th or subsequent pregnancies.
  In  Dr. Trask's collection  24 cases occurred in the 1st pregnancy;  18 in
the 2d ; 17  in  the 3d ;  21  in the 4th ;  18 in the 5th ;  16 in the 6th ;  9 in
the 7th ; 5 in the  8th ;  5 in the 9th ;  9 in the 10th ;  8 in the 11th ;  3 in
the 12th ;  2 in the  13th ; and several in the  17th.
   720. Causes.—Various causes may give rise to it, and it may happen at
different periods —
   1.  During gestation. — That form of extra-uterine pregnancy which is
called interstitial foetation may give rise to it. The ovum, instead of passing
direct from  the  fallopian tube  into the uterine cavity, is retained in an in-
terstice  of the uterine fibres, where it grows up to a certain point.   As it
increases, the outer portion of the uterine parietes becomes gradually thinner
by  absorption (as in the  case of  abscess), and at length gives way, and  the
fcetus is precipitated into the abdomen, converting the case  into  one  of
ventral foetation ;9 it may also be the consequence of disease, as in Mr. Else's
and Dr. Spark's10  cases;  from softening, and from abscess  in  the walls, as
related by Duparcque.11   Any violent accident,  such as a fall or a blow, or
great fatigue, may give rise to it.   It sometimes occurs without any assign-
able  cause;  the patient,  perhaps, is awakened  from sleep  by it, as in  the
cases related by Mr. Scott of Bromley,12 and Mr. Glen of Brompton.13 It has
been  attributed to irregular  action of the uterine fibres.
   721. 2. During labor.—a. If the uterus have been attacked by inflamma-
tion  during  pregnancy, its tissue may have  been so  much weakened or dis-
organized, that the violent contractions  which take place during labor may
rupture  it, from the  want of consentaneous action in the part affected, or
from  the pressure  of some part of the child against it.   Steidele relates a
 iMed Facts and Obs., vol. viii. p. 146.
 s Mem. of Med. Society, vol. ii. p. 118.
 6 Trans, of Association, vol. ii. p. 15.
 11bid., vol. xiii. p. 357.
 » Med. Gazette, vol. ii.  p. 400.
» Ruptures de l'Utirus, pp. 15, 16.
w Merriman's Synopsis — Appendix.
 2 Ibid., p. 150.
 « Ibid., vol. iv. p. 253.
 6Med.-Chir. Trans., vol. xii. p. 537.
 8 Ibid., vol. xix. p. 72.
w> Ibid., vol. ii. p. 218.
12 Med. Repository, vol. vii. 
486
LACERATIONS  OP  THE
case where rupture  occurred in consequence of gangrene.1   My friend, Dr.
Murphy,2 has published an excellent paper illustrative of this cause of rup-
ture,  with cases  where the uterus was atrophied, thinned,  or  softened in
texture.  Duparcque quotes cases of thinning of the uterine walls, softening,
scirrhus, and gangrene.  Dr. Trask states that of 49 cases in his collection,
where the condition of the  uterus was given, in 10 it was healthy ;  in 14 it
was thinned; in 14 softened; in 1 both thinned and softened; in 2 both
softened and thickened ;  in 1 thickened ;  in 3 diseased.   In some cases the
seat of the laceration corresponds exactly with the situation of the previous
pain.  Dr. Tyler Smith believes that in many cases violent uterine action is
in itself  the cause of rupture;  the immediate cause being either emotion or
volition, or a reflex or peristaltic action.
   The period of labor at which the rupture may occur from this cause will
vary; it may be at the  beginning, before the rupture of the membranes ;
during the passage of the head through the pelvis, or after the delivery.
   b.  A certain amount of narrowing of the upper outlet may give rise to it.
This  is a purely mechanical cause.   The head of the child is forced down-
wards by violent labor pains, but is unable to enter the pelvis, from the con-
traction  of the upper strait; now if the pains continue with great power, the
head is turned to one side or the other, or posteriorly ; and the only obsta-
cle here being the uterine or vaginal parietes, the head is driven through them
at the weakest part.  They offer the less resistance, probably, from the woman
having generally borne several children.  In  one of Dr. Clark's cases, the
antero-posterior diameter of the upper outlet measured but 3 inches ; in two
others, 3^.   In case 18 of  Dr. Douglas, the pelvis measured but two inches
antero-posteriorly; and in  another case (20) there was a  bony ridge on the
top of the symphysis pubis,  to which the rent corresponded.  In one of Dr.
Ramsbotham's cases the antero-posterior diameter  was  only 2  inches ;  in
another  3  inches ;  and a third had always had difficult labors previously.
In  one of Dr. Collins' cases, the same diameter measured  2£ inches ;  and in
several it appeared  narrower than usual.   Dr. F. Ramsbotham has  never
known a case in which  there  was not some contraction.3  Dr. Roberton
collected 37.cases  from various sources, in which there was diminution of
the pelvic diameters.4
  Various explanations  have been  given of  the modus operandi of this
contraction, Dewees attributing the rupture to inflammation  and gangrene,
Denman to the effect of pressure and attrition, Dr. Burns  to pressure of the
cervix between the head  and the pelvis, and Dr. Ramsbotham  to  thinning
from pressure and inflammation.  However this cause may act, it doubtless
gives rise more frequently to rupture of the cervix than  of any other part
I quite agree with the opinion of Drs. M'Clintock and Hardy, that the
effect is more likely to  be produced when  the amount is slight than when it
is excessive.
  The sex of the child will contribute to the increase of this disproportion
—male children having the larger heads.  Now, of the 20 cases mentioned
by Dr. M Keever, 15 children were males, and 5 females; and of Dr.  Col-
lins 34 cases, 23  were males.  This  result of  an unusual  size of the child's
head  is still  more remarkable when the head is dropsical,  as in the  cases
related by Campbell, Collins, Lord, Ramsbotham, Chance, etc.5
  It occurs at all ages; but the proportional frequency is greater above 30
years  of age than previously.

 3 £w t • ^fPj iQ P/otU' d0l0r- Utero-    2 Dublin Journal ^ Med. vol.  vii. p. 198.
 s Obstetric Med. and Surgery.                                       *
 * Phys. and Diseases of Women, and on Midwifery  p 29°
   Trask's Essay, Amer. Journ. of Med., Jun., v848. 
UTERUS  AND VAGINA.
487
Dr. Collins found					Dr.	Collins found			
1 patient	of the	age	:f 16	years.	7	patients	of the	age	of 30 year<
1 "	a		21	tt	2	a	t<		32 ««
1 «	tt		24	a	1	a	a		33 "
3	tt		25	tt	1	it	it		34 ' "
2	««		26	t<	3	it	a		35 "
1 »	tt		27	(<	5	a	a		36 «
3 «	n		28	tt	1	i<	t<		37 «
l-H	a		29	<<	1	((	ti		40 "
   c. The oblique position of the uterus, or of the child's head at the brim,
 has been assigned as a cause, from its directing the force of the child's head
 against the side of the cervix uteri and  vagina.
   d.  Some one  of the tissues of the  uterus may give way previous  to  or
 during labor ; perhaps from previous disease ;  perhaps from some peculiarity
 of structure ; and in some cases, without any appreciable cause.   Sir Charles
 M. Clarke  published a case, iu which the  peritoneal covering of the uterus
 alone  was torn ; and similar cases  have been since recorded by Mr. Par-
 tridge, Mr.  White, Dr. Ramsbotham,  Mr. Chatto, and Dr.  Davis.   Dr.
 Collins has  also met with a case of this kind, and others are on record.
 Dr.  Radford published two  cases in which the  muscular coat was  torn, the
 serous membrane remaining uninjured.   Dr.  Ramsbotham met with a case
 nearly similar; and Dr.  Collins met with nine such cases.   Duparcque re-
 lates one, and Velpeau two.   Many  years ago, I assisted at  the post-mortem
 examination of  a  patient who was attacked with symptoms  of  ruptured
 uterus, sudden  pain in the  abdomen, vomiting, collapse, etc. ; and  who
. died  in  a few hours.    We found  no  rupture  in any part, but extensive
 effusion  of blood beneath the peritoneum, covering the uterus, and lining
 the  iliac  fossae ;  the  result, probably, of a  ruptured bloodvessel.  There
 were also twelve or fourteen ounces of sero-sanguineous fluid in the peri-
 toneal cavity.  Though the  extent of mischief is less in these cases, yet they
 are equally fatal.
   e.  Violence in turning the child  may rupture the uterus, and it may ac-
 company this operation, in certain states of the cervix, without any fault of
 the operator.
   f  Rigidity of the os uteri, or imperforation,  may occasion laceration.1
 There are several cases on record where the cervix uteri has been torn com-
 pletely off during labor.  Steidele, Mr. Scott of Norwich, Dr. E. Kennedy,
 Dr. Power, and  Dr. Lever, have each recorded  such cases,  and I have  seen
 one  myself.   It appears to  be  the result of pressure at  the  brim of the
 pelvis, rendering the texture of the cervix soft and easily  torn.2
   g.  Occlusion, partial  or complete, of the vagina has in many cases oc-
 casioned  rupture of the cervix  and body  of the  uterus, as I  have shown
 elsewhere.3
   h.  It  may be  caused or  aided by the peculiar presentation;  but this
 cannot be very often the case, as, out of 303  cases  collected  by Dr. Trask,
 there were  only 16 presentations  of the shoulder,  arm, or side, and two of
 the breech ;  the remainder were  head presentations.
   The duration  of the labor has  been supposed to  influence the occurrence
 of rupture; but Dr.  Trask  has shown  that this is not the  case.  In 89
 cases,  48 were not more than 12  hours  in labor; and the average  duration
 of the whole was rather more than  21 hours.  In 38 cases the pains were
 moderate, in 63 they were severe;  and in the  majority  of Dr. Roberton's
 cases the labor was under 13 hours.
i Ante, p. 268, on Rigidity of Cervix Uteri.
2 Diseases of Women.  Chapter on Occlusion of Os Uteri.
3 Ibid., Occlusion of Vagina. 
488
LACERATIONS  OF  THE
  Among the direct causes are enumerated blows, falls, anger, convulsions,
excessive movements  of the child,  over-distension,  etc.   In  one case,  M.
Malgaigne attributed it to the mal-administration  of ergot  of  rye.   Dr.
Trask gives four such cases.
  722. 3. At an advanced period of life. — The  structure of  the cervix
uteri  is much changed  in old age ;  it becomes close and dense, resembling
cartilage, and the canal through it is always reduced in size, and  sometimes
obliterated.   When the outlet for the  escape of the uterine mucus is thus
closed, it accumulates ; and if the quantity be sufficient to distend the cavity,
a process of thinning  or absorption commences in some part of the walls of
the uterus, and proceeds until  an opening is  made  into the peritoneal sac.
The same process will take place with any other fluid thus deprived of exit.
Duparcque quotes two cases of the kind.  In some few cases a similar pro-
cess has occurred during middle life, as  in the case related by Dr. Gozzo of
Naples, whose  patient was only set.  38.x
  723. Pathology. —If the laceration be the result of disease, it may take
place  at any part of the organ,  the body, fundus, or cervix; and it will
generally be found to  correspond to the situation of the pain felt by the pa-
tient previously.  The edges of the rent exhibit marks of disease, the tissue
is thinned, softened and pulpy,  breaking down easily under the finger.   The
color  may be changed to a deep  red or  brown  color, and occasionally the
odor is offensive.
  When the laceration is the result of mechanical causes, it  generally takes
place  near the cervix,  and involves both the uterus and vagina.  It may run
along the anterior or posterior surface of the uterus, or at one side.   In 6
of Dr. Jos. Clarke's cases, it was on the anterior surface, and in 1 posteriorly.
In  Dr. Simms' and  Hooper's cases, it  was anteriorly ;  in  Mr. Birch's, pos-
teriorly; and in Mr. Cathrall's case, on the right side.   In 3 of Dr.  Rams-
botham's cases, it was posteriorly ; in 1, along the  right side ;  and in an-
other, along the left.  Of 23 cases, Dr. Collins found 1 on the right, and 1
on the left side —11 posteriorly, and 10  anteriorly.  In Dr.  Trask's exten-
sive collection of cases,  we find that of those which occurred  during gesta-
tion, in  7 the laceration was of the fundus, in 1 of the posterior part in 2 of
the anterior part, in 2 of the right side,  in 1 of the left side, in 3 of the cer-
vix and vagina,  in 1 from cervix to fundus, in 1 of cervix, body, and bladder in 2
°L  eV?s}enov and inferior parts, in 1 the lower segment of the womb was torn
off.  Of those which occurred during parturition, 11  were of the fundus 13 of
the posterior part, 14 of the anterior part, 8 of the right side, 7 of the leftside,
2 of the vagina, 15 from cervix to fundus, 2 involving the bladder 47 at the
cervix and  involving the vagina  and separation from the vagina, 2 of the
 ?& VTSV6rSA 7^' 0f tho total occurring during gestation, 13 were
of the fundus and body, and 8  of the cervix : of the total occurring  during
parturition, 63  were of the body and fundus, and 64  of the cervix,  involving
more  or less, the body of the uterus and the vagina.2  In one of Dr Ro-
berton s cases, the cervix was separated  from the vagina, except a shred, in

and ia^pS^aa^!?n°r'!n " ^^  * lateral, in 3 a^tero-late^al,

or nTbi^?1011 0f the.rent ma7 be ^arly perpendicular, or inclining to one
  e     ,  llT11'! ^nsversely.   In these cases the structure of the
whew blondT.J;       \ lts  teXtureis  firm' and ^ color  natural,  except
 )ol2i ?i   IThymosed;   The edg«s of the rent are jagged and uneven.
Occasionally, but very rarely, the bladder has also been torn  *
  iBrit. and For. Med.-Chir. Review, Oct. 1848
  2 American Journal of Med. Science, April  1848  n 393
    Phys. and Dis. of Women and Midwifery,r,812*
  < Arcinves Gen. de M«d., vol. xviii. p. 109.  Laennec Picquet, These, Paris. 1822. 
UTERUS  A^D VAGINA.
489
  When the serous membrane  alone is  injured, we  find numerous small
incisions, resembling scarifications, from a  quarter to half an inch in length,
and  one or  two lines in depth, or a smaller number of larger lacerations.
They are  almost always curved,  with the convex  part  towards the fundus,
and may be situated on the anterior or posterior wall of the  organ.   In all
the cases hitherto mentioned, more or less blood is found effused in the peri-
toneal sac, and in many, the usual products of peritonitis.
  When the muscular  structure  alone is  injured,  it may present either  a
simple solution of continuity, or evidences of disease.   Blood may be found
in the cavity of the uterus, and the serous membrane may be inflamed, with
the usual results.
   The cervix uteri, when separated, has generally a bruised appearance,  is
swollen, and of a red color.   The edges are ragged and uneven.  The canal
of the  vagina is rendered continuous with that of the uterus, but the con-
nection between them is not compromised.
   When the uterus of  an old person is ruptured, from the cause assigned,
we shall discover a perforation in some part of  it, with a considerable thin-
ning of the walls around it.
   In all these cases, with the exception of those in which the os uteri  is torn
off, or the muscular structure alone injured, we find marks of extensive peri-
tonitis, unless the patient die of the shock.
   754. Symptoms.—These  vary very slightly,  whether the  uterus be  torn
completely through, or whether the peritonal or muscular tissues alone be
injured, or whether the vagina be alone damaged.
  ' Certain authors have pointed out what they deem premonitory symptoms ;
but these are exceedingly ambiguous.  The circumstances which may justly
excite our fears are, previous difficult labors, the occurrence of partial  hys-
teritis during gestation ; and during labor, the coincidence of violent labor
pains with a narrow pelvis.
   Rupture of the uterus  and vagina is  marked by a sudden,  acute, and
intolerable  pain, like a cramp;  a sense of some part bursting, giving way,
or tearing,  with an audible  noise, according to the testimony of some pa-
tients ; the suspension of the labor pains ;  recession of the head generally ;
 hemorrhage from the  vagina;  and  a rapidly succeeding state of collapse.
 Of  these symptoms, the excruciating pain and the collapse  are the most
 constant; as in some  cases the bursting or tearing is not  felt; and when
 only one tissue suffers,  the labor may continue,  and there may be no  hemor-
 rhage.  The pain continues, with little or no  intermission.   The stomach
 is disturbed, and vomiting ensues, at first  of the contents of the stomach,
 then of a greenish, and ultimately of a black matter — the "coffee-ground
 vomit."  The  countenance is pale and ghastly, with an expression of intense
 suffering and  anxiety; the surface is cold and  clammy.  The pulse  is very
 rapid,  small, feeble, and  fluttering, the  respiration hurried and  difficult;
 and the  patient requires  to be raised in  bed.   There is almost always a
 discharge of blood from the vagina;  sometimes slight, and at others  so con-
 siderable as to cause death.
   We know also, from post-mortem examination, that in most cases,  hemor-
 rhage  takes place into the abdominal cavity ;  and some  authors have attri-
 buted the state of collapse to this cause ; but though  it may aggravate the
 collapse, we know that this is present when there is no internal hemorrhage.
 When the rupture is complete, the expulsive efforts cease, because the child
 escapes partially or wholly, from the cavity of the uterus into the abdominal
 cavity where  it may be felt by  the  hand through  the abdominal parietes.
 The presentation, which  was probably  within reach  before  the accident,
 cannot now be ascertained by the finger.
   When the rupture is complete, a loop of intestine may escape through it, 
490
LACERATIONS  OF  THE
 and give rise to the  symptoms of strangulated hernia.  Duparcque quotes
 three cases of this kind from Remigius, Percy, and Beauregard.   Dr. Trask
 collected sixteen cases in which  this occurred.   A case  is related by Dr.
 M'Keever, where a yard and a half of intestine  became  strangulated, and
 sloughed off.
   The state of collapse may continue for some time, if it do not prove im-
 mediately fatal; but at length a certain  amount of reaction takes place ;
 inflammation sets in, and the patient exhibits all the  symptoms of peritonitis
 —acute  pain, exquisite tenderness of the abdomen on  pressure, tympanites,
 decubitus on  the back, with  the  knees  drawn up, quick,  small, hard pulse,
 hurried respiration, etc., etc.
   When the vagina  alone is seriously ruptured, the sudden pain is absent,
 but the collapse is more or less complete, and although  the  regular labor
 pains become feeble  or cease, the uterine action is not paralyzed, as in rup-
 ture of the uterine substance;  but if we aid in the delivery we shall find the
 uterus assist in expelling the child and placenta.   There will, of course, be
 no recession, but there will be hemorrhage,  external or internal.  In a case
 which came under my observation, the collapse was  not complete, but  suffi-
 cient to  indicate some grievous organic injury ;  the  patient  was then de-
 livered  by the forceps, during which operation the uterus acted firmly, and
 afterwards expelled the placenta without assistance.   The  external hemor-
 rhage was very moderate, but  the collapse, pallor, quick  weak pulse,
 continued for four or five days, and then  suddenly increased, and ended in
 death.   On examination post-mortem, we found that  the vagina had  been
 ruptured at its junction with the uterus, that a large  sac filled with  blood
 had thus been formed, covered at its upper part only by peritoneum,  and
 that this covering  had given way, probably at the  time when the collapse
 became complete, and that a large quantity of blood had then been effused
 into the peritoneum, but that inflammation had not set in, evidently for want
 of  time.   M.  Danyau has publishedJ a case of rupture of  the vagina only,
 which he saw, and which was characterized by cessation of pains, recession
 of the head, abdominal tenderness, collapse, etc., but the child had escaped
 into the  abdomen  through the rent.   He  refers  to  seventeen  cases of this
 kind, four of which, those of Ross, Douglas, Smith,  and his own,  recovered.
 In  none was gastrotomy performed.
   725. Terminations.—The patient may die of the  shock a few minutes
 or hours after the accident, or after delivery ; or she may survive the shock,
 and die of the peritonitis; or, lastly, she may be carried off  by secondary
 diseases,  as sub-peritoneal, or lumbar abscess, etc.2
  Of Dr. Jos. Clarke's patients—
          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        "    4  "      a
1        a    10  "      tt

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

  1 Brit, and Foreign Med. Review. April, 1852, from M6m de  la Soc. de Chirurg., vol. ii.
   Burns  Midwifery, pp. 528, 531.  Denman's Introduction, p. 261.
  Of Dr. Collins' cases—
2 women died in 14 hours after delivery.
1      «      17  «      «
1	K		24 "
1	u		25 '<
1	a		30 "
4	" on	th	e 2d dai
1	<<		3d «
4	CI		4th "
1	«(		5th "
2	(I		8th "
1	II		9th "
1	(<		11th "
1	!<		14th "
1	(«		94tfc <<
 
UTERUS  AND  VAGINA.
491
  In by far the greater number of cases, the accident proves fatal.

Of Dr. Smellie's        3 cases,  2 died.     Of Dr. Collins'        34 cases, 32 died.
  Dr. Jos. Clarke's     8  "    7  "         Dr. Beatty's         1  "    1   "
  Dr. Merriman's      1  "    1  "         Drs. M'Clintock and
  Dr. M'Keever's     11  "    9  "           Hardy's          9  "    9   "
  Dr. Ramsbotham's  13  "   10  "

  726. Some cases, however, are on  record where the patient recovered.
Heister relates a case mentioned to him  by Rungius ;  and  Spiering,  one
cured by  Forquosa.   M. Peu,1 Dr. Hamilton,2 Dr. James  Hamilton,3  Dr.
Jos. Clarke,4 Dr.  Douglas,5 Dr. Labatt,6 Dr. Frizell,7 Mr. Ross,8 Mr.  Kite,9
Mr. Powell,10 Mr. Birch,11 Mr. Smith,12 Mr. Maclntyre,13 Dr. Hendrie,14  Mr.
Brook,15 Dr. Davis,16 Mr. Church,17 M. Stobo,18 have each recorded one case
of  cure.   Dr.  M'Keever and  Dr. Collins  have each related two, and  Dr.
Ramsbotham  three  cases.   Duparcque  has  collected four  from French
authorities.   Osiander states that he has known several cases of recovery.
Velpeau quotes several cases.
  There are a very few instances  on  record where the patient has recovered,
although  the fcetus remained in the peritoneal cavity.
  In  cases of interstitial foetation, also, the patient has  sometimes survived
both shock  and inflammation.
  727. Diagnosis.—The  sudden acute pain, the cessation  of labor,  the
collapse, and the recession of the child, will  render it easy to recognize the
case.
  But when the rupture is  partial,  it may be  more difficult,  and we must
rely mainly upon  the sudden pain and the collapse for our diagnosis.    The
occurrence of peritonitis subsequently,  will serve to clear up the difficulty.
  In  a very able  paper in  the Dublin Journal, Dr. McClintock  has shown
that the  life or death of the child is  a  most valuable diagnostic sign.   In
cases of laceration the child dies almost immediately.
  The sudden  occurrence of Peritonitis in  old women may excite a suspicion
of its origin, but it will not be easy to  arrive at certainty.
  Prognosis.—From the details already given, it is almost unnecessary to
state  that the prognosis is always grave.   So very few are saved that there
is but a faint hope of the recovery of the patient.
  728.  Treatment.—The first question which presents itself, when a rup-
ture of the  uterus is recognized, is, "shall the patient be delivered at once,
or  left to nature ?"  When the  os  uteri is undilated  instant delivery may
be  impossible : but in all  cases  where it  is possible, the testimony of ex-
perience is in favor of immediate  delivery.
  Dr. W. Hunter and Dr.  Garthshore advised that the case should be left
to  nature •  and subsequent to  the publication of his Introduction  to Mid-
wifery, Dr.  Denman came to the  same conclusion.  The evidence of facts,
however,  must be allowed  to counterbalance even such illustrious names;
and that evidence is unquestionably in  favor of delivery.
  Dr. Trask's  researches confirm the  propriety of immediate  delivery;  for
of those who recovered, the average time that elapsed between  the occur-

                                    2 Outlines of Midwifery.
                                    * Trans, of Association, vol. i.
                                    6 Dublin Med. Essays, p. 343.
                                    8 Annals of Medicine, vol. iii. p. 377.
                                    i° Med.-Chir. Trans., vol. xii.  p.  537.
                                    " Ibid., vol. xiii. p. 373.
                                    14 Amer. Journ. of Med. Science, vol. vi. p.  351
                                    16 Obstetric Medicine, vol. ii. p. 1070.
                                    18  Med. Times, April 6th, 1850.
 1 Pratique des Accouchmens, p. 341.
 8 Select Cases in Midwifery, p. 138.
 * Essay on Rupture of the Uterus, p. 7.
 * Trans, of Association, vol. ii. p. 15.
 9 Mem. of Med. Soc, vol. iv. p. 253.
11 Ibid., vol. xiii. p. 357.
" Med. Gazette, vol. vii. p. 9.
15 Med. Gazette, Jan. 17, 1829.
" Lancet, May 19th, 1849. 
492
lacerations  OP  THE
rence of rupture and delivery was under five hours, whilst in those that died
it was over five  hours.   Of Dr. Trask's cases, 154 were  delivered by arti-
ficial  means, 97 died, 57  survived ;  of 89 abandoned undelivered, 65 died,
24 survived;  of 31 delivered by natural efforts, 20 died, and 11  survived;
of 6 in whom  artificial delivery was tried and failed, all died undelivered.
Thus, a comparison of those delivered by art with  those abandoned unde-
livered, gives 37 of the former saved to 27 of the latter in the hundred.  But
this is not all, for we find that the average continuance of life after rupture
in those delivered  is twenty-two hours, and in those undelivered, only nine
hours.
  729. The mode  of delivery will depend altogether upon the circumstances
of the case.
  1. If the head  have not receded, and be within  reach, or be already in
the  pelvis, it will be well  to deliver with the forceps, if  possible;  but  if not,
we  must have recourse to the perforator, and with the less  hesitation,  as
Drs. M'Clintock and Hardy have shown that the death  of the fcetus  almost
instantly follows the occurrence of rupture.
  2. If the child  have escaped into the cavity  of the abdomen, or if the
brim of the pelvis be much contracted, the hand must be introduced into the
vagina, and, if practicable, passed through the laceration, and the feet seized
and  brought  down, so that the child may be extracted  through the rent.
Care must be taken to  avoid  dragging down or injuring the intestine,  in
case it should have prolapsed.   The placenta is then to be removed, the
vagina cleansed, etc.  In all these cases the child is born dead.
  3. If the uterus have contracted  very firmly, it may be impossible to pass
the  hand through  the  rent;  or the pelvis may be  too narrow to admit  of
the  chi-ld being extracted footling, or even of the passage of the hand.   In
such cases we are advised to perform  the Caesarian section, and extract the
child and secundines through the  abdominal parietes.    Successful cases are
related by Thibault des  Bois, Lassus, Haden, Baudelocque, Latouche and
Jopel, Lambron, Glodat,  etc.   To these may be added  cases related  by the
following :—MM.  Coquin,1 Sommer,2 Ceconi,3  Ruth,4 Rust,5 Gais, Naegele,
Weinhardt,6 Heim,7 Busch, Demay,8 Lechaptois et Lair,9 Velpeau.10
  4.  This will be  the only mode of delivery, in  ruptures  occurring  during
gestation, before labor has commenced.
  " In regard to the point of duty in the management of such cases (of rup-
tured uterus), I have to remark," says Dr. Meigs,11  " that,  upon discovering
even  the smallest  commencement of a  laceration of the  vagina or cervix
uteri, the earliest practicable precautions should be taken to ensure delivery
per vias naturales, and  the prevention  of the escape  of  the child into the
peritoneal sac.   This should be done, where it is practicable and convenient,
by seizing the head, if it be the head, in  the grasp of the obstetrical forceps ;
by bringing down  the feet, if it be a breech ;  by turning and delivering, if it
be a shoulder case ;  or by turning to deliver, if it be a case of face-presenta-
tion, or departure  of the  chin, or any condition indeed in which the operation
of version would be most likely to rescue the woman from the dangers  by
which she is surrounded.
  " Should the  laceration haye permitted the child to escape at once into
the  peritoneal sac, let the attendant lose no time, but bare his arm, and
resolutely, with his hand passed  through the rent, explore the abdomen in
search of the feet,  which  he should immediately withdraw through the open-
i Bulletin de la Faculte", 1812, p. 86.
3 Bulletin de Ferussac, vol. v. p. 47.
5 Luroth, Ibid, vol. xix., p 85.
8 Journal Ge"n., vol. v. p. 58.
0 Traite" d'Accouch., p. 355.
 2 Ibid.
 4 Ibid., vol. vi. p. 280.
 6 Ibid.              . 11bid.
 9 Ibid., vol. i. p.  187.
11 [Op. cit.] 
UTERUS  AND VAGINA.
493
ing of laceration.  But  if this  be not done;  if  some hours  should  have
elapsed subsequent to the  occurrence  of the  accident;  if the woman be
already much exhausted by hemorrhage, by constitutional shock and irrita-
tion, the question will arise as to the properest manner of fulfilling the indi-
cation, which must ever be to extract the  child.   The hemorrhage will now
have been stayed :  were  it not so, the woman  would be already dead: to
pass the hand through the rent, should it be in the vagina, would be to set
the hemorrhage again on foot.   It will  be always impossible to pass the
hand through the rent in the uterus, because the uterus, being  now con-
tracted, will have reduced the size of the  rent in proportion to the conden-
sation of the organ.   The child can never be returned through a contracted
rent, having passed through it while the uterus was yet undiminished in size.
I say, then, the question arises as  to  the  mode in which the indication is to
be carried out.
   " I am firmly convinced, that, should I be called this day to the conduct
of such a case, I should feel bound by my conscience to recommend a delivery
by a gastrotomy operation.   I cannot think that a clean incised wound along
the linea alba, sufficient in length  to permit the extraction of the child from
the peretoneal sac, however exceptionable in itself merely considered, can be
held  in  the least degree objectionable, when  compared with the delay, the
fatigue,  the contusion and the renewa1 of the suspended hemorrhage, that
would inevitably attend an attempt to extract per vias  naturales."
   730.  During the stage of collapse, it may be necessary to give stimulants,
ammonia, camphor, musk, wine, etc. ;  but this should  be done with  great
judgment, so as just to  attain  our object, and no  more; bearing in mind
that whilst we may  be relieving  the collapse, we  may be aggravating  the
reaction, and increasing the danger at that period.  A  large dose of opium
may be given after the delivery.
   When inflammation sets in, of course the treatment must be actively anti-
phlogistic.  Three or four dozen leeches should be applied over the abdomen,
and repeated, if necessary.   Large bran  poultices  are  useful, and hip-baths
are recommended.   Calomel and opium, or opium alone, is the most valuable
remedy we possess.   It  should be given  in large  doses, or in smaller  ones
more frequently, so as to influence the system rapidly.
   If the rupture have arisen from narrowness of the  upper  outlet of the
pelvis, and the patient recover, and again become pregnant, premature labor
should be induced, at such  a period  of gestation as will allow the fcetus to
pass without difficulty.   It is of course desirable that the operation should,
if possible, be deferred until the  fcetus is "viable ;" but I do not think this
a sine qua non, when the  child cannot be  saved we ought to save the mother.
Dr. Collins relates a  successful case of  this  kind, in which the patient was
delivered  the first  time after the  rupture by artificial premature labor, and
afterwards naturally.   In Dr.  Douglas'  case, the  patient was delivered by
turnino-  the first pregnancy after the accident, and naturally the second.   It
would°'however, be much wiser for the  patient to avoid the risk of a subse-
quent delivery.

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

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

   i Davis's Obsteteric Med., vol. i. p. 127.     2 Jeanselme, 1'ExpeVence, Jan. 1838.
   3 Sanson, Path. Med.-Chir., vol. v. p. 294.    * London Med. and Phys. Jour.  1831.
   » Dublin Jour, of Med. Science, vol. ii. p. 241. 6 Lancet, Jun?  23d,  1838. 
VESICO-VAGINAL  FISTULA.
497
or uncommon to benefit the patient to a great extent, a complete closure of
the fistula is very rare.
   738. 4. The Suture.—This  method is  said  to  have been  invented by
Roonhuysen ;  at all events, it  has  been long known and  practised by the
profession, with varying results.
   It has been performed with success by Dieffenbach, Blandin, Chanam, and
Jobert;J by Sanson, who failed ;  by Deyber, who nearly, if not quite cured
his patient; by Malagodi of Bologna, who has published his successful case ;
by MM.  Lallemand, Duges and  Roux,  who failed;  and  by M.  Naegele.
Mr. Earle cured three cases by  this  means.   Mr. Hobart, of Cork, formerly
published a successful  case,2 and since states that he has perfectly cured at
least ten by the suture.   He says :  " In  reply to your letter, I have  only to
say, that many cases of vesico-vaginal fistula came before me within the last
fifteen years, many of  whom were  cured, some relieved, and otheis not at all
benefited.   I  think there were from  ten to fifteen perfectly cured,  and all
by the same means."  A successful  case is related in the American Medical
Recorder.3   Dr. Evory  Kennedy has succeeded in diminishing the orifice
several times;  and in one  case in  which the twisted  suture  was used, the
cure was complete.   Mr. Hayward, of Boston, U.  S., has  published a very
interesting case, which was perfectly successful.4
   On the other hand, the late Dr. Colles, of Dublin (whose name alone is a
 sufficient guarantee for all  that science, and skill, and care could do),  allowed
 me to state that he has repeatedly tried the common interrupted suture, but
 though  he has by  these means lessened  the orifice, he has never succeeded
 in closing it entirely : and  this was the result under very favorable  circum-
 stances.  He  has  also  seen very unpleasant consequences result from the
 operation ; hemorrhage  (the edges of the fistula having  been removed by
 the knife) to a great  amount;  fever, hectic, etc.
    M.  Naegele  has described an instrument, consisting of two small plates,
 joined at the back like  the pages of a book, and fixed in a handle of steel.
 The anterior  edges are brought together by a screw fixed in the  handle,
 and the edges of the  wound being  included, are retained in apposition, and

                                 [Fig. 178.]
         Duck-billed epeculum of Sims, slightly modified by Bozeman, (one quarter size.)

the lower part of the handle removed.5  M. Lallemand has also invented
one, which he calls a "sondeerigne," by  which a similar effect is produced,6
but,' not having seen the instrument, I am unable to give a description of it.

  i Lancet, May 12th, 1838.           * London Med.  and Phys. Journal, vol. v
  » April,  18-JC), p. 410.               4 Amer. Journal of Med. Sciences, Aug. 1839,
  c Erfahrunnen und Abhandlungen, etc., p. 389.
  '- Velpeau, MeU OpeVatoire, vol. iii.
       32 
498
VESICO-VAGINAL FISTULA.
He has cured one case with it, partially cured another, but failed twice.
MM. Langier and Lewziski have also contrived similar instruments.
  Very recently, however, the improvements  in the mode of operating and
materials used, have given good hopes of success  to a greater extent than
we had ventured to hope.   Many cures have been effected under the care  of
Drs. Marion  Sims, Bozeman, Simpson, Baker  Brown, Spenser Wells, Collis,
Sawyer, M'Clintock, and others.   I shall briefly mention the more important
methods.
  The first great improvement was the use of silver wire  for  the sutures  b]
Dr. Marion Sims.1 At first he used "clamps" to retain the wire, but latterlj
he has discarded them, and simply twists the ends of each suture together

                               [Pig. 179.]
The advantage of the silver wire (and the same may be said of annealed iron
wire)  is_ that it does not cut  out, nor excite  suppuration, nor  rust   The
patient is placed in a prone posture,  with  the hips raised, the  duck-billed
» Silver Sutures in Surgery.  Anniversary Discourse, etc., 1858. 
VESICO-VAGINAL FISTULA.                 499
speculum is introduced at the perineum, and, being  raised, the whole canal
is  exposed.   The edges  of the  fistula having  been pared,  a sufficient
number of sutures, about T35 of an  inch apart, are inserted, and the ends
being twisted, the edges of the wound are brought together, so that no urine
can escape.  He does not remove the wires before the  eighth day ; and he
allows his  patient a  more  liberal diet than usual.   Dr. Sims deserves the
credit of the silver wire sutures, the duck-billed speculum, and the S-shaped
metallic catheter to be left in the bladder.
   The next great step is also due to our American brethren.   Dr. Bozeman,
of Alabama,1 acknowledging the claims of Dr. Marion  Sims, and adopting
after  him the silver  wire, speculum, and  curved catheter, yet found a want
of success in keeping the edges of  the wound in steady apposition, and pre-
venting the irritation  of the wound by urine discharge, etc.   To supply this
want, he invented the " button  shield," an oval  plate of silver  or  lead not
much thicker than cardboard, and  of a size  and shape to suit the fistulous
opening.   It is perforated along the centre with a row of holes to admit the
sutures, the two ends  going through one hole.   When all have been inserted,
the button shield is pressed  down to the fistula,  and the wires are drawn as
tight as we wish, and retained  either by split shot or perforated " saddles"
squeezed flat by a strong pair of forceps.   He has also, with great ingenuity,
invented a variety of subsidiary instruments  to  facilitate the operation, for
example, crooked forceps, bent knives, ligature adjusters, etc.   The result
in little more  than two years  has been that of twenty-four operations  in
which the  button suture has been employed, only two failures occurred.

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

  Dr.  Maurice  Collis proposed, as a modification of the older operation,
that, instead of  the edges  being pared,  they should  be split with  the knife,
and the vaginal half alone included in the ligature;  but in this suggestion
he had been  anticipated by Dr. Hayward, of Boston.2  He used  iron wire
ligatures and portions  of india rubber for quills.  This  operation was per-
formed by himself twice, Dr. Sawyer, Dr. Thorpe,  and two  other  surgeons.
Two cases were completely cured, two were greatly improved, and two failed
altogether.   Dr. Collis has since used Bozeman's button shield.
  Mr. Baker Brown5 has published the history of nine successful cases treated
on Dr. Bozeman's plan.
  Professor  Simpson, of Edinburgh,4 whose  zeal leads  him to try every sug-
gestion for the relief of suffering, has  succeeded by Bozeman's operation in
curing five cases.   But not satisfied with our present means, he  has endeav-
ored to  improve  them.   Instead of the solid button shield, he uses  an oval
rino- of twisted wire, through the interstices of which the ligatures are passed,
and  being brought together over the intervening space are  twisted by an

  i Remarks on Vesico-Vaginal Fistula, etc., 1856.  On Vesico-Vaginal  Fistula 1858.
  * Surgical Reports, etc. p. 222.           3 On  Vesico-Vaginal Fistula, 18o8, p. 6.
  * Med. Times and  Gazette, 1859, Jan. 1st and 8th. 
500
VESICO-VAGINAL  FISTULA.
admirable little instrument  he has invented.   By this means you can see *hr-
adaptation of the  lips  of the wound, and  he believes  that  all movement of
                              [Fig. 183.]
[Fig.  182.]
[Eig.  184.]   [Fig. 185.]

               ^u
  Fig. 182. Bozeman's suture-adjuster.  The long figure gives a face view of the instrument, the short
ngure gives a lateral view of its extremity (half-size).
  Fig. 183. Tubular needle for passing wire threads through the lips of vesico-vaginal fistulas.  A wire
is represented as passing through the tube.  The figure is of full size-the extremity of the  needle
looking thicker and larger than it really is.  Only the commencement of the handle is represented in the
woodcut.
  Fig. 184. Fork or pulley used in drawing through the wires to prevent them from cutting the vaginal
mucous membrane above the wound (half-size).
S'iec. 185.  Blunt hook tor directing the point of the needle (half-size). 
    Fig. 186. The iron-wire splint finally adjusted as it is being              '■'
  passed along the threads down to the pared wound.
    Fig. 187. [Dr. Coghill's instrument for finally tightening and
  fixing the suture.  In using it, one end of a wire having been
  brought through one of the small tubes which are on the sides of
  the instrument near its lower extremity, and the other through
  the opposite of these tubes, the instrument is pushed down close
  to the lower bar of the splint, both ends of the wire suture being
  now drawn quite tight, so as to make the splint compress and               I
  consolidate the parts, a turn of the  instrument suffices  to  fix             . 11
  them there.  To make sure of this, however, a turn or two more               1
  may be given, when the wires are to be clipped off with a pair of             ™
  stout sharp scissors, close to the point of the instrument.]


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

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

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

Two  grains of opium should be given immediately, and a grain three times
a day for two or three days;  the object being to  lock up the bowels, but I
ao-ree with  Dr.  Simpson  that  it is  probable  that  the beneficial effects are
not limited  to producing constipation.  Moderate diet may be allowed, but 
504
VESICO-VAGINAL FISTULA.
the patient must remain in bed.  The bowels need not be disturbed for
seven or eight days ;  but I think it better to  have them evacuated before
we remove the shield.  As neither the  shield nor  ligatures occasion  any
irritation, we need not be in a hurry to remove them, and it is clearly better
to leave 'them  unnecessarily long than take  them  away  too  soon.   The
eio-hth or tenth day is quite soon enough.   All that is  necessary is to  clip
across the wires close  to the  shield with the  scissors, and with the forceps
remove the shield.  In  some cases it will be advantageous  to leave  the
wires a few days longer, and then very quietly withdraw them.   The vagina
should  be syringed with cold water every  day from the beginning, but no
attempt should be made to see whether any orifice remains until a few days
after the removal of the  shield.   If no urine  escapes per  vaginam we may
rest satisfied, and in a week or so  carefully examine  the cicatrix with a
blunt instrument, keeping  a silver catheter in the bladder meanwhile.   If
no unhealed  spot be discovered, we  may still further test  its soundness by
injecting the bladder full of cold water ; if none escape  by the cicatrix (and
we can see if it do), we  may be  satisfied that the cure is complete.   But
there is a source of confusion and doubt which  I  may mention.  After a
catheter has remained  so long in the bladder, the sphincter and urethra  lose
their power to  a certain extent, and urine may dribble along outside the
catheter, leading us to fear it is escaping  through the  fistula.   Or, as  in a
patient of Dr. M'Clintock's, the  power of these parts may be lost more com-
pletely, so that when she is allowed to get up, she can retain urine only for
a short time, and, without examination, we should conclude that the opera-
tion had failed.   Inspecting the bladder, and  observing  whether any escape
through the fistula, is the true test in these cases.   The urethra by degrees
recovers its retentive power.
   139. 5.  Dr. Blundell saw a fistula  in  the  neck of the bladder,  near the
urethra, cured by laying open the urethra to the rent, and then healing it
up,  as is done in ordinary fistula.  Dr. Porter, of the Meath Hospital,  per-
formed a similar operation, which terminated successfully.
   U0. 6. "Elythro-plastie."—This  name is given to the  operation by
 which  a  portion of integument is taken  from  a  neighboring  part,  and
 applied to the vesico-vaginal  fistula, and retained by sutures ; the old  con-
nection being maintained until union  has taken place.   It is exactly similar
to the rhino-plastic operation for repairing  noses.  It was  suggested by
Velpeau, but first practised by Jobert.   Of his four operations, one patient
 was cured at once, one by a second  operation,  one died, and with one it
failed.   M. Roux did not succeed with it.   I am  not aware that any other
 surgeon has tried it.
   t41. 1. Closure of the  Vagina.—When using the caustic for the cure of
"vesico-vagiual fistula, in  the year 1833, M. Vidal de Cassis chanced to touch
the vaginal mucous membrane with it; this caused considerable inflamma-
tion, and on making an examination subsequently, he found the sides of the
 vagina adherent.   The patient also observed  that the dribbling of urine had
 entirely ceased.  Unfortunately, a careless examination was afterwards made,
 and these adhesions were  destroyed.  But the  hint was not thrown away;
 for on the next occasion, in the  same year, M. Vidal de Cassis attempted to
 relieve the fistula in this way, and was perfectly successful, until the clumsi-
 ness of an assistant destroyed these adhesions also.   There is no doubt that
 in many cases this would be found a valuable means of relief.  Caustic of
 any kind will answer the purpose of exciting  inflammation, though adhesion
 may not always take place.   I  have seen a circle of the mucous membrane
 removed, and the parts brought together by suture, for the purpose of clos-
 ing the orifice of the vagina,  but union did not take place.
    When we have recourse to this method, care  should be taken to leave a 
VESICO-VAGINAL  FISTULA.
505
very minute opening for the escape of the menstrual fluid, if menstruation
have not ceased.
  142.  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.1   Various cases of relief by this means are on record.  Dr. Gooch, in
1814, suggested to Mr. Barnes, of Exeter, the employment of an india rubber
bottle,  of sufficient size to  fill the vagina, and having upon  one  side of it a
small piece of sponge, to be applied to the fistulous  opening.   Mr. Barnes
used this with  great  benefit to his patient.2  M.  Duges  has  proposed a
similar plan, but the pessary was  made  of different materials.3   Dr. Evory
Kennedy has succeeded in taking casts  (with wax)  of the vagina,  with the
fistula, in several cases ; and from them he made moulds, and had caoutchouc
bottles cast in the moulds.   These were  large enough  to fill the  vagina, and
to close both the fistula and the outer opening,  so as entirely to prevent the
escape of urine.   I have attained the same  object by means of a  piece of
sponge covered with  thin  bladder.  It  should  be  large enough to fill  the
vagina, and of  a suitable  shape.  A narrow neck,  of  the dimensions of the
vaginal orifice, is  to  be formed, by wrapping it with twine, which  is to be
covered with lint.   The whole has much  the shape of an egg-cup.   It should
be dipped in oil previous to being used,  and then it can be easily introduced,
and the stalk filling up the external  orifice, no urine can escape.   It can be
removed and replaced by the patient herself.
  Various other suggestions have been made, but either of these plans will
relieve the patient from the constant dribbling  and offensive odor,  and will
allow the excoriations to heal.
  If the patient cannot pass water with the plug in situ,  she should learn '
to withdraw it and re-introduce it herself.  Dr.  Burns states that " Dr. Bal-
manoo showed me a patient who derived much comfort from having a hollow
tin globe, like a pessary, inserted into the vagina.  It was perforated at the
upper  part, like a pepper-box, and from the under a catheter  descended,
which  entered into a  flat flask, suspended between the thighs.  Little or no
urine escaped by the vagina."4

  743.  III.   Vesico-uterine and  Vesico-utero-vaginal Fistula.—M.
Jobert, in  his recent work,5 has entered  very fully into some variations from
the ordinary vesico-vaginal fistula, to which it is right that  I  should briefly
allude.   The first of  these is the vesico-uterine—when  the  opening is
directly from the bladder through the uterine  parietes, without injury to the
septum between the bladder and vagina; and the second—the vesico-utero-
vaginal—in which there is a fistulous communication between the bladder,
uterus,  and vagina.   Dr. Bozeman doubts the existence of the former, but I
have proof that he is mistaken.
  The  extent of destruction in either case varies very much : there may be
a small perforation  with  smooth edges, a ragged wound, or very extensive
destruction of the parts involved.
  744.  Causes.—In  the  majority of  cases, so far as we know,  the method
of production is mechanical in the first instance.   A large fcetal  head, a
tight pelvis, or  a prolonged second  stage of  labor, may give rise to inflam-
mation  and  sloughing from pressure, and if the cervix  uteri  have been
brought down before" the  head into the pelvis, pressure on this part  may
determine  the complication  of the  uterus with  what would otherwise  be u
  i Davis's Obstetric Med., vol. i. p. 128.        2 Med.-Chir. Trans., vol. vi.  p. 58G.
  » Duparcque, Ruptures de l'Uterus, p. 339.     4 Midwifery, p. 93,  note.
  s Traite" des Fistules Yesico-Utennes, etc.  Paris, 1852. 
506
VESICO-VAGINAL fistula.
simple vesico-vaginal fistula.  No doubt the awkward or violent use of the
forceps may also inflict this injury.
   Dr.  Simpson has  shown,  however, that vesico-uterine, vesico-rectal, and
utero-intestinal fistulas, may be the result of a very different cause—viz., of
pelvic  abscess opening into  the bladder and uterus, the bladder and rectum,
or the  uterus and some part of the intestinal canal.   The cases he relates
are very interesting,  and that of vesico-uterine  fistula the  more so, from a
cure having  apparently  taken place from spontaneous  contraction  of  the
openings.1
   Perhaps a post-mortem examination alone could have made us, in the first
instance,  acquainted  with the exact nature of vesico-uterine fistula ;   but
now that it  has been ascertained, there  is no real difficulty in making out
the case.  There is  incontinence  of urine ;  a careful examination  with  the
finger  in the vagina and a catheter  in the bladder will show that in this
canal  there is  no breach  of surface :  an examination  with the speculum
allows us to see the  urine welling  up through the os uteri, and finally if we
pass the catheter through the fistulous opening in the bladder,  we can touch
it with a metallic sound passed into the cervix  uteri.  In  a case which
came under my care there was no difficulty in coming to a positive conclusion
by these means.
  Vesico-utero-vaginal fistula? present the same symptoms as the more  sim-
ple vesico-vaginal fistulae,  only that, on examination,  we  find a greater
extent of destruction, the anterior lip  of the os uteri being  more  or less
destroyed.  The urine escapes in  every position,  and  the catamenia  are
discharged mixed with urine.
   The prognosis is more serious, inasmuch as the uterus has participated in
the injury ; it is possible in  either  variety, but especially in the  first, that the
sloughing may extend so far as to compromise the life of the patient.
  745.  Treatment.—1.  Prophylactic.   It is as yet an unsettled  question
how far we may be  able  to  prevent so melancholy  a consequence of labor.
When  we recollect that  the  cause is, first, pressure of the cervix  between
the head of  the child and the symphysis pubis, and secondly,  general pres-
sure of the vaginal parietes from the head being too long  detained in  the
pelvic  cavity, we  cannot doubt that, in some cases at  least,  we have  the
remedy in  our  own  hands.   If, when the os uteri is dilatable, the anterior
lip be gently  pushed  up above the head during an interval, and maintained
there during a pain,  it will escape  injurious pressure, and this is not difficult
to accomplish.  Again,  a labor prolonged in its  second stage, so  much as
to occasion inflammation and sloughing,  will generally be  found  to have
exceeded the  period when assistance becomes necessary;  and if the forceps
be admissible, they will be safer in careful hands than the delay.  When the
forceps cannot be used, the alternative is either further delay or craniotomy ;
the former of which may incur the risk of this injury, which should therefore
always be taken into consideration in our decision.
  746   2. Curative: a.—Vesico-uterine fistula.   An attempt has been
made, by plugging  the  canal of the cervix  uteri,  and keeping a  catheter
constantly in  the bladder, to  prevent the passage  of the urine through the
wound,  and so afford it an opportunity to heal.  Again,  it has  been advised
to apply the  nitrate  of  silver to the fistula, but, to  say nothing of  the diffi-
culty, neither of these plans appears to have been successful.   One of Ai
Jobert's plans is as  follows :  he dissects off the reflected vagina from  the
anterior  lip until he  arrives at the fistula, the  borders of which are to be
refreshed with the bistoury, and sutures applied in  the situation most suit-
able to the direction  of the wound.  A second method consists in an attempt
to close the communication between the uterus and vagina, leaving open

                  1 Ed. Monthly Journal, Dec. 1852, p.  532. 
recto-vaginal  fistula.
507
that with the bladder, by first dividing  the  cervix laterallv, then dissecting
the vagina from the  anterior lip, and uniting it by section to the posterior
lip.   He gives a case of complete success by this latter process.
  In the case which came under my care I adopted a simpler plan ;  I pared
out the inner surface of the cervix uteri, and put in four silver sutures  with
Bozeman's button shield, which I removed on the fourteenth day.   I found
the  orifice much  less,  but not entirely closed.   I  intended  to  repeat the
operation, but as  the patient found she could retain urine for three hours
without any  escape  she felt  her condition  so much  improved that she de-
clined any further attempt.   Since then I see that a  German physician, Dr.
Simon, has succeeded in completely curing  a case in this manner.
   b.  Vesico-utero-vaginal fistula.—In this  complication M. Jobert proposes
three  different operations.   The  first consists in dissecting off  the vagina
from the  remains of the cervix, then  paring the borders of the fistulous
opening, and lastly in uniting  by suture the remains of the cervix with the
edges of the  vesico-vaginal opening;  the second, in dissecting off the vagina
from the cervix, in dividing this latter at each side, and after refreshing the
edges of the fistula, in  uniting by suture the posterior  lip of the os uteri to
the  edges of the fistula.  The third differs  only in a depression being made
in the anterior lip  to  fit more accurately  the edges of the vesical fistula.1
If necessary, incisions may be made laterally in the vagina, or semicircularly
at its orifice, to relieve  the strain upon  the ligatures.  M. Jobert gives the
details of four cases, three of which he  states were cured.

   747. IV.  Recto-vaginal Fistula.—There can  be no doubt that recto-
vaginal fistulas are  less frequent, and more easily cured, than those fistulas
which involve  the bladder.   There are  a few cases, but very few, on record,
where this defect  was congenital;  most commonly it arises from causes con-
nected with labor, as in the  case of vesico-vaginal fistulas, that is, from too
prolonged pressure  of the  child's head giving  rise  to  inflammation  and
sloughing, or from the  awkward use of instruments;  and in addition it may
occur as a laceration, or from disease of the rectum, or  from a pelvic abscess.
This injury  may exist  alone, or it may be combined with a  vesico-vaginal
fistula.
   The extent, situation, and direction of  the wound may vary  to any ex-
tent, but  in  almost  every case the sphincter ani is uninjured.   When  we
examine the parts, the mucous membrane  of the vagina and  rectum is red
and  congested, the  mucous follicles unusually developed, and the septum
thickened when the  injury is recent, but when of long standing, the edges
are  hard and cicatrized.
   748. Symptoms.—The edges  of the wound, at least when recent, secrete
a certain  quantity of  matter, which  is discharged  by one or other outlet.
When very recent, the  vagina may be found inflamed to  a  greater or less
extent, and  giving rise  to  a  purulent discharge.   But  the  characteristic
symptom is the escape of air or fasces  through the  vagina, which, however,
may be modified  by various circumstances.   When  the fistula is small or
oblique, air  may escape, but the fasces  will be retained unless they are very
fluid.  Unless  the opening  be direct  and large, solid matters  are rarely
passed, but their  presence at the orifice is a continual irritation.   When the
opening is of sufficient size,  fascal  matter and gas escape involuntarily, and
the  condition of the patient is most pitiable.  Even  if the bodily injury did
not affect her health, her distress of mind in addition  is generally sufficient
to do so ;  she is  cut off from society, and  in the solitude of her own suffer-
ings, her spirits and health are apt to deteriorate.

                        1 Traite" des Fistules, etc., p. 70. 
508
recto-vaginal fistula.
   In some cases, however, matters do  not become  so  desperate, although
 such instances are not common.  For  example, when the injury is small in
 extent, and the result of laceration rather than sloughing, it may heal with
 quiet  and care ; or, if small, it may be closed by granulations or by  the
 formation of  something like a  flap or valve.  I had  a patient who had a
 small recto-vaginal fistula  for several years,  through which  nothing passed
 unless she took physic or had a diarrhoea, and from which she suffered very
 little annoyance.
   749. Treatment.—The methods of cure do not differ much  from those
 I have  enumerated for vesico-vaginal  fistula ;  they are,  however,  more
 easily applied.   These are,  1,  cauterization ;  2, compression ;  and 3,  the
 suture.  Whichever we try, we must  remember  that  the  entire  fistulous
 opening must be included.
   When  the  fistula is small, cauterizing  by the  acid  nitrate of mercury,
 nitric  acid, nitrate of silver, or the  actual  cautery, has succeeded in  the
 hands of Dupuytren, Amusat, and others ; and if  it fail, we may pare  the
 edges of  the wound from the rectum to the vagina, and apply sutures, with
 absolute quiet and rest.  Cases  of cure by these means have been recorded
 by Noel,  Saucerotte, Fielding, Portal, Mott, etc., etc.
   M.  Cullerier, Sr., proposed compression, and invented an instrument for
 the purpose, wdiich he said succeeded;  but it seems to  have failed in other
 hands.
   The insertion of a seton has been tried  by Dr.  Barton, of Philadelphia,
 in the case of a recto-vaginal fistula following an abscess, and with success,
 but it can only be suitable in very rare cases.
   As M.  Jobert  observes, although some or all of  these methods  may suc-
 ceed when the opening is moderate, there remains a class of cases in which
 they must fail, because of the extent of the mischief.   For such cases he
 has  proposed  a plan, which he  terms "autoplastic  par  glissement," which
 consists in renewing the edges of the fistula, in the insertion of the inter-
 rupted suture, in relaxing the  surrounding  tissues  by incisions, in appro-
 priate regimen.   The  patient being placed on her back, with the thighs
 drawn upwards, the superior  wall of the vagina is to be raised by a univalve
 speculum,  and the lower depressed  so  as to bring the fistula into view.
 Its borders  are to be  removed by the knife, and three or four sutures, ac-
 cording  to  the extent of the  opening from  the  rectum  to the  vagina,
 inserted through the parietes  of both vagina and rectum, guided and guarded
 by the finger  in the latter canal.   When  all the  sutures are inserted, the
 parts are to be cleansed, and  the  sutures tied.  Then there are  to be made
 incisions through the  vaginal parietes, for the purpose of taking off the
 strain from the sutures, and these may be longitudinal, transverse, or semi-
 circular according as either is likely to afford most relief.  After the opera-
 tion, the patient must be kept quiet, and the  bowels  constipated by diet or
 medicine,  until the sutures  are removed on the sixth day.  Every day the
 vagina must be syringed with emollient fluids, and when the union is com-
 plete, the bowels may be freed  by enemata.1   M.. Jobert gives three very
 interesting cases  in which the operation was successful.  The chances  of
cure will be greatly increased, nay, I almost  think rendered  certainties  by
the employment of wire sutures near together and Bozeman's button shield
After the edges have  been well pared  in the whole of their thickness  the
sutures should be inserted  at a sufficient  distance  from the margins,'and
should embrace the walls of  the rectum as well as the vagina.   Then they
may be passed through the double row  of  holes in the shield, and twisted
tight  enough,  but not  too  tight.  The  shield may be left on a  fortnight,

                        1 Traite"  des Fistules, p. 340. 
LACERATION OF THE  PERINEUM.
509
and the bowels (which must be constipated by opium) should be freed by
an enema the day before we remove the shield.

  750. V. Laceration of the Perineum. — When this accident is of slight
extent, it  may not interfere with the comfort of the patient; but when ex-
tensive, it will be a cause of constant distress ;  and in either case the proper
cure of the wound is important;  as, if callosities form, or irregular cicatrices,
much impediment may be offered in subsequent labors.  It is  an  accideut
much more common with first labors than afterwards.
  It will be recollected that when the head of the child  descends so  as to fill
the cavity of the pelvis, it necessarily makes pressure upon the lower part of
the rectum and the sphincter ani; that it then receives  a direction forwards
and downwards, and successively distends the central space  of the perineum
aud its anterior border.  When the perineum  offers much resistance, as with
first children, the mucous  membrane of the posterior  wall of  the vagina,
owing to  its  laxity of connection with the subjacent tissue, is partially everted
and 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.
This  is not  to be confounded with  the laceration  of the true perineum, of
which we are about to  treat.
  751.  The situation and extent of the rupture vary  according to the cause
and  the  circumstances of the case.
  1.  It may  commence at the anterior border, and extend to the sphincter ani,
and this is the most frequent extent.
  2.  The rent may involve the entire  perineum,  and  extend through the
sphincter  ani, laying the cavities of the rectum and vagina into one.
  3.  The central  space of the perineum  is sometimes ruptured, leaving the
anterior edge (the fourchette) and the sphincter ani untouched.  Cases are
related by  Hernu, Coutouly,  Lachapelle,1  Meckel,2  Lebrun,3 Thiebaut,4
Frank, Martin,5 Moschner,6 Jungmann, Marter de Konigsberg,7 Trinchinetti,8
Merriman,9 Waller,10 Douglas,11 Jobert,12 Ellis,13 and Thatcher.14   And  a case
occurred in this city.   Dr.  Simpson has related the case of a perineal fistula,
the consequence and proof of this occurrence, continuing till the patient's
death, a year afterwards.15
  The rent may run along  the central raphe of the perineum — on  one side
— diagonally — or in the form of the letter V or Y.  In most of the above
cases, the child actually passed through  the central opening ;  but  in some
cases, by careful management, it was transmitted through the natural orifice,
without rupture of the fourchette.16
  4. The recto-vaginal septum, sphincter ani, and  part of the perineum may
be torn, so as to permit the transit of the child, leaving the  anterior portion
of the perineum entire.
  752. Causes. — The accident may arise from a deviation from the ordinary
mechanism of parturition ;  from mal-conformation of the  passages or soft,
parts  ; from  mal-presentation ;  or from mismanagement.

  1 Duparcque, Ruptures ou De"chirures, etc., p. 368.
  2 Xeue Jour,  fiir die Chir., vol iv., 1811.   3 Annals de MeU Phys., July, 1825.
  * Jour, de la  Soc. de Me"d., vol. xxxiv. p. 178.
  5 Arch. Ge"n.  de MeU vol. xxxiv.          6 Bull, de Ferrusac.
  ? Siebold's Journal, vol.  xi. p. 726.        8 Obs. sur l'Accouch. diff., Milan, 1819.
  9 Synopsis of difficult Parturition, p. 263, 4th  ed.
 10 Waller's Note in Denman's Introduction, p. 36.
 " Dublin Hospital Reports, vol. iii.        12 Bull, de la Soc. Med. d'Emulation, 1822
 i= Amer. Jour, of Med., Jan. 1840, p. 260.  " Edin. Monthly Jour.,Jan. 1851.
 is Ediu. Monthly Journal, No. i. July, 1855.
 i« Denman's Introduction  to Midwifery, p.  36. 
510
laceration of the  perineum.
  1. If the sacrum be too perpendicular, the head of the child, instead of
receiving its direction anteriorly, in the direction  of the  axis of the lower
outlet, will be forced downwards upon the posterior portion of the perineum.
  2. If the arch of the pubis be too acute, so as  to prevent the presenting
portion filling its upper part, extraordinary dilatation of the orifice  of the
vagina will be necessary, and  the head will be pressed with unusual force
upon the anterior part of the perineum.
  3. A similar effect is said  to be caused by a thickened state of the urethra
and circumjacent parts, in the arch of the pubis.
  4. The too rapid passage of the head may be attended  with this accident.
This may depend upon the extraordinary violence  of the  pains, or upon the
small size of the head, which prevents its receiving the successive changes of
direction from the plane surfaces of the pelvis, and  the changes in the axes
of the cavity and lower outlet.
  5. Exostosis in any part of the pelvic cavity may so act upon the direc-
tion in which the fcetal bead is propelled, that rupture of the perineum may
result.
  6. Excessive breadth  of  the perineum, by receiving the force  of the
descending head in its centre, may be a  cause of laceration, because the head
rests in the centre, and distends it, instead  of gliding forwards to the ante-
rior edge.
  7. 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.
  8. The tissue of the perineum may  be  weakened by  disease, or  by too
much pressure, so as to offer little or no resistance.
  9. Occlusion of  the  lower  outlet by  the hymen.   As this  membrane,
though much thinner than the perineum, is  far less distensible, if it do not
give way, the perineum may.   I attended a  case in which the hymen resisted
the pressure of the head (with strong pains) for two hours after the perineum
was perfectly distensible, and in which  there was  every probability that the
perineum would have been lacerated, had not the hymen ruptured.  Lacera-
tion of the hymen may also be extended into the perineum.
  10.  Mal-position of the child's head,  by presenting a longer diameter than
usual to the lower outlet, may give rise to this accident.
  11.  Mal-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 exert-
ing too much voluntary force at the time the  head passes through the lower
outlet.
  13.  The perineum may be torn, in consequence  of want of care when in-
struments are used.   They ought generally to be removed just as the head
passes through the vaginal orifice.
  From this detail of the causes which  may produce or predispose to  lacera-
tion of the perineum, it will be seen that it may not always be in our power
to prevent its occurrence.
  753.—Symptoms.—If the laceration be  very slight, no ill consequences
will ensue; the parts will either heal  or contract, so that an examination
would scarcely reveal the fact;  if it extend to the sphincter, the patient may
feel a want of support at the lower outlet, and a sense of " falling through •"
but even  in such cases, such  is the wonderful reparative power of nature
the mischief is  often remedied.   I have  seen many cases in which at first 
                  laceration  of the  perineum.              511

there seemed no prospect of relief but in an operation, recover and suffer no
inconvenience.   On examining such cases after recovery, I found the vaginal
orifice  not much larger  than  natural, but more posterior, with its borders
thickened and contracted as if in process of and to facilitate contraction, the
vulva had been somewhat drawn backward.   I am  now so satisfied of this
as a not  unusual process, that unless  I had  the opportunity of inserting
sutures within thirty hours after  delivery, I should postpone  all operative
interference for six  months  or more.   It  is  said to influence  subsequent
cohabitation, and though I doubt it, may favor procidentia of the uterus.
   If the recto-vaginal septum be torn, the condition  of the patient will be
very pitiable.   The fasces (for some time  at least) pass through  the vagina
involuntarily, and the utmost attention to cleanliness will  not suffice to pre-
vent the offensive  smell,  which renders  the  patient an  object of disgust to
herself and her friends.  The lochial discharge passing over the  wound will
for a time prevent any natural efforts at cure ; and the edges may become
callous, or degenerate into ulceration.
   754. Treatment.—1. Preventive management.—A few words may not
be misapplied in pointing out the best mode of preventing this occurrence.
   1.  Defects in  the passages,  which render  the mechanism  of expulsion
inefficient, may often be  remedied by  the  application of the  hand in such a
manner as to give a direction forward to the head.
   2. Direct support should be given to  the perineum when  distended; but
this is frequently carried to excess, and  produces the accident it is intended
to prevent; it should be moderate and gentle, just so much as  to support
the parts, but no more.  I must altogether- object to  any  attempt to retard
the passage of the child, as erroneous in theory, and mischievous in practice.
   3. When the perineum  is  rigid and  undilatable, benefit may  be derived
from fomentations with  hot water, the use of warm oil, lard, or pomatum.
   4. Under no  circumstances  is it justifiable to dilate the external orifice
 with the hand, as formerly recommended; on the contrary, instead of draw-
ing  back  the perineum, it ought to be carried forward.
   5. If laceration be threatened in consequence of the persistence of  the
hymen, it may be incised with a blunt-pointed bistoury.
   6. The patient should always cease forcing, and cry out or remain per-
fectly  quiet during the exit of the child.
   755.  2.  Curative treatment.—Slight cases, as I have said, will generally
heal without assistance.   Even when the rent is more extensive,  a cure may
be effected without  further interference than great cleanliness, keeping  the
patient in one position,  so as to preserve the  edges of the wound in contact,
and constipating  the bowels after free purgation.   If this do not succeed,
we are advised to use a  degree of compression, passing a binder  around  the
hips, and a pad on either  side  of the perineum, so as to secure  the apposi-
tion of the  lips of the laceration.  Strips of adhesive  plaster have been
applied, but they do not answer.  In many cases  either of these plans has
succeeded, but in many  cases also they have both failed, especially when  the
recto-vaginal septum is  involved.  However, we have still another resource—
   In the suture, which was first proposed  by Ambrose Pare, and practised
by Guillemeau, La Motte, Saucerotte, Trainel, Noel, Dieffenbach, Roux, etc.
Before this can be attempted, however, the primary inflammation must have
subsided ; nor is it forbidden, even though a  considerable time should have
elapsed.  M. Montain cured a case  on  which he operated thirty-six days
after 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, etc., succeeded with
the first, but according to Duparcque,  the  success and failure have been 
512
laceration  of the  perineum.
nearly equal.  Mr. Alcock cured one,1 and Mr. Rayer two patients in this
way.   Dr. Mettauer,2 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
wround  are not  closely applied in  the whole extent, and the union is often
partial.3
   The  same observation may be applied to the twisted suture, although it
has succeeded with Morlanne, Saucerotte, Noel,4 Dieffenbach,5 etc. M.  Lan-
genbeck's method of operating consisted, 1, in separating for some little dis-
tance the anterior wall of the rectum from the posterior wall of the vagina ;
after removing the surface of  the laceration, in applying sutures, beginning
at the  rectum ; 3, in including  the angles of the  torn vagina in  the last
suture,  at the fourchette, by which means  the canal  of the vagina is com-
pleted,  and any discharges carried off;  4, in tightening all the sutures after
all have been  inserted ;  5, in taking off the strain upon them, by making an
incision through the skin on each side of them.6
   M. Jobert has used a new kind of suture ; " after paring the edges of the
wound, he threads a broad lace  lengthwise through them, and then drawing
the lace, he pinches all the edges to a point"7 precisely as  the mouth  of a
bag is closed by drawing the string.  One case of cure is quoted.
   M. Reybaud passes a row of pins through the pared edges of the  fissure,
with  the points  to the vagina, which are to be guarded by slips of gutta
■percha; the edges of the  fistula are to be  brought together  by tying the
corresponding pins' heads with waxed thread.8
   The  quilled suture is evidently better adapted  for the purpose, as the
entire surfaces of the laceration may be brought into  contact.   Dupuytren
succeeded  once,  Roux  and  Dieffenbach  several times,  M. Dubois failed,
but Mr. Davidson succeeded completely.   He thus relates the case :9  "On
the 6th of 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 rec-
tum,  and another, rather more than half an inch from the  first, towards the
vagina; after which I pared the edges of the wound, which I had not pre-
viously done,  that I might not be annoyed  by the oozing of blood, so  as to
be enabled to  place the ligatures more accurately. The ligatures being intro-
duced, I employed, as cylinders, two pieces of elastic gum catheter, about an
inch and a half in length, one of which was  placed in  the loops  which the
double  ligature formed on one side, and the other between  their separate
ends, tying them firmly upon the cylinder.  Baron Roux found, in his cases,
that the use of the quilled suture  caused an eversion of the ed°-es of the
wound; to remedy this, he had recourse to several small sutures, at different
points between the different ligatures.   To effect the same  object, and also
with  a view of keeping the divided parts more closely and firmly in contact,
I adopted the following plan, the materials for which I had prepared pre-
viously  to the  operation : I armed  a curved needle with a piece  of narrow
tape,  four inches long, having  a knot at one end ;  this was passed down each
end of  both cylinders about half an inch, and brought outwards, the end of
the tape being prevented slipping through by the knot; the tapes were then
placed in such a situation as to be intermediate to the ligatures; this  being
done, I turned the cylinders gently towards the edge of the wound, and tied
the corresponding tapes over it,  which, I think, rendered it much more solid
  i Merriman's Synopsis, p. 110.     2 Ed- Med  and gurg Journal) yol  xix>   g5l)
  3 Cooper's Surgical Diet. p. 1209.   * Capuron, Mai. des Femmes, p 489
  6 Lancet, March 3d, 1838.         6 Gazette des Hopitaux, 22 Jan., 1853  p  38
  * ltanking's Abst., vol. xxi. p. 200.  8 Ibid., p. 201.   9 Lancet, May 4th  1839 
                 laceration  of the  perineum.              513

than any number of small ligatures could have  done."  The bowels  were
constipated by opium, the urine drawn  off night  and morning, and the diet
consisted of small quantities of gruel and hard biscuit.   The ligatures were
removed on  the seventh day, and union was found to have taken place
throughout.  Of course we should now use iron or silver wire sutures.  The
urine was evacuated naturally  after nine or ten days, the bowels relieved 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 con-
tact, Dieffenbach makes  an  incision  through the skin, on  each side.   Dr.
Horner has suggested  that the sphincter ani should be  divided on  each side,
in order to allow the parts to  remain in contact.  In one case he also con-
structed a flap for the upper  and lower half,  from opposite sides, so as to
supply the loss of substance.   His plan  of  dividing the sphincter has been
also recommended by Messrs. Copeland, Bransby Cooper, and Baker Brown.1
The  latter  gentleman, who  has  published several successful cases,  also
advises constipation for some time  after the  operation.   He takes a large
superficial portion from each side, and  passes three ligatures deeply through
the parts, and three superficial ones, so as to secure the exact apposition of
the edges of the" wound.   The bowels should be freed well before the opera-
tion, and opiates  given, so  as to constipate them ;  when union is attained,
this may be remedied  by an enema.   The catheter must be passed morning
 and evening for some time.
   [In Dr.  Horner's case the rupture occurred in  a  young married lady
 during her first  accouchment;  but it was  only after the birth of her second
[Fig. 193.]                         [Fig. 194.]
 
514
LACERATION  OF THE  PERINEUM.
The patient, of rather a full habit, and well organized in other respects, was
rendered miserable and helpless by a want of control over the natural evacua-
tions, and by a constant tendency to diarrhoea, only to be restrained  by the
continued use of opiates. Much of the fcecal matter passed forward through
the rima vulvas, which added to the distress of her situation.
  An operation  was performed in the usual way, by paring off the cicatrix
of each  margin of the perineum,  and then fastening it  carefully with inter-
rupted  stitches  along  the  rectal and  vaginal  edges  of the rupture, the
sphincter ani muscle being divided  on  each side the anus;  a procedure
which Dr. H. considers proper in all old cases of the kind.   Unfortunately,
the menstrual flux came on prematurely, and  everything like  adhesion gave
way.
  Nearly fifteen months subsequently a second  operation  was performed.
Additional  difficulties had now to be contended against.   The portion pared
off from the perineum had reduced its extent; the  slit from the vagina into
the rectum had  been elongated or deepened.  If the  attempt to produce
permanent lateral adhesion had failed before, its success was  still less  pro-
bable now.   Under these considerations  Dr. H.  determined so to modify
the operation, that  if unsuccessful the condition  of  the patient should,  at
least,  not be rendered worse by it.   The patient being  under the  influence
of a mixture of  chloroform and ether, two flaps were made from the peri-
neum and adjoining parts of the vulva, the one on the right and the other
on the left.
  By placing the base of the right flap  below, and the base of the left flap
above, the crossing  of the two flaps formed  a partition between the rectum
and vulva ; the  free side of the  right  flap forming the  upper part  of the
rectum,  and the free side of  the left the  lower part of the  vagina.   The
approximation of the flaps and  the contiguity of their raw  surfaces were
secured  by  interrupted stitches along the rectum  and vagina.  In forming
the left  flap, owing  to a sudden  contraction, its transverse  part  being  first
made, was not as desired, but fell  short of Dr.  H.'s intentions.   For the
first ten days or  so there was a strong indication of success.  A large  firm
stool  now occurred, and on examination immediately afterwards the flaps
were found not  to  be  adherent.   They were, however, in situ, so  that the
partition formed by them between the rectum and vagina was still kept up.
In a  month after the operation  the left flap had  become  shrivelled away
almost entirely, and the right flap had lost one-half its original size ;  it still
remained, however,  as a barrier between the two  canals ; and  by the intro-
duction  of a linen compress into the vagina, upon the flap,  so as to keep it
in its  place, the  discharge of fasces was to a great extent regulated.   The
patient  felt the call for defecation, could make timely provision  for it, and
was much improved in respect to comfort.   An examination  of the patient
six months  after the operation showed that the indications  of an operation
having been performed had subsided.  Upon a superficial examination there
appeared to be  a regular division  between the  anus and vulva—an  actual
reproduction of  the perineum.  There was in fact, however, only the claus-
trum made  by the operation—its edge was  still loose, but it had the effect
of directing the discharges from the rectum backwards, and those from the
vagina forwards.  The recto-vaginal fissure had diminished much in  depth,
and the condition of the patient had been much improved.  She could  par-
ticipate  in her house-work—had a much better control of flatulent and fcecal
discharges than  formerly, and  was  apprized of their approach.   "It  yet re-
mains 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 
INVERSION  OF  THE UTERUS.
515
that the vertical incisions for the flaps be first made, as the relaxation of
the tension of the parts  affects  much the state of the flap when the trans-
verse cut is first made, and thus interferes with the plan of the operation.1]
  The diet should be spare:  a little gruel and biscuit will answer very well.
Of course, absolute rest is necessary.
  " If the radical cure fail," Dr. Burns  observes, "the patient  must use a
compress, with  a spring bandage, if the  stools cannot be retained.   But it
sometimes happens that  the torn  extremity of the rectum,  or the anterior
parts, containing  a fragment of the sphincter, or a portion  of the internal
sphincter, as it  has been called, forms a kind of flat valve, which rests on the
posterior surface of the coccyx, so that the orifice now resembles a slit, and
the fasces, unless very liquid, remain in the hollow of the sacrum, and  do not
pass through the vulvular orifice till an effort be made to expel.   Sometimes
the perineum unites, but the  septum does not, and the inner surface  of the
rectum protrudes into the vagina.   In these cases the edges of the septum
must be made raw, and stitches used."
  In a case which I had the  opportunity of seeing through the kindness of
Dr. Beatty, not only had the sphincter been torn through,  but the  lacera-
tion extended nearly two inches up the recto-vaginal septum.  Dr.  Beatty
first pared the edges of this laceration down to the sphincter, and inserting
four wire sutures, fixed them with the button shield, which was removed on
the eighth day, and the union found to be  complete.  After an interval of
six weeks the edges  of the torn sphincter were removed, and three  or four
wire sutures inserted and tightened by twisting.   A  rectum bougie was
kept constantly in the orifice, and  the bowels were constipated  for  a week
each  time.    After eight days the ligatures were removed, and  the  cure
found  to be perfect.   The patient  has now perfect command  over the
sphincters.
                      CHAPTER  XXIII.

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

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

   1 An Essay on the Symptoms, Causes, and  Treatment of Inversio Uteri, p 2
   2 Williams, Lancet, July 27th, 1839.    s Edin. Monthly Journal, May,' 1849, p 773
   * Jourdan, Diet,  de M6d., vol. xxiii. p.  289.
 I  8 Dublin Journal of Med. Sciences, Sept., Nov., 1837.
   6 Waller's Ed. of Denman, p. 244, note. 
INVERSION  OF  THE  UTERUS.
517
pressed, then carried downward  by the annular contraction of the  uterus,
and, finally, completely everted.   Nauche considers the inactive state of the
uterus, and some effort made by the patient, or by an attendant pulling the
cord, as the principal causes.1  Capuron enumerates, as predisposing causes,
the development of the womb, the dilatation of its orifice, and the atony or
flaccidity of its walls.  The exciting causes may be the weight of the  fundus,
violent expulsive efforts, tractions by the funis, and the dragging downwards
by  a polypus.2  Henkel attributes this accident  to  violent  after-pains;
Meissner to  a  bodily predisposition,  owing to a laxity of fibre.   Siebold
says, that atony of the uterus, with a large pelvis, and the too rapid abstrac-
tion of the contents of the uterus, may expose the patient to inversion.3
Boivin and Duges enumerate, among the  principal causes of inversion, a
flaccid, distensible state  of the uterine parietes ;  inertia of the uterus, espe-
cially if, at  the  same  time, an  effort be made for the extraction of the
placenta;  irregular  uterine contraction, too prominent  sacral promontory,
dragging at the cord, and uterine polypus.4
   It is very credible, that violence in extracting the placenta may be followed
by inversion ;5 or, as Denman observes, "there is reason to believe that the
uterus has  been inverted, when, on account of a hemorrhage, or some other
urgent symptom,  the hand has been  introduced within the cavity of the
uterus while in a collapsed or wholly uncontracted state, and the placenta
being withdrawn before it was perfectly loosened, the fundus of the uterus
has unexpectedly followed,  and  a complete inversion has been occasioned.6
Forcibly pulling the  funis, for the purpose of detaching the placenta,  may,
perhaps, under certain circumstances,  give rise to this accident, but it is not
a  frequent cause.   Shortness of  the funis, or the shortening of it by coiling
around the neck of the foetus, has also been alleged, but, I believe, without
any foundation.  Cords of ten  inches long will permit, and have permitted,
the  exit of the fcetus without displacing the womb, and it is very rare indeed
to  find the funis  so short.  As  to the shortening of the cord when  it is
twisted around the neck, this can never be  the  cause of inversion,  since it
rarely occurs but when  the cord is longer than usual,  and it  very  seldom
reduces the length of the cord below twelve inches.
   But inversion may occur quite unconnected with parturition, as  I  have
already stated.   If  a tumor form at  the upper part of the fundus uteri, it
will first distend the uterus mechanically,  and then, by  its weight,  it may
descend through the os uteri, dragging the fundus after it, and so produce
complete inversion.   Such  a case I  saw in Jervis-street Hospital, under the
care of Surgeon Lynch.  Cases of this kind are also related by Dr. Browne,7
M.  Leblanc,8 Dr. Oldham, and one,  more  recently, by  Dr. Higgins, who
successfully removed both the uterus and the tumor with the  knife, having
previously tied a tape  around  the upper portion  as a precaution  against
hemorrhage.   The patient  bore the operation  well,  and recovered perfectly.9
   759.  Symptoms. — We shall  first examine the symptoms which arise in
acute inversion, i. e., when  it occurs soon after delivery, and when the dis-
placement  is nearly or quite complete.  These  are always serious and alarm-
ing, indicating the important nature  of the accident.   The most  universal
symptom  is  a  sudden exhaustion or  sinking,  which comes on  immediately
after the inversion.   It does not  depend upon flooding, for it occurs in many
cases where there is  no hemorrhage.   The countenance becomes deadly  pale,
the voice weak, the pulse rapid,  small, and  fluttering, nausea and vomitings

  i Mai. Prop, aux Femmes, vol. i. p.  131.   2 Mai. des.^Femmes, p. 495.
  s Handbuch der Frauenzimmerkrankheiten, vol. iii., p. 365.
  * Diseases  of the Uterus, p. 137.          5 Manning on Female Diseases, p. 285.
  « Midwifery  p. 421.                    7 Dublin Med. Journal, vol. vi. p.  33.
  »Meiu  de  i' \cad. de Chir., vol. iii. p. 379.   9EJ. Monthly Jour. July, 1819, p. b89. 
518
INVERSION OF  THE
UTERUS.
occur, etc., so that the patient is suddenly threatened with the extinction of
life.1  Several authors speak of more decidedly nervous symptoms, and even
of convulsions,2 but by some, at least, the restlessness and agitation preceding
dissolution,  appear to  have  been  mistaken for  convulsions.  When  the
inversion is slighter in degree, these phenomena will generally be found less
strikingly marked.  Hemorrhage, even  to  a very large amount, not unfre-
quently occurs, aggravating, though  not changing, the symptoms  already
enumerated, and materially enhancing the danger of the patient.   Mr. Newn-
ham observes, " When the uterus has become inverted, immediate hemorrhage
takes place, which is  quickiy followed by faintness and a sense of fulness in
the vagina, and in  the greater number of instances,  almost by immediate
dissolution."3
  Our suspicions  of inversion will  be excited when this persists  longer than
usual, and an examination  should instantly be made to ascertain the cause,
if possible.   In many cases, however, there is no hemorrhage at all, or not
in proportion  to the  inversion, but  merely the  nervous  symptoms  and
exhaustion;  nor does the difficulty of rallying the patient seem to be less in
these cases than in those accompanied by flooding. .
  There is  generally a  very violent uterine contraction immediately pre-
ceding or accompanying the  inversion,  leading the patient to anticipate a
second child ; this supposition  is further confirmed by the pressure  of the
inverted uterus as it passes  through the pelvis.   Even on an examination
per vaginam we may  be  deceived, by mistaking the uterus for the breech of
a second child.   The  patient complains  of  great pain,  with a sense of drag-
ging from the loins, and  occasional retention of urine.    If pressure be made
on the abdomen, we shall not be able to feel the contracted uterus, and this
being at a time when  it is large, constitutes  a marked and valuable symptom.4
When  the inversion is incomplete, we may sometimes feel  the uterus above
the brim of the pelvis, but having a cup-like depression superiorly.
  If we examine per  vaginam, we shall find a tumor either in the cavity of
the pelvis or hanging through the vulva.   This tumor is globular, sensible,
elastic, with a rough and bleeding surface,  wider below than above, where it
is tightly encircled by  the cervix uteri.   If the displacement  be not reducible,
it sometimes happens that the tumor is attacked by inflammation, running
on into sloughing and gangrene, owing to the strangulation caused  by the
contraction  of the cervix, and ending in the death of the patient.   If the
placenta have not been  previously expelled, it will be found adherent to
some part of the  tumor, adding  greatly to its bulk.  A considerable differ-
ence in the size of the tumor will be observed according as the  inversion  is
complete or  incomplete, recent or of old  standing.  If quite complete, we
may acquire  further  information from a visual examination.   The tumor  is
of a red color when the inversion is recent, but gradually becomes of a dull
brown.5 ^ If incomplete,  we shall still be  able to  detect it  in  the vagina,
though, if there be depression merely, we may not be able  to reach it!
  760.  The foregoing are the most prominent symptoms of acute inversion ;
those which characterize the chronic stage of the disease, whether that stage
be the issue of an acute attack or the result of a gradual displacement, are,
of course, much less formidable.  The. patient is subject to occasional hemor-
rhages, and to a constant and profuse mucous discharge  during the intervals.6
Every month the surface is observed to be  covered with red drops, which
are in fact the menses.7   The patient complains of pain,  a sensation of weight
in the pelvis, and  dragging from the loins.   If the uterus protrude through

  1 Duncan's Annals of Med., 1800, p. 390.     2 Burns's Midwifery, p. 518.  '
  3 Essay on Inversion, p. 86.               * Denman's Midwifery, p. 420.
  5 Boivin and Duges, Dis. of Uterus, etc., p. 114.
  6 Gardien, Traite" des Ace, vol. iii. p. 325.    7 Clarke, Dis. of Females, vol. i. p. 154. 
INVERSION  OF  THE  UTERUS.
519
   the external parts, its sensibility will gradually diminish, in consequence of
   the formation of a kind of epithelium upon its surface ; and if it be exposed
   to rude  contact, or if acrid secretions be allowed to  accumulate upon it,
   circumscribed inflammation may occur, followed by ulcerations, either super-
   ficial or profound, and involving some danger to the patient, if not remedied.
      The constitution of the patient sympathizes deeply with so extraordinary
   an accident. ^ After recovery from the state of exhaustion or nervous depres-
  . sion into which she was first thrown, the repeated hemorrhages and constant
   leucorrhcea will render her countenance  pale and exsanguined, and subject
   her  to various  secondary symptoms,  such as syncope, dropsical effusions,.
   hectic, etc.
      761.  Terminations.—The  patient may die  from  exhaustion or from
   hemorrhage soon after the accident, according  to  Heister,1 Peu,2 Levret,
   Giffard, Windsor, Clarke, Denman,3 Boivin, and Duges ; or  from the more
   distant consequences of the repeated hemorrhages, as related by Mauriceau,4
   Haighton, Cooper, Windsor.   Fatal cases are also related by Peu, Portal,5
   Vanderweid, and Millot, Chapman,6 Saviard,7 Heister,8 Smellie,9 and Mauri-
   ceau.  Boivin and Duges  add, that "death following  a very few days after
   the inversion, may have been occasioned by pains, convulsions, and syncope,
   caused even by the violence which  the uterus  has  undergone."
      Distension and inflammation  of the bladder may occur,  involving  con-
   siderable danger.10  The  inverted uterus  may be strangulated, and be sepa-
   rated by sloughing or  gangrene with  great danger, although cases are on
   record where this termination issued favorably.11  Or, if the  patient do  not
   sink from the primary shock, and if no destructive process take place in the
   tumour, it will, after a while, shrink very much in size,  and the  patient may
   suffer comparatively very little annoyance.  Denman mentions the case  of a
   patient who consulted  him for  an  inverted uterus  twenty years before  her
   death;  and Lamotte another, "in which the inversion was  complete thirty
   years before."  Very rarely the detruded organ has  become  the  seat of
   malignant disorganization, either cancer or corroding ulcer.
      762.  Diagnosis.—The facility  of the  diagnosis will depend very  much
   upon the extent of the  inversion ;  when incomplete, it is very difficult,  and
   even when complete it will often require great care.  It is less obscure if the
   examination be made soon  after the accident.
      1.  If incomplete, it may be mistaken for polypus uteri, but it will be  dis-
,   tinguished by its bleeding and rough surface, by its insensibility, and  by the
   "cut de sac" within the os uteri.   In a case published by Dr. M'Clintock,12
   the  diagnosis was by no  means so easy.  The tumour was  not  large, nor
   peculiarly  sensible, nor had it a rough surface ; moreover, there was some-
   thing like a neck  to it, and a well-marked os uteri surrounding it.    The
   finger alone could not have distinguished it from polypus,  but at no  part
   could a bougie be passed into  the  uterine cavity, and when the tumour  was
   drawn down, all appearance of cervix  and os uteri was  obliterated
      2.  If complete, it will  resemble  prolapse of the  uterus, but  ni&y 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.

       1 Surgery, vol. ii. p. 559.            2 Prat, des Accouch., p. 585.
       s Midwifery, p. 422.                4 Traite" des Accouch., vol. ii. p. 294.
       s Obs 76                        6 Midwifery, Case 29.
       »Obs! 15,36.                    8 Obs., Case 369.
       » Midwifery, Case iii., p. 444.        10 Burns's Midwifery, p. 519.
      » Ryan's Journal, March 12th, 1836.  12 Dublin Quarterly Journal,  Feb 1859. 
520
inversion  of  the uterus.
  The value  of some of these  characteristics, such as the  hemorrhage, the
state of the cervix, and  the  size of the tumor, is  limited to a short period
after the accident, and to those cases which occur after delivery.
  763. Treatment.—1. Of acute inversion.  Our first object is unquestion-
ably to  reduce  the displaced organ ;  and if we are  on  the spot when the
accident occurs, it is in general  not very difficult.   It  is of  the  last  import-
ance that the reduction be  attempted instantly.   Every hour increases the
difficulty, and the lapse of four  or five, according to Denman,1 may render it
impossible.   The period when  the inversion  becomes irreducible, will be
found to vary somewhat in different cases, and according to the experience
of different practitioners.  There is also a great difference,  according  as the
inversion is  complete or incomplete.  It has  been  stated to  have been
reduced  spontaneously,  when the  fundus  uteri was merely depressed,2 and
even when the  displacement was complete.
  But no anticipation of such an occurrence will justify our losing a moment
in  attempting  to re-invert the uterus.   The  protruded  organ  should be
grasped firmly and passed  in through the vaginal orifice, followed by the
hand (previously well oiled,)  which,  when in the vagina,  should be  closed
and formed into a cone, and made to press  mainly upon  the fundus  uteri.
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 allowed to be expelled by the uterine con-
traction.  This will insure  the  patient against a repetition of the accident.
 We should also assure ourselves, before the removal of the hand,  that  the
 restoration  has been complete.  I need not  say that (unless  counter-indi-
 cated) the operation  will be more easily performed under chloroform.
   Mr. Newnham advises that we should endeavor to "return  first that por-
 tion  of the  uterus which was  last expelled  from  the os uteri."  It will  be
 found very difficult to attend to this minutely, when the hand with the uterus
 is in the cavity of the pelvis, for want of room ; and whilst the tumor  is
 external, the re-inversion does  not take place ; it is expressly stated by seve-
 ral authorities, that they did not feel  the reduction properly commence until
 the vagina was stretched to its full extent.
    764.  In many cases  the  placenta  remains  attached to  the  womb at the
 period of inversion, and different opinions have been held as to the propriety
 of removing it before reducing the  displacement.   Baudelocque, Gardien,
 Capuron, Boivin and  Duges,  Radford,  and  others, recommend  its prior
 removal;  but Denman, Clarke, Burns, Carus,  Newnham, Blundell, Gooch,
 etc., as decidedly oppose it.  Mr. Newnham remarks, " It has been recom-
 mended by  several  respectable authorities  to remove first  the  placenta, in
 order to diminish  the  bulk of the inverted  fundus,  and  thus facilitate  the
 reduction.   But it is surely impossible that this proceeding can  be attended
 with  any beneficial consequences, whilst  the  irritation  of the uterus would
 necessarily tend to bring on  those  bearing-down efforts  which would  pre-
 sent a material obstacle to its  reduction, and would increase the  hemorrhage
 at a period  when every ounce  of blood is of infinite importance." "Besides,
 returning the  placenta while it remains attached to the uterus, and its subse-
 quent judicious treatment as a  simply retained placenta, will have a good
 effect in bringing on that  regular and natural uterine  contraction  which is
 the  hope of  the practitioner and the safety of the patient."  It may  be
 doubted, I  think, whether the removal of the placenta is attended  with so

     '- Midwifery, p. 420.             2 Capuron, Mai. des Femmes, pp.  504,  509. 
inversion of  the  uterus.
521
much danger ;  for in many instances it has been found impossible to reduce
the uterus in consequence of the great addition to its bulk which the adhe-
sion of the placenta occasions; and in such cases there is no hesitation about
the propriety of removing the placenta, nor have I met with  any evil effects
recorded as the  result of so doing.  I  have no  doubt, therefore, that as
removing the placenta would facilitate  the  reduction of the inversion by
lessening its volume, that the proper  method in general would be to peel it
off before attempting to restore the organ.
   705.  When  the  tumor is in danger  of strangulation  from the circular
band of the fibres  of the cervix uteri, or in case such band should seriously
impede the reduction, it has  been recommended to divide it with a bistoury.
Of course  the bladder and rectum should be  emptied previous to returning
the uterus, unless we are present at the moment the accident occurs ; at that
time, the operation occupies so short a time, that catheterism may be defer-
red until afterwards, and constipation for twenty-four hours will rather be
an advantage.   If the inverted  uterus and the neighboring parts should be-
much swollen, or if the patient be feverish, it may be necessary to take away
some blood and  foment the parts before attempting the reduction.
    766. But should the disease  be of some  days' standing, are we to look
upon the reduction as hopeless ?  Certainly not.  There are  cases on record
 of the attempt having been successful  after days and weeks have elapsed, and
the condition of the patient is so distressing  that no means, however appa-
 rently unlikely, should be left untried.   In  Loffler's case, 6 or 7 hours had
 elapsed; 17 in Mr. White's case ; 24 in Mr. Winter's ; 28 in Mr. Dickenson's ;
 3 days in Mr. Cawley's ;  7 in  Dr. Radford's Tease 6); 8 in MM. Chopart's and
 Anc's ;  8  in Mr. Ingleby's ; 10  or 12 in  M.  Lauverjat's ;  13 in  M.  Hoin's ;
 and 12 weeks in Dr.  Belcombe's.   Recently  Mr.  Canney1 reduced one of 5
 months' standing;  and  M. Barrier,2 one of 15 months, both under chloro-
 form ;  and I have no doubt that this agent will be found of great value in
 facilitating the operation.   Plenck advises dilatation of the os uteri before
 attempting the  reduction, and  perhaps  in some cases this may be possible.
    If we succeed in restoring the womb to its natural state and situation,
 great care will be  requisite to avoid a recurrence of the accident, or, what is
 more likely,  a  prolapse  of the  uterus.   The patient should remain longer
 than usual in the horizontal position, with the head low, the pelvis elevated,
 and the knees bent.   A dose of opium will be found very useful, and, if there
 be much exhaustion, it must be repeated, and stimulants in proper  quantity
 be given.   A pessary has been advised, in  order to maintain  the uterus  in
 its place,  but this will very rarely be  necessary.  When the lochial discharge
 has entirely ceased, it may be beneficial to use some astringent injections into
 the vagina once or twice a  day, especially if leucorrhcea be  present.
    767.  If the  inversion be  irreducible, we must then  consider how far it
 may be advisable  to content  ourselves with palliative remedies, such  as
 returning the tumor into the vagina to protect it from injury, and  support-
 ing it either  by a bandage and compress, as  recommended by Dr. Hamilton
 for prolapsus uteri, or by a pessary.
    Should  this plan  not be  practicable, or fail  of success, it may then be a
 question as to the propriety of  extirpation.    There is abundant evidence  to
 prove that life may be preserved after the loss of the womb.  Rousset relates
 a case where the uterus was destroyed by gangrene, and the patient recovered ;
 and Rousset, Primrose,  Radford, and Cooke, have given cases in which the
 uterus appears to  have sloughed off,  without compromising the patients life.
 This being the case, there is every encouragement, within certain limits,  to
 effect  that" removal by art which nature thus so beneficially accomplished.
            i Med. Times and Gazette, S.'pt. 18th, 1852. p. 286.
            2 Ibid., Sept. 4th, 18-32, p. 231, from Archives Gen , Mai, 18o2. 
522                inversion  of  the uterus.

In this opinion Sir C. Clarke fully coincides:  he observes, " In those cases
of inversion of the uterus where the woman has passed the menstruating age,
when her comfort is destroyed  by the disease, and when the  profuseness of
the discharge threatens her with death, from the debility which it produces,
it  may be advisable to recommend the performance of an operation which
has  been attended  with success,  viz.,  the  removal  of the  inverted  uterus
itself."   " How far it may be right  to resort to this operation during the
menstruating part of a woman's life,  the author has no means of judging."1
The operation, however, has been  performed during the "menstruating part
of a woman's life," with complete success.   We may therefore conclude that
the operation is perfectly justifiable, provided 1st, that the patient is in a fit
state of health for  an operation ; and 2dly, that the uterus  be not affected
with scirrhus or cancer.
   The operation has been successfully performed. by Ambrose Pare, Petit,
Carpi, Sclevogt, Vater, Laumonier, Bouchet, Boudol,  Dessault, Hunter of
Dumbarton, Chevalier, Johnson,  Hamilton, Clarke of Dublin,  Newnham,
Windsor,2 Davis, Hull, Blundell,3 Moss,4 Lassere,5 Williams,6 Higgins,7 Ged-
dings, Teale, M'Clintock, etc.   Other cases less fortunate are  on record.
   The  operation consists in applying a ligature  of silk, whipcord, fishing
line, or silver wire,  around the tumor at  its highest part,  and gradually
tightening it, as the patient maybe able to bear it, until the tumor is entirely
separated.  Or a double ligature  may be passed through the centre of the
neck of the tumor, and each half  included  in a separate ligature.   Or, as
was successfully done by Dr. Geddings,8 and Mr. Teale,9 we may prefer, after
tightening the ligature to a certain degree, to remove the tumor immediately
by cutting below the  ligature,  or what is  simpler, and I think safer, the
tumor being drawn down may be removed by the ecraseur, as was done by
Dr.  M'Clintock.  We must take care to include only the uterus and  not to
wound the peritoneum.   Before doing this, it will be  necessary to satisfy our-
selves of the adequacy of the ligature to restrain any hemorrhage.
   The  symptoms which  arise  after the  application of the  ligature are just
such as we might expect from  the strangulation of so  important a viscus.
The patient suffers from nausea, vomiting and pain, which greatly diminish
in the more favorable cases, but which are the prelude  to peritonitis in the fatal
ones.  When these symptoms  are  violent, it will be necessary to loosen the
ligature, and wait some hours before again tightening it.  A full dose of opium
should also be given, and the bowels kept free by enemata.  The strength of the
patient should be maintained  by a nutritious, though not stimulating diet.
   [Extirpation of the uterus, when it is the seat of no malignant disease, is
a  terrible operation, and, even under the circumstances mentioned in the text,
of doubtful propriety.  Not only have  some women lived many years afflicted
with inversion, but in several instances without any great pain or suffering
in their general health.  In some cases, too, the uterus has returned spon-
taneously, after the lapse of considerable time, to its natural condition, and
the individuals have conceived and borne children. '  Several very instructive
cases of the kind are related by Professor Meigs, in his edition of Colombat,
two of which occurred under his own notice.]
   If the  inversion  be caused by  or complicated with polypus, it may be
necessary to remove both, and the polypus  should be excised before apply-
ing the ligature to the uterus.

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

                          SUDDEN DEATH.

  768. I do not know whether, strictly speaking, I ought to include among
complex labors that appalling occurrence which many, perhaps most men of
much experience, have witnessed at least once  in their  lives, of a patient
whose delivery has been natural, and whose condition  such as  to excite no
alarm, suddenly, and without apparent cause, dying.  A more fearful accident
can hardly be conceived, aggravated as it is  by the contrast of a few hours
before, and by the wholly unexpected nature of the event.
  But though such cases do occur, and are now and then registered in the
journals, comparatively little attention has been bestowed upon the subject
until of late.   Dr. Ramsbotham, sen., published a paper on the subject, which
was afterwards incorporated in his Practical Observations;x and the subject
is noticed by Mr. Travers,2 and Dr. Meigs.3   Very lately, Dr. Cormack4 has
written  upon the subject; and  more recently it  has occupied the attention
of the French Acadamyof Medicine.  But by far the most complete investi-
gation is  an essay by my friend Dr.  M'Clintock,5 who has very  kindly given
me permission to make free use of the cases he has collected and published
therein.
  At present it is quite impossible to give a complete and satisfactory history
of the subject; probably the best plan I can adopt is to lay the cases  before
the reader, classifying  them so far as I am able, with such practical deduc-
tions and  suggestions as they may warrant.   In  this, I  do but follow Dr.
M'Clintock's arrangement, adding a few cases from my own experience, and
some from various sources which may have escaped him.
  769. I.  Syncope.—It appears beyond question that many of these casea
are examples of fatal syncope, though we are not able to trace its  cause in
each  case.   For example, Dr. Merriman relates the  following instance:—
" An accoucheur was once attending a young woman in labor of her  first
child.  Soon after it commenced, and during his absence, she fainted, with-
out any obvious cause.   On his return the circumstance was mentioned, but
as by this time she appeared perfectly recovered, no further notice was taken
of it, and she was safely delivered without any unusual symptoms.  On the
third day after the delivery she took a dose of aperient medicine, and while
in the act of relieving herself, fell back and immediately expired."
  One of the three cases  mentioned by Dr. Denman certainly comes under
this head.   He relates it as follows :  " Another raised herself in bed to take
nourishment about half an hour after delivery.   She fell  back and died im-
mediately.   She was opened by the  celebrated Dr. Jenner.  There was no
effusion of blood in the brain or in any other part; but the heart was found
flaccid, perhaps somewhat enlarged,  and not a drop of blood in either auri-
cles or ventricles."6  The second case was that of "a woman in labor who
was  put to bed, and made an effort to change  her situation;  she  died in-
stantly in  the act of moving, but she had previously complained of a pierc-
ing pain in her  head and loss of sight."   Another was  in such a situation
that the child was expected to be born the next pain ;  she threw herself back
  ip   116 2d Ed                2TnqUiry into Constitutional Irritation, p. 48.
  » Woman and her Diseases, p. 557.   4 London Journal of Medicine, vol. ii.  p. 941. _
  6 Med. Press, Dublin, March 10th and May 5th, 1852.
  6 Introduction to Midwifery, p. 427. 
524
SUDDEN DEATH.
and died instantly.   The  two last cases are the only ones I have found in
which death took place before delivery.  I do not think they died of apop-
lexy, but whether of fainting or asphyxia I cannot decide.
  The account given by the Rev. Dr. Buchanan of the death of his wife, is
a very graphic picture of fatal syncope occurring about the fourteenth day,
and is the more interesting as the description of a non-medical person.1   Dr.
Simpson mentioned a case to the Edinburgh  Obstetrical Society, which
appears to me to come under this division.   " A patient attended by one of
the pupils of the hospital,  rose up and stood for the first time, about a week-
after  delivery.   She  immediately fainted and  expired."2   The Nashville
Journal of Medicine and Surgery3 gives two cases of collapse after parturi-
tion, which proved fatal,  related by  C. R. Winston, M.D., of Nashville,
Tennessee.
  Of a similar kind appear the cases related by MM. Robert, Danyau,  etc.
In M.  Robert's case, the  patient, aged twenty-five,  who was much excited
by political occurrences, was delivered of her third child.  All went on well
until the ninth day, when being  assisted from  her  bed, she suddenly sank
down  and expired.4  M. Robert has met with  two  other cases : one was a
primipara, the other had borne several children, and  both died  on the  six-
teenth day.  A post-mortem examination threw no light upon either of these
three cases.  M. Danyau mentioned that MM. Dubois, Moreau, Baudelocque,
and himself, had each seen similar cases.   In his case  the  labor was  easy
and the recovery excellent; he visited her on  the twentieth day, and found
her agitated and perplexed ; in a short time afterwards she passed into an
adjoining chamber, and there died.   At the autopsy no  air was  found in
the veins or heart;  the only pathological change worthy of  note was a vas-
cularity of the pericardium, and slight effusion into its cavity.
  Dr.  Chisholm has related a case of arm  presentation, in which he turned
and delivered with no more difficulty or hemorrhage than usual, on Jan. 12th,
1854.   She went on well until the 19th, when he was suddenly sent for,  and
found her dead.   " The account given by her friends was, that while  sitting
up in  bed, after having taken her breakfast as  usual, she was seized with  a
pain in her back which made her scream out: shortly afterwards, she fell
back  fainting;  and having made a very  imperfect rally from this,  soon
faiuted  again  and expired."   A post-mortem  examination threw no light
upon the cause of death.   There were no signs*of asphyxia in the lungs, and
no traces of disease anywhere;  but  the heart was rather softer and paler
than usual, and uncontracted, with clots in all its cavities.5
  Early in the year 1852, I was requested  by a medical friend  to see with
him a patient who  had miscarried a few hours before, with very little pain
and no hemorrhage.  On visiting her half an hour previously he had found
her fainting, without any ascertainable cause.   Although we were not  five
minutes  on our way, she was dead  before we arrived.  No post-mortem
examination could be obtained, and yet I think that we cannot hesitate to
regard this as  another example of fatal syncope, and  not death from organic
disease, for up to  the previous  day she had been in perfect health.   Some
time ago, I attended  a  lady in a miscarriage, who  had not more than the
usual amount  of loss, after which she felt very faint, but  recovered.   She
went on quite  well  for several days, when suddenly one evening I was  sent
for, as she thought  herself dying.  I found that she had become very faint,
without any apparent cause, and notwithstanding every means that we could
try she gradually sank, and died in a few hours, with  no other symptom than
faintness.  She had suffered a good deal from morning sickness, but other-

 >1 Memoirs of Rev. Dr. Buchanan, p. 378.     2 Ed.  Monthly Journal, 1849, p. 767
  3 L'Union Medicale,  10 Jan., 1852.          * Feb., 1851.
  '' Edin. Monthly Journal, Sept., 1854, p. 348. 
SUDDEN DEATH.
525
wise had been a stout healthy woman.   I was refused permission to make
an examination.  Although  the  death  in this case was less sudden, I can
only suppose it to have occurred from syncope.
  But what is the condition  which gives rise to this  fatal syncope ?   We
know  little or nothing.  It does  not  depend upon  hemorrhage,  nor the ,
shock  of labor,  nor fear; for the distance of  time  from the labor, in many
cases,  shows that from such effects, if  they existed, the patient must have
recovered.   They appear, in  fact, to be cases  of cardiac paralysis.   Unfor-
tunately, in most of  the cases the unexpected suddenness of the event de-
prives us of the  opportunity of treatment; but knowing the possibility of
such an accident, may put us on  our guard, and lead us to be very  cautious
in permitting the patient to sit up or to make exertion if she be unusually
delicate, or if anything in the labor or convalescence excite our fears.
   770. II.  Another cause of sudden death is what has been called, "idio-
pathic asphyxia,"  which, Dr. Christison observes, "causes death  almost
instantaneously,  or in a few minutes, or sometimes not for  an hour and  a
half.   The symptoms are those of fainting merely, and the only appearance
in the dead body is flaccidity of the heart, with an unusual or total want of
blood in its cavities."
   M.  Chevallier, who was,  I believe,  the first to describe this  form of
 sudden death, gives us an example of  it: the case of a  woman who  died
 shortly after having been delivered of twins.   After the birth of the second
 child  she  appeared a good deal  exhausted, and as the discharge  of blood
 was very moderate, the accoucheur thought  it best to defer the extraction
 of the placenta.   She recovered  a little, but about  two hours afterwards
 grew  suddenly faint,  breathed short, and died in about half an hour."   "All
 the viscera were free from disease.  The uterus contained the placenta, with
 a small quantity of blood ;  but  all the cavities of  the heart were in a state
 of relaxation, and completely destitute of blood.   There was no  blood in
 the vena cava near the heart, and the emptiness of its ascending branch ex-
 tended as  low  as the iliac veins."1   He quotes  also  a  similar case  from
 Morgagni,2 in which the patient died before  the expulsion of the  placenta,
 aud  the  heart  was  flaccid and  nearly empty.  Without attempting to ex,
 plain the production of such  a  disease,  and  attributing it to  some loss  of
 power, first  in  the minute  vessels, and  afterwards in the larger ones, and
 the heart,  M. Chevallier contents himself with recommending the horizontal
 position, the employment of stimulants, brisk friction, warmth, in some  cases
 a hot bath, stimulating enemata, etc.
    I  am  at a loss whether to place Dr. Ramsbotham's  cases (43,  44, 45)3
 under this head or the former.   The fatal  attack  took place soon  after de-
 livery, without hemorrhage  or any apparent  cause, but the death was not so
 sudden as in the former class—in one case about two hours after delivery,
 in another about three, and in a third  two days after.   That eminent author
 thus  graphically describes  the  symptoms,4 " Shortly after the birth of the
 child, and the removal of the  placenta, when the woman has previously ap-
 peared to be  doing well, she complains of  unusual  faintness;  says she  is
 extremely ill;  at the same time she is unable to describe what is the matter
 with  her.  If inquiry be  made  into the state of the uterus, that  viscus  is
 found to be tolerably well  contracted; if inquiry be also  made as to the
 quantity  of blood escaping externally, that is not  unusually large.  The
 woman complains of no pain about the belly ; there is no mark of derange-
 ment; notwithstanding, she presently gets worse  ; the pulse begins to flag;
 the countenance assumes a pallid, cadaverous aspect;  she becomes extremely
 restless,  and ceases to express her feelings except by a moan.  By and bye

     i Medico-Chir. Trans., vol. i. p. 160.               2 Epistola xlvii. Art., 44.
     s Pract. Observations, 2d Ed., p. 118.               * Ibid., p.  11/. 
526
SUDDEN  DEATH.
she is  seized with a violent pain, or rather stricture, across the chest,  and
soon ceases to breathe, to the astonishment and grief of all around her." _
  Dr. M'Clintock mentions two cases related to him by Mr. Barker,  of  this
city.  " In each of these cases, death took place quite suddenly and  unex-
pectedly, not many days after delivery."  " As may be  supposed,  Mr. B.
submitted the bodies of these women to a very extensive and close scrutiny  ;
but he failed in discovering anything to account for death, except an unusual
flaccidity of the heart, with complete absence of blood in its cavities.   We
may fciirly conclude with him, therefore, that dissolution was the result of
idiopathic asphyxia, or  of some cognate syncopal affection."1  Professor
Beatty has recorded a case of a healthy woman, set.  40, in the  ninth month
of pregnancy, who  complained of weakness  and  sick  stomach, and imme-
diately afterwards fell  back dead.   He examined the body most carefully,
and the appearance led to the conclusion that the cause of death was idio-
pathic asphyxia.
  But what relation does this idiopathic asphyxia bear to the former cause
of death—I mean fatal syncope ?   Are they essentially different, or merely
varieties of the same condition ?  Dr. Samuel Wright seems to  regard them
as pretty much the same, both consisting of a sudden paralysis of the heart.2
The post-mortem appearances mentioned by M. Chevallier are nearly iden-
tical with those given  by others of mortal syncope, and the symptoms only
differ in the  rapidity of their course.   It is  possible that in the  one case the
paralysis may commence in, or be limited to, the  heart, and in  the other to
the lungs, but  it is very difficult to speak  decidedly on the subject.3  And
certainly,  as Dr. M'Clintock  observes,  " if  we look  upon the idiopathic
asphyxia  of M. Chevallier as nothing more  than a variety or form  of  syn-
cope, the  liability of its invading a woman  in childbed becomes still more
apparent, from the state in which her constitution is left by the act of par-
turition ;  a state of which the prominent characteristics are,  an unusual
proclivity to diseased action, an excited condition  of the vascular, and a
morbid sensibility of the nervous, system.   The  shock of labor is  not re-
covered from  for many days, and during this period (the length  of which
necessarily  varies under different circumstances) the  vis  vitos is  minus;
hence  any impression  of a severe  kind, whether affecting  mind or body, is
not met by the same vital resistance as at other times."
   But the difference in degree, the more gradual progress towards death, is
an advantage so far, that it gives time for the employment of remedies,  and
Dr.  Ramsbotham observes, that when the patient has been kept  up,  and
after-pains  have recurred,  she has recovered.  The  ocurrence  of the after-
pains,  I take it, are rather  an effect than a cause  of the improvement,
   Prompt administration of stimulants, aspersion with cold water,  a current
of air, warmth to the feet,  perhaps  galvanism, and especial attention to the
uterus, so as to prevent any loss of blood, are the chief means  at  our com-
mand, and which ought to be continued in as long as there is the least hope.
   771.  III. The shock  to the  nervous  system of a  prolonged and severe
labor may sometimes  prove fatal,  without hemorrhage or organic injury,
and this especially when the mind has been  anxious or depressed previously.
Mr. Travers observes, that "pain, when amounting  to a certain degree of
intensity and duration, is of itself destructive.   Difficult and protracted  par-
turition is every now and  then  fatal  from this cause ;  and even in cases in
which neither extraordinary difficulty nor protraction was experienced, a fatal
prostration  has sometimes supervened, which has admitted of no  other ex-
planation.   The delivery has been complete, without any degree of physical
     1 Med. Press, March 10th, 1852, p. 146.
     2 Path. Researches on Death from Suffocation and from Syncope etc p  14
     3 Med. Press,  March 10th, 1852, p.  146. 
SUDDEN  DEATH.
527
injury, and not more than an ordinary quantity of blood has escaped from
the vessels of the uterus ; yet the woman, in spite of the encourgement de-
rived from the consciousness of safety to herself and infant, and of comfort
from  the  conclusion that her sufferings were at an end, has never rallied,
either in strength or spirits, but after an interval not exceeding a few hours,
passed in a low and sinking state, has unexpectedly, and with little percep-
tible  alteration, expired."1  He  relates two instances of this kind, one of
which is as follows: "A young lady, happily married, impressed, probably,
by some unexpectedly fatal occurrence in the circle of her friends, entertained,
from  the commencement of  her pregnancy,  a morbid fear of death in child
birth, which, although unwarranted by any indication,  became, from its con-
tinuance and  increasing strength, a  source of anxiety to one of her imme-
diate and confidential  relatives.  She was  attended by a skilful and expe-
rienced accoucheur, who was also her relation.   He  assured me that the
labor was in all respects easy and safe, and that  not a single unfavorable
circumstance attended  it.   The child  was  still-born  and imperfect.   The
mother died suddenly,  six hours after delivery.  Every region of the body
was examined with care by an eminent anatomist, and presented the appear-
ance  of health."
   One  or two remarks  appear  to me to be called for in  qualification of the
above statement.   1.  That the  pain  of a severe  and protracted labor will
occasionally produce such serious results  I  firmly believe, for I have  known
it, but I also believe it  must be the pain of the second stage, either unusually
severe, unusually prolonged, or unusually effective, owing to  some peculiarity
of constitution  of  the  patient.  I do not  believe that  such a termination
occurs  from a prolonged first stage, when the second stage is short.   2. We
must not attach too much importance to the fear of  dying in childbed, al-
though it is calculated to be injurious, as a depressing cause ; for we every
day meet with patients who do well, notwithstanding the most decided con-
viction that they shall die.   It probably requires, in addition, some peculiar
 bodily  condition for it to  produce its mischievous  effects.  3.  I think it
might  be suggested, with some show of probability,  that the case quoted
 from Mr. Travers belongs rather to one of  the former classes.
   Dr. M'Clintock  quotes a case in which  there was certainly some hemor-
 rhage,  but in which the death appears to have been more owing to the ex-
 haustion and shock of  the labor.   It  occurred in  the  practice of Dr. Cup-
 paidge  of Castlerea, who states, " In the  beginning  of last month,  I was
 sent for  one  morning, at ten a.m., to see Mrs.  O, a farmer's wife, who was
 the mother  of  five children, and of  rather delicate constitution.   Her last
 labor had been very tedious, and was terminated  by instrumental assistance
 (the forceps, I believe).   On  my arrival,  I  learned that she had  been  in
 strong labor for three  days and nights.   She seemed much exhausted, and
 was  perspiring freely, with a feeble, rapid  pulse.    The pains were frequent
 and  violent, and the foetal head was pretty low in the  pelvis. After waiting
 some time, and seeing the child made no  advance, I applied the  forceps,
 and  extracted  it with  ease, but not  in time to save its life.   The placenta
 came away in a very few minutes, and I put on the binder tightly.  In about
 a quarter of an hour, observing her to yawn and appear restless, I examined
 if there was any discharge, and put my hand over the uterus.  It felt rather
 relaxed, and on making pressure it  contracted, expelling  a small quantity
 of blood.  By this  she  seemed  improved, but in about twenty minutes began
 •vain to si"-h and  yawn, and toss her arms about, which made me grasp the
 uterus more forcibly, whereby a few coagula were dislodged.  Symptoms of
 prostration  with extreme  restlessness, dejection of countenance, and rapid
1 Inquiry, p. 48. 
528                      SUDDEN  DEATH.
intermitting pulse, now began to develop themselves, and though I gave her
abundance  of  burnt whiskey, the  only stimulant procurable^ she continued
to sink, and expired an hour and a half from the time of delivery."1  There
can be no question here, I think,  but that  the  fatal result was attributable
to the exhaustion and shock of labor, although, under such circumstances,
very slight loss of blood has a powerful effect.
  I remember  a case which occurred  at the  Western Lying-in Hospital, and
which  taught  me a lesson.   A patient had  been  long in  labor, and was
showing signs  of constitutional suffering, but as the pains were good, and
[he head was descending, though  slowly, it  was determined, in consultation,
to wait for two hours.   Within that time the woman  delivered herself, but
the shock and exhaustion were so great, that she never rallied, but sank in
a few hours without another symptom.   Perhaps I may be allowed to men-
tion another case, which  occurred in my  own practice, as an illustration
of the violent shock sustained, though the case does  not  fairly belong  to
this  chapter, as  the patient did not die.   The wife of an  officer was de-
livered  very rapidly of twins, and immediately after,  the double  placenta
was expelled without hemorrhage, and all seemed well.   But within half  an
hour she complained of being weak, her pulse  became quicker and  feeble,
and she exhibited all  the  symptoms  of collapse.   The uterus relaxed, and
on pressure a clot was  expelled, but the entire loss  was not much more than
in an ordinary labor.   I had the  advantage  of Dr. Johnson's valuable as-
sistance, but it was two hours before the collapse yielded to our efforts, and
she then rallied.   No  doubt, in this case,  the  loss had some  effect, but that
was owing to  the depressing effects  of the shock  of sudden delivery upon
a  delicate  nervous  woman,  without  which  I am sure  it would have been
harmless.
  There can be little difficulty in  distinguishing this class of cases from the
others of which I have spoken : the history, the length and difficulty of the
second  stage of labor, the operation, etc.,  will  generally be sufficient, even
were the symptoms  more alike ;  but there is  no sudden fainting, nor is the
aspect of the  patient  that of one fainting, but rather that of one  sinking
gradually, but more or less rapidly, and with  a  severe shock to the nervous
system.
  The treatment which seems to have the best effect is the union of  an
anodyne with  stimulants.   Wine and brandy must be  given liberally  at
first, until some degree of reaction is obtained, and then the  quantity may
be diminished, and chicken broth  gradually substituted.  Meantime  a mix-
ture should be added, consisting of camphor  mixture gvj., carbonate  of
ammonia gij.,  and laudanum gtt. Ix., of which the patient may take a table-
spoonful every one,  two, or three  hours.   The most perfect quiet should  be
observed, the room should be darkened, and the patient allowed to sleep  as
long as she can.
  772.  IV. The  absorption of air by the  uterine sinuses, was suggested
by the younger Legallois in 1829, and by Ollivier in 1833,2 as being possibly
the cause of some, at least, of the sudden deaths after delivery.  The elder
Legallois had  found in some of his experiments, that sudden death resulted
from air penetrating to the vena cava from  the uterine veins.   Of the possi-
bility of this occurrence one  cannot doubt, and the researches of Dr. Rose
Cormack3  have  very  much  elucidated this subject;  his experiments and
subsequent observations, justify,  I  think,  the  conclusions given  by Dr.
M'Clintock, viz., that  the admission  of air  into the current of the blood is
capable of destroying life suddenly ;  that it is highly probable that air may
nnd an entrance  into the vascular system through the  uterine vessels; and
     i Med. Press, March 10th, 1852, p. 147.          2 Dict. de MeU  Art. Air.
     f London Journal of M6d., vol. ii. p. 941. 
SUDDEN  DEATH.
529
that in certain  cases of sudden  death after delivery, the  only cause which
could  be  detected was  the presence of air bubbles in the heart  and vena
cava.   Dr. Rose Cormack has collected seven cases in support of this view;
in six, the presence of air in the veins was demonstrated, and none exhibited
any other morbid lesion sufficient to account for death.  He  observes,  " If
a  large quantity of air have  entered  the circulation, unequivocal  evidence
of this will be found by listening to  the heart, when the churning sound will
be  heard.  If death does not  almost at once close the scene, the phenomena
of  asphyxia will set in, their rapidity and violence depending  upon the
quantity  of air which  has entered,  on its passing up to  the heart in one
large volume, or in divided quantities, on the  presence or absence of hemor-
rhage,  qjid on the strength of the patient."1
   There is a case related  by  Dr. Ramsbotham which resembles death from
this cause, but unfortunately  the veins and heart were not examined.   The
woman had been delivered of a dead child, which was followed by the ex-
pulsion of a quantity of offensive gas.  The placenta had to be withdrawn,
and then  the uterus contracted, and the woman appeared well between two
and three o'clock.   Between five and  six she died quite suddenly.   Nothing
appeared, on post-mortem examination, to account for her  death."2
   Another case has been recorded by  Mr. Berry, more recently.3  A woman,
aged twenty-tw^), was  delivered of  her first child, after a natural  labor, at
seven  p.m., June 17th, 1850.   The  placenta came away in twenty minutes,
unattended  by any immoderate loss of blood.   At half-past eight she ex-
pressed herself as comfortable,  and at eleven took some gruel.  At one
o'clock in the same night, her husband, who lay in the same room  with her,
became alarmed by the patient's difficult breathing and feeling of faintness,
and immediately sent for her medical attendant, but before his arrival at
two o'clock, she was dead.  On examination, the abdominal organs, including
the uterus, were healthy, with the exception of a granular  condition  of the
kidneys.  The mouths  of the uterine vessels were patulous ; the lungs were
congested, and  contained tubercles; the heart was enlarged and distended,
and, upon making an incision into  it, a gush  of air escaped, and it became
flaccid.   No blood was found in its  cavities.   About an ounce of serum was
found  in the pericardium.  The brain  was quite healthy, and there were no
signs of decomposition  in any part of the body.
   Mr. G. May, jun., has published three cases.   In the first, death  occurred
on  the rupture of the  membranes before delivery.  After  death there was
nothing to account for it but distension of the heart by air.  The second
died six hours after delivery, and the third on the  eighth day.   Nothing
adequate  to account for death was discovered  except air in the  heart and-
large vessels.4
   "The mechanism," says Dr. M'Clintock, "by which the introduction of
air into the veins can be effected, admits of being explained in a few words.
The veins of the gravid womb present four remarkable characteristics—viz.,
their extraordinarily large size, their freedom  of inosculation,  the  total
absence of valves, and their termination on the internal surface of the uterus,
at the  site of the placenta, by large open orifices.   If the uterus be examined
soon after delivery  at  the full  term,  the majority of these apertures  will
readily admit a goose  quill,  and some  will even allow the little  finger to
penetrate  without  laceration.   During  contraction  of  the uterus all the
openings are hermetically closed, but when it is relaxed, they again become
proportionally more or less patulous.   From  this it is manifest  that the
same condition of the  organ which  causes flooding is exactly that which is
  i London  Journ. of MeU, vol. ii.  p.  950.        = Pract. Obs. in Midwifery, p. 122.
  s Prov. Med. and Surg. Journal,  Nov. 27th, 1850
  * British Med. Journal, June 6th, 1857.
       34 
530                      SUDDEN  DEATH.
indispensable for the ingress of air; so that the latter, when  it does take
place, is almost of necessity preceded or accompanied by hemorrhage.1
  But the question then arises,  How comes  air into the uterine cavity ?   It
may penetrate, doubtless,  during the process of expulsion  of  the  child, or
during  the interval  before the expulsion of the placenta, or it may be the
result of decomposition, as in Dr. Ramsbotham's case.  That air is expelled
from  the uterus occasionally, during, or immediately after  labor, we know.
Dr. Meigs has noticed it a great many times; Dr.  Rose Cormack  has also
observed it;  Dr. M'Clintock witnessed it  in four different cases; I have
repeatedly noticed it;  and it is mentioned  by other writers.  So that we
may conclude, with  Dr. Cormack, "I have not only no difficulty in believing,
but am  constrained to admit, that  should any impediment be offered in such
cases to the free exit of air by the os uteri, it must be forced into the uterine
veins, were their mouths not protected by  coagula ; and  thence  it would
rapidly  pass, by the  current  of the circulation,  up the vena cava,  into the
right auricle.."2
  The intensity  of the symptoms probably  depends partly  on  the  quantity
of air and partly on the  condition of the patient.   Death may occur sud
denly, or, life being  prolonged, the patient  may die of asphyxia at a  later
period.   The character of the symptoms in the severer cases  being similar
to those in the cases of fatal syncope or of  idiopathic asphyxia, renders the
diagnosis between the three during life almost, if not quite, impossible ; it is
only by the detection of the presence of air in the heart  or great vessels after
death, that we can positively assure ourselves of that having been the cause
of death.
   As to the treatment of these cases, Dr. Rose  Cormack observes, "In the
most rapid class of cases in  which  death  is suddenly threatened from paraly-
sis  of the heart from over-distension, we  must first strive to relieve the heart
from that  condition ;  when  the phenomena are chiefly those of  asphyxia
from more gradually increasing obstruction  in the lungs, the various means
for treating  asphyxia must  be  resorted to, and among  these, in many cases,
I believe the alternate use of hot and cold douches will be found to be very
valuable, especially  if combined with stimulants, judiciously  varied, and skil-
fully administered,  externally  and internally.  In  many instances repose,
dashing cold water in the face, keeping the  surface warm, and time, may be
the only means which ought to be used."3
   773.  V.  The formation  of a fibrinous  coagulum in the heart was first
pointed out by Dr. Meigs as a possible cause of death.   He says, " It is  '
well known that the coagulability of the blood  is greater  in proportion as
any hemorrhage progresses; therefore  a woman who  has lost  during her
labor forty or eighty  ounces of blood,  has the rest of it more  coagulable
than it was before the flooding commenced.    Again, fainting consists in the
too little intensity of the  presence of blood  in the brain; and a woman just
gone through a flooding,  experiences a sensation of  faintness  from lessened
vascular distension  of the  encephalon.   If she suddenly assume  an  erect
position, the tension becomes instantly lessened in consequence of the gravi-
tation of the blood.  But (and this is the danger) if she faint badly while
her blood  is become  thin  and highly coagulable  from  hemorrhage, the
scarcely moving current partially stops in the heart, and when she comes out
of the deliquium, if ever, she does so with a coagulum in the auricle and ven-
tricle ;  she has got a false polypus in the cavities, and will  surely die."4  In
another place he observes, "I beg you  to consider briefly the effects to be
produced by a mass of fibrinous remainder  of a clot suddenly  found within,
    1 Medical Press, March 10th, 1852, p. 147.
    2 London Journal of Medicine, vol. ii. p. 941.           s  Ibid., vol. ii. p. 938.
    * Obstetrics; the Science and the Art, p. 308. 
SUDDEN  DEATH.
531
and moulded by the cavity or cavities of the heart.  Inasmuch as the venous
blood can only get back to the arterial side bypassing through the pulmonic
heart, such a clot, if of large size, must either wholly or very greatly hinder
the return of the venous blood.   In fact, it would be equal to a partial
ligation  of  the cava  superior or inferior.   Death  is  likely to  follow  the
occurrence,  either immediately or within a few hours.  I have observed it to
occur within eighteen hours, in thirty-six hours, in eighteen days."1   In  one
case he mentions, the symptoms were sudden sinking, mental anxiety, rapid
pulse, and^effusion into the pleura?.   A post-mortem justified his diagnosis.
   A case in which the cause of death was considered to have been a clot in
the heart, is related by Dr. Keith.   He attended the patient of twins, Nov.
1850 ; the labor was tedious, and she was kept under the influence of chloro-
form for thirteen hours.   The  first child was delivered by the  forceps ;  the
second came footling.   When the  placentae were expelled, there was a great
rush of  hemorrhage, which was arrested by the contraction of the uterus.
The patient  fainted ;  but  gradually recovered; slept; and  on awaking,
showed  no  unusual symptom.   From this time to the fifth day she went on
pretty well, considering the previous history.   The lochia were natural,  and
there was some milk in the breasts.   " During this whole period, however,
there was an unusual degree of restlessness, and an undefined feeling of  dis-
comfort, for which, though frequently asked, she could give no definite cause.
The pulse was also  faster than usual, and very small."  "On the morning
of the fifth  day, the nurse told me that  she had spent a good night; and her
own principal request  was, that she might have a partridge for dinner.   On
feeling the  pulse, however, it  was  much  more rapid than on the preceding
day, and very feeble."  "I  left at ten o'clock, and at twelve an urgent mes-
sage was sent to my house.   As I  was out at the moment, Dr. Duncan  was
sent for, and at half-past twelve he found her pulseless, and evidently sink-
ing.   I  saw her half an hour  later; she seemed then  to have very slightly
revived, after taking a large quantity of champagne and brandy.  The pulse
was, however, quite gone at the wrist, the heart's action extremely rapid  and
feeble, the  breathing very laborious."  She died at three o'clock.   On ex-
amination,  an effusion of serum and a thin layer of lymph were found in the
peritoneal cavity ;  the uterus was  healthy; the right side of the heart  was
unusually distended ;  "and on opening the right auricle it was found quite
filled with a large mass of fibrine, quite colorless, and especially at one part,
where it adhered to the wall of the  auricle, of  a  firm and  leathery consist-
ency."2   It is a little difficult in  this case to disentangle the  effects of the
latent peritonitis from those of the clot  in the heart.   I have seen more than
one case of fatal peritonitis of which there were no  characteristic symptoms
during life, the main anxiety being caused by the quick pulse ; but I think
in the present case there appear to have been symptoms resembling asphyxia,
which can hardly be said to be referrible to the peritonitis.
   The only practical  inference  from such cases is, the care  necessary not
merely to arrest hemorrhage, but  to guard the patient against its conse-
quences.  The horizontal position, with the head as low,  if not lower than
the body; the use of stimulants and nutriment, judiciously administered ; the
equable warmth of the body after the  hemorrhage  has ceased;  and above
all, great caution, for  several days, about sitting up in bed, or removing to
the sofa, and making  any exertion, are all available means for the preven-
tion of this accident,  which ought never to be neglected.
   774  VI   Disease of the heart. —For more  than  one reason, we might
naturally fear for the result of delivery when there exists organic disease of
the heart   The disturbance  of the circulation, and the impediment to the
i, and her Diseases, p. 377.         2 Ed. Monthly Journal, Jan. 1852. 
532
SUDDEN  DEATH.
 free course of the blood which vavular disease  offers, even in moments of
 tranquillity, must be many times increased during the turmoil of labor, with
 its repeated arrests of respiration and recurring  congestion.  If under ordi-
 nary circumstances the impediment gives rise to effusion, much more may
 such a result be expected during the labor; and an effusion into the cavity
 of the arachnoid, pleura, or peritoneum may be very serious.   Again, after
 delivery, the volume of blood previously required for the fcetal nutrition, and
 circulating in the uterus, will be thrown into the general circulation, adding
 to the existing embarrassment  of injured valves, or a diseased heart, unless,
 indeed, there  be considerable discharge — which in  turn, however, if exces-
 sive, may equally, though for an opposite reason, be a source of trouble.
   At a meeting of the Edinburgh Obstetrical Society,1 " Dr. M'Cowan stated
 that on the 16th of June, 1846, he was requested to visit Anne Barker, aged
 twenty-one, said to be in labor of her first child.   On  his arrival, he found
 her suffering  from spurious  pains, and  complaining much  of  difficulty of
 breathing, and pain in  the left  sub-mammary  region.   The face was very
 cedematous, as also the lower extremities.   Under the  usual treatment, the
 pains subsided.  During  the two following days, she complained occasionally.
 On  the 19th,  she had  much pain in the side ; respiration laborious ; pulse,
 which had hitherto been about  70 or  80, rose to  120, but feeble.  Venesec-
 tion to  ten ounces produced faintness without alleviating the pain.   She was
 then cupped to four ounces with immediate relief.   About three a. m. of the
 20th, labor commenced,  and proceeded naturally and speedily till nine  a. m.,
 when she was delivered of a still-born male child, and instantly expired.
   "Post-mortem.—The  body presented a generally cedematous  appearance.
 On  opening the  thorax, the pericardium was found distended  with a dark
 fluid.   The heart was much enlarged, extending about two inches to the
 right of the sternum ; right ventricle very thin and dilated.   The aortic open-
 ing could with difficulty  admit  the  point  of the  little finger; its valve was
 hard and cartilaginous.  The whole heart was filled with coagulated blood.
 The surfaces of the pleurae were strongly adherent;  the greater part of the
 left lung was hepatized.  The uterus  and  other organs seemed healthy."
   At the same meeting, Dr. Simpson mentioned that he had seen a similar
 case of sudden death some years before, and which, from the history of the
 patient, he attributed to  disease of the heart.
   Dr. M'Clintock mentions, that on  two  occasions he has  seen a  patient
 die almost under his hands, immediately after delivery, from this cause ; and
 he mentions another lady who died suddenly on the tenth  or twelfth'day
 and who was known to labor under organic disease of the heart.  He relates
 also another case, furnished to him  by Dr. Fitzpatrick, in which death took
 place on the fifth  day,  and which seems, at least in a great measure attribu-
 table to the same  cause.
   A case of sudden death, on the day  after delivery, has been related by Mr
 Young,2 in which  no abnormal appearance was detected, except hypertrophy
 of the heart and disease of the aortic valves.   Mr.  Young  attributes her
 death to this and  to the distended state  of the stomach, and large size of
 the liver arresting the functions of  the heart.
   Now  there is no difficulty in such cases  in detecting organic disease; and
 if  the accoucheur do ascertain the  fact, is  he justified in remaining passive ?
 1 think  not.   If,  as these  cases show,  the original embarrassment of the
circulation may be increased to  a fatal degree by continued labor, why allow
it to go on ?   We cannot prevent labor, but surely we can shorten  it: and
if ever there is a case in which the use of the forceps is  justifiable merely to
shorten  labor, this is certainly one.   I am happy to  have the authority  of

 i Ed. Monthly  Journal, May 1849, p 766.    2  Association Journal, Nov.  19th, 1853. 
SUDDEN  DEATH.
53 3
Dr. Simpson to confirm this  opinion;  and still more happy to  be able to
quote a successful case so treated.  In the summer of 1851, my friend,  Dr.
Stokes, asked me to take  charge of a patient who had  been admitted into
the Meath Hospital, with extensive valvular disease of the  heart, disturbed
circulation, dyspnoea and oedema.  She was in the eighth  month of preg-
nancy at that time ; and before the end of the ninth month, under Dr. Stokes's
judicious  treatment, the oedema  had  subsided, the circulation become tran-
quillized,  and the respiration easy, unless she were agitated or exerted her-
self.  Fearing the effect of labor upon her diseased heart,  I determined to
shorten it as much as possible.  I arrived at the hospital about half an hour
after the commencement of labor, fortunately the os uteri had rapidly yielded,
and I found the head in the pelvis.  I immediately applied  the forceps, and
delivered  her in about five minutes  of a  living child.  The placenta  was
expelled immediately.   When  I applied the  forceps,  she was beginning to
show signs of distress in respiration, and more than usual  congestion ;  but
after delivery this instantly subsided, and she recovered speedily and well from
the labor.
   775.  VII.  Obstruction and rupture of the pulmonary arteries.—We are
indebted to the researches of Mr. Paget for a knowledge  of the effects of
obstruction in these vessels ; and in his second paper he suggests that many
of  the cases of sudden  death for which no apparent cause has been  found,
may have been owing  to clots  obstructing the pulmonary arteries, and  that
the cause of this coagulation is some change in the composition of the blood.
   The  first case of the kind recorded, I  believe, is the following, by Mr.
Havers.1   A  delicate lady, aged thirty-four,  was delivered  of her  second
child,  after a natural and easy labor.   The removal of the after-birth was
attended  with  some little difficulty, and was followed by a gush of blood so
sudden and violent as to place her life in imminent danger.   This took place
on the  18th of August, and she progressed favorably till the morning of the
23d, when her  attendant " found her restless, her countenance sallow, her
eye unusually bright and wandering, and her manner catching and irritable.
She said  she  had passed a bad night, which she referred  to the fulness of
her breasts producing a feeling of palpitation and distress  at the pit of the
stomach.   Her tongue was slightly coated, and her pulse as usual, quick
and weak."   These symptoms subsided  under an  alterative  dose,  and
matters went on well until the morning of the 30th.   " She  had been  on the
sofa and  easy chair each day, was in good spirits, and apparently in good
health.   On that day she was better than  usual;  she  made her lunch at an
early hour, and told her nurse  that she was  so well that  she would dress
herself without assistance ; while in the act of dressing she fell on the bed ;
the nurse observed  some frothing at the  mouth, and slight convulsions of
the face.   She spoke feebly  once, then laid  herself back  and died."  Mr
Pao-et was present at the post-mortem examination.  " With the exception of
the°cicatrix of an old abscess in the apex of the right lung, and paleness of
the heart, to be just now referred to, the organs were generally healthy.  The
muscular  structure of the heart was pale and thin, especially that of the right
ventricle, which contained some dark blood.  Each of the pulmonary arteries
contained a clot of blood nearly filling the calibre of the vessels.   1 he chief
clots were about an inch and a  quarter in length, mottled  and firm, and in
some instances slightly adherent to the sides  of the vessel    In  tracing the
divisions of the artery, numerous other clots were found, of the same character
as  the larger ones, and extended even into the  smaller ramifications of the
arteries."   Mr. Paget was of opinion that these clots existed two days before
the death of the patient.
i Med. Times and Gazette, Feb. 14th, 1852. 
534
SUDDEN  DEATH.
  Since the publication  of the foregoing case an  additional example has
been afforded in an illustrious exile.   The Duchesse de Nemours recovered
very well after her confinement, and  on the  14th  day, whilst her maid  was
dressing  her hair, she suddenly exclaimed, "I feel  ill," and died.   A post-
mortem examination showed that death was owing  to a clot in  the pulmo-
nary artery.
  And still more recently Dr. Mackinder has related two cases.  " In the
first, the patient was 32  years of age,  and had been delivered of her second
child after a natural and easy labor.   Seventeen  days afterwards, while ap-
parently  in good health, she rose up convulsively,  said she was choking, and
died.  On subsequently  examining the body, a  large, branching,  fibrinous
plug was found completely stopping up the right  pulmonary artery,.and its
immediate ramifications, while the entrance to the  left pulmonary artery gave
lodgment to a large and tolerably firm concretion.   The heart  was  rather
thin, and  the lungs slightly  congested, but there  was  no further  trace of
disease about the body.   " In the second case, the patient had an easy labor,
and for a few days afterwards all appeared to progress favorably, when she
imprudently left her bed-room, and exposed  herself  to cold.  Shortly after-
wards she was "seized with difficulty of breathing,  gasping,  and cold clammy
sweats, from which  death relieved her in twenty minutes."1   Unfortunately a
post-mortem examination could not be obtained.   How far these obstructions
may be the result of simple coagulation, or in  part, at  least, owing to what
Virchow has termed "embolism," is difficult to say  until  our information is
more complete.
  A very interesting case of  rupture of the right pulmonary artery during
labor, followed  by instant death, has been published by Dr. Crooke.2  The
labor was going on slowly, but well, and on the  occurrence of  a  powerful
expulsive pain,  the  patient's face became livid, and she complained that "her
heart was leaving  her,"  and died in  a few  minutes.   On  post-mortem ex-
amination all the viscera were healthy; there was  fluid  blood and coagula
in the cavity of the chest, which  was found to have escaped from a rupture
of the right pulmonary artery.
  Of course, it will require more observations before we can arrive at  any
very positive conclusions; it does not  seem  improbable, however, that such
clots,_ which would  more  readily form after hemorrhage, might occasion as-
phyxia and death.  In the present state of our knowledge of the subject, I
fear we can deduce no further practical instruction than  the necessity of
arresting  hemorrhage as  speedily as possible, and keeping the patient in an
horizontal position until  the  blood has so far recovered as  to lose its  dispo-
sition to coagulation.
  776. VIII.  General dropsy.— When  ascites  and  anasarca  occur to  a
considerable extent during pregnancy, the patient may die immediately after
delivery,  without any very obvious cause, but  apparently from asphyxia, as
the following case will show: Mrs. ----, aged thirty-eight, was in the sixth
month of her fourth pregnancy  when  she suddenly became dropsical: the
hands, arms, body, and lower extremities were swollen ; there was much fluid
in the peritoneal  cavity, for she was  larger than if at the full term.  The
pulse was 120,  and the  respiration sometimes difficult, and always  hurried
Labor came on unexpectedly in the country, and  I  did not see  her until it
was over.   The  child was  dead;  the placenta  had to  be  extracted, and
though there had been some hemorrhage, she had  not the aspect  of a person
sinking from  that cause.  When I saw her her  lips were blue, her aspect
pale but  not pallid, the surface warm, the respiration hurried, and the pulse
100, and  weak.    She had spoken  after delivery,  but could not  answer my
                1 Med. Times and  Gazette, July 23, 1859. p. 96.
                2 Medical Press, Sept 17th, 1853, p. 193. 
SUDDEN  DEATH.
535
questions, though she seemed to understand me.   She haa  no convulsions,
nor any head symptoms.   She gradually sank in spite of our utmost efforts,
and died about three hours after delivery.   No post-mortem was permitted.
What was the immediate cause of death ?  Not hemorrhage, nor an affection
of the head — not fainting, certainly.   There may, for aught I  can tell, have
been a clot in the heart, but I came to the conclusion that it was asphyxia,
from effusion into the lungs.
   777.  IX. Minute perforation of the intestine. — I saw a case of this kind
a short time ago, which  might have  been mistaken for one belonging to
some of the former classes, had there not been a post-mortem examination.
Mrs.  C----, aged thirty, was confined  of her first child after a  natural  labor,
and recovered well up to the sixth day, except that  she had  no milk.  On
the sixth day she had an attack of weid, without abdominal pain, from  which
she recovered as usual after twenty-four hours.   On the tenth  day she  had a
rigor, with diarrhoea, and some griping pain, from which she was  soon relieved.
On the twelfth day the rigor returned,  with abdominal uneasiness and  slight
tenderness, a pulse of 110, no thirst, some diarrhoea, the lochia natural.  At
this time I saw her;  and leeches  having been applied,  calomel and  opium
given, I merely suggested a full opiate at bedtime.   The next day she  was
much better ;  pulse 84, neither pain nor tenderness of the abdomen, no rigor,
and the bowels quiet.   The day after I did not see her, as she told her medical
attendant in the morning that she felt quite  well.   On his  visit the next
morning  (the  fifteenth day after delivery), he found her in  a state  of the
most complete collapse, pulseless, voiceless,  and bathed in a cold clammy
sweat.   She rallied a little  under the use of stimulants, but died   in  the
evening.  At the post-mortem examination we found no peritonitis, and the
uterus  was perfectly healthy ; but the termination  of  the  ileum  and com-
mencement of the colon were much inflamed, and on raising this part  of the
intestine a quantity of fluid fcecal matter escaped from a minute perforation,
and we found  more of it in the pelvis.  In this case the cause of death  was
 evident__collapse after perforation;  but the extreme  minuteness  of the
 perforation, and the  rapidity with which  death took place,  were very re-
 markable.
   778. Scarlatina.—The first of  the  following cases  may fairly be con-
 sidered  one of sudden death, and I believe it is  the only one of the kind
recorded.  I  have added the second as  illustrative, although  the patient
recovered.
   Case I.—December 14, 1858, sent  for  to Mrs. S., and received the fol-
lowing history:—A  delicate lady, suffering a  good  deal during pregnancy,
 taken in labor of her fifth child  December 13, and was delivered early in
 the morning,  after  an easy labor of a few hours.   Placenta came away
 naturally ;  no hemorrhage ; pulse  quiet and good.
   During the  day she went on quite well;  lochia natural.
   In the evening  Dr. Smith  found  the  pulse alarmingly quick and  very
 weak,  without anything to account for  it.  No paiu ;  no local distress;
 no excessive discharge.                   „,,,,.,   i          i
   Dr Jacob  of Maryborough, was sent for, but nothing  local or general
 could be ascertained with any certainty to account for it, unless it  might
 be the  commencement of a latent form of uterine phlebitis.   Some calomel
 had  been given on  this supposition, but was  suspended on  account of
 diarrhoea  Nourishment and wine were liberally given, with  benefit  to the
 pulse and strength.   The next day, December 14, I was sent for, and arrived
 at 10 p m  the report at that time being that the patient was rather  better.
 I found that there had been no rigor; there was neither enlargement of the
 uterus  nor tenderness of it or any part of abdomen; no swelling; no tym-
 panitis •  lochia plentiful, but rather pale, and not offensive;  urine copious, 
536
SUDDEN DEATH.
and  passed  naturally;  pulse  140,  very  weak  and wavy.   Upon  minute
questioning, she told me that she  had  neither pain nor  distress  of  any
kind.   Countenance  pale, but calm  and easy;  neither hurry nor distress in
breathing, alas nasi quiet; no  headache.   I examined the chest very care-
fully ; on percussion it was resonant everywhere;  respiratory murmur full
and  equable;  not an abnormal sound  throughout.   Upon examining the
heart, there was no  enlargement, but  the rhythm of the sounds was de-
stroyed  by the disappearance of the first  sound; there was no impulse, but
the second sound was natural.
  This,  then,  was the only deviation  from the healthy condition  that  I
could detect, after a most careful examination  of every organ of the body.
And what  explanation  did it afford of the perilous condition of the  pa-
tient ?   I confessed that explanation I had none to give ; all I ventured to
say was, that the  uterine system was not in fault, but that the disease  was
in the heart or circulating fluid.
  I lay  down about 2 o'clock,  and  at 5 a.m., they came  to  me to say that
the pulse had begun  to sink again.   I found her iu precisely the same con-
dition as before, with that exception.    The pulse was 150  or 160 ;  the
respiration rapid, but not difficult;  and, in spite of strong stimulants, her
state  went from bad to worse, until  she lost the power of swallowing,
became  insensible, and  finally died  about  11 A.M., without pain, struggle,
or convulsion.
  I returned to town, I may frankly confess, very much puzzled, and by no
means comfortable;  but the mystery was  cleared up when  I heard,  two or
three days  afterwards, that the nurse and the lady's husband were laid up
with a very severe form  of scarlatina.   I  have no doubt that the scarlatina
poison,  acting  on a system weakened and  rendered unusually susceptible by
delivery, had caused  death  before the  ordinary  symptoms  of  that  disease
had time to develop themselves.
  Case II.—On February 23d, Surgeon Morgan asked me to visit Mrs. B.
with him.   She had been confined, February  21,  of her thirteenth child,
after a  natural labor, and  was doing well until the morning of the  23d,
when she  awoke with palpitation and a  weak pulse of 140,  but without
pain.
  I found the  pulse 130, and very weak.   There was a nervous tremulous-
ness about her, and a frightened look.   She complained  of  nothing  but
excessive weakness;  no  pain, no distress.  The uterus felt  rather larger
than usual,  but not tender ;  lochia quite natural, and without odor.   Some
milk in the breasts.   On examination the  lungs appeared perfectly healthy,
and  there was no  abnormal sound  in  the heart, but the first sound  was
weaker or less  loud than the second.
  In short, we could find no satisfactory  local  cause  for the patient's  con-
dition, and, in  fact, no deviation from organic health, except in the  rhythm
of the heart.  Remembering the former case, I asked if any of the family
had  recently had scarlatina  or measles,  but was told  that they had not.
Under such absence of grounds for correct diagnosis, it was clear that our
duty was to treat the prominent symptom (exhaustion) actively, whilst we
took some precautions as to certain possibilities.
  This we did by the exhibition of stimulants and  nutriment, and by poul-
tices to  the abdomen.  Without troubling the  reader with the daily  report,
I may briefly state that the  patient  became weaker on the  24th and 25th ;
at noon of which day Dr. Morgan  thought she  was  dying.   No local de-
rangement could be detected at any time,  and she took freely,  and retained,
both food, spirits, aud medicine.  Her  nights were rather restless, and her
sleep not refreshing.   On the evening of the 25th we determined to  try the 
PUERPERAL  FEVER.
537
full exhibition of quinine, and  accordingly gave her six grains at bedtime,
and three grains every three hours when awake.
  The next day there was a perceptible improvement; she had slept better,
and  felt more comfortable.  The pulse was only 120, though weak.  The
quinine, claret, and Hoffman's liquor were continued.
  February 27. A more decided improvement.  Pulse 116, fuller and firmer;
feels stronger, and  had no weakness  at noon, as previously.  As she com-
plained of headache and  singing in the ears, the quinine was omitted, but
food and wine continued.
  On the  28th I found her so much better that I ceased my attendance.
She  had slept very well; pulse  104, aud fuller ;  no local distress ;  no feeling
of excessive weakness.   From this time Dr. Morgan informs me that conva°
lescence progressed favorably.
  Up to this point we were at  sea as to the nature of the attack, although
we had the benefit of Dr. Corrigan's  assistance;  but on the evening of the
28th I think  the solution  of the problem was afforded by the fact of one of
the servants  showing unmistakeable evidence of scarlatina.
   I  fear it may be  thought that  I  have extended this  chapter to a dispro-
portionate length ; but the subject is new in a systematic treatise, and so
inadequately understood,  that I felt that the main value would consist in a
detailed account  of the principal facts which have  been recorded.  When
the subject is better known, we shall be able to condense.
                      CHAPTER  XXV.

                         PUERPERAL FEVER.

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

  779. Puerperal Fever is probably the most fatal disease to which women
in childbed are  liable, and it is by no means of rare occurrence.  Its phe-
nomena vary very much, and it has consequently been  differently described,
and under various names, such as Puerperal Fever, Childbed Fever, Peri-
toneal Fever,  Low Fever of Childbed, etc.  Another source of apparent
contrariety has been the  prevalence of the  disease epidemically, and  the
varying characteristics of these epidemics.   Unfortunately, the  uniformity
of the disease was assumed until  comparatively recent times; and, as Dr.
John  Clarke observes, each author erected his own experience into a stand-
ard by which to judge of the descriptions and practice of others.
  According to Dr. Hulme's researches, the older writers were not ignorant
of this disease.    It is  described  by Hippocrates  and Avicenna.   Plater
(1602) makes it to consist in  inflammation of the uterus.  Sennert (1656)
describes it, and recommends bleeding.   Riverius  (1674)  attributes  it to
suppression'of the lochia, and Sylvius  (1674)  to deficiency  of  the lochia.
Willis (1682) takes the same view of its nature  as Plater.   It  is  mentioned 
53 8
PUERPERAL  FEVER.
by Revnalde, Pechey, Strother (by whom it was first called Puerperal Fever),
and other early English writers ; by Viardel, Peu, Mesnard, and other ancient
French authors, and by the Germans.
  From  careful investigation it has been proved that the disease prevails
epidemically, and that it  is more  virulent in  hospitals.   It  is everywhere
more frequent  among the lower classes than the higher.   In Dublin this is
even more remarkably the  case than in London.
  780. For the purpose of giving a more distinct view of the prevalence of
puerperal fever, I have made out (as accurately as possible) a chronological
list of the different epidemics, with  the  names  of the authors  by whom
they are noticed  or described, and  the  pathological  characteristics when
ascertained.
Date of Epidemic.	Place.	Author.	Characteristics.
1664	Paris,	Peu, (Lee).	
1746	Paris,	Malouin,	Peritonitis, Hysteritis, etc.
		Jussieu,	Disease of Ovaries.
1750	Lyons,	Doulcet,	Peritonitis, U. Phlebitis.
1750	Paris,	Pouteau,	Hysteritis, Erysipelatous.
1760	London,	Leake,	Inflam. of Omentum, etc.
1760-61	Aberdeen,	Gordon.-	
1761	London,	White,	Peritonitis.
1767	Dublin,	Jos. Clarke.	
1769	London,		
1770	London,	Leake,	Peritonitis (partial).
1771	London,	White.	
1773	Edinburgh,	Young.	
1774 to 81 |	Paris, London,	Tenon, Doulcet,	
	Vienna,	etc.	
1774-87, 88	Dublin,	Jos. Clarke,	Peritonitis.
1782	Paris,	Doulcet,	Peritonitis, Hysteritis.
1783	London,	Osborn,	Peritonitis.
1795	Vienna,	Jaeger,	Peritonitis, Phlebitis.
1786	Paris,	Tenon.	
1787	Gottingen,	Osiander.	
1788	London,	Jos. Clarke,	Hysteritis, Peritonitis, etc.
1787-8	London,	Do.	Peritonitis, Hysteritis, etc. Peritonitis.
1789-90, 91, 92,	Aberdeen,	Gordon,	
1803-10, 12, 13,	Dublin,	Collins, Douglass,	Peritonitis.
1808	Barnsley, Yorksh.	Hey,	Peritonitis.
1812-13 r	Leeds, Yorkshire, Sunderland, coun-	Hey,	Peritonitis.
1813 -j	ties of Durham, and Northum-berland, Dublin,	V Armstrong,	Peritonitis.
1811	Heidelburg,	f Naegele. \ BayrhoflFer.	
	v " *** o>		
1812	Holloway, London,	Dun,	Peritonitis.
1814-15	Edinburgh,	Hamilton.	
1816 1817-18	Paris, Pennsylvania, U. S.	Tenon, Dewees,	U. Phlebitis, Hyster. Perit. 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, 1835-36-38	London, London,	Ferguson, Do.	Peritonitis, Hysteritis. Phlebitis, etc.
2825-27, 28, 29 {	Dublin (Lying-in Hospital,)	Collins.	1
 
PUERPERAL  FEVER.                     539
Date of Epidemic.		Place.	Authors.	Characteristics.
			f	Inflam. of Peritoneum, Ute-
1829		Paris, (Maternite"),	Tonnelle, J	rus and appendages, and Uterine Phlebitis.
1829-40, oc-	f	London, Birming-	1™ „	
casionally,	1	ham,Dublin (Ly-ing-in-Hospital.)	VE. Kennedy.	
1831	{	Birmingham, ■> Aylesbury, J	Ceeley.	
1836-34		Vienna,	Bartsch,	Uterine Phlebitis.
1836-7	{	Dublin, (Newl Lying-in-Hos. j	Beatty,	Peritonitis, Pleuritis, etc.
1838		Paris, London.		
1842		Rennes, London.		
1843		Rouen.		
1844		Rouen, Rennes.		
1845	{	Rouen, Paris, Griitz.		
1846	{	Rouen, Dublin, Scotland.		
1852	{	Brakel, West- \ phalia, /	Disse,	Typhoid fever.
1854-5		Dublin,	M'Clintock,	Do.
   781.  From a review of the history of the epidemics of puerperal fever, it
 appears that there is some remarkable connection between them and lying-iu
 hospitals.   I  do not mean to assert that the epidemics always originate in
 and are kept up by these institutions, but I refer to the fact that we have no
 record  of any epidemic independent of them in earlier times.  The first in
 France, England, and Ireland occurred in the Hotel Dieu of the former, and
 in the  lying-in  hospitals of the latter countries;  and although our earlier
 writers  allude to inflammation of the womb, etc., occurring in childbed, they
 make no mention of its prevailing extensively or as an epidemic.  No doubt
 it has since been observed in private practice, in London, Edinburgh, Dublin,
 Leeds,  etc.; but its extent in these cases is, after all, comparatively limited.
 In Dublin the higher ranks have been singularly free from attacks of the dis-
 ease.   Dr.  Joseph Clarke practised for forty-four years in this city, during
 which time  he attended 3847 cases of midwifery, and yet in that number he
 met with only three casps of peritonitis, and three others where the disease
 is doubtful,  but which may have been uterine phlebitis, although, during that
 time, puerperal fever was more than once epidemic in the hospital.   It has,
 however, certainly been more frequent of late years.
   782.  Perhaps the most general fact connected with  puerperal fever is  the
 presence of local disease.   In  almost all cases of the epidemic,  when an
 opportunity of post-mortem examination has been permitted, local lesions of
 some kind or other have been detected, and even where this opportunity was
 denied  little doubt was felt by the medical attendants that such existed.   It
 seems very probable, also, that in many cases where the local disease seemed
 but  slight, there  would now be recognized  very important changes, for we
 know that a patient may die of  inflammation  of  the uterine veins or lym-
 phatics, with  very  obscure symptoms, and without either  enlargement or
 obvious tenderness of the uterus, and that  these morbid lesions may easily
 be overlooked if the examination be hasty or superficial.  It is only fair,
 however, to  state that Dr. Copland, in an excellent article on puerperal fever,
 differs from  this  view.   He states that his  experience has " convinced him
that a most  rapidly fatal  and a  most malignant form  of puerperal fever is 
540
PUERPERAL  FEVER.
occasionally developed in lying-in  hospitals, which is certainly not charac-
terized by uterine phlebitis nor by purulent collections in the  uterus or its
appendages, nor  even in  some cases by peritonitis, the  chief lesions  often
being merely a remarkable alteration of the blood, general lacerability of the
tissues, or loss of their vital cohesion soon after death, with a dirty, muddy,
offensive, and sometimes  a scanty  effusion  into the  serous cavities."1  He
adds, however, that such cases are  rare.
   The local  affections in  puerperal fever embrace all the  usual results of
inflammation, and involve all  the tissues of the  organs of gestation, either
separately or together.   The  most frequent appears toj be peritonitis, ori-
ginating very probably in the outer covering of the uterus, but  spreading to
the entire serous  cavity.   We find  also inflammation of the muscular tissue
of  the  uterus  with  its  consequences,  abscess,  softening,  and gangrene;
inflammation of the  lining membrane, softening, and gangrene ; inflamma-
tion of the veins and  lymphatics, with the secondary affections thence arising,
inflammation and purulent deposits in different organs, muscles and joints;
and inflammation of the ovaries,  with its consequences.
   783.  I  must repeat my conviction that there are not many cases  of puer-
peral fever without some local disease of the organs employed in parturition,
or  of the neighboring tissues ; but are we thence necessarily to  conclude
that puerperal fever is always simply a local affection, the local disease being
primary and the fever secondary ?  Must we adopt Dr. Robert Lee's opinion,
that his " observations are subversive of the general opinion now prevalent,
that there is a  specific, essential, or idiopathic fever, which attacks puerperal
women, and which may arise independently of any local affection in the uterine
organs, and even prove fatal without any change  in the organization of their
different textures ?   As the constitutional symptoms thus appear  to derive
their origin from a local cause, it would  certainly be more philosophical and
more consistent  with the principles  of  nosological arrangement to  banish
entirely from medical nomenclature the terms puerperal or childbed  fever,
and substitute  that of urine inflammation, or inflammation of the uterus and
its appendages, in puerperal women."2
   In the former editions of  this work  I adopted Dr. R. Lee's views, and
employed his arrangement; but whilst  I confess my obligations to his able
researches, and agree with him as  to the presence  of local lesions generally,
I am bound to  state honestly and frankly that more extended experience
has led me to doubt  the accuracy of these  views, and to  believe that malig-
nant puerperal fever is something more than  a local affection, and that the
constitutional disease is often rather primary than secondary.  At  the same
time I have no doubt that Dr. Lee's views  are applicable  to many cases.
   What, then, is the essential nature  of the  malignant epidemic, puerperal
 fever ?   This is a question not easy of solution, and one which  has  led to the
 expression of very different opinions.  It has been regarded as

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

                  Inflammation of the Omentum and Intestines, by
   Hulme>                          Leake,                        La Roche.

            1 Dictionary of Pract. Med.  Part xiii. p. 500.
            2 Researches on the more  Important Diseases of Women, p. 3. 
PUERPERAL  FEVER.
541
Warier".
Johnson,
Forster,
Cruikshank,
Peritonitis, by
Bichat.
Pinel,
Gardien,
Capuron,
Gordon,
Hey,
Armstrong,
Clarke,
Campbell,
Collins.
Pouteau,
Home.
Lowder,
Willis,
Puzos,
Peritonitis connected with Erysipelas, or of an erysipelatous character, by
Peu,
Petit,
Selle,
Finch,
          Young,
          Abercrombie,
          Gordon,


     Fever of a peculiar nature, by

             Levret,
             Doublet,


   Disorder of a putrid character, by

Tissot,             Le Roi,

   Disease of a complicated nature, by
Armstrong,
Hey,
Campbell, etc.
Hamilton.
White.
Kirkland,
Walsh,
Tenon,
Tonnelle,
Fever with Biliary disorder, by
       Stoll,
Lee,
Ferguson.
Doulcet.
   If  we regard  the peculiar characteristics  of different epidemics, we find
them extremely varied.   In one, the lochia are suppressed;  in another, they
are profuse ;  and in a  third, unaltered.  Diarrhoea  is common  in  one epi-
demic, constipation in another;  typhoid symptoms in one ;  inflammatory in
another.   And as to the  effects  of remedies, we  find as great a diversity;
one  high authority recommends  saline purgatives, which fail in the hands
of other practitioners ;  another loses  all his patients until he bleeds largely
at the commencement, whislt others lose all who are so bled.   Calomel is  the
universal remedy in one epidemic, opium in  another, purgatives in a third,
inunctions in a fourth, turpentine in a  fifth, etc.
   Now,  from these variations, the inference is obvious,  that the type of  the
disease varies in different epidemics, and that the treatment must necessarily
differ.   But I  think we  may go a  step further ; and if any one will  carefully
compare a case of simple inflammation  of the womb  or peritoneum  in child-
bed  with a case  of malignant epidemic puerperal  fever, their  symptoms,
general  and local characteristics,  course, and the  effects  of remedies,  he
will  be  obliged  to  come to the conclusion that,  although the latter may
exhibit local disease, it is not exclusively nor  primarily a local affection.
   784.  I should wish to speak very cautiously and guardedly on so difficult
a subject, but after a careful comparison of the experience of others  with  my
own,  I am inclined to believe that the  essential difference between epidemic
puerperal fever and simple inflammation  consists in a morbid deterioration
of the blood in the former case, which is rarely present in the latter, or not
till an advanced  stage ;  whether this  deprivation result from some general
noxious influence or from some malign peculiarity of the constitution.  The
following considerations seem to  support this view:  1.  Puerperal  fever
prevails  most during the winter and spring months, in moist and cold  weather,
or during alternations of cold and warm moist weather, as the following table
shows :— 
542
PUERPERAL FEVER.
Table  I.  (Dr. Gordon's.)
October .
November
December
January .
February
March
1821, March
  "  April
May
June
July
August
September
October
November
December
Cases of Puerperal.				Cases of Puerperal.
. 13			April	. 6
	8		May ,	. 6
	12		June July	
	8		August	. 5
	6		September	. 5
Table		II. (Dr. CampbelVs.)		
3ases of Puerperal.				Cases of Puerperal.
. 1			1822, January .	. i
	7		" February.	. 6
	2		" March	. 5
	2		" April	. 4
	3		" May	. 4
	1		" June	. 3
	. 1		" July	. 2
	. 7		" August	. 1
	. 13		" September	. 3
	11		" October .	. 2
Table  III.   (Dr. Ferguson's.)
January . February1 March April*. . May . . June . . July . . August . September October . November December	1827	1828	1829 3 7 3 1 1 6 3	1830	1831	1832 2 1 1 2 2	1833	1834	1835	1836	1837	1838	"3 0
	1 ' 3 4 V	2 2 ' 4 3 3 3 8 4 8		3 2 1 1	' 4 1 2 2 9 2		1 2 2 2 1 1	' 3 4* o	2 2 ' 2 5 6 5 2 2	4 6 6 6 2 4 3	3 3* 2	9 ' 8' 9	34 17 22 34 20 16 5 4 12 11 9 21
Attacked. Died . .	10 i	37 7	24 6	7 2		8 5	9 3	9 5	26 10	31 9	9 2	26 20	205 68
1819, January
  "  February
  "  March
  "  April .
  "  May  .
  "  June  .
January
February
March  .
April   .
May   .
June
Table
Table IV.	(M. Dugls\)
Cases.	
. 81	1819, July .
. 82	" August
. 65	" September
. 47	" October
. 67	" November
. 35	" December
e V. (M. D	elaroche's, Geneva.)
Cases.	
. 77	July
. 43	August .
. 76	September
. 55	October
. 35	November
. 40	December
Cases.
 40
 40
 53
 69
 74
 63
Cases.
 37
 36
 51
 51
 66
 61
1 Hospital closed Feb. 1838.               2 Closed from April to Nov. 1838. 
PUERPERAL  FEVER.                     543
  Thus, the most injurious months in Aberdeen were October, December,
November;  in Edinburgh, November,  December, January;  in London,
January, March,  February, December, May; in Paris, November, October,
February; in Geneva, January, March, February : and during these months
we find other diseases prevail most whose characteristic is depravation of the
blood.
  2. The two  epidemic diseases which most commonly prevail at the same
time, and under somewhat similar circumstances, are erysipelas and typhus
fever, especially the  former, whose  presence in  surgical  hospitals is always
indicative of impending  puerperal fever.   Some have  gone  further, and
expressed their opinion of these diseases being so far identical, as that in-
fection  from either  erysipelas or typhus  fever  may give rise to puerperal
fever.   Mr. Nunnelly, in his work On Erysipelas, considers the two  diseases
to be identical, prevailing during the same atmospheric conditions,  exhibit-
ing  the same general symptoms, and each capable of reproducing the other.
Dr.  Hutchinson and others have seen both puerperal fever and erysipelas in
the  same patient at the same time, and I have noticed that the infants of
women attacked by puerperal fever are very liable  to erysipelas or diffuse
inflammation.  It is also beyond  question, that infection carried from  a
patient suffering  from erysipelas to a lying-in  woman, may in her  give rise
to puerperal fever.   I  am not, however, about to contend for the identity
 of these two diseases, but merely to point out the great probability that the
 essential feature  of erysipelas is a morbid alteration  of the blood, or, in the
 words of Mr. Nunnelly, that "it is highly probable, if not certain, that  there
 is some change produced in  the state of the blood, which change may de-
 pend upon alterations we are unable at present to appreciate, but which is
 likely to occur in many tissues, and may thus affect  the  mass of the blood,
 more or less quickly, and to  a greater or less extent, according to the  influ-
 ence they have upon, and the connection they have with,  the blood in a state
 of health."1
   As to typhus fever, there is evidence on record that  women in childbed,
 exposed to  the  contagion  of typhus, have  exhibited all  the  symptoms of
 puerperal  fever.   The late Dr. Labatt mentioned to me that he had known
 a patient laboring under typhus fever, and brought into the lying-in  hospital,
 originate puerperal fever in  patients in the same ward, who had recently
 been confined.  And  Dr. Collins mentions a  similar instance.  No doubt
 exists  at present,  I believe,  that  in typhus  fever the state of the blood is
 much deteriorated,  and that this constitutes a most important, if not essen-
 tial, character of the disease.  As bearing upon the present question, I may
 quote the following passage from Dr. Ormerod :2 " Besides the sudden in-
 crease  under  such  circumstances,  of the number of patients suffering from
 fever there is observed  in all epidemics, from the plague of Athens down-
 wards  a tendency of all diseases  to assume, as far as may be, the  epidemic
 tvpe ' Much  probably,  of this is  explicable on the supposition of the  exist-
 ence'of the same atmospheric condition affecting all who cannot resist it, in
 the same way  ; but however this maybe, as far as general impressions in the
 absence of notes will justify the assertion, simultaneous with the occurrence
 of  fever in the  medical wards, phlebitis and  troublesome  sores are more
 commonly met with in the surgical wards of this hospital, and erysipelas of
 the head and  face  in both."   Much more evidence  of a similar kind  might
 be adduced, but this is sufficient for my purpose.
    aaoucea        ^ ^^ ^ ^^ ^^ certam forms f puer.

 peral fever and the secondary fever which occurs after great surgical opera-
 tions, and which there  can be little doubt is owing to the absorption of mor-
     ' i On Erysipelas, p.  72.            _    ' On Continued Fever, p. 168.
      3 Med. Times and Gazette,  April 23, 1859. et seq. 
544
PUERPERAL FEVER.
 bid matter.   This very closely agrees with the conclusions expressed by Dr.
 Ferguson, as follows : " 1, the phenomena of puerperal fever originate in a
 vitiation  of the fluids ; 2, the causes which are capable of vitiating the fluids
 are particularly rife after childbirth;  and 3,  the various forms of puerperal
 fever depend upon this  one cause, and may readily be deduced from it;"1
 and he quotes in confirmation  the analogy drawn by Cruveilhier between
 the surface of the uterus and an amputated stump.2
   785. Thus  then we find that the same seasons give rise to erysipelas,
 typhus fever,  and puerperal fever; that they prevail epidemically  at  the
 same time ; and as an epidemic take on the same type, and appear capable,
 the one of giving rise to the other, or of co-existing in the same patient.
 Further,  that the symptoms of certain forms  at least  of puerperal fever are
 similar to those  which occur after great surg'ical  operations, and that the
 secondary lesions are similar.   Now,  in  erysipelas,  typhus fever, and  the
 secondary fever after operations, there can be little doubt of the depraved
 condition of the blood, and it is  highly probable that their low typhoid
 character is owing  to this  blood-poisoning.  I  think,  therefore,  that  the
 conclusion, that the peculiar character and malignancy of certain epidemics
 of puerperal fever also depend  upon a morbid condition of the blood, how-
 ever produced, in addition to the local disease, is inevitable."3
   Unfortunately we have but little direct evidence  of the state of the blood
 in puerperal fever.  Dr. Arnott's researches  have  disproved John Hunter's
 opinion, that phlebitis destroyed life by an extension  of the inflammation to
 the  heart;  and with other investigations  have shown that it is owing pro-
 bably to  deterioration of the blood.   M. Bouillaud, in 1825, attributed the
 typhoid symptoms in phlebitis to a mixture of pus with the blood ;  and  he
 adduces the  experiments of Baglivi, Magendie, and Gaspard, as confirming
 his opinion, they having produced similar results by the injection of  putrid
 matter into the system.   We know from  the observations  of  Dance, Ton-
 nelle, Duplay,  Lee, and many others, as well  as from  our own observations,
 that pus is found in the uterine  veins in considerable quantity in some forms
 of puerperal fever, and we find that the symptoms described as characteristic
 of irritative phlebitis closely resemble those of puerperal fever.
   Mr. Moore states that he  " has seen a black precipitate in the blood of a
 person laboring under the adynamic form of the  disease.   Such a deposit
 is often found  in typhus and  in  the last stage of  infectious  erysipelas  and
 phlebitis.   Another  similarity  between the blood  in  this affection and  in
 other diseases of a typhoid and  malignant character, is the peculiarly, offen-
 sive odor  occasionally arising from it."*
   In the  epidemic which occurred in 1845, in Paris, and  which presented
 the symptoms of low typhus, MM. Bidault and Arnold state  that the blood
 was  dark and  semi-coagulated, as in low typhus fever.5  And  in the epi-
 demic  which occurred at Gratz in  the same year, Dr. Schoeller mentions
 that the blood was very fluid, and exhaled a peculiar bat-like odor;  in other
 respects it resembled the blood of persons  poisoned by Prussic acid.6
   Dr. Scanzoni has recently  maintained that the special causes of puerperal
fever originate in the altered condition of  the blood, and consist mainly in
the presence  of pus.7
  i On Puerperal Fever, p. 53.                    2 Anat Path#j Liv. 13.
  3 For further details, I refer the reader to  a review in the  Brit, and For. Med.-Chir
Review for  October. 1855, to Dr. Murphy's paper in the Dublin Quarterly Journal, Auc
1857, Dr. Fordyce Barker's able paper, read before the New York Academy of Medicine
and to Dr. Simpson's valuable lectures in the Med. Times and Gazette, beginning April

  * On Puerperal  Fever, p. 183.                    5 Gazette MSdicale,  Aug. 1845.
  6 Med. Jahrbuch. der K. K. Oester.  Staats, Oct. 1845.
  1 Ranking's Abstract, vol. vii. p. 335. 
PUERPERAL FEVER.                     545
  In a case of puerperal peritonitis, on the evening of the second day, Dr.
Simon found  that the blood  formed a tolerably firm clot, and was covered
with a buffy coat of an  inch  and a half thick; the chemical  analvsis fur
nished similar results to  those obtained by MM. Andral and Gavarret.
  In  cases  of metro-peritonitis, quoted  by Dr. Day, from the analysis of
Scherer, Haller, Becquerel, and Rodier, the blood presented an increase of
fibrin, and a great diminution of blood corpuscles.
  Dr.  Copland states that he  is not  acquainted with  any analysis  of the
blood in the most malignant form of puerperal fever, except that which Dr.
Day quotes from Haller, who  states that the blood was of a very dark-brown
color.   The clot was dark, of  a loose consistence, and  covered by a buffy
coat, over  which was  a delicate  membrane, which presented under the
microscope a  firmly  granulated appearance and fat vesicles.  The serum was
turbid,  but after standing for some  time it  became clear ; its reaction was
alkaline; its  specific gravity 1025.   The fibrin  was 5-16; the  blood cor-
puscles 77-52.   According to  Becquerel and Rodier,  the cholesterin and
phosphates are increased.
  Although the evidence I have now adduced may not be sufficient to prove
that purulent  depravation of the blood  is the sole or essential cause of
malignant puerperal fever, I think  it affords  ground for believing that the
general element which constitutes the difference between this  form of puer-
peral fever and simple  inflammation  of the uterus and  peritoneum, may
consist in some form of deterioration of  the  blood, depending either upon
atmospheric malaria  from without or absorption of some noxious  matter
generated within the body.  At all  events,  I cannot  but agree with Mr.
Moore, that "in puerperal fever, typhus, cholera, and  other  epidemic and
contagious  diseases belonging  to the  class neuroses, there  is, besides in-
flammatory action,  another element unknown, but  which has an essential
influence upon the intercurrent phlegmasia? arising in their course, and which
may yield at one point only to appear at another."1
  786.  Various causes have been assigned for the production of this disease :
it has been attributed to difficult labor,2 to uterine inflammation,3 to an accu-
mulation  of noxious humors,* to violent  mental  emotions, stimulants, and
obstructed perspiration  ;5 to  miasmata; to  admission  of cold air  to the
body and  into the  uterus;  to hurried circulation ;  to  suppression  of the
milk ;  to diarrhoea ;6 to putrid contagion from alteration in the fluids during
pregnancy ;7  to  hasty separation of the placenta ;  to too  tight application
of the  binder;8  to  sedentary employment; to stimulating or spare  diet;
to fashionable dissipation; to retained portions of placenta; to floodings
from  non-contraction, according to Mr.  Skey; from violence  but not from
want of contraction, according  to Dr. Armstrong ;  to  inflammation  of the
intestines  and omentum, from  the  pressure of the gravid uterus ;9  to at-
mospheric derangement; to erysipelas, metritis or phlebitis, and to con-
tagion of a specific kind.
  A word or two upon  some of these supposed  causes may not be  out ot
place.   I do not think we can fairly regard difficult labor as a  direct cause,10

  i On PuerDcr&l Fgvgf p 126.
  2 Of 1.116 cases in the Dublin Lying-in Hospital in 1819-20, 68  were first labors; but
they were not remarkably tedious.
  3 F. Plater, Prax. Med., 1686, vol ii. chap. xii.   Hoffman 1/34 vol. iv. part i. Bur-
ton, 1751, Essay on Midwifery, part iv.  Smellie, Tissot,  K.rkland, Denman, etc.
  * Sennert, Opera, vol. ii. part ii.: Ulcers, b. n. ch v.
  5 F Cooper, 1766, Comp. of Med., part iii. sect. iii.  Leake, vol. u. part xxxm.
  6 R W. Johnson, 1769, New System of Midwifery, part  iv._chap. vii.
  i T Miller 1770, Obs. of Prevailing Diseases, part iii. ch. n.
  8 Mining on  Female Diseases, eh.  «.     • Dr. Hulme on Puerperal Fever, p. 147.
  io Armstrong on Puerperal Fever, p. 2.
       35 
546                    PUERPERAL FEVER.
although the condition in  which the woman is left  may render  her more
obnoxious to the epidemic.  Primiparae certainly seem somewhat more liable
to be attacked,1 and also  patients who at the time of  labor are in a weak,

  [We have had repeated opportunities of studying epidemic puerperal fever.
To  each visitation of the disease in Philadelphia and  its suburbs, witnessed
by  us, the same remarks are applicable  as  were  made in  the account we
rendered to the College of Physicians, of the very fatal and extensive epi-
demic which prevailed in Philadelphia during the .spring of 1840.   Namely :
that the disease occurred alike in the young and middle  aged, the robust and
delicate, in those surrounded by every comfort  and afforded every attention
demanded by their  situation, as in the poor and destitute ; as well in those
confined for the first time, as in those who had already borne a  number of
children;  and as well  after the most rapid  and  easy labors,  as after those
that were protracted and difficult.3]
  Mental emotion may undoubtedly be considered  an effective predisposing
cause.  Under its influence females are peculiarly exposed to puerperal fever,
and less able to bear it; thus it has been remarked, that unmarried women
are often victims.*   Several of  the worst cases I have  seen were  mainly at-
tributable to this cause.   Cold may fairly be  admitted into the list of causes.
Portions of placenta remaining in  the uterus, and putrefying, may, I believe,
give rise to puerperal phlebitis, although this is by no means invariably the case.
   Gastro-enteric irritation  may certainly be  propagated to  the neighboring
tissues;  and  cases  which appeared  simple  at first  may thus assume  the
character of puerperal fever, especially during an epidemic.
   That hemorrhage during or after labor does not prevent  puerperal fever,
we have abundant proof; but that it reuders a  patient more liable to it,
except so far as it reduces her strength, may  be doubted.
   To a  considerable  extent, as we have seen, the state of the atmosphere
influences the disease; in damp, moist weather, it is  much  more  prevalent,
and less so in warm, dry weather.
   Whatever that which we call epidemic  influence may be, there can be no
 doubt that to it the  majority of cases are attributable, especially the worst
 and most fatal.
   787.  Another very important question yet remains  for Our investigation,
 viz., that of the infectious or contagious nature of puerperal  fever, particu-
 larly when it is epidemic.   Of the  simple cases of peritonitis or phlebitis after
 labor, occurring  sporadically, I do not  know that any one considers them
 contagious; but of the low malignant fever, opinions have varied consider-
 ably.  Drs.  Hulme, Hay,  Armstrong, Dewees,  Davis, Baudelocque, Ton-
 nelle, Jacquemier, Kiwisch, Dewees,  Meigs, etc., deny  the contagion; Drs.
 Gordon, Young, Clarke, Denman, Burns,  Hamilton, Blundell,  Gooch,  Mr.
• Ceely,  Drs.  Ramsbotham, Rigby, Lee,  Copland, Channing, Holmes, etc.,
 affirm it.
    In all cases where a disease  is epidemic, it is, and ever must be, a difficult
 matter t6 decide as to the extent of its infectiousness, because, in order to
 be exposed to either the contagion or infection, a person must also necessa-
 rily be placed in circumstances favorable to  the exertion of  its influence as
 an epidemic.   But  after a close  and careful examination of the history of
 epidemics, of the cases recorded, and of the  opinions of men of the greatest
 experience, I believe  that the weight of evidence is in favor of puerperal
 fever being  infectious and contagious, i. e., that it may be communicated

        i Collins' Pract. Treatise, p. 384.
        2 Dr. Jos. Clarke's Essay, Med. Comment,  1791, p. 311
        3 [Trans. College of Physicians, Philadelphia, old series, vol i. p. 51].
        4 Home, Chir. Exp., p. 83. 
PUERPERAL  FEVER.
547
from a patient laboring under it to another who is in contact or close neigh-
borhood with the affected party.
  788.  Leaving  the general question of contagion from one patient to
another, let us for a short space examine  into the evidence in  favor of the
communicability  of  the  disease by  a third party from a patient laboring
nnder it to another during or after her delivery, as this has a direct practical
bearing upon the duties  of medical  men.   The exact value of the facts on
record will be better estimated by a little  classification.
  1. It seems impossible to doubt that contagious matter capable of exciting
puerperal fever may possibly be conveyed by a third party unaffected by it;
ibr example, in the cases on record of puerperal fever following the services
of medical men and  nurses who were in attendance upon erysipelas immedi-
ately before.  The instances are too remarkable and too  numerous to be
regarded as coincidences, nor would even the prevalence of an epidemic of
puerperal fever at the time invalidate our conclusions; it might certainly
render the cause more influential.
  2. It is the recorded opinion of Rokitansky, Semelweiss, and others, that
morbid matter acquired  in the  dissection  of subjects not dying of childbed
fever may be conveyed by  the dissector, and  excite the disease in a patient
delivered by him; and to this, among other causes, has been attributed the
presence of puerperal fever in the wards  of the Vienna Lying-in Hospital.
A celebrated foreign' practitioner attributed two outbreaks or this  disease
among his  private  patients to his  having handled morbid specimens just
before attending a patient in her accouchement.
   3. We should, therefore, have less difficulty in believing that similar effects
may be produced by those passing from tb,e dissection of puerperal patients
to the delivery of healthy  ones, especially if the most rigid precautions were
not observed. For instance, in the autumn of 1821,  Dr. Campbell, of Edin-
burgh,  attended the dissection of a  married woman who died of the disease,
after an abortion of the early months;  he removed the pelvic viscera and
external parts, and  carried the whole in  his coat pocket to the class room.
The next  morning,  dressed in the  same  clothes, he assisted, with some of
his pupils, at an instrumental delivery at  Bridewell.  This woman was seized
with the same  affection, and died.   The same night he  accompanied Dr.
Orr to  the delivery of a woman residing in the north back of the Canongate;
she was equally unfortunate ; and three other poor women shared the same
fate in quick succession.   In a subsequent year, 1823, he assisted at the dis-
section of  a childbed fever case, but could not wash his hands with the care
he  desired ;  thence  he went to attend two  other women  in labor, both of
whom  died  of puerperal fever.
   At a meeting  of the College of Physicians, Philadelphia, U.S., Dr.  War-
rington stated that,  after assisting at an autopsy of puerperal peritonitis, he
was called  upon  to deliver three women in  rapid succession.  All  these
women were attacked with different forms of what is commonly called  puer-
oeral fever
   « Mr  Davies states that in the  autumn of 1822 he met with twelve cases,
while his medical friends in the neighborhood did not meet with any or at
least with verv few.   He  could attribute this  to no other cause than  his
havin- been  present at the examination  of  two cases,  and his having con-
veyed^the infection to his patients, notwithstanding every precaution.
   "A vouno- surgeon, shortly after examining the body of a sporadic case
that had died, delivered three women, who all died of puerperal fever." _
  -Air  Inodeby  states that two gentlemen, after the post-mortem examina-
tion ^ a case of this disease, went in the same dress  each respectively, to a
nase of  midwifery.  The one case was attacked in thirty  hours afterwards
the other in three days.  One  of the same surgeons attended, in  the  same 
548
PUERPERAL FEVER.
clothes, another  female, and she was attacked on the evening  of the fifth
day, and afterwards died."1
  Now with regard to cases attended immediately  after the post-mortem
dissection, there seems little room for doubt as to the exciting cause of the
fever.   It may have been conveyed in the clothes or on  the hands of the
accoucheur, but  it is, at any rate, adequate  to the effect, end the sequence
is too simple and too close to be rejected.
  4. Can we venture  to say the same of the following case:  Dr.  Merriman
mentions in the Lancet for May 2, 1840, that he was present at the exami-
nation of a case of puerperal fever at two p.m.  He took care  not to touch
the body.  At nine o'clock the same evening he attended a woman in labor;
she was so  nearly delivered that he had scarcely  anything to do.  The next
morning she had rigors, and died in forty-eight hours.
  We  do not know whether puerperal fever was epidemic at the time, but
the cause suggested seems so  inadequate that we should be inclined to look
for some other explanation.
  5. So far, then, we have seen medical men engaged in handling morbid
matter, their dress and persons exposed to the effluvium from dead bodies,
and passing directly to attendance upon lying-in-women ; here we have a
distinct, appreciable exciting  cause adequate to the production of disease in
healthy persons, and which may have  been, and  probably was,  conveyed to
the patients %ho were first attended, and in whom puerperal fever  appeared.
But in several instances the disease was not confined to the  first women
attended, but appeared in others delivered  successively.   How  are we to
explain this, and how can we explain the pertinacity with which  puerperal
fever seems occasionally to track the footsteps of one or two practitioners,
whether at first lighted up by  morbid matter derived from dissection  or not?
Take the following examples.  Dr. Gooch mentions  that "A general prac-
titioner, in large midwifery practice, lost so many cases from puerperal fever,
that he determined to deliver  no more for some time, but that his partner
should  attend in his  place.   This plan was  pursued for one month, during
which  not a case of the disease  occurred in their practice.   The elder prac-
titioner being then sufficiently  recovered, returned to his practice, but the
first patient he attended was attacked by the  disease, and died." This latter
fact seems to us to prove that the disease was epidemic at the time.  Similar
instances have come to our own knowledge more recently.
  Dr. West, of Philadelphia, states that seven females delivered  by Dr. S
Jackson, in rapid succession, were all attacked with puerperal fever, and five
of them died.  These were the  only cases that occurred in that district  for
the women became alarmed, and sent for other assistance.
  A physician in Boston, U.S., had the following consecutive cases : — On
March 24th  April  7th, 10th, 11th, 27th, and 28th, and May 8th, seven in
all, of which five died.  He then left town.
_  Another physician writes to Dr. Holmes as follows :_" The first case was
m February, 1830, during a very cold time.   She was  confined on the 4th
and died on the  12th.  Between the 10th and 28th of this month I attended
six women  in labor  all of whom did well  except the last, as also two who
were confined March 1st and 5th. Mrs. E., confined February 28th, sickened
and died March  8th   The  next day, March 9th, I inspected the  body, and
™  "JS? ?ft!I ^nded alady, Mrs. G., who sickened and died on the 16th
laX t   I attended another, Mrs. B., who sickened but recovered.  March
J?pH LWT  oFi°?   ™  ^V?°m t0 attend aMrs-  H-  wh0 sickened  and
died on  the  21st   The 17th I inspected Mrs. G.   On the 19th I went di-
rectly from Mrs. H.'s room to attend another lady, Mrs. G., who  also sick-
1 Copland's Dictionary.  Art. Puerperal Fever. 
PUERPERAL FEVER.
549
ened  and died on  the  22d.   While  Mrs. B. was sick on the 15th I went
directly from her room, a few rods, and  attended another woman who was
not sick.   Up to the 20th of the month I wore the same clothes   I  now
refused to attend any  labor,  and did not until April 21st,  when  havin°-
thoroughly cleansed myself, I  resumed my practice, and had no more puer-
peral lever.   The cases were not confined to a narrow space   The  two
nearest were half a mile  from each other, and half that distance from my
residence.   The others  were from two to three miles apart.  There were no
other cases in their immediate vicinity."
   Dr. Ramsbotham has known the  disease to spread through a particular
district, or to be confined to the practice of a particular person, almost every
patient being attacked by it; whilst  other practitioners  had not a single
case ;  and he considers  the distemper as being capable of conveyance not
only  in  common  modes,  but  through the dress of the attendants on the
patients.
   In Sunderland, 40 out of 53 cases occurred in the practice of one surgeon
and his assistant.
   Dr. Roberton, of Manchester,  states, that between  the  3d of December,
1830,  and January 4th, 1831, a  midwife attended  30  patients of  a public
charity, 16  of whom had puerperal fever, and  all died.  Other midwives of
the  same institution  attended 380 women during the same time, and none
suffered from  it.   He also mentions  the  case  of a  practitioner, who intro-
duced the catheter for a poor woman in puerperal fever, late one evening,
and attended a lady in her confinement during the  same night, who was
attacked with puerperal fever on  the second day.
   Analogous cases have been recorded by Dr. Pierson, of Salem, U. S., Dr.
Peddie, and Mr. Becroft;  and such examples  are, doubtless, very startling,
and require a careful examination, to  ascertain their exact value as bearing
on the question  at issue ; but we  shall first hear what Dr. Meigs says on the
other side.  His first argument is from personal experience :—" I have prac-
tised midwifery for many long years.   I  have attended some thousands of
women in labor, and  passed through repeated epidemics of childbed fever,
both in  town and  hospital.   After  all this experience, however, I do not
upon careful reflection and self-examination, find the least reason to suppose
that I have ever conveyed  the disease from place to place in any single in-
stance.  Yet for many years I carefully considered whether such  a transfer
by a third person  might be possible, and carefully read the statements of
various authors to that  effect.   In the course of my professional life, I have
made many necroscopic researches of childbed fever, but never did suspend
my ministry as accoucheur on that account.   Still I certainly never was the
medium of its transmission.  I have, in numerous instances, gone from the
bedside of women  dying  of childbed  fever, whether sporadic, or the  most
malignant degree epidemic, without making my patients sick.  I have  also
endeavored  to assist my brethren, when they had such cases and I had none.
In a series of labors, 468 in number, and beginning with No. 1, I find  that
Nos.  18 and  19 were affected, and that No.  18 died with childbed fever;
No.  31 was  sick, but recovered ; Nos.  195 and  259 were sick, but recovered;
but 291  died, as did also  293.  Nos. 332, 339, 435, 444, and 445  were
attacked, and recovered.  The above cases—viz., 18, 19, 31, 195, 259, 291,
293, 332^ 339, 435, 444,  445, 455, are, in all, 13 cases in 468 labors, of which
3 died and 10 recovered.   Now, if I was the medium of contagion for any
one of that  series  of  468  confinements, why did I poison them in the ratio
and order above set forth ;  and why did I not communicate the disease in
more than 13  out of  468  cases ?   What became of my nebula from 31 to
195 •  to  259,  and  between 291 and 445, and so to the end, or  46* ?  Such
a table is far more easily explained by regarding the falling-out of the cases 
550
PUERPERAL  FEVER.
as coincidences and accidents, than as material causations, through a private
pestilence."
   Again, as regards the singular limitation of the disease to the practice of
one person, Dr. Meigs observes :  "At page 631 of'my work On Obstetrics,
second edition, I  have related the circumstances attending the practice of a
physician at Philadelphia, who, in one  of our epidemic  seasons, lost a con-
siderable number  of women in childbed.   His  patients  were scattered over
a great superficies of the city and  districts, some of them being more than
two  miles  from the others.   At that  time many women were  attacked, in
various parts of Philadelphia, as well as in the  State of Pennsylvania ; yet,
so far as has come to  my knowledge, no other medical gentleman happened
to encounter such a great number of childbed fevers  as he did.   I visited, in
consultation with him, some of  the very worst of the cases,  and touched the
patients, and was as liable to imbibe or to  be clothed with the effluvia from
their bodies as he was ; nevertheless, I did not carry poison or other cause
of disease to any patient of mine;  and if not I, then how should he become
capable of doing  so ?   He is a gentleman who is scrupulously careful of his
personal appearance, of great  experience as a practitioner,  and well in-
formed, as  to  modern opinions on  the contagion of childbed fever.   Still
those of you who  are  contagionists will say that he carried the poison from
house to house, and if so, then you ought to give some rationale of the fact.
Did  he carry it on his hands ?  But a gentleman's  hands are clean.  Did
he carry a  nebula or halo about him ?  Then why not I also ? If the nebula
adhered to his clothing, it might as well as have adhered to mine.   What
will you say, young gentlemen, of the experience of my friend, Dr. D. Rutter,
formerly of Philadelphia, but now of the city of Chicago, who passed through
terrible scenes here, in an epidemic of childbed fever, some years ago, when
he had  a most extensive  midwifery practice in town and country ?   During
that sad time, I saw several fatal cases with him  in consultation ; and though
he seemed to be tracked  by the cause of the disease, to judge by the numer-
ous attacks of it in his lying-in patients, I was  not  tracked by it.    I took
no precaution, except such as every decent man should  be supposed  always
to take ; yet I never did carry the disease from his cases to any houses where
I visited lying-in  women.  But he was charged  with being a carrier of con-
tagion.   How could he carry the cause ?   What was the cause ?   Was it
some ozone that stuck to his hands or coat:  Was it a nebula, a halo, or  a
miasm that mixed with the hairs of  his head or  the woollen  or cotton fibres
of his dress ? or an exhalation from  his skin, or a halitus from his lungs, like
the fiery breath of Cacus ?  And can you say of  him, as  Yirgil sings__
                   " «Faucibus ingentem primum, mirabile dictu
                     Exomit.—JEneid, lib. viii. p. 252.

Come now, was not such poison more sticky than birdlime, seeing  that Dr.
Rutter, worn  out with fatigue, and  wounded in spirit by his cares for the
unfortunate victims of an epidemic disease, left the  city for  the purpose of
gaining some  strength, and to escape from the  repetition  of such disheart-
ening labors, and that even  a quarantine could not  liberate him from this
poisoned cloud ?   One might hope  it would  have been blown  away by the
wind, or that it would have evaporated or become  too  dilute  to kill, after
a ride of seventy miles, and an absence  of ten days.   But it happened,' after
this rustication of ten days at a distance of thirtv-five miles from  the city
that  your birdlime or cloud still  adhered to  him,  as  your contagionists
would say.   And more than that, he could not  even wash it away  or shave
it off;  for upon coming back to the city, and to his  professional toil, before
he engaged in practice again, he caused his head to be  closely shaved ; he
entered a warm bath and washed himself clean; he procured a new wig 
PUERPERAL  FEVER.                     55]
 new clothes, new hat, new gloves and new boots.   He did not touch anv-
 thing he had worn and took the precaution to leave his pencil at home
 and his watch   Well, what do you think happened  next ?   He went out to
 attend a lady in labor,  who had a favorable  parturition, yet was next day
 assailed by a horrible childbed fever,  of  which she died in  spite of all his
 effort^, and mine  to help him ; for he called  me in in consultation imme-
 diately after being summoned himself to her chamber.   I know that that
 lady died with  peritonitis.  I was a  great deal with her in her illness, but
 she did  not poison me or my clothes;   for  although I went  on with my
 practice  I poisoned nobody, and made nobody have even so much  as  a
 nnger-ache.   Dr. Rutter repeated this attempt at personal disinfection at a
 subsequent period,  which was two years  later, and with the same ill-success
 1 he gentleman was much and  disparagingly spoken of on account of the
 above mentioned  events in his practice, which I cannot but regard  as  both
 cruel  and unjust,  particularly as his success  in  the  treatment  was  most
 brilliant; for during the epidemic he  had charge of  seventy cases, of which
 he lost only eighteen, and I know not the man who can boast of a higher
 triumph of his art of healing in this malady."1
   789. Let  us now look a little closer  into this matter.  The broad fact
 apparently established by the foregoing observations is, that puerperal fever
 does sometimes prevail  chiefly, or is  altogether limited, to the patients of
 certain practitioners, and the  question arises, To what is this owing ?  The
 question is not, whether contagion is  the only, or the chief,  or the ordinary
 means  by which the disease is propagated ;  for it is  admitted on all hands
 to prevail epidemically.  Nor is it the  question, whether,  under favoring
 circumstances, contagion may not be conveyed  to  the patient by the ac-
 coucheur, for we have  related cases in which  it seems  impossible to doubt
 that this took place.  We must therefore eliminate from the foregoing  ex-
 amples the case of the physician who  wrote to Dr. Holmes, because,  having
 made post-mortem  examinations, his  experience  may rather be referred to
 section 3. • In most of  the instances, we are  not told whether the  practi-
 tioners examined  the bodies  after death  ; if they did,  we  cannot deny that
 there was a possibility that they might have carried the infection.
   Again, if, as Dr. Rigby remarks, "the discharges  from a patient in puer-
 peral fever are highly contagious," it is at least possible that the case of the
 midwife mentioned  by Dr. Roberton  may be  thus explained,  inasmuch as
 her duties about  her patients would  necessitate  more or less  contact with
 the excretions.
   Excluding these  classes of cases, evidence  enough remains to show that
 the fever does sometimes follow in the track of particular accoucheurs;  and
 the real question before us is,  whether it  does  so by contagion conveyed by
 him from other patients, in spite of the  ordinary precautions, or in certain
 cases, notwithstanding the extraordinary precautions  of baths, change of
 air, change of clothes, etc., or whether in such cases the prevalence of an
 epidemic of  puerperal  fever is a  sufficient explanation, admitting it  to ex-
 hibit caprices similar to other epidemics.   It is impossible to bring the
 matter to a  demonstration either way, difficulties meet us  upon either sup-
 position, and perhaps the best plan to adopt will be for us  to weigh these
 difficulties separately.
   Against the explanation which  attributes, with Dr.  Meigs, all to epidemic
 influence, is the  fact of  its greater prevalence in the practice of  certain me-
 dical  men, and its  being in some cases apparently limited to them.  That
one man  should see more cases than  another of any epidemic disorder is
common enough, and would be no difficulty in the present case ; but that
1 On Childbed Fever, p. 102. 
552
PUERPERAL  FEVER.
one should see all, and others none, does seem rather startling.  But is the
proof of the latter sufficiently conclusive  and sufficiently extensive ?   Dr.
Gooch does not  tell us whether the disease was epidemic or not,  nor does
Dr. West.   [The cases referred  to by Dr.  West occurred in the practice of
Dr. S. Jackson,  at Northumberland, Pa., and they formed the entire extent
of the disease in that neighborhood, at the period of their occurrence, and
for several years before and subsequently.]  The gentleman who4 wrote to
Dr. Holmes states that no other cases occurred in the vicinity, but we have
rejected his example as being one of possible contagion on the ground of
his post-mortem examination^.   In  Sunderland there were at  least thirteen
cases which occurred  in the practice of others, besides  the surgeon and his
assistants.   The two  examples related  by  Dr. Meigs occurred during epi-
demics.  So that it must be confessed that  the evidence we possess to  show
the insufficiency of  epidemic influence as an explanation, and the  necessity
of finding some'other cause for  its  greater prevalence in a particular direc-
tion, is neither extensive nor positive.
   The explanation which  attributes this peculiarity to contagion, has the
merit of being simple and apparently adequate, but the  difficulties on ex-
amination are more numerous and fully as  great.  Assuming  for a moment
that the disease  can be only communicated during labor, let us recall to our
readers what takes place during an ordinary visit to a  patient in  puerperal
fever, during which time the infection is  to  be taken.   The visit may occupy
five or ten minutes, the physician stands by the bed, feels the pulse, examines
the abdomen, but does not come in contact with  the discharges.   Having
made his  investigations, he washes  his  hands carefully,  and then pays more
visits, passing through the air, until evening, or until he is called to a -labor.
If many hours elapse, he must have washed his hands several times.   Yet,
in spite of all this, we are to suppose that  he carries morbid matter on his
hands or clothes, acquired from the fever patient, enough to poison the
lying-in woman.   And not only this,  but the explanation is supposed to be
equally valid even though he change his clothes, thus limiting the infection
to the hands, and even though he use chloride of lime or potash.
   If the  morbid matter be conveyed on the hands, the infection, we sup-
pose— and such seems to be the general opinion — must be imparted during
labor ;  but if on the person  or clothes, the effect might of course be pro-
duced subsequently,  and  hence another difficulty.   During  the  visit,  the
consulting physician  is as close to  the  fever patient, examines her, handles
her quite as  much at  the visit as her ordinary attendant, and, it may be
assumed,  adopts afterwards  much  the  same  precautions.  Yet we do not
hear of his conveying the fever to  his own patients  in  any case, and we
 have Dr. Meigs's positive statement that such an occurrence never took place
 ,n his practice.   The advocates of contagion should  explain this.
   Again, in all  contagious diseases the intensity of  the contagion  imparted
to, and conveyed by, a healthy person  (as in scarlatina, for example) must
surely be in proportion to the shortness of the time which  elapses between
his visit to  the sick person and to the party to whom he conveys it; in other
words, that his  chance of so conveying it would diminish with the lapse of
time.  For example, an accoucheur visits a patient  in puerperal fever, sup-
 pose, and acquires  this contagious property ;  if this rule be true, the first
 patient he  attends  will be more liable to take  the disease than the second,
 and the second  than the third.  How then explain the  fact, on the principle
 of contagion, that no such sequence of attacks is observed ? the cases affected
 observe no such order, as the reader will see by turning back to Dr. Meigs's
 'egistry.
   Moreover, in  two of the most striking cases we have quoted, Dr. Gooch's
 ind  Dr. Rutter's there is a circumstance which is  not reconcilable with, or 
PUERPERAL  FEVER.                     553
explicable by, the doctrine of contagion, as we understand it.  In the one
case a month, and in the other ten days, of absence elapsed, and the latter
was accompanied  by a complete renewal of clothing, and yet the first case
attended by both was attacked by puerperal fever.   Are we to attribute this
to remaining contagion, and, if not, does it not point directly to some other
influence which may have operated previously as well ?
   Thus, a belief in the contagiousness of puerperal fever under ordinary cir-
cumstances, and excluding the cases in sections 1, 2, and 3, must involve, ou
the one hand, the conclusion that it  is of all contagious disorders the most
virulently contagious, inasmuch as it  assumes that it can  be conveyed by  a
healthy person exposed for  a few moments only to its  influence, to  a third
party hitherto in  health, and this  notwithstanding  that the hands, the only
part in contact with the sick person,  have been carefully washed, the  clothes
changed, aud the entire person exposed to the  air, it may be for hours ; and
yet  on the  other hand, that this  contagious  property  limits itself  to  the
ordinary attendant, and does not affect the consulting physician.  Admitting
that we can not fully and  satisfactorily explain the  limitation of the  disease
on the supposition of epidemic influence only,  I ask the reader whether the
difficulties attendant  upon  the  explanation  by contagion  are  not more
insuperable ?
   In conclusion, therefore, whilst I feel compelled by the evidence on record
to admit the possibility of puerperal fever being conveyed and communicated
or excited by those  who  attend  midwifery cases after being  employed in
dissection or post-mortem examinations, and also by those who are much in
contact with the fever patient  or the discharges,  especially if strict pre-
cautions are  not adopted as to cleanliness and change of dress ;  I do not feel
that in other cases, where no such conditions exist, that the evidence at all
justifies our attributing the spread of the disease to contagion, and I think
fewer difficulties  and  contradictions are incurred by  attributing its extension
to epidemic influence, and its  limitation to conditions or circumstances of
which we are at present ignorant.
   Convinced ourselves from personal observation, that contagion or infec-
tion is one," at least, of the means to which the propagation of puerperal fever
is to be referred, we nevertheless admit that there are a number  of facts—
chiefly however of a negative character—which it is very difficult to recon-
cile with the contagiousness  of either of the forms of the disease.  One of
the strongest evidences in favor  of its contagious or infectious character, as
Dr. Tyler Smith very correctly remarks, is that the  only successful efforts to
reduce the mortality from puerperal  fever,  have been those directed to the
removal of infection  and contagion.   In the course of a few years the mor-
tality in the great hospital at Vienna, from this affection, was  reduced from
1 in 10, to 1 in  74 of the women delivered, by the enforcement of measures
to prevent the inoculation and injection of the  puerperal patients.
   790. N"ow, what are the precautions which  ought to be taken by persons
who practise this branch of the profession ?  We have seen that in all proba-
bility the contagion  if at all conveyed, is so either  by the  clothes  or the
hands of the practitioner,  from a patient laboring under the disease, or from
the dead body.   I would suggest the following :—1. That when engaged in
close attendance upon a patient laboring under puerperal  fever, the medical
attendant should, if possible, procure a  substitute  to attend  any new case
of labor;  but if he cannot, then, 2.  He  should,  before such attendance,
chano-e every portion of his  dress,  and wash his  hands in a solution of
chlorate of lime, as well as in  soap and water.   3.  Dr.  Semelweiss'sugges-
tion  of paring  the nails close, is worth adopting, as  particles  of morbid
matter may  easily  be concealed underneath,  and  applied  to the mucous
membrane of the vagina.  4.  At the termination of each visit to a patient 
554
PUERPERAL  FEVER.
in puerperal fever (or in any infectious disease), the hands  should  be care-
fully washed with soap  and water before  leaving the room, and his clothes
repeatedly changed and well aired.   5. That if a medical man have patients
in childbed, one of whom  should be attacked by puerperal fever,  his daily
visit should be first paid to the other patients and afterwards to the puerpe-
ral case, if the distance permit of his so doing.  6. It will be wiser for any
one engaged in midwifery  practice to procure  an  assistant to make post-
mortem examinations for him ; and if he  be present, he ought  not to wear
the same dress in attending obstetric cases  until  it have  been well aired.
If  the  autopsy be made by himself, extraordinary precautions should be
taken as to repeated ablution, with solution of chlorate of lime, etc. ; and  a
complete change of dress;  or  perhaps, as Dr. Copland suggests, he ought
to  allow some days to  elapse  before attending obstetric cases.  7.  These
remarks apply to all autopsies, no matter of what  disease the subject died,
although  they are more  stringent in cases  of death from puerperal;  and also
to attendance  upon and dressing cases of erysipelas, diffuse inflammation, etc.
   791.  In treating of puerperal fever, various arrangements  or classifications
have been adopted to include the different forms of the disease.   Thus Dr.
Douglas describes three forms :—

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

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

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

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

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

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

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

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

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

  793. I. Inflammation of the Peritoneum.—This variety of the disease
was the one chiefly observed in the epidemics in London, Aberdeen, Leeds,
Edinburgh, and formerly in Dublin-; and it has occurred in other epidemics!
It appears to  affect the  peritoneum  covering the  uterus  primarily, and to
extend from thence to the remaining portion of the serous membrane,' involv-
ing not unfrequently the uterine appendages.
  The attack may commence even before delivery, of which I  had an exam-
ple ; but more generally from twenty hours to three days afterwards.   Dr.
Joseph Clarke mentions that two of his patients were  ill during labor; three
were attacked  on the second day,  one on  the fourth, and one on the ninth
day.  In the epidemic of 1788, one was attacked four days before delivery
one on the day of delivery, eight on the second day, and three on the third.1
  794. Symptoms. — The first symptom is either sudden rigors, pain, or
some variation in the pulse.   Dr. Campbell has remarked that in 'some who
were attacked early, the sinking of the pulse which takes place after delivery
in ordinary cases,  was absent, and its frequency rather increased.   Generally
speaking, the rigors are first noticed; to  these succeed heat of skin, thirst
1 Essays in Med. Comment, 1791, pp. 311-315. 
puerperal  peritonitis.
557
flushed  face, quickened pulse, and hurried  respiration.  The heat of skin,
however, soon  subsides, and during the  course  of  the  disease it  may not
exceed the natural standard.  To these symptoms succeed nausea, vomiting,
pain in  the head, and increased sensibility of the  uterus.  In some cases the
uterine  tenderness (not amounting to pain)  is contemporary with the rigors,
or immediately succeeds them.   Pain  in  the  abdomen soon attracts notice.
It generally commences in the hypogastrium, or in one of the iliac regions,
gradually radiating  over  the abdomen.   The pain  may be slight or severe,
continuous, or in paroxysms — the intermissions being more remarkable  as
the disease advances.  After the remission,  the pain shortly returns with
increased violence.  We  are not, however, to consider the pain as pathog-
nomonic of the disease, for we sometimes  see abdominal pain resembling that
in puerperal peritonitis,  which  afterwards  disappears altogether.   And  in
certain  cases of undoubted  puerperal peritonitis there is no pain, or pain  of
slight duration.  I have seen five or six cases  of intense puerperal peritonitis
 (as shown by dissection)  in  which there was neither pain nor tenderness.
   Dr. Ferguson  has carefully estimated the frequency of this symptom, and
he has  found that

            The number of  his patients who had no pain was .  .  19
                                   ■who had pain for 1 day was 51
2	tt	48
3	tt	22
4	ii	18
5	it	6
7	it	5
8	it	4
  The pain from the first is accompanied with more or less sensibility of the
hypogastrium ;  this tenderness becomes exquisite as the inflammation ex-
tends, until at length  the  patient cannot bear the slightest pressure ;  even
the weight of the bed-clothes is intolerable, and the tension and pressure of
the parietes are avoided, by lying on the back, with the knees drawn up.
The enlarged uterus can frequently be felt through the integuments, above
the brim of the pelvis, at an early stage of the  disease.1  Shortly after the
disease is established, the  abdomen becomes tumid and tympanitic, and in
some  cases,  at  a  more advanced stage, the presence of effusion may be de-
tected.   The air which gives rise to the tympanites may be contained either
in the intestines or the peritoneal sac.
   The effect of the disease upon the lochial discharge varies; in the ma-
jority of cases it continues  to  flow as usual; in some,  the  quantity is  di-
minished ; and in  others it is suppressed.2  The secretion of  milk is much
more  uniformly influenced  by the attack.   If it have commenced before the
incursion of the disease, it is suspended, and the  mamma? become flaccid ;
if the disease precede, the secretion is generally prevented.  It is remarka-
ble, that a great number of the  patients lose all  interest m their infants, and
even refuse to give  them suck.                           .
   The pulse is uniformly high throughout  the disease, varying from  110 to
140 in a minute, and  towards the termination to 160 and upwards.   It is
generally small and wiry, but is liable to modifications, from treatment, and
from the peculiar character of the epidemic.3
   The  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
wtth  a yellowifh or white fur at the  edges.   The thirst is considerable  at

       i Camnbell on Puerperal Fever, p. 33.  Lee on  Puerperal Fever, p. 21
        Sev on Puerperal  Fever, p. 23^ Armstrong on Puerperal Fever, p. 4
       s Hulme on Puerperal Fever, p. 6.  Campbell on Puerperal Fever, p. 35. 
558
PUERPERAL  PERITONITIS.
the beginning and towards the termination  of the disease, but much less
during its height.  The stomach is disturbed  at a very early period, and the
nausea and vomiting continue at intervals throughout the attack.  At first,
the matter voided is merely the contents of the stomach, mixed with mucus;
afterwards bilious  matter is ejected; and  lastly, green, brown, and  black
fluids, constituting what is called the "coffee-ground vomit."  Mr. Murray
found this to  consist chiefly of resin, together with mucus, gelatine,  phos-
phate of lime, and muriate  of  soda in small proportions.1  In many cases
the irritation  extends  throughout the intestinal  canal,  and diarrhoea is the
result.   This,  by some, has  been  held to  be  a favorable  symptom, but  by
others  as an aggravation of the disease ;  and certainly my own observations
would  rather incline me to the latter opinion.   The dejections vary in char-
acter and consistence, becoming very dark and foetid towards the termina-
tion in bad cases.
   The urine is  generally turbid or high  colored, and somewhat diminished
in quantity; and the  patient  has frequently some difficulty in  voiding  it.
Dr. Hulme observes that " The patient at first often complains of some diffi-
culty in making water,  and discharges it in small quantities ; but this usually
goes off after having  a  stool  or two.   The urine, after standing for some
time to settle,  generally appears of a brown color,  and deposits a  crude
sediment, half-floating, at the bottom of the glass."2
   Throughout the course of the disease,  the  skin  is much about the natural
heat, and dry, but as a fatal termination approaches, it becomes  cold and
clammy.
   The intellectual faculties  are rarely affected.   Dr.  Gordon, indeed, men-
tions that delirium was occasionally, but rarely, observed in the epidemic he
describes; but in general the  patient retains her consciousness  and senses
until very near the end.   The countenance is very much changed ;  the fea-
tures are all drawn upwards, and expressive of great anxiety and suffering.
A patch of crimson, like a hectic flush, is  sometimes observed on one or both
cheeks, and is an unfavorable symptom.
   Such are the characteristic  symptoms as  laid down by those who  have
had most experience in the disease.   Its duration will vary according to the
virulence of the epidemic; some cases have  terminated fatally on the first,
second, or third day of the attack ;  others from the fifth to the tenth.   Dr.
Denman fixes the general termination on the  eleventh day; Mr. Forster,
from the  fourth to the sixth  day ;  Dr.  Leake, the tenth  or eleventh day;
Dr. Hulme, the seventh  or eighth  day;  Dr. Hamilton,  the fifth  or sixth
day ; Dr. Gordon, on the fifth day ;  Mr. Skey, within a week ; and M. Bang,
on the sixth  day.   Dr.  Campbell states  that the greater number of his
patients died on the fifth day ;  one  died on the first;  three on the  second ;
three on  the third;  four on the fourth;  seven  on the  fifth; one on the
sixth ;  two on the seventh ;  and one on the eighth day ;8  Dr. Blundell says
that it may destroy the  patient  within twenty-four hours  from the com-
mencement of the disease, or  that  " three  or four days, not to  say five or
six, may be the average duration  of the affection."4   Dr. Collins thus gives
the result of his experience : " In fifty-six deaths in the hospital,  it proved
fatal at  the following periods from  the date  of the seizure, viz., two in
twenty-four hours;   one  in  twenty-seven;  one in thirty-six; nine on the
second day; fifteen on the third ;  thirteen on the fourth ;  four on the fifth ;
five on the sixth ; three on the seventh; two  on the eighth ; and one on the
eleventh day."5
   795. Morbid Anatomy.—The peritoneum may, in some few cases, ex-
hibit no signs of inflammation ; but generally it  is found more  or less vas-
  1 Campbell on Puerperal Fever, p. 181.           2 On  Puerperal Fever, p.  9.
  8 Ibid., p. 50.        * Obs*etricy, p. 74.        s Pract. Treatise on Mid., p. 374. 
PUERPERAL  PERITONITIS.
559
 cular, especially that portion of it covering the uterus.  Dr. R. Lee has given
 it as his experience,  that  " puerperal peritonitis commences in the peri-
 toneal covering of the uterus, and extends from thence with greater or le<s
 rapidity, according to the severity of the attack, to the whole peritoneum
 In some cases the inflammation is confined to the uterus, and it is generally
 most severe m this situation, or in the parts immediately surrounding that
 organ ;  even when it has extended to the other viscera, and affected them
 most severely, the peritoneum of the uterus invariably exhibits signs of
 recent inflammation.   The lymph is, for the  most  part, thrown  out in
 thicker masses upon the uterus than in any other situation ; and this viscus
 seems always to suffer in the greatest degree.  In the cellular membrane,
 under the  peritoneum, serum and  pus are also  not unfrequently found de-
 posited.   The cellular tissue also, which  surrounds the vessels of the uterus
 where they enter and quit the organ, not unfrequently contains some serous
 or purulent fluid, and the same appearance has been observed in the cellular
 membrane connecting together the muscular fibres."1
   Dr. Collins states, that "in  thirty-seven of the fifty-six women who died,
 the following post-mortem appearances were discovered :—the abdomen
 being ostensibly  the  seat of the  disease,  the morbid  appearances were
 chiefly found there;   however in seven we  observed  fluid effused  into the
 thoracic cavities, similar in appearance to that met with in  the abdomen.
 Effusion of fluid, though differing in character and quantity, was invariably
 found to have taken place.  In twelve it seemed to be  serum  of  a straw
 color ; in  eighteen, it  was sero-purulent, something of the consistence of
 thick cream ; and in seven it appeared bloody-serum, with quite a glutinous
 feel when  rubbed  between the  finger and  thumb.  In these latter cases,
 which rapidly proved fatal, there was no lymph whatever found; whereas,
 in the other varieties, it was  usually found  deposited in large  quantities,
 particularly in the vicinity of the uterus, but often over the  entire  surface
 of the intestines and  abdominal serous membrane.  In almost every body
 examined,  the peritoneum exhibited great increase of vascularity; nor could
 we discover in any instance that the inflammation seemed to penetrate deeper
 than this membrane.   The  uterus, in a  great majority of cases, was  quite
 natural in appearance ; in some, it was  soft and flabby;  and in a few, un-
 healthy matter was found in its sinuses.  The ovaries, in numerous instances,
 had suffered  much in structure from the effects of inflammation ; being gene-
 rally much enlarged, and so softened in texture as to be broken in pieces by
 the least pressure."2
   Thus we find vascularity of the  peritoneum and thickening  somewhat in
 proportion to the duration of the disease, a layer of lymph covering the
 intestines and omentum, and agglutinating them together, effusion of serum,
 etc., to be  the most general effects of this disease.   These  appearances may
 be limited to the uterus and pelvic viscera, or they may embrace the entire
 abdomen ;  in some rare cases they appear almost confined to the omentum.
   The quantity of serum with  flocculi of lymph floating  in  it varies con-
 siderably, and I think somewhat in proportion to the duration of the disease.
 In those cases which rapidly prove fatal, we more frequently find the  organs
 covered with a layer of semi-fluid lymph; but in more prolonged cases, in
 addition, we find more  or less  effusion.   It does not vary  in chemical com-
 position'from that in ordinarv peritonitis.  It may be clear or turbid, of a
yellowish white color, with shreds of lymph in it, resembling very much the
whey produced in making cheese.  In some rare cases blood is found in the
 peritoneal sac, either alone  or mixed with the serosity.  Punform matter is
also frequently found, especially in the pelvis, around and behind the  uterus,

  i More Important Diseases of Women, p. 24.       2 Pract. Treatise on Mid, p. 398. 
560                 PUERPERAL PERITONITIS.

where the inflammation has apparently been most intense.  It is  sometime*
contained in a cyst, which is  apparently a  concretion  of the  outer surface
of the pus.
   But the effusion of serum  or pus may not be confined to the free surface
of the serous membrane merely, but may occur beneath it.  In an epidemic
which prevailed in Dublin, Dr.  Sam.  Cusack states that "Two kinds of
effusion were met with  in the  cells of those tissues  (sub-serous and pelvic
cellular  tissue), one a reddish serum, occasionally so  copious as to  pervade
not only the cellular tissue about the uterus, the pelvic cavity,  and the iliac
regions, but even sometimes to distend the cells of the delicate  cellular tissue
which connects together the two layers of the mesentery.   The other specie^
of effusion is  not  of so fluid a nature, resembling  jelly in appearance and
consistence.   This also occupies the cellular tissue, and is most conspicuous
where the looseness of the peritoneum admits of free  effusion.  Thus the lax
nature of the cellular tissue connecting the  layers of the peritoneum, which
form the broad ligaments of the uterus, admits  of its being  poured out in
considerable quantities  in that situation."1
   796.  Diagnosis.—1.  From after-pains, or hysteralgia.—These affections  *
occur soon after delivery, and diminish or disappear  by the  third or fourth
day—about the period when puerperal  fever commences.  After-pains are
accompanied by a perceptible  contraction of the uterus, which is absent  in
puerperal fever.  The  pulse is sometimes accelerated  by after-pains, but is
seldom  steady in its frequency; in puerperal peritonitis it never falls below
its frequency at first, but generally increases.   The  hypogastric  tenderness
in after-pains is not great, except during a  pain, and it goes on decreasing;
whilst in puerperal peritonitis it rapidly increases.   The constitutional dis-
turbance is incomparably greater in  puerperal peritonitis, and it augments
every day ;  whilst in hysteralgia it diminishes.  The sedative, which gener-
ally relieves after-pains, has little  or no influence upon  the pain in puerperal
fever.   Notwithstanding these distinctions,  there   are  undoubtedly  many
cases in which the diagnosis  is by no  means  easy  at  first; and  our treat-
ment should be arranged so as to err (if we be in error)  on the'safe side.
   2. From intestinal irritation.—This affection frequently assumes  many  of
the characteristics  of  puerperal  fever.   There  are, however, several points
of difference.   It is generally accompanied by marked evidences of gastric
and intestinal  disorder.  The tongue is loaded,  there is flatulence, nausea,
and vomiting, constipation, or diarrhoea.  The abdominal pain is  diffused,
and does not radiate from the  uterus,  as in  puerperal peritonitis ; neither is
the uterus enlarged, nor tender.   The abdomen may be enlarged  and tense,
if there be much secretion of air;  but percussion  will at once distinguish it
from enlargement  by the effusion of  serum :  it is rarely very tender  on
pressure, and  gentle friction  affords  relief.   It  may  occur at any period
after delivery,  and at first may occasion some anxiety from the resemblance
of the  symptoms to those of puerperal fever;  but twenty-four  hours will
generally clear up the  difficulty; the  pulse falls, the milk is secreted, the
lochia are not unhealthy, and the pain and distress are relieved by medicines.
A little inquiry will generally elicit the fact that the bowels had been neg-
lected previous to delivery.2
   3.  From ephemeral fever, or weid.—The  commencement of ephemeral
fever may excite some alarm,  from its resemblance  to puerperal  fever;  but
its duration is  shorter,  its decline  rapid, and its constitutional  symptoms less
severe.   There is also far less abdominal irritation,  and the breasts continue
distended.3
   4.  From hysteritis.—The main distinction is the character and  situation
   1 Edinb. Med. and Surg. Journal, No. 98.       2 Lee on  Diseases of Women, p. 22.
   3 Armstrong on Puerperal Fever, p. 22. 
PUERPERAL  PERITONITIS.
561
of the  tenderness:  in puerperal  peritonitis,  the slightest touch  on the
abdominal parietes causes acute torture ;  whereas, in hysteritis, the patient
can bear  pressure very well,  until we can feel the enlarged uterus   Any
increase of  pressure, after the  abdominal parietes are in contact with the
uterus, gives acute pain.1   The  symptoms  of hysteritis are also more local
  797.  Prognosis.—The general prognosis is unfavorable, even in sporadic
cases, but still more  so when the disease is epidemic.
  Dr. Hulme declares it to be as bad as the plague.'
Dr. Leake lost	13	cases out of 19
Dr. W. Hunter	31	32
Dr. Clarke	21	" 28
Dr. Gordon	28	" 77
Dr. Campbell	22	79
Dr. Armstrong	4	44
Dr. Lee	40	100
Dr. Collins	56	88
Dr. Ferguson	68	205
   In the epidemic in  Paris (1746),  in Edinburgh (1773), and in Yienna
 (1795), none recovered.
   Mr. Hey  observes, " For some time after the commencement of this fatal
 malady, it proved  fatal in every case that came within my knowledge; and
 though a few patients recovered under the treatment which my father and I
 had formerly found successful with puerperal fever, yet the success was very
 small till the method hereafter described was fully adopted."2
   Dr. Ferguson states, " If we take the results of treatment adopted in vari-
 ous puerperal  epidemics, by various  practitioners, we shall find that on a
 large scale one in  every three will die, with all the resources which medicine
 at present offers.   To  save two out of three, then, may be  termed good
 practice in an epidemic season."3
   If the  epidemic be  as  severe as some which have  occurred in Dublin, it
 would be very successful practice to save one out of three.
   798. Treatment. — It must be  borne in mind, that when any peculiar
 mode of treatment is advised, the  character of the  epidemic is the test of its
 propriety.   Forgetfulness of this rule has been the source of much contro-
 versy, and no slight acrimony.  As Dr. John Clarke  remarks, each author
 takes the epidemic he has witnessed as the type of all, and remorselessly con-
 demns all treatment which does not agree with that which  he has found sue
 cessful.  There is no question that the employment of antiphlogistic remedies,
 by Gordon, Hey, Armstrong, etc., was a  great improvement upon  the old
 methods,  in  the epidemics which  they witnessed ;  but it is not to be  taken
 for granted that it would have answered equally well  in the previous ones.
 For many years past it has been found either inadmissible or injurious in the
 cases we have had in Dublin.   The type of  the disease and the state of the
 patient have  not only prohibited the  use  of  the lancet, but have indicated
 very clearly the necessity  of a  line  of treatment very different, if not the
 opposite.   Thus, in all cases, we  must carefully appreciate the general con-
 stitution of disease and the special character of the epidemic, as well as the
 state of the patient, in order to decide upon the most suitable treatment, with
 reasonable probability of success.  Moreover, in cases  where bleeding is ad-
 missible, it has appeared to me that the time for its beneficial use is very limited.
After the disease  has lasted more than from twelve to twenty-four hours, I
have seen but little benefit from bleeding; and the same observation I have

    i Armstrong on Puerperal Fever,  p. 20.          2 On Puerperal Fever, p. 10.
    • Ibid, p. 112.
       36 
5 62
PUERPERAL  PERITONITIS.
heard from Dr. Charles Johnson, of this city, whose opinion is most deservedly
of the  highest authority.
  Having premised thus much, I shall describe the treatment which has
ordinarily been found the most  efficacious.
  If the pulse be firm, a large quantity of blood is advised to be taken from
the arm.   Dr. Gordon recommends from 20 to 24 ounces,  at the beginning,
and, if necessary, this may  be repeated.  The blood generally exhibits the
buffy coat.   Dr. Ashwell  considers Dr. M. Hall's  method  of placing the
patient upright  and  bleeding to  incipient syncope, of great value in puer-
peral peritonitis.1  Should  any circumstances forbid a repetition of the vene-
section, a number of leeches (from 60 to 100, Campbell) may be applied  to
the abdomen, and  when they fall off, the abdomen should be fomented,  or
covered with a light  bran  poultice.   The fomentation, or poultice, may  be
repeated at intervals,  as it has a very soothing effect.
   This practice boasts the  support of  very great names—Denman, Leake,
Gordon,  Armstrong,  Hey,  Campbell, Mackintosh, Jos. Clarke, MM. Duges
and Tonnelle, Blundell,  Conquest, Gooch,  Dewees, Lee, Meigs, etc. ;  but it
was recommended with limitations by Kirkland, Hull, Gardien, Douglas, etc.;
and in some epidemics, as I have said, it is either inadmissible or injurious.
Dr. Collins remarks, that " In fifteen only of the eighty-eight did we deem
it advisable  to bleed  generally:  seven of the  fifteen  recovered."  "I am
satisfied, however, that in hospital,the immediate application of three or four
dozen  leeches, followed  by the warm bath, in which  the patient should re-
main as long as her strength will bear it, will be found in the great majority
the most judicious means of removing  blood."2
   After  full depletion, the next  powerful remedy is mercury, alone or in
combination with  opium.  Without explaining its  modus  operandi, it is
sufficient to state the fact, that it has  been  found to exercise a remarkable
influence over inflammation of serous membranes.  It may be given in large
doses (gr. x. every three or four hours), or in smaller ones, more  frequently
repeated (gr. ij. every hour); and it should be continued until an impression
is made upon the disease, or until the  mouth is affected, unless purging be
induced.  The mouth will  be affected much more rapidly, and with smaller
doses, if to each be added a very minute quantity of tartar emetic, say Jgth
 of a grain ; but this  will not do if there be nausea  or vomiting.  I am  in-
debted to Dr. A. Smith for this suggestion.   After a  decided effect is pro-
duced, the dose may  be diminished, and the intervals lengthened.  For the
 purpose of preventing  intestinal irritation, it  is  usual to combine  it with
 Dover's powder of opium.   Perhaps  it is  not too much to say, that the
 benefit of the opium  in this combination  is not confined to the prevention
 of intestinal disturbance, but that it exerts  a  positive and beneficial influ-
 ence upon the inflammation.   When the calomel acts on the bowels, it may
 be omitted, and the opium  alone continued; and I have seen as much benefit
 from it alone, as from the calomel.   Some years ago I saw a case of puer-
 peral  peritonitis, in  consultation with a friend, and we administered large
 doses of opium (gr. j.  every hour) with the greatest  benefit.   Since then,
 several similar cases  have occurred to me.  Dr. Stokes was the first to point
 out the value of opium  in bad cases of  peritonitis, where bleeding was inad-
 missible ; and I have repeatedly verified his observations.
    Mercurial frictions are a valuable  mode  of  affecting the system, and  for
 this purpose I would strongly recommend the Linimentum Hydrargyri of the
 London Pharmacopoeia.   But I may say of mercury as I said of bleeding,
 that though very efficacious in  many  cases, there are others in which its
 effects are injurious,  or in  which  it is inefficacious.

     1 On Parturition, p. 481.        2 pract# Treatise on Midwifery, pp. 391, 393. 
PUERPERAL  PERITONITIS.
56?
   Tartar emetic was recommended by Hulme, and used by several since his
time, with apparent benefit.  The state of the stomach, in many cases how-
ever, will prevent its exhibition.
   Purgatives have been warmly-recommended by Hulme, Denman, Gordon,
Hey, Armstrong, Chaussier, St oil;  and as strongly  reprobated by Baglivi]
John Clarke, Cederskiol, Thomas, Campbell.   " My own experience," says
Dr. Ferguson, "with  regard to  aperients is, that whenever they'create
tormina, there is the greatest risk of an attack of metro-peritonitis succeed-
ing.   This  so  constantly  occurs,  that I invariably mix some  anodyne —
usually Dover's powder, or hioscyamus, or hop, with the  purgative."   If the
bowels be constipated, an enema of turpentine and castor oil will be useful.
The spontaneous diarrhoea is not always beneficial, but will often need to be
restrained by astringents, or opiates.
   Emetics were employed before 1782 by English practitioners, and in 1782
they were recommended by Doulcet, of Paris, who relied upon them exclu-
sively, and  derived from  them extraordinary success.   Other practitioners
have also used them successfully;  but they have failed so often, as to have
gone out of use, especially in  these countries, perhaps  in consequence of our
mistaking the proper cases.  M. Tonnelle states  that  M. Desormeaux tried
them with  great success  in 1828, but that  in  the next  year they generally
failed.   In  September, 1829, they succeeded, but in  October and"November
they failed.   They did not, however, appear to produce  any aggravation of
the symptoms.  Dr. Ferguson remarks, that " The practical question, then,
is, what are the cases in which the remedy is applicable ? The clue has been
already given, I imagine, by Doulcet himself;  it is when the violence of the
malady has fallen on the  liver especially, and when there is early nausea and
spontaneous vomiting."1
   In the year 1814, Dr. Brennan, of Dublin, proposed  the internal use of
turpentine,  which he  regarded  as a specific, and which in many cases was
very successful.  He gave it in doses of a tablespoonful at a time, in a little
water, sweetened.  Drs. Douglas,2 J. A. Johnson, Dewees, Payne,3 Kinneir,
Blundell, and Waller, have found it more or less useful.   Drs.  Jos. Clarke,
and other practitioners, tried it, but without success.   Dr. Clarke  observes,
" In addition to the usual routine of practice, numerous trials were made
with  the rectified  oil of turpentine, in doses from six  to  eight drachms ;
sometimes in  plain water,  sometimes combined with  an  equal quantity of
castor oil.  The first few doses were generally agreeable to the patient, and
seemed to  alleviate the pain.  By a few repetitions  it  became extremely
nauseous, and several patients  declared that  they would  rather die than
repeat  the  dose.   In more than  twenty trials  of this  kind, not a single
patient recovered."*  . It is certainly beneficial when the intestines are tym-
panitic  especially  in  the form of enema, and as a counter-irritant  to the
abdomen ;  but I have never seen it exert any remarkable influence upon the

   At an advanced state of the  disease, blisters are very useful.   They may
be applied  to any part, or the whole of  the abdomen, and dressed with
mercurial ointment.                          ,,..,.
   Recolin  Dance, and Tonnelle have recommended injections of warm water
into the vagina and uterus, three or four times a day.  Drs. Lee and Camp-
bell have tried them  in a few cases with decided advantage.  I  have fre-
quently 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

    ~  -r*      i v „„„ r. ood                  2 Dublin  Hosp. Reports, vol. iii. 
564                  PUERPERAL HYSTERITIS.

the pain of moving the patient is an  insurmountable obstacle to their fre
auent use.
 * Loeffler, as Ceeley of Aylesbury, have seen good effects result from the
application of cold to the abdomen.
  The irritation  of the stomach may  be allayed by  effervescing draughts,
containing a few drops of laudanum,  or by a few grains of the subcarbonate
of potash, dissolved in aq. menth. virid.
  A selection of these remedies will afford a tolerably good  chance to the
patient, if we are called early ;  but in many instances  we shall fail, either in
cutting short the disease, or in curing  it ultimately.   It is  of the greatest
importance, however, that all the means at  our command  should be tried
perseveringly, and that our forebodings should not be allowed to diminish
our exertions.

   799.  II.   Puerperal Hysteritis.—Inflammation affecting the  proper
tissue  of the  uterus  has been  frequently described.   It is mentioned by
Astruc, Vigarous, and Primrose.  Pouteau observed it in the epidemic of
 1750.   Ricker and Boer have described it under the term Putrescirung or
Putrescent der Gebarmutter, and cases of it have been recorded by Smith,
 Danyau,1 and Tonnelle.2  In certain  epidemics it is tolerably frequent, occur-
ring either alone  or  as one  among  other local affections.   Thus, Tonnelle,
 in  222 fatal cases of puerperal fever,  found 79 cases of simple metritis, 29 of
 superficial softening, and 20 of deep  softening.   M. Duges found the uterus
 affected in 3 cases out of 4;  and  Dr.  R. Lee states, that in 45 dissections,
 the muscular coat of the womb was softened in 10 cases.
   This form of the disease may be the only affection in certain  cases of puer-
 peral fever, or it may be the most prominent, though  not the  sole affection,
 or it may only be one of several forms of local disease.
   800. Symptoms. —These will vary  somewhat, according to the character
 of the epidemic, and a great deal according to the severity of the attack. In
 the milder form, where the disease does not proceed so far as to disorganize
 the uterine tissue, I have generally found it commence, on the third or fourth
 day, with rigors, followed by heat of skin, thirst, and headache.  The pulse
 rises to 100 or 110 ;  the tongue is dry and furred ;  the countenance expres-
 sive of suffering, but without the anxious, pinched, drawn-up character we
 find in puerperal peritonitis.   The patient complains of uneasiness, pain and
 tenderness in the uterine region, and upon  examination we find the uterus
 more or less enlarged, hard,  and tender.  The abdomen, at first, is soft and
 without any tenderness, which is first felt when  we perceive that we are
 making pressure  upon the enlarged uterus.  As the disease advances, the
 abdomen often becomes tympanitic,  and in some cases the inflammation ex-
 tends to the peritoneum.
    The state of the lochia is by no  means uniform ;  in many cases they are
 diminished or suppressed;  in others, their character is changed, and they
 become offensive; in other  cases, again,  they  are  quite unaltered.  The
 secretion  of  milk is generally arrested.  There  is occasionally  another
 symptom, which I think is  more marked in hysteritis than  in  any other
 variety of puerperal  fever,  viz., dysuria, which causes much distress, and
 which  may amount to retention, and  this especially, as Dr. Dewees has
 remarked, in cases which have required instrumental  aid.
    The severer form of hysteritis, as described by Dr. R. Lee and M.  Ton-
 nelle,  is ushered in  by rigors, followed by increase  of heat and headache.
 There is occasionally delirium, and other evidences of cerebral disturbance.
 The countenance is pallid, anxious,  and disturbed; the skin, at first hot and
                    1 Repertoire G6n.  d'Anatomie, vol. v. p. 1.
                    2 Essai sur la M6trite Gangreneuse, 1829. 
puerperal  hysteritis.
565
dry, becomes cold, with  sometimes a blue or yellowish tinge.   The respira-
tion is hurried, the pulse rapid and feeble, with great prostration of strength
The tongue soou becomes foul, and the lips and teeth covered with sordes'
More or less of nausea, vomiting,  and  diarrhoea are generally present.  The
patient complains of pain at the  hypogastrium, where the enlarged  uterus
may be felt, and which is very tender on pressure. The lochia are diminished,
or altogether suppressed, and frequently they become foetid or acrid.
  This form  presents a very different aspect to the former.  It is quite
evident, that  in addition to the local  affection common  to both, the consti-
tution is deeply involved, either in consequence of its  previously impaired
condition, or owing to some peculiarity of the epidemic, or  in consequence
of the local disease  having  produced a more rapid and profound impression
on the general system.
  801.  Hysteritis may terminate—1.  In resolution; as  is the case with the
mild variety which I have  described, and in which  there is a gradual subsi-
dence of the symptoms.
  2.  In abscess;  which may open into the uterine cavity, or into the peri-
toneal sac.   I had an opportunity of  seeing a case of the latter kind, some
time ago, in a patient, whose case has been published by my friend, Dr. Beatty.
  3.  In softening.  This termination was observed 49 times by M. Tonnellfe,
and 10 times by Dr.  R. Lee.   "Among the 222 fatal cases of puerperal fever
observed by M. Tonnelle, in the Maternite, at Paris, in  1829, there were 49
in which the muscular tissue was  found softened.   M. Tonnell? states, that
softening of the uterus, after showing  itself frequently in the first half of the
year  1829, and particularly about January, disappeared  entirely  in  the
months of July and August, which were characterized in a remarkable man-
ner by the frequency of inflammation of the veins., Afterwards, it began to
rage  anew with great violence in  September and October, and again disap-
peared in the last two months, during which  time the mortality was incon-
siderable."1
  4.  In gangrene.   This  has been described by M. Boer, in his  valuable
work,2 and  by Ricker,3 and noticed by Siebold, Busch,  Boivin and  Duges,
Danyau, etc.
   802.  Morbid Anatomy.. — The  peritoneal coat of the  uterus very often
exhibits marks of inflammation.  It may be vascular, and coated with lymph,
or softened.  The size of the womb  is  manifestly increased, and its substance
soft and flabby.   Small collections  of purulent matter are sometimes found
in its parietes, which in these spots exhibit various degrees of absorption.
Boivin and  Duges  observe that " Pus is  sometimes found even in the sub-
stance, and generally nearer to  the  exterior surface than the interior;  thus
pus collects into distinct abscesses, from one to five inches in  diameter, some-
times into  a  simple or  multilocular deposit, with a greenish or viscous ap-
pearance ;  at other times it is infiltrated into the fleshy  fibres, imparting to
them a yellow reddish color, perceptible  through the peritoneum.  In this
latter case tumors form, which are sometimes hard and projecting, upon the
fundus  uteri;  at  other  times flattened, soft, and broad; these latter come
further down towards  the  lateral parts, and often form a continuation, to-
gether with purulent infiltrations, between the laminae  of the  broad liga-
ments  with the cellular  tissue of  the pelvis and the substance of the liga-
ment of the ovarian vessels, frequently giving rise to those  large abscesses
of-which we  have  already spoken."4   The substance of the uterus may be,
In patches, reduced to a mere pulp, of a dark purple, yellowish, or greyish
color, and occasionally of a bad color.  This softening generally commences
  i Lee on more important Diseases of Women, p. 38.
  2 Xaturliche Geburtshiilfe, etc, vol. i. p. 202.      » SieboM«8 Journal, vol. n. p. 62.
  * Boivin and Duges, Diseases of the Uterus, etc., trans., p. d-b. 
566
PUERPERAL  HYSTERITIfc.
at the inner  membrane, and  penetrates more or  less through the substance
of the uterus.  According to Dr. Ferguson's experience,  " The point of in-
sertion of the placenta is the most ordinary seat of all uterine lesion, whether
of abscess, softening,  or phlebitis; the next point, the large and congested,
lead-colored cervix uteri."  False membranes of coagulable lymph are found
on the lining membrane of the cavity, mixed  with blood and lochia.
  M. Tonnelle states  that the disease in  Paris exhibited two distinct forms,
"the softening of the uterus, properly so  called, and the putrescence.  In
the first form, the softening affected only the internal membrane of the uterus,
and it presented itself under the appearance  of irregular  superficial patches
of a red or brown color, which occupied almost all the points of this surface ;
its  limits were not determined, the diseased tissue passing by irregular gra-
dations or  shades into the healthy tissue.  In the second species the soften-
ing extended deep into the substance of the uterus.   The tissue of this organ
was so softened that  the fingers could not seize  it without passing through
it in all parts.   The  superficial softening  was combined almost always with
some alteration  of structure—peritonitis, metritis, or uterine phlebitis; and
it did not appear to M. Tonnelle that the existence of these had  a very sen-
sible influence on the  progress of the symptoms.   The softening in the second
degree was also  sometimes combined  with other disorders ;  but it formed
usually the principal  alteration,  often the only one, and invariably impressed
upon the disease the  most decided typhoid  character."1   MM.  Boivin and
Duges,2 and'M.  Duplay, have noticed similar changes, and the latter author
especially has accurately described  the circumscribed mortification found on
the internal surface of the uterus.   The cause of this peculiar  softening has
been much debated, some attributing it to a specific action of the parts or to
alteration of the blood, anjd others to inflammation ; in some cases it appears
to be the result of inflammation, but in others there is no evidence of pre-
vious or concurrent inflammatory action.
   803.  Diagnosis.—When complicated with peritonitis, the diagnosis is
very difficult; but when  the  uterus  is alone affected, it  is easier to  distin-
guish it: —
   1.  From after-pains,  weid, etc., it differs  very widely in its  persistence,
and in the  gravity of  the accompanying constitutional symptoms.
   2.  From puerperal peritonitis.    The most marked distinction between
them is the tenderness on pressure, which, when the peritoneal sac is inflamed,
is  general  and  superficial,  rendering  the  slightest  pressure intolerable;
whereas, in hysteritis, the abdomen will bear pressure  very well all  over,
until we ourselves feel that we are pressing the enlarged and hardened
uterus.  The only exception to this rule I have  met with are those cases of
peritonitis  where there is no abdominal tenderness.  The pulse in hysteritis
is weaker,  and the patient sinks more rapidly than in peritonitis, the lochia
are  more frequently  foetid, and  the  entire symptoms  have a more marked
typhoid character in  the severer form.
   804.  Prognosis.—In  the  milder form many cases recover;  the uterus
remains hard and tender for some time, but the pain and tenderness diminish,
the  pulse  becomes quieter, the tongue  clean, the bowels regular, and the  •
appetite returns.  The preservation or  reappearance of the natural cha-
racter and smell in the lochia is a valuable sign, and a still better is the con-
tinuance of a good secretion of milk.
   In the severer form, especially when it prevails epidemically, the prognosis
is very unfavorable,  almost every well-marked  case  proving fatal, and the
patient dying with symptoms of a bad typhoid character.
   805.  Treatment. — The  reader  will  bear in mind  the observations  I

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

    806. III.  Inflammation of the Uterine Appendages.—Under this head
 is included inflammation of the serous membrane, and  proper tissue of the
 ovaries,  fallopian tubes, and  broad ligaments.  It  is not always  possible
 to separate these affections  from inflammation of the peritoneal cavity, with
 which they are so often conjoined ; but there are  cases  in which they  exist
 alone, or predominate in  a  striking manner,  or where the consequences of
 the disease continue longer in these parts.   Puzos has described such cases
 by the term, "Depots  laiteux dans Vhypogastre," and Levret, as "Engorge-
 mens  laiteux dans le bassin."  The  observations  of  MM. Husson  and
 Dance likewise prove that  this is a frequent, and often fatal,  termination of
 inflammation of the peritoneal coat of  the uterus  and its appendages.   M.
 Tonnelle found  fifty-eight cases of  inflammation  of the ovary and four of
 abscess,  out of one hundred and ninety cases  of puerperal fever. _
    807  Symptoms —As inflammation of the uterine appendages is generally
 combined with more or less inflammation of the peritoneal  cavity, the symp-
 toms will  present many of  the characters of peritonitis but probably in a
 moderate  degree;  and  as  they subside, or as the  local affection  becomes
 more developed, we shall detect mischief  in the situation  of these append-
 ages   The  pain is less acute and less universal than in general  peritonitis :
 iUs seated in one of the iliac fossaa or the  lateral portion oJ «.e hypog«-
 trium from whence it may radiate to the groin and down  the thigh.   A
   Si examination will detect a degree of  hardness in the  part, compared
 with the rest of the abdomen, perhaps a definite swelling with great tender-
 ne s on pressure.   Percussion/which probably yields a clear sound over the
 nbdnmen generally gives a very dull sound over this portion.
    AnTJrr/exLination will often throw light upon the seat of the dis
 east  the vagina will be found hot  and painful at its  upper part, and the


    w  „?   nresfntin* an array of constitutional symptoms very similar to
 dre'inpeSftis which,  therefore, I need not repeat.  If the d1Seasc be 
568
INFLAMMATION  of  the
extensive, there is  generally observed much  exhaustion  following  the first
stage, and the attack may prove quickly fatal.
   Should the disease not prove fatal, the attack may terminate —
   808.  1. In resolution, without the  organs  being seriously injured ; or in
some cases  adhesions may be formed between continuous portions of the
•serous membrane, which, though for the present innocuous, may be injurious
subsequently.   Boivin and Duges relate  a case  in  which anteversion was
caused by these adhesions.   If the fallopian tubes have been involved, the
cavity of one or both may be obliterated, or they may become adherent to
some neighboring part, so as to prevent altogether their  ordinary functions.
   2.  In suppuration.  Matter may form in either ovary  or broad ligament,
or a more extensive  pelvic  abscess may be formed, including these organs
and the neighboring tissue.   The matter  may escape into the peritoneum,
and excite fatal inflammation ; but this is  comparatively rare, or the abscess
may  open into the bladder,  vagina,  or rectum, or make  its way to  the sur-
face of the  abdominal parietes.   Many examples of each are on record, and
I have myself seen most of them, but in my experience the opening has most
frequently been into the rectum.
   809. Morbid Anatomy. — In some  cases we find, on  dissection, that the
 disease has been confined to the  serous membrane, presenting similar phe-
 nomena to those already noticed—thickening, effusion of lymph or serum,
 etc.   The broad ligaments, fallopian tubes, and ovaria, are  red and vascular.
 The  morsus diaboli is of a vivid  red  color, and sometimes softened, and in
 its cavity, or under the peritoneum, deposits of pus may be discovered.   Dr.
 John Clarke states that " Inflammation is often observed running along the
 fallopian tubes, which, when cut open, will be seen loaded with blood.  The
 ovaria, too, are often affected in the  same way.   Pus is often found in the
 cavity of the fallopian tubes, and also in  the substance of the ovaria, which
 are in  some cases  distended by inflammation and matter, so as to equal in
 bulk a pigeon's egg."1 Effusion of serum or purulent  matter may also be
 found between the  folds of the broad ligaments.
   The ovaria  may be imbedded  in lymph, the product  of inflammation of
 their serous coat.    Sometimes they are  swollen, red, and pulpy.   One or
 both  of these  organs  may be  affected.2  Dr. Gordon mentions that in his
 cases of puerperal, the right ovary was always diseased, and the left healthy.
 Upon laying open  the ovaries, their structure will be found more or less dis-
 eased.  There is a great increase of vascularity,  and frequently a softening
 of their proper tissue.  In a few cases it  is utterly disorganized.   Blood is
 sometimes effused into the Graafian vesicles,  so  as to destroy their texture.
 Pus may be found in small masses throughout the ovary, or that organ may
 be reduced to a sac full  of  purulent matter, which may escape in different
 ways, as already noticed.3
   810.  Diagnosis. — The situation  of the pain and tenderness, the dulness
 on percussion, the  slight increase of hardness, and the results of an internal
 examination, are the only grounds of diagnosis during the earlier acute stage.
 If, however, the disease continue, and do not terminate  in resolution, these
 symptoms become  more marked, and we cannot easily make  a mistake as to
 its nature and seat.
   811.  Treatment.—In some cases venesection  may  be  necessary, but
 more commonly leeches to  the  part will be sufficient;  they should be  in
 sufficient numbers,  and may be repeated if necessary.  After the leeches fall
 off,  a  poultice,.hot,  soft, and  sloppy, should  be  constantly applied, not
 merely  to  encourage  the bleeding,  but for its  soothing effect  upon the
 inflamed parts.

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

   812.  The foregoing  description applies to those cases which occur as a
variety of  puerperal fever, in connection, it may be,  with other local  affec-
tions, and during an  epidemic :  but inflammation and abscess may  occur
after delivery, independent of an epidemic, and with no other complication :
nay, it may happen to  married women who have had  no children, and even
to virgins.  I  hope the reader will pardon the irregularity, if, in  order to
complete the  subject,  I introduce here a brief summary of the peculiarities
of the disease in its more isolated and chronic form.
   As  I have  just observed, this species  of  inflammation of the uterine
appendages may occur, though rarely,  independently of  pregnancy and
labor, but far  more  frequently  after labor, and at  varying intervals; the
first intimations being  perceived in some cases from three to ten days after
delivery, and  in  others not until  the lapse of some weeks.
   813. Causes. — It  is very difficult to assign any  special cause  for this
attack.   It may follow blows, falls, or a fright;  but it is  more frequently
the result of cold or of excessive sexual intercourse.   From the coincident
 suppression of  the milk or lochia, it has been frequently attributed to either
 accident, but, as I believe, without sufficient grounds.  That it may occur
 in  consequence of the  long-continued pressure of the child's head in lingering
 labor, I do not doubt; but it is evident that this is not a frequent cause,  as
 most of the  cases I have seen occurred after natural labor.   Lastly, it may
 be the termination of a more general acute inflammation.
   814. Invasion.—The mode of invasion varies a good deal:—
    1.  In certain cases  there are few, if any, preliminary symptoms: uneasi-
 ness, perhaps, but not amounting  to pain,  in one or other iliac region, and
 upon placing the hand on the spot, a tumor is detected.
    2  Or after  a favorable convalescence for  some  days, just as the usual
 term  of' our attendance expires, the  patient  experiences  a  slight febrile
 attack, with  some shooting  pains in the  abdomen,  which subside after  a
 time, though the fever continues without apparent cause, until, in the course
 of time, the local disease develops itself.       ,,,.,.
    3  Again  in other cases, the  attack is purely local, and  its nature pretty
 evident; from  the beginning there is pain in one or other iliac region, ten-
 derness, and shortly after, tumefaction, with fever
    4  Lastly  the affection may  at first assume  the  charactei  of a more
 general affection of the peritoneum, the pain extending over the abdomen,
 occurring mainly  in  paroxysms,  with  tenderness on pressure,  and fever;
 but by and  by the  general tenderness and  extended pain subside, and
 become, as it were, localized, by which the character of the attack is made

 eV8ie5Dt'Symptoms-Having thus  briefly alluded  to the various modes in
 which-th'cVSZe eom*eJe*,Ivref"^*to«W%™ S^tliJir
 order of  their  importance and prevalence, rather  than  m  that  ot

 ^T'The^presence of tumefaction or of a distinct tumor, is invariable ;  it
        in Til  cases and characterizes the disease.   It may be found com-
 TSv  ab le  PoupLt's  ligament, and the linea  ilio-pectinea, sometimes
 pletely  above  roup^     *      ,         extending upwards as high as
 rSS"-^^ Hnea alba; or it may be sitnated moi. 
570
INFLAMMATION  OF  THE
deeply in the pelvis,  just reaching to Poupart's ligament, protruding the
groin, and from its fixedness giving the impression of being firmly connected
with these parts.  In the  former case, the tumor is  larger, more  defined,
and far more  movable :  in the latter, it is rather undefined, immovable and
more  painful.   In both it is equally hard ;  in fact, as hard as a stone  until
suppuration commences;  and  equally tender on  pressure.   If a vaginal
examination be  made in the former  case,  we do  not always discover any
change ;  the  vagina  may  be  cool, no  tumefaction  may be detected,  and
movement of the uterus may occasion little  pain.  But in the latter cases,
and also  in the former when the inflammation is much  diffused, the vagina
is hot, somewhat tender, and at one of its sides, or at its  upper part in the
" cut de sac," on one  side of the cervix uteri, a hard, painful swelling  may
be detected, which is  evidently connected with the  tumor in the groin, and
in these cases the uterus cannot be moved without acute pain.
  2. Although the period  at which it may be developed  varies, yet sooner
or later pain is an accompaniment of  the disease.  It maintains, as it were,
its seat in the tumor,  from  whence stings of pain radiate in all directions.
When the tumor is high, that is, above  the brim of the pelvis, the  pain is
more limited to the tumor; when situated in the pelvis and groin, it extends
across that cavity, down to the anus,  to the back, and down the thigh.   In
these  cases it  is almost always difficult, in some cases  quite  impossible, to
straighten the thigh, so as to stand upright.  Walking, too, is both difficult
and painful.
   3. In these latter cases, also, when  the tumor occupies a  portion of the
pelvic cavity, we often find the patient distressed by tenesmus, and a desire
to make  water, the consequence, probably, of an extension of the  irritation
to the bladder and rectum.   Occasionally, when  the tumor is large, it offers
a mechanical impediment to the  functions  of these viscera, and the patient
may suffer from dysuria, or be unable to evacuate the intestinal canal.
   4. The amount of fever, as well  as the time of  its setting in, varies.  In
some  cases it precedes or accompanies the  first  local symptoms ; in others,
it supervenes after the tumor has been detected  some time.   In a few  cases
it is almost confined to the evening, and during  the process  of suppuration
there are, in almost all cases, evening  exacerbations.   The pulse ranges from
90 to 110 ; the  tongue is loaded, the skin  hot,  the thirst considerable, and
the urine high colored.   The appetite is always  bad.   These  symptoms are
somewhat mitigated, or at least the patient suffers less, in cases not connected
with parturition.
   816.  Terminations.—After being fully developed, and running on even
for a considerable time, the disease  may terminate :
   1. In  resolution.—This most  frequently  occurs with cases in which the
tumor is above the  brim, and  limited in extent;  and  in such, we find the
pain diminishing and  ultimately ceasing, the tumor first becomes less tender,
then less in  size,  until at  length it disappears.  This  process will occupy
from one to three  months.
   2. In  abscess.— When suppuration takes place we can  generally feel  a
degree of softening, with an obscure sense of fluctuation in the tumor, either
externally or internally;  the  patient complains  of more  throbbing, and
occasionally of rigors, and by degrees (if not anticipated) the coverings are
thinned,  and the matter may escape—
   a. Externally, through the abdominal parietes covering the tumor.
   b.  Into the vagina, through which  the matter escapes.
   c. Into the intestinal canal, and especially the  rectum, with the evacua-
tion of matter per stool.
   d.  Into the bladder. 
UTERINE  APPENDAGES.
571
  e. Into the peritoneum, where it gives rise to peritonitis, always alarmino-
but not always fatal.                                                   °
  /. Into the surrounding cellular tissue, where it may burrow until it finds
an outlet.
  The matter may be evacuated by any of these  "routes ;" and if the open-
ing be sufficiently large, the sac may be emptied, and the abscess fill up and
heal.   But  if  the opening be small,  the  discharge  may continue for an
indefinite length  of time, the opening remaining  fistulous, and the cure being
proportionably difficult.  I have repeatedly seen  the matter  evacuated by
the first three ways, and I think equally frequently.  I have also seen it  pass
into the bladder, but very rarely.  I have  never yet  seen it evacuated  into
the peritoneal cavity, and I cannot but think it very rare.
  3. The extent of the disease, or the secondary affections caused by it,  may
prove fatal  after an indefinite length of time.
  817.  Diagnosis.—A good deal of light will be thrown upon the diagnosis,
when the disease occurs within a reasonable time after parturition, and espe-
cially when the patient has  suffered from abdominal pain : in such  cases, if
we  discover a tumor  in one of the iliac fossae,  with  tenderness and  pain, we
shall have adequate grounds for diagnosticating  this affection.
  If, however, the attack occur  independently of child-bearing, or at a  con-
siderable interval afterwards, there may be difficulty in distinguishing between
it and some of the chronic organic diseases of the ovary, especially when the
tumor  is above  the  pelvic brim: our safest  guide, probably,  will be the
amount of  pain and constitutional disturbance, which is much greater in the
disease I have been describing.
  An ileo-ccecal abscess when  situated rather lower than usual may  easily be
confounded with an ordinary pelvic abscess, which is the more undesirable,
as  if we  attempt to open  it we may penetrate into the intestine.   I have
seen one  such  case, and the only grounds  of  differential diagnosis I could
make  out was an unusual resonance  of the  tumor on  percussion, which I
believe never exists with pelvic abscess.
   I have known this affection mistaken for sciatica; and when the  tumefac-
tion is  mainly  confined to the pelvis, and pressure is made  upon the nerves
issuing from that cavity, the pain may be limited to the track  of the nerves,
so as to deceive  any but a careful  observer.   However, a minute investiga-
tion will probably enable us to trace the pain into the  pelvis, and then an
external, and especially an internal, examination  will at once reveal the cause
of the pain.  The flexion of the thigh, which  alone might also mislead, will
of  itself lead to  an examination of the groin,  and so to the detection of the
tumor.
   818. Treatment.—The indications of cure  are, 1, to procure resolution
of  the  tumefaction ;  or, 2, to  promote suppuration and evacuation  of the
matter.                                                . .
   1.  If we  are called in at  an  early period  of  the attack, it is often  possible
to  arrest its  progress, as  has been well remarked by Dr. Doherty;  nay,
even where the disease  has lasted some  time, as in the cases mentioned by
Puzos  it is in some cases quite possible  to  procure  resolution.   For this
purpose Mauriceau and the author just named, advise  repeated venesection
with  purgatives,  alteratives,  absorbents, etc.   I believe that the  repeated
application of leeches will be found more effectual at less expense of strength
A dozen  should  be applied over the tumor, followed by bran poultices, and
repeated  if necessary,  i. e., if the pain and throbbing be not relieved.   I
we  succeed in arresting the  progress of the  inflammation, a succession of
smail blisters will be of great use.  Fomentations, and an occasional  hip-
bath  also afford  great  relief to the patient; but  still more comfort is derived
from' vaHnal injections of warm  water, twice a-day. 
 572          INFLAMMATION OF THE  VEINS OF THE

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

   819. IV.  Inflammation of the  Veins of the Uterus,  or Uterine
 Phlebitis. — This form  of the disease  has been frequently noticed  by the
 more modern authors; amongst others, by Dr. John Clarke, Waller, Meckel,
 Louis, Dance,  Tonnelle, Lee, Boivin, and  Duges, Ferguson,  etc., and  in a
 series of papers on Metro-peritonite, by M.  Nonat.1   Nor is it very rare;
 for M. Tonnelle found pus in the veins in 93 cases ; and  in the thoracic  duct
 in 3 cases out of 134; and Dr.  Robert Lee, in 45 cases, had 24  of uterine
 phlebitis.
  820. Causes.—Dr.  Robert Lee considers  that it may be the result of
 mechanical injury to  the  uterus, either during the labor, or by the force
 used to extract  the placenta.  "Uterine  phlebitis,"  he says, "appears to
 result from the mechanical  injury inflicted upon the uterus  by protracted
 labor; from the  force required for the extraction of the placenta in uterine
 hemorrhage ;  from retained portions  of the placenta undergoing decomposi-
tion in the uterus ; the application of cold, and, perhaps,  of contagion ; or
from any of the causes which produce the other varieties  of uterine inflam-
mation.   M. Dance considers deranged states of the lochia to be  a frequent
34
1 Revue Med. Franc, et Etrang., 1837. 
UTERUS,  OR  UTERVNE  PHLEBITIS.
573
cause of the disease ;  but these are consequences and not causes of uterine
phlebitis.1    It  may follow  after hemorrhage, or arise  from cold, or  the
decomposition of retained portions of the placenta.   It may be excited by
any  of  the  causes  of  the other  varieties of  puerperal fever.   Dr. Bartsch
observes, "  As to  the  causes under which uterine phlebitis was developed,
we found it occurring most  frequently—1.  In women who approached  the
critical  period of  life, especially if they were primiparops.   2. In women
affected  with varicose tumors of the thigh, and  external genital organs.
3. In females, who, during pregnancy, were  submitted to the  influence of
depressing  passions-  fear of exposure, jealousy,  sorrow, etc.  4. In indi-
viduals who, from  the symptoms they presented, had frequently employed
abortive remedies.   5. From mechanical injury of the uterus during  preg-
nancy, especially if it were followed by abortion.   6. In females subject to
chronic  disease, as cough, difficult menstruation,  hemorrhoids, fluor albus,
chronic diarrhoea, and constitutional syphilis.  7.  After flooding, during or
after delivery, especially from  placenta  praevia,  after difficult labors, after
obstetrical  operations, especially those requiring the introduction  of  the
hand into the  uterus.  8. Finally, the greater number of cases occurred in
the  months  of February, March, April, and  May, in females who, the  yeai
before,  had been attacked by 'la grippe.'"2
   821.  Symptoms. — In women of previous good health, the attack com-
mences generally in twenty-four  or thirty-six hours after delivery.  The pa-
tient complains of pain in the uterus, more or less acute, preceded, accom-
panied,  or  followed by rigors.   The uterus  is tender on  pressure, and  the
lochia and  milk are both suppressed.  There is  headache, and slight inco-
herence ; a sense of general uneasiness, and sometimes nausea and  vomiting,
with acceleration of the pulse.   After a time, these symptoms are succeeded
by increased heat of surface, tremors of the muscles of the face  and extremi-
ties, rigors,  great thirst, dry brown tongue, frequent vomiting of green fluid,
rapid full pulse, hurried respiration, etc.  The head becomes more  involved,
aud we find the patient in a state of drowsy insensibility, or violent delirium
and agitation, followed by extreme exhaustion.   The  surface  of  the body
assumes a  deep  sallow or  yellow color; and occasionally petechial or vesi-
cular eruptions have been  observed  on different parts of the body.   The
pain may or may  not increase,  but the uterine tenderness is certainly aug-
mented  and the  abdomen  is often swollen and tympanitic.   In some very
rare cases  there is little or no local distress,  and the existence of the disease
could not'be discovered except  for the secondary affections.   Such was the
case with a patient under my care.   She had no  uterine pain  or disturbance,
no tenderness on  pressure;  and yet, on the seventh day after delivery, a
smart febrile attack  preceded the formation of a  large abcess  near the left
elbow-joint: after which, a  second followed,  on the top of the shoulder,  and
a third in the right arm,  above the  elbow.                       .
   822   The patient may die during the acute stage, but the  majority  live
longer', and exhibit the  most interesting phenomena connected  wi    his
varied of puerperal fever, and distinguishing it from all others.  I allude to
the  secondary diseases of other  organs.                      Teeand Fer-
   The  brain though  often functionally disturbed (135 in 304, Lee  and ler
a Jon)  h not frequently the seat of organic disease.  Its vessels  are some-
time , con-ested  and  lymph diffused in the pia mater, or serum in the ven-
Moles    According to M  Duges, there is  arachnitis  once in 266 cases.
Portions ofthetain are occasionally softened and disorganized; or there

IS ^tlh^Z^^oltf^ of the pleura, effusion of

     i Diseases of Women, p. 54.             » Report iu Lancet, April 16th, 183G. 
574          inflammation of the  veins  of the
in	10 cases
in	4 "
in	8 "
in	3 "
in	2 "
serum of the same character as that in the peritoneal sac, and occasionally
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 color, with infiltra-
tion of purulent matter ;  or they may be in a state  of " complete dissolution,
having all the characteristics of gangrene, except in many cases its peculiar
foetor."

       M. Tonnelle found pneumonia
                         tubercles
                         abscess
                         gangrene
                         pulmonary apoplexy

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

  The liver  is occasionally diseased : its  substance  may be congested, soft-

    i Diseases of Women, p. 49.            * Ferguson on Puerperal  Fever, p. 36.
Ill . in	i 4	uase. cases
. in	1	case.
. in	8	cases.
. in	5	a
. in	5	tt
 
                  UTERUS,  OR  UTERINE PHLEBITIS.             575

«ned, or contain abscesses.   M. Tonnelle met  three cases  of abscess in the

»22™ f r+UC\Ure °f the Spleen ma^ be  softened and disorganized.  M  Ton-
nelle relates two cases of abscess

d Jband dZvJ7Tl in,flaTatl0n °f .thdr 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 ureterfand

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

  i Med.-Chir. Trans., vol xiii.    2 Diseases of AVomen, p. 50.    * Midwifery, p. 139.
  * Lee on Diseases of Women, p. 50.   Beatty, Dublin Journal, vol. xvi. p. 340.
  6 Ibid.,  pp. 12-24.
  6 Ferguson on Puerperal Fever, p. 39.  J. G. Sasse, de Vasorum Sanguif.  Inflam.
Halle, 1797.
  1 Diseases of the Uterus, trans., p. 327. 
576     INFLAMMATION  OF  THE VEINS OF THE  UTERU8.

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

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

      i Dictionary of Practical Med., part xiii., p 535.
      * Diseases of the Uterus, p. 329.         s Revue SKd  1837.
      4 Vol! xv. p. 64.                       Diseases of the Uterus, p. 339
        37 
578
GASTRO-ENTERIC FEVER.
i
ledge not to be  distinguished from them.  The secondary lesions also re-
semble those in phlebitis.
   As to the treatment, we  are  quite at a loss; as yet, we  know of none
capable of controlling the disease.

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

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

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

   Case III.—Mrs. M----was  confined  about the same time as the last
 case, under the care  of  Mr. Morgan.   Her labor, which  was natural, was
 followed  by smart hemorrhage.   About the third day  she was seized with
 violent pains in the abdomen, increasing in paroxysms to an intense degree.
 There was no rigor ;  the pulse  rose to 120, and the skin became hot, but
 there was no thirst.   The breasts were full and the lochia  natural.  _ Although
 the abdomen generally was tender on pressure, there was no peculiar tender-
 ness over the uterus.   A full dose of laudanum relieved the pain to a certain
 extent  and the  bowels were  freed  by  medicine.  We then  applied the
 mercurial'ointment, on lint, over the. abdomen, and a  poultice over it, and
 srave small doses of  calomel, Dover's powder, and James's powdery three
 times a-day.  The next day she was much better.  Pulse  110.   Tongue
 coated;   the  skin  cooler;  some pain and flatulence   with uneasiness on
 pressure   Milk  and lochia natural.   The day after she was attacked with
 violent diarrhoea and severe  pain  in  the  bowels, accompanied  with great
 exhaustion, so that we were obliged to give wine  and had some  difficulty in
 controlling the bowels by means of opiates, astringents, anodynes, enemata
 etc   After we had succeeded in quieting the bowels  by these means and
 relieved the pain, the pulse  still continued for  some days above the natural
  tndard    In other respects the convalescence proceeded quite satisfactorily
    Althoucrh the foregoing brief cases can  scarcely give  an adequate idea of
 the attwk being so alarming as it really was, yet those engaged in midwifery
 nract c?wiU  feel that, coming  on  so soon after  delivery, and commencing
 wthsucrformidable symptoms, I might be excused  for fearing that ha
 I nc would be more serious than it  proved.   The commencement of the
 aTtTck  in many cases closely ,ese«nbled  that of puerperal fever,  and it waa 
580                  GASTRO-ENTERIC  FEVER.

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

   829  VII Malignant Puerperal Fever.—This form is comparatively
rare, except when  the disease  prevails epidemically.  It  may attack +he 
582              MALIGNANT  PUERPERAL FEVER.
   patient  before delivery, immediately after, or after some days,  and perhaps
   the most frequent time is at the end of the second or the beginning of the
   third day.   " In the case of a female attacked before delivery," Dr.  Cop-
   land observes, " to which I was called by Mr. Barnwell, the symptoms were
   the same as those observed by me in other cases.  This patient was  seized
   early on the 12th of February with acute pain throughout the abdomen,
   with enormous distension, and exquisite tenderness;  with  very rapid, full
   and soft pulse, varying from  130 to 136, and  with frequent vomiting.   I
   saw her in the afternoon of the same day.  The vomiting and state of the
   pulse were as here stated.   She complained of headache and of thirst, and
   was Very despondent.  Her tongue was broad, flabby, slimy, and tremulous;
   her countenance pale, anxious, and covered by perspiration, and her gene-
   ral surface warm, moist, and clammy.  Labor pains came  on that evening,
   but were even inefficient, the action  of the  uterus  having ceased.   Mr.
   Barnwell administered  secale cornutum,  which ultimately  induced uterine
   action,  and she was delivered after a labor of about twenty  hours.  On the
   following day (the 16th),  the  distension and tenderness of the abdomen
   were diminished ; but the sickness and vomitings, with borborygmi and  flatu-
   lent eructations,  continued.   Apathetic  depression of spirits,  anxious ex-
   pression of countenance,  flabby and slimy state of tongue, a  very rapid,
   fluent,  and weak pulse, clammy state of the  skin, scanty amd almost sup-
   pressed urine, quick and  oppressed  breathing, a feeling  of pressure of the
   diaphragm, requiring the head and shoulders to be elevated, were soon fol-
   lowed by the symptoms ushering in dissolution.1
      830.  The same author has given a graphic  picture of the  attack  when
   it occurs almost immediately after delivery.    He says that "the earliest
   indication  of the impending mischief,  is  the  great rapidity,  softness, and
   weakness of the  pulse, often  attended by pain  and tenderness at the epi-
   gastrium, by sickness and vomiting, followed by general distension and  pains
   darting through the  abdomen.  But in the majority of cases there are neither
   chills nor rigors :  in a few a feeling of  coldness only ;  and in still  fewer,
   slight rigors.   In this state of the  disease the patient soon  becomes de-
   spondent, predicts her dissolution, is afterwards apathetic, and makes little
   or  no inquiry for her infant.   The milk and lochia are either little or  not at
   all diminished, or are  more than usually abundant.   The  abdominal pain
   and distension are sudden  and quick in 'their accession; but the pain soon
   ceases,  the  distension  remaining, and  afterwards changing  its character if
   the disease  continues above  two or  three days.   The  tongue, from the
   commencement,  is  flabby, broad, and slimy,  or covered by  a mucous  or
   creamy coating;  the  pulse is usually from 120 to 140, or even upwards,
   fluent, soft, or broad;  and the general surface presents a lurid, or dusky, or
   dirty hue,  and is covered by a clammy or offensive perspiration.  The  coun-
   tenance is pale  and inexpressive, unless where the  pain is acute, when  it
•  becomes anxious  and covered with perspiration.  The mind is but little
   disturbed,  beyond a state of complete apathy.  As the disease proceeds,
   respiration is short, suspirous, or difficult;  the pulse, small, soft, or irregular';
   the bowels frequently relaxed, and the stools  offensive  or passed without
   control.  Distressing feelings of sinking, leipotlrymia,  or restlessness  super-
   vene, and are soon followed by symptoms of impending dissolution."
      I think it will be found that in the majority of cases the milk is not secreted
   at all, or very slightly, and that the lochia, which may appear  natural for a
   day or  two, become  scanty, and with an  offensive odor.  I have also seen
   the  abdomen remain in  its natural  state, neither painful,  tender, nor dis-
   tended ; but these are rather exceptions.
1 Diet, of Pract. Med., part xiii. p. 519. 
                  MALIGNANT  PUERPERAL  FEVER.              583

  831. The most common  period, I have said, for the incursion  of the
disease, is on the second, third, or fourth day ;  but it may occur even later.
Its  commencement may be marked by a rigor, or more frequently  bv a
creeping,  chilly feeling, a  sort  of imperfect rigor.  Dr. John Clarke ob-
serves, "It has hardly occurred to me  to see  a case iu which the  disease
began  with a shivering  fit, which is common in the commencement of many
other fevers, and in the cases where the  constitution  sympathizes with the
local inflammations which have  been  already treated of.  If there was any
degree of rigor, it has been  so slight as to have  escaped the attention of the
patient, and the observations of her attendants.   Indeed, so great a diminu-
tion of the sensibility accompanies the whole complaint, that even  if a slight
rigor should  take place, the patient might not observe it, or being sensible
of it at the time, might not  afterwards remember it."1  Coincident with this
symptom, or  preceding it,  or independent of  it, we always find  the  pulse
unusually quick ; instead of being from 80 to 90, it is generally from 120 to
130, and often higher, confirming the accuracy  of Dr. John Clarke's obser-
vation, than no woman can  be considered safe whose pulse is not under 100.
But not only is it rapid, but  it is generally small, weak, and easily  com-
pressed, not at all  a pulse which would justify blood-letting.
  At an early stage  in the disease, many patients complain of pain in the
stomach, bowels, or region of the uterus, accompanied by more or less ten-
derness, and followed by distension.  This, however, is by no means always
the case.  In a patient I saw some time ago, who  died  on the third day of
the disease, there was  neither pain, distension, nor tenderness in any  part
of  the abdomen.   In others, we find distension with but little pain  and no
tenderness.    Sickness  of stomach, vomiting, and  diarrhoea, may occur at
the very  outset of the disease, or on the second  or third  day,  or  not till
towards the termination of  the disease ; in some cases it does not occur at
all.   Dr. John Clarke says that the purging  commences  on  the third or
fourth day, or even later.
  But however the disease  may commence, and however slight and  few the
local symptoms may appear, to the experienced eye they are  always  most
formidable, and generally run a rapid course.   The fever has a low, typhoid
character ;  the patient is nervous,  depressed, and fearful;  the  pulse is soft,
small, and increasing in rapidity ;  the respiration  quick, hurried,  high, and
often panting;  the abdomen in many cases swollen, tympanitic, and painful;
sometimes generally tender, sometimes  only in  a particular part;  the lochia
are sometimes altogether arrested,  sometimes merely diminished in quantity,
but more commonly,  at least after a day or two, changed in quality, with a
foetid odor;  in some rare cases they continue quite unaltered to the last.
The secretion of milk, however, I have found  invariably suppressed in the
worst  cases ;  in others, arrested  after it had occurred.   The urine appears
generally diminished in quantity.   The mental  functions are but  little dis
turbed till towards the termination, when  it is not uncommon for the  patient
to be  partially or temporarily delirious, but never violent.  In many  cases
there is a peculiar nervous hurry, an excitement of manner, with tremulous
movement of the features and hands.  In most cases she  is greatly depressed
and fearful, anticipating an unfavorable result; in some few others  I have
known the hope of life vivid to the end.   A patient I saw lately prognos-
ticated her speedy removal  to the  drawing-room an hour before her death.
It is very remarkable, that in most cases  the natural affections of a  mother
seem  perfectly quiescent, the patient rarely asking after, or manifesting any
interest in her child after the disease has fairly  set in.
  In the epidemic described by Dr. Joseph Clarke, he says, that " It always
  i On  Pregnancy and Labor,  etc., volume on Diseases of Women, published by the
Sydenham Society, p. 419. 
584
MALIGNANT  PUERPERAL  FEVER.
began with a distinct chillness or shivering.  The pain in the cavity of the
abdomen was not more frequent in one  part  than  in  another, nor was the
tenderness  so great as to be much affected by such trifling  causes as the
pressure  of the bed-clothes.  Little  or no vomiting appeared in any stage
of the disease, no delirium, and no unequivocal marks of  putrescency in any
part of the system.  The pulse  in general beat from  120  to 140 strokes in a
minute.   The lochial discharge and secretion of milk were not subject to any
general law.  Sometimes they continued regular for a short time,  and some-
times they  were suppressed from the beginning."1
   Dr. Douglas  has thus sketched this  form of puerperal fever as it appeared
in the Dublin Lying-in Hospital in 1812  :—" The sensorium  here is seldom
in any degree disturbed, whereas in the  other varieties it is so frequently,
and even sometimes is excited to high delirium.  The pulse  here  is usually
from the moment of attack soft, weak, and yielding, and in  quickness  often
exceeds  160 ; whereas in the first species it  is full, bounding, and incom-
pressible ;  and  in the  second, small, hard, and incompressible, and in  both
moderately quick.   The  eye, instead of being suffused  with  a reddish pr
yellow tint, as in the  others, is here  generally pellucid,  with  dilated pupil.
The countenance, instead of  being flushed, as in the  others, is  here pale and
shrunk, with an indescribable expression  of anxiety, an expression altogether
so peculiar that the  disease could on many  occasions  be pronounced or
inferred from the countenance alone.   The surface  of  the body, instead of
being, as in the others, dry, and of a high pyrexial heai;, is here usually soft
and clammy, and of a heat not above the natural temperature ; and not only
is the skin  cool, with clammy exudation, but the muscles, to the  impression
of the finger, feel soft and  flaccid, as if  deprived of  the vis insita by the
influence of the contagion.   Indeed,  there is  such  prostration of strength
and depression  of the vital principle from the very outset of the attack, that
I must suppose the contagion to act upon the human  frame probably through
the influence of the nervous  system," etc.2
   Dr. Gooch found that " the  cases which were so  numerous in  these un-
healthy seasons had the common symptoms and course  of puerperal fever.
They began a few days after delivery; the leading  symptoms were, diffused
pain and  tenderness, with some swelling of  the  abdomen,  a quick pulse,
which was  generally at first full and vibrating.    Sometimes it was small, but
still it was hard and incompressible ; the skin was hot, though not so hot as
in other  fevers ;  the tongue  was white and moist;  the milk was suppressed.
As the disease advanced, the belly became less painful, but  more swelled,
and the breathing short;  towards the end, the pulse was very frequent and
tremulous,  and  the skin covered with a clammy sweat;  even in this state the
tongue continued moist and  the mind clear, and death took place generally
about the fifth day."3
   In the epidemic which appeared in Paris, in 1838, M. Voillemier describes
the typhoid form  as  beginning with  a long and severe rigor, often a few
hours only after delivery; pain very intense over the whole abdomen, which
rapidly became  swollen ;  pulse feeble, compressible, and undulating,  often
150 ;  respiration hurried, anxiety extreme, severe frontal headache ; counte-
nance sunk, pale, aud covered with a clammy sweat;  constant vomiting of
green matters ; purging, stools foetid.  The patients rapidly sank at the end
of a few  days, or even hours.   There was no  regularity  in the condition of
rdther the lochia or milk.4
   Dr. Copland thus sums up the characteristics of the attack: "Whatever
             1 On Puerperal Fever.  Sydenham Soc, p. 355.
             2 Dublin Hospital Reports, vol. iii. p. 154.
             3 On the More Important Diseases of Women, p. 40.
             * Journ. des Connoiss., Me.l.-Chir., Dec. 1H39, Jan. 1840. 
MALIGNANT  PUERPERAL  FEVER.
585
may be the period or mode of its accession, this variety of the disease always
pursues a rapid  course, and  unless early arrested  by energetic  means, "it
almost always tends to  general contamination of the fluids and  structures,
and to death.  At the  commencement, the nervous system  of organic life
and the blood appear to be suddenly and seriously affected, as shown by the
general loss of vascular tone and of sthenic action, by the disturbance of all
the vital functions, and relaxation of contractile parts.   The earliest symp-
tom is often the remarkable rapidity of the pulse, which is also broad, open,
soft, or fluent; or small, thready or irregular,  but always very quick  and
compressible.  Rigors  and chills are generally absent; or if they have been
present, they are  either slight or of short  duration.   In  the most rapidly
fatal cases, or such as arise in crowded or close lying-in wards,  they rarely
occur ;  and in these  the disease may be  complicated, or present no promi-
nent  lesion  or  affection; the  whole  frame  participating in the  malady,
through the  medium of the organic, nervous, or vascular systems ; or if any
prominent lesion  appears, the peritoneum  or  other shut cavities must fre-
quently experience it, and present the appearances hereafter to be noticed."1
   I have quoted thus largely from  different authors, to show,  in the  first
place, that we are not to expect any absolute regularity of symptoms, which
will vary, not merely according to individual peculiarities, but also accord-
ing to the peculiar character  of the epidemic, which may differ each year,
 and which certainly does differ in different cities : and secondly,  as illustrat-
ing the broad fact that the disease has a constitutional rather  than a local
 origin.  The most invariable symptoms are, the typhoid character,  the vital
 depression, the  quick weak pulse, suppressed milk, and disordered lochia ;
 and I have seen  more than one patient die without a single other symptom ;
 neither pain, nor tenderness,  nor swelling of the  abdomen or its contents.
 Of course,  in most cases other symptoms are added, such as I have already
 enumerated ; but I feel it important to impress upon my junior readers that
 the disease is to be judged by the character of the symptoms preseut, and
 not by their number nor by the amount of suffering.
    The disease advances with varying rapidity, and in its progress the symp-
 toms increase and assume a more fatal character.   The heat of skin is not
 augmented,  but the surface is pallid, clammy, and assumes a dirty color, with
 dark circles about the eyes.   The pulse becomes quicker, smaller, and weaker,
 and, towards the end,  irregular and intermitting.   The respiration  is rapid,
 irregular, and often sobbing ; the tongue moist, sometimes clean, but gene-
 rally loaded with  a whitish  or  yellowish fur, indented by the  teeth, and
 tremulous.   Occasionally, though rarely, it is  dry and brown,  as in typhus
 fever   The nausea  and  vomiting  may increase or diminish,  and there
 are frequent eructations, of bad flavor.  The abdomen becomes very tense,
 with constant,  or more commonly irregular, stings of pain, with  heat,  or
 general tenderness.  The patient may either suffer from intense restlessness,
 anxiety or lie in a semi-torpid state.   The mind gradually becomes apathe-
 tic and'indifferent, and the patient may either gradually and quietly, though
 rapidly,  sink, or dissolution may be preceded  by  restlessness, dyspnoea,
 lividity of countenance, etc.
    Dr  John Clarke mentions two symptoms worthy of notice,  but which 1
 think'are by no  means common : - " In  some instances aphthae will appear
 over the whole internal surface  of the mouth and tongue the hard and  soft
 pITate the uvula, tonsils, and pharynx, so that they will all become perfectly
 whhe and swelled.   The irritation from this cause produces a constant dis-
 nos tion to cough, which is also partly occasioned  by the secretion of a thick
 mucus about the pharynx, which  chokes up the trachea, keeping up a per-
 petual difficulty of breathing.   In some instances similar aphthous appear-

                  i Diet, of Practical Medicine, part xiii., p. 520 
586
MALIGNANT  PUERPERAL  FEVER.
ances will be found about the anus." , "In some instances purple spots have
appeared before death, as in petechial fevers, probably depending either on
great weakness of the vessels, which allows the fluids to escape into the cellu-
lar membrane, or upon some alteration in the state of the fluids themselves,
by reason  of which they are not so easily retained, or partly on the one, and
partly on the other."
  832. The local symptoms  will vary very much, according to the part
principally affected;  for  I believe that any of the forms of local disease,
already described, may be found complicating this low childbed fever.
  1. In some  cases, there are absolutely no symptoms indicating abdominal
disease.  Neither pain, tenderness, nor  distension is present.  In a case I
saw, to which  I have  referred, although the  symptoms were of the worst
kind, the only local symptom'up to death was inflammation of a small branch
of varicose veins of one leg, which was soon much relieved.
  2. Peritonitis appears to be the most frequent local affection, judging from
the descriptions  of the different epidemics; but the practitioner would be
greatly deceived  who expected it to present the  acute and well-marked symp-
toms usual in the ordinary cases of that disease.  All the local characteristics
are, if I may be allowed the phrase, muffled.  There may be pain, even severe
pain, but it rarely amounts to the agony we wituess in idiopathic peritonitis;
very often it is but slight, and in paroxysms, diminishing as the disease ad-
vances ; and  in  two or three cases, in which I  found after death universal
peritonitis, there had been neither pain nor tenderness.
  3. If the inflammation chiefly or solely occupy the womb or its appendages,
there may be a good deal of  pain, tenderness, and enlargement;  or it may
be slight and obscure, and only to be. detected by a careful  and minute ex-
amination.  In  the latter cases, I have most  commonly detected a tender
spot on the one  side or other of the body of the  uterus, and sometimes even
when there has  been no  perceptible enlargement, and no tenderness when
the uterus was generally pressed.
  4. In some  of the worst cases I have  seen, presenting the most  marked
typhoid character, with apparent freedom from local disease and running the
most rapid course, the only local lesion was uterine phlebitis, sometimes  ac-
companied with  tenderness on pressure at the  sides of the uterus, but very
often without pain or tenderness.   But in such  cases the disease is too quick
in its course for  the secondary characteristic lesions to show themselves, and
therefore during life we can only assume  the  probability of venous or lym-
phatic inflammation.
  In general,  subject to the modifications I have  mentioned, the local affec-
tions will present the symptoms  and characters I have already described
under the  several heads; and I repeat  that, in the low malignant childbed
fever, we may find any of these local affections, or even  two or more com-
bined.
   833. The duration  of  the disease varies much.   In certain epidemics,
cases have ended fatally in twenty, twenty-four, or thirty hours from their
commencement; generally speaking,  however,  the final termination  is most
frequent from the third to the fifth  day.  Dr. Collins thills  enumerates  the
periods of the commencement and termination  of the cases he has recorded :
— "Of eighty-eight cases that occurred during my residence, one had  the
disease well-marked before delivery;  one was attacked in six hours ; one in
nine ; one in ten ; three in twelve ;  one in thirteen ; one in fifteen ;  two in
seventeen; one  in eighteen ; one in twenty;  one in twenty-one ; and two
in thirty hours  from delivery.  Thirty-two were attacked on the first day;
twenty-nine on the second ; eight on the third ;  two on the fourth, and one
on the eighth  day.  The disease seems to run  its course with great rapidity
in most instances.   In fifty-six  deaths in the hospital, it proved fatal at the 
MALIGNANT  PUERPERAL  FEVER.              581
following periods after the date of the seizure : viz., two in twenty-four hours;
one in twenty-seven;  one in thirty-six; nine on the second day;  fifteen on
the third; thirteen on  the fourth ;  four on the fifth ;  five on the sixth ;  three
on the seventh; two on the eighth, and one on the eleventh."1
  834.  Pathology. — Morbid Anatomy. — I must refer my readers to the  '
foregoing sections  of  this chapter for a description of the peculiar morbid
appearances observed in the different species of local affection, peritonitis,
hysteritis, phlebitis, etc.; but in this malignant form there is in addition,  as
Dr. Copland has observed, an impaired cohesion of the tissues generally, and
more or less of a turbid serous effusion into the serous cavities. He mentions
also that in several cases in which  bloodletting had been practised,  " on every
occasion I  was struck by the peculiar faint odor and very dark hue of the
blood ; by the very soft state  of  the clot when  the blood did separate into
crassamentum  and serum ; by the appearance which occasionally presented
itself, of a  mass exactly resembling in color and consistence a common jelly,
the coloring matter covering the bottom of the vessel in the  form of  a pre-
cipitate ; and  by, in  some  instances, a slight separation only of serum, the
large, loose, gelatinous crassamentum, consisting  chiefly of this jelly-like
matter, the lowest stratum  of which  contained the black or dark-brown pre-
cipitate of coloring matter.  These appearances of the blood  were  presented
in several cases in the hospital, in 1823 and three or four subsequent years,
 in which cases blood had been  taken before I saw the patients.  It may here
 be remarked that I have seen many cases of this form of the disease, in which
 leeches had been applied to the abdomen ;  but in nearly all, and  especially
 in  those which occurred in the hospital, the blood which flowed from the
 bites did not coagulate; and  great difficulty, almost amounting  to an im-
 possibility, of  arresting the bleeding from them,  was  generally observed,
 owing both to the state of this fluid, and to the impaired vital cohesion of
 the  tissues  characterizing  the advanced stage of the malignant form of this
 domestic pestilence."2
    In a former section of this chapter, I have adduced other evidence of an
 altered state  of the  blood, and judging from all the evidence we possess, I
 am  inclined to  believe that the  pathology  of  this malignant form  of  the
 disease consists in a depravation  of the circulating fluid,  either from absorp-
 tion of noxious matters, or from inflammation of the veins, or  from both
 combined,  and accompanied by a  diminished cohesion of the tissues generally.
    835. Causes. — I  have  already  enumerated  every imaginable cause, I
 think, to which puerperal fever has  been attributed, and I need not now re-
 capitulate  them.  I shall merely  observe, that a natural  and easy  labor does
 not necessarily preclude  an attack, nor does  a considerable loss of blood
 confer any immunity ; on  the contrary, when the disease prevails, whatever
 depresses the svstem seems to favor its  production.  It is  chiefly when  the
 disease is  epidemic  that we  see  this low and malignant form, and a know-
 ledge of this fact, and of the coincident prevalence of erysipelas, should  put
 practitioners on their guard,  and induce tenfold more care  and watchfulness
 than usual   Nor although the  more numerous cases occur in  hospital or
 dispensary practice,  are we  to anticipate  an immunity  in private practice.
 During the epidemics in this  city, there  have been several cases  among  he
 richer classes which proved fatal.   And in the more  recent epidemic, the
 previencTS the disease among the better classes has been still more  re-
 markable   In  addition, I have  remarked that during an epidemic, even if
 The disease  do not  appear in private,  lying-in women  do not  recover as

  fra[ havrakeTdy said enough about contagion, and earnestly cautioned those

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

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

           PHLEGMASIA DOLENS. —CRURAL  PHLEBITIS.

  839. This disease, under various appellations,—anasarca serosa, buckne-
mia sparganosa,  phlegmasia lactea, oedema lactium,  milk leg,  white leg,
swelled  leg, etc.  etc.,—has been long  known to the profession, although
there has been, and still is, much difference  of opinion as to its exact nature.
It was described  by Roderick a Castro, in 1603, and subsequently by Mau-
riceau, Puzos, Levret,  Petit,  Leake, White, Hull,  Trye,  etc.   It consists in
a colorless swelling of one  or  both legs (simultaneously or successively)
shortly  after delivery,  with pain, tenderness, and fever, lasting a certain
time, and  running a pretty definite course.  The left  leg is far more  fre-
quently affected tb^an the right, although it is not easy to account for it.
  It may occur with first children, but it is more frequent after subsequent
deliveries.  Women of a delicate constitution or lymphatic temperament are
said to be the most liable to its attacks, and especially those who suffer from
any uterine irritation after delivery.  It not unfrequently follows extraction
of the placenta, as in  Mr. Chatto's case.1   Women who have suffered from
it once are very apt to have a slight return of it after the next confinement,
without any repetition  of the cause.  I have a patient in whom this occurred
several  times, each time in a  slighter degree.
Med. Gazette, Sept. 14th, 1839. 
PHLEGMASIA  DOLENS.
591
  It may commence at any period after delivery, and the time makes a con-
siderable difference in our judgment of the case, according  as it begins
before or after the sixth day.  Of twenty-two cases observed by Dr R Lee
seven were attacked between the  fourth and twelfth day, and fourteen after
the second  week.   Levret mentions its occurrence on  weaning the child •
and Dr. Blundell,1 that in "some  rare instances it makes its appearance even
months  after delivery."
  But it is not necessarily or exclusively a  "post-partum" disease, and as it
has an important bearing upon the correct  pathology of the affection, I may
be excused  for entering into a little detail upon this subject.  The. earliest
writer who mentions its occurrence unconnected with parturition is, I believe,
Puzos,  who relates two cases of pregnant women, one  of four, and the other
of seven months, in whom it occurred.   Dr. Meigs  says that he has met with
many examples of phlegmasia dolens in pregnancy.  Denman,  Burns, De~
wees, M'Clintock, etc., mention  its occurrence after  abortion, especially
when a  portion of the ovum has been left behind.  Drs. Willan and  R. Lee.
Mr. Lawrence, Drs. Copland and  Dewees, have recorded cases which occurred
in patients laboring  under malignant  ulceration  of the cervix  uteri.  Dr.
Blundell has  met  with  the disease  in  connection with malignant fungous
growth from the same organ.  Dr. Copland relates a case consequent upon
hysteritis, in a lady who had not  been pregnant for some years.  The attack
has  also followed suppression of  the menses by cold, as in the cases related
by Tommasini and Boulogne, Dr. R.  Lee,  and Mr. M'Clintock.  Again,
there may be  no disease or disorder of  the womb or its functions, as in  the
cases of phlegmasia dolens  accompanying  dysentery related by Dr. Mayne ;
and lastly, it may occur in  the  upper  extremity,2 or in a well-marked form
in the male sex.
   840  Symptoms. — As we  have generally to  do with the disease as it
 occurs  in women who have suffered from  irritation or  inflammation of the
 womb,  it is not surprising that the  ordinary premonitory symptoms should
 commence with pain or  uneasiness  in  the lower  part of the  abdomen, ex-
 tending along the brim of the  pelvis.  I have seen this  pain extremely
 severe,  like an exaggerated after-pain, and lasting  for  some hours.   In some
 cases there is a well-marked or imperfect rigor,  in others  nothing of  the
 kind.   The patient is irritable, depressed, and complains of great weakness,
 headache, and thirst.   Dr. Denman  remarks that, "Before the  appearance
 of any  swelling or sense of pain in the limb  about to be affected, women
 become very irritable,  with  a sense of great weakness, and  grievously op-
 pressed in their spirits, without any apparently sufficient reason ; complaining
 only of transient  pains  in the  region  of the uterus, and  from these  the
 approach  of the disease has frequently been foretold.   After a short  time
 they are seized with an extremely acute pain in the calf of the leg, extending
 to the inside of the heel, and then, observing the course of  the  lymphatics,
 stretching up to the ham, along the  internal  part of the thigh, to the groin,
 occasioning a slight soreness on the  lower  part of the abdomen."3
   Sometimes,  however, there are no precursory symptoms, the patient being
 suddenly seized with pain in the calf  of the leg; or it may commence like
 rheumatism, affecting the back and hip-joint;  as  Dr. Burns  has remarked,
 " Sometimes  there is no uneasiness  in the belly,  and the first symptom is
 sudden pain in the calf of the leg.  Within twenty-four hours  after the  pain
 is felt the limb swells, and becomes tense ;  it is hot, but not red—it is rather
 pale and  somewhat  shining.   The  swelling sometimes proceeds from  the
 groin downwards ; but in most cases it is  first perceptible about the calf of
 the leg, and proceeds upwards.   It is  generally followed by an  abatement.
         i Obstetricy, p. 785.        J Dr. Winn, Med. Times, Aug. 14th, 1852.
         » Introduction, p. 506. 
592
PHLEGMASIA  DOLENS.
but not a cessation of the pain.   Sometimes the  disease begins like  rheu-
matism, affecting the back and hip-joint.   Then the upper part of the thigh
becomes painful and swelled, and next the calf of the leg suffers ; sometimes
the limb at first feels colder than the other."1
  When the disease begins in the pelvis, the pain speedily extends below
Poupart's ligament down the thigh, to the ham, calf of the leg, and foot.  It
is  constant, but occasionally remitting, and not much  relieved by posture,
though a depending position materially increases it.  Shortly after the com-
mencement, the inguinal region  is tumefied and tense, and in a day or two
the thigh becomes swollen, tense, white, and shining.  This swelling may be
confined to the thigh, or extend to the heel, and it will vary much in amount;
occasionally, the  leg is enormously increased in  size.   When  the  pain
originates in the back and hips, the nates and vulva become swollen, glassy,
and tense.   When the disease  commences in the calf of the leg, the swelling
is first observed there or at the ankles, gradually extending itself up the leg
and thigh.   The  temperature  of the limb is generally increased, though in
rare cases  it is below the natural standard.  At the  commencement and
decline of the disease, the limb pits upon pressure ;  but when the  distention
is very great, it does not.  Just as Dr. R. Lee has described: — "In several
well-marked cases, however, of crural phlebitis at the invasion of the disease,
the impression of the finger has  remained  in different  parts  of the limb —
more particularly along the tibia; but as the intumescence  has  increased,
the pitting upon pressure has disappeared until the acute  stage has  passed
away.   At the  onset of the disease I have also observed in  several cases a
diffuse erythematous  redness of the integuments along the inner part of the
thigh and leg."
   In most  cases the  femoral vein may be traced from  the groin  down the
thigh,  feeling hard, and rolling  under  the finger like a  cord.  Of course,
this is  not the case when the attack is limited to the leg.  There is a degree
of tenderness over the  entire  limb, but it is very marked  along the course
of the inflamed vessel;  generally there is neither redness nor discoloration,
but in  some few  cases a faint  red streak  may be perceived.   The inguinal
glands share in the irritation,  and may be swollen and hard ; in  some rare
^.ases they  suppurate ; and according to Dr. Burns, mortification  has taken
place,  and  amputation  been necessary.2   Abscesses may also  form in the
cellular membrane.   Either leg may be  affected;  but, as I have already
observed, the left is more  frequently attacked ; and it not uncommonly hap-
pens that the sound leg participates in the disease before the other is per-
fectly well, and then  the disease runs a similar course a second time.  Mr.
Sankey observes,  "Most of my patients have had both  legs affected, though
not at the  same time ; but after  going through  the process  Dr. Wynn has
described in one,  the other becomes affected ; and unless  prevented by the
application of blisters, goes through the  same  stages,  and takes the same
time as the first."3   In the cases of double attack which I  have  seen, the
second  limb was  certainly more  slightly  attacked  than the  first;  although
this does not accord  with  the  great  experience of Dr.  Denman, who found
the second as severe  as the first*  I have already  stated  that patients who
have suffered from phlegmasia dolens after one labor, are very liable to have
Blighter returns, without apparent cause, after the  next labor.  When once
the swelling takes place, the limb becomes  useless;  the patient can neither
Oend it nor place it on the ground.
   The  constitution, as might  be expected, suffers  considerably during the
attack : the pulse becomes quick (from 100 to 140) though weak, the tongue
white and coated, the thirst considerable, the countenance pale, the appetite
  1 Burns, Midwifery, p. 609.                  » Midwifery, p. 609.
  8 Ed. Med. and Surg.  Journal, vol. x. p. 102.    * Introduction to Midwifery, p. 507. 
                         PHLEGMASIA  DOLENS.                    59^





 fnlin  VS1S aCC°U-nt °J sWtoms> commencing perhaps with a rigor or chill
 followed by pain in the abdomen, pain and swelling in the  thifh and le"'
 quick pulse, etc., the acute stage may continue, for one, two, or three weeks'

 comforialira'nd Zt^ Tl^™ h*™S -^sided  the'patient is m01^
 comfoitable, and the disease takes on a  more local character   Dr  Stokes

 bcliTe'disease  '     ^^ **  SWdling' *" ^ f-^^le and  mo?e
   841. Terminations.—I. The disease may,  and most  frequently  does
 terminate in resolution;  the general symptoms gradually subsiding, (he dis'
 ease becomes local;  and after five or six weeks the  swelling  diminishes, the
 tenderness  disappears, the  general  health is restored,  and by slow degrees
 the  patient recovers the use of her limbs.   It is long, however, beforf the
 affected leg entirely loses its wooden feel, and attains  its  natural power of
 motion and sensation.                                          r
   2  The subsidence may be still more gradual, the limb continuing swollen
 with an occasional increase of the tumefaction for months, the patient having
 imperfect sensation in it,  and  imperfect command over it.   In such cases I
 have noticed  a dense, thickened feel of  the skin, or  subcutaneous cellular
 tissue ; and in one or two cases the  patient had an attack  of cutaneous in-
 flammation, resembling large hives (Uticaria), which lasted for a few days
 and was  somewhat painful, but  then disappeared.   The  veins sometimes
 remain varicose,2  but I  should hardly think that this is  the effect of the
 disease.  It is more likely to have been the effect of the previous pregnancy.
   3. Suppuration may take place, even to such  an extent  as to supersede
 and change the character of the original disease, and even to  threaten death
 from exhaustion.
   4. _ Death may occur, either suddenly, perhaps  on  the  patient raising her-
 self  in  bed  ;  or more gradually,  from exhaustion, from  paralysis,3 or from
 some of the secondary diseases consequent on phlebitis.   Dr. Burns observes,
 " This is not generally a  fatal disease, but it is tedious,  and often accompa-
 nied with hectic symptoms.   Death, however, may be caused by suppuration
 or gangrene ;  or by exhaustion, proceeding from the violence of the consti-
 tutional disease ; or by exertion made by the patient, which has sometimes
 suddenly proved fatal; or, after the leg appears to  be  getting better,  daily
 shivering with vomiting, pain in other parts, and rapid pulse,  with delirium,
 precede death."*
   842.  Morbid Anatomy.—1.  On opening the limb it is  found to be dis-
 tended with serum, effused into the cellular membrane.
   2.  The vein is found to be obliterated in some part of its course by clots
 of blood firmly adherent to its parietes, which are thickened ;  its inner mem-
 brane is of a deep red color, the result either of staining or of inflammation
—most probably the latter.   A layer of coagulable lymph is sometimes found
lining the different  vessels, and they have  been observed to contain purulent
matter.  The  veins which have been  found to participate 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.
  3.  Evidences of inflammation of the absorbents have been found in a eon-

  i Burns, Midwifery,  p. 608.                 2 Lee on Diseases of Women, p. 119.
  8 Todd, Cyclop, of Pract. Med. Art. Paralysis.
  * Midwifery, p. 609.
       38 
594
PHLEGMASIA DOLENS.
siderable number of cases, and in some, purulent matter has been detected,
according to M. Bouillaud.1
  4. M. Duges  has shown that inflammation of the nerves occurs, at least
occasionally, as a complication of this disease.2
  5. Proofs of the occurrence of the secondary effects of phlebitis may be
found in different parts, especially in the serous cavities, and  in  the forma-
tion of abscesses of the limb, and even of more distant parts.
  843.  Pathology — We are now in a condition to inquire into the pathology
of this affection, which has given rise to so much dispute, and  to such varie-
ties of opinion.  The older notions on the subject  are  mere speculations.
For instance, Mauriceau considers it to be owing to a reflux upon the lower
extremities of certain  matters, which ought to  have been evacuated in the
lochia.3  Puzos*and Levret5attribute it to deposits of milk in  the affected
parts {depots du lait); and the same opinion has  extensively prevailed in
these countries, as one of the popular names for the disease (milk leg) testi-
fies.  With some practitioners it was customary to keep the child constantly
to the breast, to prevent the  metastasis when threatened, or to remove  it
when it had occurred.
  In the year 1784, Mr. White of  Manchester, published an inquiry "Into
the nature  and cause of that swelling of one or both of the lower extremities
which sometimes happens to lying-in women ;" and he suggested or adopted
the opinion that the disease depends on obstruction, or on some  other mor-
bid condition of the lymphatic vessels and glands of the affected parts.   Mr.
Tyre, of Gloucester, in  an essay on this subject  in 1792, attributed the
swelling to a rupture of the lymphatic vessels, as they cross the brim  of the
pelvis, under Poupart's ligament.   Soon after this, Dr. Ferriar maintained
that there is a general inflammatory state of the absorbents in this disease.
Dr.  Hull (1800) considered the proximate cause of this disease to  be an
inflammatory affection, producing suddenly a considerable effusion of serum
and coagulable  lymph  into the cellular membrane of the limb.  All the
textures — muscles, cellular membrane, lymphatics, nerves, glauds, and blood
vessels — he supposed to become affected.
  So far the  opinions were  a mixture  of theory and observation, without
any attempt to base them upon pathological research.   The first light thrown
upon the subject by a post-mortem examination, was by Dr. Davis, Professor
of  Midwifery in University College, London,  who in 1817  examined the
conditions  of the veins in a patient who had died with the disease, and found
that they were the seat of extensive inflammation.   The dissection is as fol-
lows : — " March 6th, 1817. — The left lower extremity presented  an uniform
cedematous enlargement, without any discoloration, from the hip to the foot.
This was found, on further examination, to proceed  from the  ordinary ana-
sarcous  effusion into  the cellular substance.   The  inguinal glands were  a
little enlarged, as they usually are in a dropsical limb, but pale colored, and
free from the slightest sign of inflammation.   The  femoral vein, from the
ham upwards, the external iliac  and the common iliac veins  as far as the
junction of the  latter with the corresponding trunk of the right side, were
distended and firmly plugged  with what appeared externally a coagulum of
blood.   The femoral portion of the vein, slightly thickened in its coats, and
of a deep red color, was filled  with a firm bloody coagulum, adhering  to the
sides of  the tube, so that it could  not be drawn out.   As the red color of
the vein might have been caused by the  red clot everywhere in close contact
with it, it  cannot  be deemed  a proof of inflammation.  The trunk of the
profunda was distended in the same  way as  that of the femoral vein; but

    1 Diet, de Med. et de Chir. Prat.  Art. Phlegmasia dolens.            2 Ibid.
    R Mai. des femmes grosses, vol.  i. p. 446.        * Traits dea Accouch., p. 350.
    5 L'Art. d«s Accouch., p. 932. 
PHLEGMASIA DOLENS.
595
the saphena and its branches were empty and healthy.  The substance filling
the external iliac and common iliac portions of the vein, was like the lamf-
nated coagulum of  an aneurismal sac, at least with a very  slight mixture of
red  particles;  the tube  was completely obstructed by this matter, more
intimately  connected to  its  surface than  in  the femoral vein;  adhering,
indeed^ as firmly as the coagulum does to any part of an old aneurismal sac°;
but in its centre there was a cavity containing about  a teaspoonful  of a thick
fluid of the consistence  of pus, of a lightish brown tint, and poultaceous ap-
pearance.  The uterus,  which had  contracted to the usual  degree at  such a
distance of time from the delivery, its appendages and blood-vessels, and the
vagina, were in a perfectly natural  state.   There was  not  the least appear-
ance of vascular congestion about  the organ, nor the slightest distension of
any of its  vessels.   Its  whole substance was, on  the contrary, pale, and the
vessels everywhere  contracted and empty.   The state of the abdominal cavity
and its contents was perfectly natural.   That the substance occupying the
upper part of the venous trunk, and the fluid in its  central cavity, had been
deposited there during life, from inflammation of the vessel, does not admit
of doubt.  I am also decidedly of opinion, in consequence  of its  firmness,
and close adhesion to the vein, that the red coagulum in  the femoral vein
was the result of a similar affection extending along the tube ; and that the
passage of the blood through it, in the whole tract submitted to examination,
must have  been completely obstructed before death."1   He then taught that
phlegmasia dolens  resulted from this cause, and in  May,  1823, published a
paper with cases and dissections.2
   In January,  1823, M. Bouillaud related  several cases and dissections  in
which the crural veins  were  obliterated in women  who had suffered from
oedema of  the lower extremities after delivery ; and M. Bouillaud distinctly
stated that he considered obstruction of the crural veins to be the cause not
only of the oedema of lying-in  women, but of many partial dropsies.3  The
date of this paper, although  earlier than  Dr. Davis's paper, in no way in-
terferes with the claim of the  latter to be the first who discovered and  taught
that phlegmasia dolens is essentially crural phlebitis.  In  1824, M. Velpeau
published some researches, from which he  concludes that not only the veins
are involved in the inflammation in some cases, but that inflammation of the
lymphatics is at least as frequent a cause of phlegmasia dolens.*
   In 1826, Mr. Guthrie hinted that probably the inflammation of the veins
of  the leg' might  be merely an extension from  the uterine veins, and  Dr.
Robert Lee believed that he demonstrated  this in 1829, by tracing the  dis-
eased veins back into the uterus, and finding there  the disease equally well
marked •  " The left hypogastric or external iliac vein," he  says, " was in the
same condition, but in some cases reduced to a cord-like substance, and  its
cavity throughout completely obliterated.  The branches of this  vein, taking
their origin in  the uterus, and usually termed the uterine plexus, were found
completely plugged up  with firm red coagula."5  More recently Dr. R. Lee
has laid before the  Medico-Chir. Society the results  of his  experience m the
following summary: the  paper  contained the record of forty-three cases of
phlegmasia dolens.  The first nine cases were accompanied by pos -mortem
descriptions and preparations illustrating the  disease;  and the  author wa,
led from the whole of the facts thus adduced, to the conclusions he had for-
meriy expressed, "That the inflammation of the iliac and femoral veins gave
rise to S the phenomena of  phlegmasia dolens, and that the inflammation
commenced in The uterine branches  of the hypogastric veins, and from thence
emended to the femoral trunks  of the affected side."  The next series com-

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

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

           i Lancet, March 19th,  1853, p. 276.
            z British and For. Med. Rev., July 18ot,  p. 71.      _
           s Bateman's Report: Ed. Med. and Surg. Journ., vol. m. p. 1-8. 
598
PHLEGMASIA DOLENS.
   As the bowels are almost always in some degree disordered, appropriate
remedies must be tried.  If diarrhoea  be not present, purgatives may be
given, and we are advised to prefer the saline.1   I have seen much benefit
result from small doses of tartar emetic given along with the cathartic, during
the acute stage.   Some effervescing draughts may also be given.
   Different statements have been made  as to the  effect of blisters ; some re-
garding them  as  specifics.   Mr. Sankey observes :2  " What I consider a
specific is a blister applied to the calf  of the leg, immediately on discover-
ing the complaint.   The first I apply to the  calf of the leg, as the pain is
generally most severe in that part, and there  is less fear of its not healing
than  if applied lower.  If required, I repeat them every two or three days,
not  at  the  same place, but  higher or  lower, according to the seat  of the
pain."  Others, as Dewees, etc., altogether rejecting them  as mischievous.
My own experience is decidedly in favor of their utility, although in many
cases turpentine fomentations will answer equally well.
   In the more acute  and severe cases,  and especially if there be evidence
that there is irritation or  inflammation  of the uterus, it will be advisable to
give small and repeated doses of calomel and opium until either the  symp-
toms give way or the constitution is brought  slightly under mercurial influ-
ence.  In milder cases  an occasional mercurial purgative  is beneficial, but
it will rarely be necessary to continue its administration steadily.
   When the pain is severe, or the  patient irritable, restless, or  sleepless,
opiates will be found very useful,  and  with them, as  Denman has  recom-
mended, we may combine diaphoretics or diuretics.3
   When,  by these means,  the acute stage has been terminated, and the con-
stitutional symptoms  relieved, the local and general treatment must  be
changed.   Gentle support may be afforded to the limb by a tight flannel
bandage,  and slightly stimulating  frictions employed.   In this stage, espe-
cially, the frequent application of small  blisters has been recommended.  Dr.
Denman thus expresses himself: —"Then, also, but not sooner, it is  neces-
sary and proper  to support  the swelled limb  by a  slight  flannel bandage,
drawn gradually tighter, and to use different applications, such as the vola-
tile liniment, or one composed of three parts liniment, saponis, and one part
of tinct. cantharid., and sometimes small quantities of  the ung. hydrargyri.
The frequent application of small blisters to different parts of the limb^has
been also then strongly advised, and in many cases with evident advantage.
Electricity has been tried ; but of its real benefits I am not  competent°to
judge.   Certainly, many patients  have  been much relieved  by persevering
in the use of warm  sea-bathing;  and they are to be encouraged, but with
some  caution, to use exercise."
   Tonics  may  also be  given — decoction  of  bark or quinine, with  dilute
sulphuric acid, will be found the most serviceable.  With these means must
be combined an improvement in the diet, gradual, yet decided—meat broths,
and a fair allowance of wine or malt liquor.
  If at any period of the disease the lochia should become offensive, vagina]
injections  of tepid milk  and water should be used  once  or twice a day.

  1 Dewees, Diseases of Females, p. 492.
  2 Ed. Med. and Surg. Journ., vol. x. p. 402.    » Introduction to Midwifery, p.  509. 
PUERPERAL  MANIA.                     5 9 Q
                     CHAPTER  XXYII.

                         PUERPERAL MANIA.

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

          1 Dublin Journal, vol. v. p. 61, Old Series.
          a Gooch on the More Important Diseases  of Women, etc, p. 127. 
600
PUERPERAL  MANIA.
more frequent in proportion among the higher ranks, for  out  of 144 cases
of mental derangement in  females  of  opulent families, the  attack came on
during childbed or lactation in 21.   Dr. Haslam states, that  of 1644 femalea
in Bethlem Hospital, 84 were cases of  this kind ;  and Dr. Rush mentions 5
cases out of 70 at the Philadelphia Lunatic Asylum.
   The attack may, in  some few cases, be a continuance or a  further de-
velopment of the nervous affections of  pregnancy; the nearer the_ approach
to mental derangement during this period, the greater the probability of an
attack after delivery.
   851. There are two  periods, however, at which patients  seem especially
obnoxious  to it — 1st, immediately after delivery, to which  the  term paro-
phrosyne puerperarum has been given ; and 2dly,  about the fourth  or fifth
day, when  the  full ■ secretion of milk  is established, and then  it has been
termed mania   lactea.   Dr.  Burrowes  adds a  third  period—about the
fourteenth  or fifteenth  day, and he then attributes it to the effect of  cold in
checking the  secretion of the milk.    I  find that  of Esquirol's cases,  16
became delirious from  the  first to the  fourth day;  21 from the first to the
fifteenth day ; 17 from the sixteenth %o the sixtieth day; 19 from the sixtieth
day to the  twelfth month ;  and 19 after forced or voluntary weaning.  Of
Dr. Burrowes'  cases; in 33  the access was before  the fourteenth day; in 11,
after the fourteenth and before the  twenty-eighth day.
   852. Symptoms.  The premonitory  symptoms vary a good deal.   In one
sense,  hereditary predisposition, or the nervous  affections of gestation, are
premonitory, but in most  cases we shall  generally find, previously to an
attack, a degree of exhaustion, conjoined with great excitability, headache,
and want of sleep ; or the  attack  may accompany or follow convulsions, as
I have  seen in  more  than  one  case.  Dr. Haslam remarks:  " The  first
symptoms  of the approach of this disease  after delivery are, want of sleep,
the countenance becomes  flushed,  a  constrictive pain is often felt  in the
head, the eye assumes  a morbid lustre, and wildly glances at objects in rapid
succession  ; the milk  is afterwards secreted in less  quantity, and when the
mind becomes more violently disordered it is totally suppressed."
   Writers speak of various species of  puerperal  insanity, principally of two,
however,—those  cases in which  the  form is melancholia, or  mania, and
those  in which  phrenitis, or inflammation of the membranes of the brain,
 exist; the former is the true puerperal  mania, and may be distinguished
 into two varieties — those where fever is present, and  those in which it  is
 absent.  " Mania," says Dr. William Hunter, " is not an uncommon appear-
 ance in the course of the month, but of that species from which they generally
 recover.   When out of  their senses, attended with fever, like  phara-
 phenitis, they  will, in all probability, die; but when without fever, it is
 not fatal,  though it {i.e.,  the  fever) generally takes place  before they get
 well.   I have had several private  patients, and have been called in where  a
 great number of stimulating medicines and blisters have been administered ;
 but they have  gone on at another time talking  nonsense until the  disease
 has gone  off, and they have become  sensible.  It  is  a species of madness
 they generally recover from, but I  know of nothing of any singular  service
 in it."   "Putting together," says  Dr.  Gooch, "This  statement  of Dr.
 Hunter with my own  experience, I extract from it the following meaning :
 that there are  two forms of puerperal mania, the one attended  by fever,  or
 at least — the  most important part of it — a rapid pulse ; the other accom-
 panied by a very moderate disturbance of the circulation; that the latter
 cases, which  are very far the most  numerous,  recover;  that the  former
 generally  die.   This  agrees closely with  my own  experience."  Dr. Bur-
 rowes states that he  has  not seen any case attended with fever, "except
 when coincident with the first secretion of milk, or where  inflammation of 
PUERPERAL  MANIA.
601
the breasts or other parts has occurred, or upon forced weaning where there
has been  abundance  of milk."   But this  is far from  being generally true.
I have seen several cases in which mania occurred before the secretion of
milk,  and yet the pulse was very quick, and the skin hot, with thirst, loaded
tongue, etc.
 # In  the one variety we find the attack preceded by wakefulness, excita-
bility, headache, and after a while the mind is evidently  astray ; the patient
may be joyous or melancholy, singing and talking incessantly, or obstinately
silent, suspicious of every one, fancying injuries and offences on the part of
her husband or friends, and  forgetful of her child.   The heat of the body
may be slightly increased ;  that of  the head is generally so, with a partial
pain  and  sense of pressure or tightness, throbbing in the temples, and
noises in the ears.   The  skin is  generally  relaxed and  moist, but dis-
colored ;  the face pale, the tongue whitish and loaded ; the  abdomen  soft,
and usually free from tenderness; the pulse weak and quiet; there is  little,
if any, sleep, and but little thirst; the bowels  are torpid, and the  stools un-
healthy, often offensive.
   In other cases we find the skin hotter, the pulse quick and small, the face
often pale, sometimes flushed, the eyes  red  and vivid, and a delirium more
resembling that of fever, with a brownish dry tongue, and sordes about the
teeth.
   Dr.  Burrowes has described an attack of puerperal  mania,  somewhat
different  from  the above.   " In every  instance,  this variety has come on
before the fourteenth day from  delivery ; it is preceded by pervigilium, the
ideas are  at first rapid and  confused, images  like those of dreams appear,
and  the delirium is  soon confirmed by these illusions  being considered as
realities, and the speech and action corresponding with these impressions.
The  muscular  powers are  rarely violently exerted, though  the patient fre-
quently attempts  getting  out of  bed  without any  fixed object: on the
contrary, she generally lies  supine; the  countenance is rather vacant; the
eyes  are half closed, or fixed  on  vacuity, and, when roused, follow some
imaginary object; the tunica conjunctiva is  often highly injected, and the
pupils  very little  sensible  to light; the head is hot; the  skin soft and
relaxed, and partial  sweating about the throat and neck.   She continually
mutters incoherently ; loses consciousness, except when  suddenly or strongly
 urged ;  if spoken to, answers shortly, and  perhaps rationally,  but  lapses
directly into the former state of indifference ;  the  pulse is quick  and uncer-
tain ; bowels generally easily moved ; lochia and secretion of milk suspended.
About the fourth or fifth day the debility is  greater; there is more coma;
 the pulse is  quicker,  smaller  and more unequal, with slight subsultus;  pick-
ing at  surrounding objects, or the  bedclothes;  averse  from food or drink;
insensible  of evacuations ;  the tongue throughout presents  nearly a natural
appearance, though  sometimes tremulous when protruded.  It is usually
fatal by the seventh or eighth day;  and  if the patient  survive, chronic
insanity commonly supervenes,  and  melancholia oftener than  mania." x   #
   That active inflammation  of the brain or its membranes may occur during
childbed is  beyond question, but  as it is very  rare, and  does not strictly
belong to  the question of puerperal mania, I  shall not at present enter upon
its consideration.                           .          .         ...
   Thus then we mav have  an  attack of mania  supervening upon delivery,
or occu'ring  from the'fourth to the fourteenth day, with or without  precursory
symptoms f in two varieties the main distinction appears to be in the pulse
   in  nnP it  is  quick, in the  other natural;  the third variety resembles low
_in one  it is  quick, in
fever.
» Commentaries on Insanity, p. 371. 
602
PUERPERAL  MANIA.
  The state of the uterus is apt to be overlooked, because there  are but few
symptoms, if any, referrible to it, and partly also because the patient is not
always able  to answer questions rationally.   As far as my own experience
goes,  I should say that, 1, in certain patients no uterine complication occurs
at all; 2, that in others, the  uterus becomes involved in  the  course of the
maniacal affection ;  and 3, that in some we may trace distinct marks of uterine
disorder from the commencement, such as suppressed milk, offensive lochia,
and  tenderness  in  some  part of the uterus.   I suspect, moreover, that a
division  of these classes  into  two will  correspond  very  closely with Dr.
Gooch's classification by the  pulse; the first class,  and part of the second,
presenting almost always a quiet pulse ; the severer cases of the second, and
all the third, having the pulse rapid, with high fever.
  In  all  the varieties the  stomach  and bowels are much disordered.   The
character of the mania is not in any way  peculiar to childbed.
  853. The progress, duration, and termination of the attack vary a good
deal  in  different patients.   Dr.  Burrowes  observes, that sometimes the
slighter attacks which occur immediately after delivery will disappear under
the operation of a smart purgative, and an opiate.   Of the 92  cases  given
by Esquirol, 55  recovered:  4 recovered  in the first month, 7 in the second,
6 in the third, 7 in the fourth, 5 iu the  fifth, 9 in the sixth, 15  between the
sixth and twenty-fourth, 2 after two years.   Of these, 38 recovered in the first
six months.   Of 37 cases given by Dr.  Burrowes, 35 recovered :  9 recovered
in the first month, 5 recovered in the second,  5 in the third, 3 in the fourth,
2 in the  fifth,  4 in the sixth,  1 in the seventh,  2 in the eighth, 1 in the ninth,
1 in the twelfth, 1 in the fourteenth, and 1 in the twenty-fourth month.   That
is, 28 recovered in the first  six  months.   Of 80 cases by Dr. Haslam, 50
recovered.
  But it may continue much longer,  Of the  cases  described by Esquirol, 6
died; 1  six months after delivery, 1 in a year, 2 after eighteen months, 1  in
three years, and 1 in five years.   In Dr.  Burrowes' table, it is stated  that 1
recovered after two years, 1  after three years, 2 after four years, 1  after six
years, and 1  after seven  years; but he says that he never  met with one
permanently fatuous from puerperal insanity.  Of  Esquirol's 92 cases, six
died, or  1 in 15.   Of Dr. Burrowes' 57  cases, 10 died, or 1 in  6 ;  7 within
twelve days of the  access of delirium, 2 within seven days, and 1 after four
months.   Two of them had active  uterine disease, and two others died of
relapses  after they had recovered from puerperal mania.   Thus we  find that
the  number  of  cases that recover is very considerable;  out of  229, 146
recovered, or more than one-half.  Of 90 of  those who  recovered, 66 were
cured within six months, and the remainder at irregular  intervals up to two
years.  Some we find continued insane much longer, remaining  so for four,
five, six, and seven years.   But, on  the  other hand,  a large proportion of
deaths has sometimes occurred : 1 in 15 at La Salpctriere, and 1 iu  6 among
Dr.  Burrowes' cases.
   [In simple uncomplicated  cases of puerperal mania, although the disease
may  frequently be protracted, the diagnosis, according to our experience, is
for the most part favorable.   Distressing as  the symptoms always are, and
alarming as they often become to the friends of the patient and to the inex-
perienced practitioner, the uncomplicated forms of puerperal mania will  be
found almost invariably to recover under judicious treatment.  It  has been
pertinently remarked, that "the question is not so much whether the patient
will get  well,  as when she will get well."]
   I do not think,  however, that any statistics from  a lunatic  asylum can be
taken as a correct standard of the mortality in puerperal mania, for patients
are not sent there  until  the  disease is more  or  less  chronic: now, a great
number of those who recover, do so within a short time after confinement, 
                         PUERPERAL  MANIA.                     gQ3







months afterwards "   He states, also, that none of his patients wifh a slow
or moaerate y excited pulse died, whereas, in  the  fatal cases, the pulse wal
very rapid, though some with a rapid pulse recovered.   In  the  two cases I
have  referred to,  the pulse was very rapid, yet both recovered   " Night
passed in sleep, a pulse slower and  firmer, even though the mind  continue
disordered, promise safety to life.   On the contrary, incessant sleepS™
a quick, weak, fluttering pulse, and all the symptoms of increasingP exhaus-
tion, portend a fatal termination, even though the condition of mind may be
apparently improved.   In the cases which I have  seen terminate fatally the
patient has died with symptoms of exhaustion, not with  those of oppressed
brain, excepting only one case."1
   I should myself lay great stress, in forming a prognosis, upon the presence
or  absence of  uterine complication, as well  as upon the frequency of the
pulse.  Any complication, indeed,  must diminish the chance of recovery
   854.  Causes.—I shall now consider the causes  of this distressing malady
 lhere seems little doubt that in many cases  (Dr.  Burrowes says in  half the
number, or possibly more, and Dr. Gooch bears  the same  testimony) the
predisposition  is hereditary, and of course mental deviations during gesta-
tion render an attack  of puerperal mania extremely probable.  Sleepless-
ness,  which so fearfully increases  nervous irritability, seems a very general
predisposing cause.
   Among the  exciting causes we find cold, irritation, irregularities of diet,
distress of mind, sudden mental shocks, frights, disordered bowels, excessive
secretion of  milk, and constitutional irritation thence arising, etc.  ; or the
attack may form a part of or follow convulsions, as in  a case  which came
under my care not long since.
   Great stress is laid upon  moral causes by the French writers.  Esquirol,
as I have before  mentioned, states  their frequency, compared with the  phy-
sical, as four to one :  and Georget mentions that out of seventeen cases, there
were but two not proceeding  from  a direct moral cause.  During the inva-
sion of France, in 1814-15, eleven out  of fourteen  cases were from terror.
British writers do not attribute so large  an influence to this cause.
   855.  As to the proximate cause or pathology, it is not very easy to speak
positively.  I may allude to four different views on the subject:  1. From its
occurring in many cases immediately after delivery,  some have attributed it
to disease  of the uterine system.  Fabret mentions  a case of cancer which
excited mania.  Dr.  Briere has related a case  of  mania  from inflammation
of the womb.   Dr. Cooke discovered disease of the womb  in two cases of
puerperal mania.  Dr. Burrows mentions having seen abortion and mania,
the result of inflammation of  the womb, in two cases in which he was  con-
sulted ;  one died, and the other recovered; and in two of the deaths in his
table there was disease of the uterus, but whether it preceded the mania or
not does not appear.   In one  of the species of puerperal mania described
by Dr. Burns,  he  says, "the  delirium is connected  with the state  of  the
uterus, particularly of the veins which are inflamed."2  At a  meeting of the
Obstetrical Society of Dublin, Dr.  Montgomery mentioned a case of puer-
peral  mania in which  the uterus and ovaries were found in a state of in-
flammation ; and Dr. Hardy another,  in  which peritonitis existed, but was

     i Gooch on Diseases of Women, p. 124.             3 Midwifery, p. 619. 
604
PUERPERAL  MANIA.
not suspected till  after death.  I  have certainly seen  uterine inflammation
follow  puerperal mania,  but that  it existed  previously I cannot say:  the
usual symptoms were absent.   Still these  cases, which are  all I have been
able to make out, form  so  very small a proportion to the  cases in  which
there has been no disease of the womb, that without denying that the con-
dition of the uterine  system  is in some way  connected with puerperal mania,
it is clear we cannot  attribute it solely to organic disease of that organ.
  2. Other writers regard the  disease as inflammation of the  brain  or its
membranes.   Now it is granted, of course, that such cases do  occur,  but
they are rare; and it is  contended that in ordinary cases puerperal mania
does not arise from inflammation, and the results of post-mortem examina-
tions are in favor of  the latter opinion.   Burns,  Campbell, Davis, Lee,  and
others, speak of it  as a modification of  phrenitis; Burrowes,  Pritchard,
Gooch, etc., as not being inflammatory.  The latter distinguished observer
thus gives the result  of his experience: " In No.  1, the disease occurred in a
pale lady, without any heat of skin or much quickness of pulse, and was  not
relieved by loss of blood.   In No. 3, it occurred in one whese constitution
was drained  and enfeebled  by nursing.  In  No. 4, it occurred  in a pale
woman, habitually hysterical, subject to bear dead children, from want of
power to afford them life for nine  months.  In No. 5,  it occurred in one in
whom, for urgent reasons, the circulation had been reduced to  the lowest
ebb consistent with life.   In No.  7, in  one who had been  living very  low
for  a week, with such marked symptoms of the irritation of debility, that
at first sight I thought it was the close of some  disease that had been over-
looked.  It  was speedily relieved,  not by cupping and purging, but by  tho
tranquillizing  and  sustaining power of opium.   In No. 8,  the disease  was
treated, though with all possible  prudence and moderation, as an inflammatory
state of'the brain, by leeches, cupping, purging, and low diet, yet the patient
died, not with symptoms of oppressed brain, but with those of exhaustion ;  and
on  examining the body, the whole venous system was found  extraordinarily
empty of blood.   In  No.  10, the patient fell  as if shot, under the stroke of the
lancet; and  on examining the head, there was found no effusion, and empty
bloodvessels.  In No. 11, the disease came on  after puerperal convulsions
(a disease generally,  but not always, depending on cerebral congestion), and
after one of those enormous bleedings commonly practised in these cases, and
no  morbid  appearances were discovered after death, in the brain.  These
cases, if fair specimens of puerperal insanity, lead straight to the conclusion
that the disease is not one of congestion or inflammation, but one of excite-
ment without power."1  Add to this, that Esquirol found no traces of cere-
bral inflammation upon most careful examination.
  3. Dr. Marshall Hall believes that the disease "results, in general, from
all  the circumstances following parturition combined, but chiefly from  the
united influences of  intestinal irritation and  loss of blood."  " I am per-
suaded," he adds, " that real puerperal phrenitis is comparatively a rare  dis-
ease, that puerperal mania is seldom of an inflammatory character, and that
it is especially to be treated  by those measures which are suited to the mixed
case of intestinal irritation  and exhaustion."2  That  many cases occur in
patients exhausted from  some  cause, the extract I have given from  Dr
Gooch will prove, and that the  stomach and bowels are disordered  in most
cases is recorded by almost  all writers, so that we cannot deny that Dr. M.
Hall's view has much to support it.  Nevertheless,  it does not  seem to
express the whole truth, nor is the want easily supplied with any degree of
precision.
  4. The explanation of Dr. Gooch, which  I have already quoted, as to the
: Diseases of Women, p. 144.
a Diseases of Females, p. 251. 
PUERPERAL  MANIA.
605
peculiar nervous susceptibility induced by the organic changes consequent on
impregnation and  child-bearing, although I believe it to be correct, is neces-
sarily vague ;  nor is the view of Dr. Ferriar more accurate.   He says:  " I
am inclined to consider puerperal mania as a case  of conversion.   During
gestation and after delivery, when the milk begins to flow, the balance of the
circulation is so greatly disturbed as to be liable to much disorder from the
application of any exciting cause.  If, therefore, cold affecting the head, violent
noises, want of sleep, or uneasy thoughts, distress a puerperal patient before
the determination  of blood to the breasts is regularly made, the impetus may
be converted to the head, and produce either  hysteria or insanity, according
to its force or the  exciting cause."
   Perhaps it is best simply to enumerate the elements which  may concur to
produce the attack.   We have  the nervous shock varying  in  degree, but
always increasing  the nervous irritability ;  the great vascular change;  the
disturbance of respiration and circulation ; the  exhaustion ; and in  many
cases the loss of blood ; this combination must necessarily leave the nervous
system in  a favorable  state for the operation of the exciting causes I have
enumerated, and the result is mania.
   856. Treatment.—The treatment of puerperal mania is very simple as
regards the materials, yet requiring calmness and judgment in their appli-
cation.
   1.  Those who regard it as any modification of phrenitis, of course recom-
mend bloodletting, with  more or  less liberality.   Now,  from  what I  have
said as to  the  nature  of  the  disease, it will be  clear that in most cases it is
inadmissible, or, if ever used, it must be with extraordinary  caution, and by
means of  leeches, in  cases where there is  strength and  quickness of  pulse,
 and flushing of the head and face.   I have, however, never found it advisable;
 and Esquirol, Haslam, Gooch, Burrowes,  and Pritchard, are all opposed to
 it.  The   last-named  author  remarks:  "If we  consider that the  greatest
 danger to be  apprehended  for  patients laboring under puerperal madness
 arises from a state of extreme exhaustion, that many women die from this
 cause within a short interval from the commencement of the disease, and that,
 if they survive this period, the healthy state of the mind is in most instances
 restored, it will be evident that our chief endeavors must be directed to the
 present support of life."   "Bloodletting, as a general remedy for puerperal
 madness,  is condemned by  all practical writers  on whose judgment much
 reliance ought to be placed."1
   2   When the  stomach is  overloaded,  when  indigestible food has  been
 taken  or  even for the purpose of lowering the pulse by the shock of vomit-
 ing emetics have been found useful.  They must, however, be used with cau-
 tion  when the face is  pale, the skin cold, and the pulse quick and weak.  Dr.
 Gooch prefers ipecacuanha to antimonials.  Dr. Burrowes recommends nau-
 seating doses of tartar emetic, with the saline mixture and  digitalis, for the
 purpose of reducing the violence and fury of the  patient;  and Dr. Beatty
 informs me that he has derived great advantage from tartar emetic.
   3   From the almost universally disordered state of the  bowels  great relief
 is afforded by one or two brisk purgatives of calomel, followed by castor oil
   7e2 powder.  The stools are dark-colored, and highly offensive ;
 andfaaddition to the advantage of clearing out the bowels, purgatives act

 ^f tSr^twerhr be^frtl, the greatest benefit will be derived
 from narcotics   Denman prefers small and repeated  doses of opiates  but
 from narc°"cs_      d pritFchard recommend full doses, and  with this I con-
 ^^^^Do^Vo^Wt twelve drops of black drop, or an equi-
» On Insanity, p. 313. 
606               EPHEMERAL  FEVER,  OR  WEID.

valent of the other preparations of opium.   If opium disagrees, hyoscyamug
must  be  given;  and should sleep be induced, repeated small doses may be
administered ; when the head  is very hot, and face flushed, we should  post-
pone  the exhibition of opium ;  and we must guard against constipation.
  In  more than one case  recently under my care, in which opiates had no
effect in quieting  the patient  or procuring sleep, we tried the inhalation of
chloroform, and with great benefit: she became quiet, ceased talking, and
occasionally was put to sleep for an hour or two at a time.  Mr. Waters, of
Liverpool, has published three cases of this disease in which the exhibition
of chloroform was most beneficial: all recovered speedily.1
  5.  The head may be shaved, and a cold lotion  applied; if the delirium
continue,  a blister may be applied, but it is not generally necessary.
  6.  In protracted cases, or when the  patient is exhausted, nourishing diet,
broths, etc., and even tonics,  must be allowed;  ammonia, with  cinchona;
oil of turpentine, wine, etc.
  7.  As  uterine inflammation  not uncommonly arises in the course of or
follows puerperal mania,  a close watch  should be  kept for the  earliest
symptoms, and if they appear, calomel in small and repeated doses, or mer-
curial inunction, should be added to the other remedies, with such other local
applications as may be deemed advisable.
  8.  It will be necessary to keep the most careful watch upon the patient;
the  nurse, who ought, if possible, to  be  one familiar with  such  attacks,
should never leave the room ;  friends ought to be absolutely refused admis-
sion ;  the apartment kept slightly darkened, and the entire house perfectly
quiet.
  9. When the mania disappears, and the patient is convalescent, a change
of air and scene is most advisable.
                    CHAPTER  XXVIII.

                   EPHEMERAL FEVER, OR WEID.

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

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

   The diet may be  nutritious after the paroxysm  is over, and mild  tonics
 may be given, if necessary.  Dr. Campbell recommends  five-gram doses of
 camphor four or five times a day, for some days, to allay nervous  irrtiabihty
   Great  care must  be taken, after the fever has terminated, to  avoid  all
 occasion of cold, or any cause which may  reproduce the attack.

        i Midwifery, p. 341.                   » Burns's Midwifery, p. 572.
        » Campbell's Midwifery, p. 541. 
608
sore nipples.
                     CHAPTER  XXIX.

                           SORE NIPPLES.

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

            Subborat. soda?, ^ij.
            Cretae prsecip.,  3j.
            Spt. vini,
            Aquae rosae, a a ^iij.  M. Ft. lotio.

  ' Braithwaite's Retrospect, vol. x.       a M'Clintock and Hardy's Midwifery, p.  14. 
inflammation  and abscess of  the breast.      609
         R  Cerae albas, givss.
            01.  amygdal. dulc. |j.
            Mel. despumat., gas., dissolve ope caloris, dein adde gradatim
  Bals. Peruvian, giiss.
          Ft. ung.

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

          INFLAMMATION AND  ABSCESS OF THE BREAST.

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

                           iL'Union Med.. 1858
39 
 blO      inflammation  and  abscess  OF  the  breast.

 axillae. ^ If, in these cases, the nipples be flat, or the milk do not run freely,
 the fascia, particularly in some  habits, rapidly inflames.  Others  are more
 prone to have  the  dense substance  in which the acini and ducts are em-
 bedded, or the acini themselves, inflamed."1  Exposure to cold,  mental
 emotion, moving the arms too  much  at the time  the breasts are  so much
 enlarged, are all said to give rise to  it.   Inflammation very frequently ex-
 tends itself from the nipples, along the lymphatics, to the deeper tissues, as
 already mentioned.
   868. Symptoms.—The severity  of the  symptoms  will depend  upon the
 depth and extent of the inflammation.  When the  subcutaneous  cellular
 tissue and the skin  alone are involved, there will be some  local pain and
 soreness,  with a circumscribed hardness and tension,  and a blush of inflam-
 mation upon  the skin.  But when the fascia  or gland is  involved, the pain
 is very severe, extending to the axilla ; the swelling considerable, the tension
 great, and the constitution  suffers proportionably.  The  pulse is quick aud
 full, the skin  hot, there are headache, thirst, sleeplessness, etc.   The  skin
 covering the inflamed part may  be of a uniform red,, or red in patches.   If
 the gland be inflamed, the breast has a nodulated feel, as if it consisted of
 several large tumors.  The secretion of milk is, at  least for a while, sus-
 pended ; but  it will take place after the acute stage has somewhat subsided.
   After the  inflammation has continued for  some time,  suppuration takes
 place, and the matter makes its way to the  surface.  This occurrence is
 marked by shivering, followed  by heat and  perspiration, and a sense of
 fluctuation in the tumor, which is prominent and smooth.  The pointing is
 frequently in the neighborhood of the nipple.   By degrees the  intervening
 substance is  absorbed, and  the  cuticle giving way, the matter is evacuated"
 The matter of superficial abscesses is  simple, or, as it is called, " laudable"
 pus;  but when the abscess is more  extensive,  sloughs of cellular tissue  and
 fascia are discharged.  In a healthy person, when  the matter has been com-
 pletely evacuated, the abscess soon heals up, leaving only a degree of hard-
 ness for some time.
   Such is the general course of the disease; but there  are some important
 variations.  "It sometimes happens," says Dr.  Burns,  "if the constitution
 be scrofulous, the mind much harrassed, or the treatment at first not vigilant,
 that a very protracted and even  fatal disease may result.   The  patient has
 repeated and almost daily shivering  fits, followed by heat and perspiration,
 aud accompanied with induration  or sinuses in the breasts.   She loses  her
 appetite, or is constantly sick.   Suppuration slowly forms, and perhaps the
 abscess bursts; after which the  sympfcms abate, but are soon renewed, and
 resist all internal and general remedies.  On inspecting  the breast, at some
 point  distant  from the  original opening, a degree of oedema  may be dis-
 covered—a never-failing sign of  deep-seated matter there ; and by pressure,
 fluctuation may be ascertained.   This may become distinct very rapidly, and
 therefore  the  breast should be carefully  examined  at least once  a day.
 Poultices  bring  forward the abscess, but too slowly  to save the  strength,
 and therefore the new abscess,  and  every  sinus which may have already
 formed or existed,  must  be at one and the same time freely and  completely
 laid open ;  and so soon  as a new part suppurates, the same  operation is to
 be performed.   If this be  neglected, numerous sinuses  form, slowly dis-
 charging foetid matter, and both  breasts are often thus affected.  There are
 daily shiverings,  sick fits, and vomiting of bile, or absolute  loathing at food;
 diarrhoea, and either  perspiration, or a dry, scaly, or leprous state of the
skin ;  and sometimes the internal glands seem to participate  in the disease,
as those of the mesentery ; or the uterus is affected, and matter is discharged
1 Midwifery, p. 623. 
FLAMMATION  AND ABSCESS  OF THE  BREAST.      611
from the vagina.  The pulse is frequent, and becomes gradually feebler —
  gen.!? Protracted offering of some months,  the patient sinks."1
  869.  Ireatment.—The first indication is to subdue the inflammation, and
to Prevent the formation of an abscess.  For this purpose, the patient may
be bled if the fever run high; or a number of leeches  may be applied, and
repeated if necessary, followed by a large soft poultice, or fomentations.
\\ hen the bleeding has ceased, the  poultice or fomentations may be con-
tinued ;  or an  evaporating cold  lotion  substituted.   " A convenient and
sinaple mode of applying warmth is to immerse a wooden bowl in hot water,
and having wrapped  some flannel  around the breast, place  it in the bowl.
By this means an effectual and equable warmth may be kept up for a con
siderable length of time."2
   The bowels should be briskly purged by saline medicines, and  their effect
is much increased if tartar emetic, in moderate doses, be joined with them.
" I have  been in the habit of  combating this  affection in a way first com-
municated to me by my friend the late Mr.  Gregory, who employed it with
great  success in the Coombe Lying-in Hospital.   The remedy to which I
allude is  tartar emetic, whose power of controlling inflammatory affections
of the breast would lead one to  imagine that it excited  a specific action on
the mammary gland.  On the  accession  of inflammatory symptoms in the
breast, after purging the patient, I administer this medicine in doses of one-
sixteenth of a grain, repeated every hour, so as  to induce slight nausea.  It
is never ray object to cause free vomiting; and  if this should occur, I omit
the medicine  for an  hour or two, and then recommence its  use at  longer
intervals.   In ordinary  cases, I usually find, after twenty-four hours, that
the pain and fever are mitigated, and the breasts are smaller and softer."3
Indeed, this medicine has a more powerful effect in abating inflammation of
the breast than any I have ever tried.  The  diet should be bland, and chiefly
fluid.   The milk should be  gently drawn  away at intervals, and the breast
supported by a sling.
   When we find that our efforts are unavailing to prevent the formation of
matter, the second indication must  be fulfilled.  We  must  facilitate it as
much as possible, and by no  means can it be done more effectually than by
constant  poulticing—changing  the  poultice three or four times  a day.
Opium alone, or in combination with salines, should  be given, to lessen the
pain and induce sleep.
   There is some difference of opinion as to the propriety of opening the
abscess when the matter is  detected.  My  own experience  coincides with
Cooper's rule : " Perhaps, as a general rule, the surgeon should never wait
for an abscess of the breast to approach the surface, but make  an opening
as soon as the slightest degree  of fluctuation is perceptible; for if this be
not done, and the abscess is not very superficial, the  matter will spread, and
form  sinuses in  different  directions.4  Sir A.  Cooper remarks:  "If the
abscess be quick in its progress ; if it be placed on the anterior surface of the
breast • and if the sufferings  which it occasions are not  excessively severe, it
is best'to leave it to its natural course.  But if,  on the contrary, the absce>s
in its  commencement is very deeply placed—if its progress be tedious—if the
local sufferings be excessively severe—if there be a high degree of irritative
fever   and the patient suffer from profuse perspiration,  and want  of rest,
much  time  is saved,  and pain  avoided, by  discharging the  matter with  a
lancet  "5
  When quite superficial, a longer delay may be allowed ; but I am quite

  i Midwifprv n 6°5              2 Ear,e> London Medical Gazette,  vol. x. p. 153.
  » Dr  Beatty, Dublin Journal, vol. iv. p. 340. * Cooper's Surgical Dictionary, p. 946.
  » Sir A. Cooper on Disease of the Breast,  p. 10. 
612     inflammation  and abscess of  the breast.

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


   [I have added the following essay as an Appendix because of the irn-
 portance of the subject, and because I  know of no English author who has
 entered as fully into the subject.  I should be very sorry to be  regarded  as
 the  advocate of craniotomy, but  I may well contend for its employment in
 certain cases, inasmuch as I have always labored to restrict their number,
 and to substitute the forceps when possible.   The essay is  reprinted nearly
 verbatim from the " Dublin Quarterly Journal," and I have thought it better
 not  to alter its form.]
   My attention  having been called  to an article in the Number of " The
 Dublin Review" for April, 1858, p. 100, on "Obstetric  Morality," I have
 thought the subject of sufficient importance to bring it before the Obstetrical
 Society.   The article is written to -show the immorality of the operation of
 craniotomy under any circumstances, if the child be alive ; and although the
 question  has been repeatedly debated  in former times, yet as it is compara-
 tively new to the present generation, it  appears  to  me very desirable  that
 those who are now practising midwifery, and those who are preparing to
 practise it, should know the precise reasons for admitting or rejecting the
 operation.
   I  have read the review over very carefully several times, as dispassionately
 as I could, and I am  free to confess  that I am satisfied neither with the
 theological nor  obstetrical  reasoning of the author; I strongly suspect, in-
 deed, that the writer is not a medical man.
   If any apology be needed for my taking up the subject, I trust it will be
 found in the  fact that one  of  my works (conjointly with Dr. Maunsell's)  is
 taken as the exponent  of  this "Obstetric Morality."  Of the  tone  of the
 review towards  myself, though somewhat uncharitable in its imputation of
 motives, I make  no complaint; but I should have  preferred the third edition
 of my work  being taken as the expression of my present views, instead of
 the first edition,  published sixteen years ago.
   In the observations which follow I shall discard all personal feelings, and
 simply confine myself to  the question in  debate, and I shall endeavor so to
 treat the subject as to give  no  offence to those who may differ from me.  In
 a mixed  question like the  present, it is perhaps improbable that all should
 agree, but in differing, it is surely possible that  each may give the other
 credit for the highest motives, and respect  him for his conscientious adherence
 to what he thinks right.
  The question  at issue, the morality or  immorality of destroying a  living
child by craniotomy—has always been regarded in  a threefold aspect, moral,
theological, and obstetrical, the latter resting on and inseparably connected
with the  former, at least in the opinion  of one party; so that, although this
is not the place for a  moral or  theological dissertation, nor I the most com- 
614
obstetric  morality.
petent person to undertake it, yet it is impossible to avoid the subject entirely.
I shall, however, confine myself to a short statement and examination of the
arguments:  with  this advantage, that the  reviewer, having based his theo-
logical reasons upon Holy Scripture, an authority to which I implicitly bow,
we have, so far, common ground.
  I.  In the  first place, the reviewer objects to the destruction of an unborn
babe on the  grounds that it is a breach of the sixth commandment, " Thou
shalt do no murder;" and  also that it is contrary to  the denunciation in
Genesis ix. 6 — "Whoso sheddeth man's blood, by man shall his blood  be
shed, for in the image of God made He man."  If the latter text be more
than authorization of capital punishment for murder, which I do not deny,
it is clear that it must be subject to limitation, otherwise it would prohibit
killing in self-defence, or  in defence  of another, which is considered lawful
by the Roman Catholic Church, and it would render war unlawful. If, then,
it be  thus modified, there is no reason why the limitation  may not be  ex-
tended so as to include the operation in question, provided I can show, that
it cannot justly be considered a breach of the sixth commandment.
  What, then, constitutes murder, and in what does it essentially differ from
killing  or homicide?  For our present purpose we shall derive the best
assistance from the law of the  land, which is the highest practical exponent
of the law of morals.  I am indebted to a  distinguished legal friend for the
following definitions : — " Murder is the killing any person under  the king's
peace with malice prepense, or aforethought, either  express or implied  by
law :" so say Lord Coke, Sir Matthew Hale, Sergeant  Hawkins, etc.  " Of
this description, the malice prepense, malitia precogitata, is the chief char-
acteristic, the grand criterion by which murder is  distinguished  from  any
other species of homicide."1  It should, however, be  observed,  that when
the law makes use of the term malice aforethought as a description  of the
crime of murder, it is not to be understood merely in the sense of a principle
of malevolence to  particulars,  but  as meaning  that the  fact has been
attended with such circumstances as are the ordinary symptoms of a wicked,
depraved, and malignant  spirit,  a heart regardless  of" social  duty, aud
deliberately bent upon mischief."2
  This malice may be either express or implied by law.  Express malice is
when one person kills another with a sedate, deliberate mind  and formed
design: such formed design  being evidenced by external circumstances, dis-
covering the inward intentions, as, lying in wait,  antecedent menaces, former
grudges, and concerted schemes to do the party harm.3
  Malice is implied by law from any deliberate and  cruel act, committed
by one  person against another, however sudden, thus, when a man kills an-
other suddenly, without any, or an  inconsiderable  provocation, the law im-
plies malice, for no person, unless  of an abandoned heart, would be  guilty
of such an act upon a slight or no apparent cause.*
  I think it will be at once admitted that killing a child in utero, which I
shall prove  can be by no means  born alive, and which must die in a few
hours,  but the  prolongation of  whose  life, even for those few  hours,  will
most seriously, if not irreparably, endanger that of the mother,  cannot be
brought under the definition of murder;  there  is no  malice aforethought
expressed or implied ; it  is  done from necessity, and without any evidence
of a "wicked, depraved, or  malignant spirit:" it  is not, therefore, in  any
true sense murder.  Had there been the slightest reason for thinking it so, I

  1 Blnckstone's Commentary, vol. iv. p. 198;  Gustinean's case,  1 Leach, p. 457.
  2 Justice Foster's Crown Law, pp. 256, 262.
  3 1 Hale, 451 ; 4 Blackstone's Commentary, p. 199.
  * East's Pleas, of the Crown,  cap. v. sect. 2, p. 215; Blackstone's Commentary, vjl.
fv p. 200. 
obstetric  morality.
615
have  no doubt that there would have been a provision made by law, just as
there has been against criminal abortion : so far from this, " an infant in its
mother's womb, not  being in rerum naturd, is not considered by law as a
person who can be killed within the description of murder."1
  Killing  or Homicide is by law divided into three kinds : it is either justi-
fiable, excusable, or felonious.  It is justifiable where the killing arises  from
imperious duty prescribed by law, as the lawful execution of a criminal; or
is owing to some unavoidable necessity, as in the case of an attack on life,
property, or chastity, where the death occurs in self-defence.  This is admitted
by the Roman Catholic authorities,  for I find in  a little work, with the im-
primatur of the Most Rev.  Dr. Cullen, the following : — " It is not a sin to
defend your own life, or another's life, chastity, or property of great value,
when unjustly attacked, even though  it cannot be defended without taking
away the life  of him who attacks it."2
   It is  excusable—1. In case of death by accident, without any culpable
neglect or default, and whilst engaged  in lawful  occupation or amusement.
2. When  death occurs in protecting one's self from an assault, or the like,
in the course of a  sudden affray, where the slayer had no other probable
means of escaping from his  assailant.
   It is felonious in the case of murder or manslaughter.
   Now  I shall be able to show that craniotomy, under proper circumstances,
is "an unavoidable necessity," and if, therefore,  it be legally justifiable to
take one life for the protection of another, we have precisely the conditions
applicable to our case, with this additional justification, that the life we take
is forfeited, i. e., it will inevitably cease, as the child cannot be born alive.
   It is the more important  to be  satisfied on this point,  for it is clear that,
 so far as craniotomy is concerned, it must be decided on moral grounds, in-
 asmuch  as, whether the child dies  in  utero or is  killed, baptism is  equally
 out  of the question.
   There is an argument frequently used by the reviewer,—" that we are not
 to do evil that good may follow,"  about which a  few words may not be
 amiss.   It is perfectly true,  as an aphorism, but, used as the reviewer uses
 it it is a petitio principii, for the " evil" is the very point in dispute.  Again,
 what is  meant by " evil ?"   Pain is  an evil, yet  we  inflict pain to save life,
 —" doing evil that good may come."   That, therefore, cannot be the mean-
 ing.  It must be  moral evil,  something involving  guilt, which would be
 unlawful.                                  , ,
   Moreover, in the way in  which it is applied by the reviewer, it is an accu-
 sation  by implication, " we  may not  do evil," etc., which is what you pro-
 pose to do.   It may  "be slanderously reported,  and some may affirm that
 we  say, Let us do  evil that  good may come;" but in the true sense of the
 word "evil," we repudiate  the  principle  as strongly as the reviewer or the

 ^B^lf^onTiid  graver objection, and one that seems to underlie
 the former, is, that in destroying the foetus in utero we  drtxojto h s u

 S^  ^orro^^^e^uo1 f eJS|J
 ^which has been created by God^ and ^^^^
 moment of existence has in  he language ^07^ ^ ^ hjg ?
 iniquities, that is that it nas mnemu t                      heaven, and





   . 1 Hale, P. C, p. 433.    • " What E,erj Christian most Know aacl Do." p. 23, aot.. 
 616                    obstetric morality.

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

 lam oneram dent sncerdotes, ut quantum  poterunt, impediant nefandumillud scelus quo,
 adhibitis chirurgicis instruments, infans  in utero interficitur.   Omnis foetus quocunque
 tempore gestionis editus,  baptizetur, vel absolute si constet de vita; vel sub coud.tione,
 nisi evidenter patent eum  vita carere."—Decreta Synodi plenari<e  Episcoporum Hibermm,
 avud Thurles habitce anno 1850.  Article "De Baptismo," p. 20.
 ^On the other hand, authorities are not wanting to justify the hunted use  of the opera-
 tion  For example in the learned work of Migne, « Theologian cursus completus,  (Paris,
 18891 at page 483 of vol. xiv., in a note we read as follows concerning remedies likely  to
 eause thePdfath of the foetus:-" Dicebit administrate ren.edu,-----si nulla spes
 affu eeat prolem baptizandi, nam salus matris ad minus tantiest quam sains temporalis
 efmomlnEa prolis, imo  magis preponderat;  illicitum ent, si spes probabihs affulgeat
 baptizandi prolem^                         A          ^ lg39j yol yi  p  253)
   Again, if we turn to the  wor                    ^    ^^ ^ matre pentu_
 find this sentence,  _   * 0ejjj° Ju  'adhibito remedi0) matrem salvavi vi, multi existi-
 rum, et e contra cert»m J™ P™ remedium, quia in his circumstantiis vix in restimationei*
 mant quod ^.^Jf.^™ .Hu™deque jus  habet mater sibi consulendi."  It is only
 JaTtoly iSS iVSomS fhimself doubtful on the point, but it is quite enough for my
 purpose that -multi ef tjmant »      ^  ^ Apostolicus,» 1837, p. 180. says:-<<Puto
   Lastly, St. Alphonsus Lag c^ medicinam ffiatri cum periculo ffletu8 animati hcere in  eo
 soT'Ss^^oTulia'spe's  appareat rationabilis de prolis vita, ut possit baphzan, post
 matris mortem."                     h   that j do not deserve the hard epithets the
 RSernhaf b^o^upon  me with so liberal a hand ; or that they apply with equal
 justice  to these authorities. 
618                   OBSTETRIC  MORALITY.
of the responsibility devolving upon the accoucheur, both as regards the
child and the mother.
  No man possessed  of common human feelings,  particularly  if he  have
children of  his own,  can fail to feel the utmost  tenderness towards the
feeble being he is to  usher into the world.  Even if  we leave the soul out
of consideration,  the  fact of a human life being involved will be  sufficient
to insure  the utmost efforts  of  skill and attention.   The accoucheur is
responsible that no hygienic arrangement shall be  neglected, no errors of
management committed, and no assistance withheld, either during the labor
or afterwards, which may tend to secure  life and health to the  child.   The
records of modern practice show  how steadily this  object has been kept in
view.   The  improved management of the first stage of labor has shortened
the duration  of the second, by the prolongation of which the life of the  child
is threatened.  The action  of the second stage, when too tedious, is  often
quickened by the  ergot of rye, and we are saved the necessity of a recourse
to instrumental assistance.   And  when we are obliged to assist in  this way,
I am certain that in every case where there is a posssibility of success, those
instruments  are preferred which involve no necessary injury to the child.  A
comparison  between the relative frequency of operations with the forceps
and crotchet at present  and in former times, both in the Rotundo and other
hospitals,  will bear out  the  truth of  this remark.   And in all the modern
text-books,  this rule  is'emphatically laid down.   For myself I can  truly
assert that I have always  taught this in ray lectures and  in my writings,
and in practice I have  rigidly followed  the same  principle, that the  child
is to be saved, if  possible.   I therefore  demur to the reviewer's sweeping
assertion that we  evince great indifference  to infantile  life.  The saddest
consummation  of  an  anxious attendance is the  necessity of hastening the
death of  au unborn  babe,  in order  that the mother's  death  may not be
thrown upon us also.
  But although the reviewer says little about it,  we must not forget that we
are equally  responsible for  another life, the mother's, and that of im-
measurably  present value to  her family and  to society;  and  special pre-
cautions are accordingly taken.   Much  of the care to which I have alluded
is equally for the  benefit of the mother, and  if some risk  be  occasionally
incurred to  secure a living child,  extraordinary care is taken to render that
risk as  small as  possible.   The responsibility does not terminate with de-
livery, but extends until  complete recover}'.   For one moment just look at
the interests involved in this  recovery.   The  husband, whose happiness is
bound up in  the  life  of his wife,  and who has intrusted that to us;  other
children, it may be, whose well-being is dependent upon their mother ; to
say nothing of a  circle of friends and dependents who look to her for com-
fort and guidance; and all these  interests now hanging in the balance, form
very onerous items in our calculations of responsibility.
   Such responsibility we incur every day, in  every case, but it is only felt
as a heavy burden in difficult or impracticable  cases.   Then we  feel that
there must be some  limitation to it,  inasmuch as our power is restricted:
we  do not  hold  life  and death  in our  hands — we  do  not determine the
character of the  labor.   What,  then, are those limits  beyond which our
responsibility does not extend ?   It appears to me, that our responsibility
is exactly in proportion to our command  of the  essential conditions of
success.   Not that we are responsible for success,  for that depends upon a
Higher Power; but that, as far as we are concerned, all the means of suc-
cess within our control shall be  applied  in  a  manner and  at a time  most
likely to insure it.  Now the first and most  essential condition, both for the
mother and the child, is timely delivery, and if  we have the power, we are
responsible  for its exercise in such a manner as will benefit both   Suppose, 
OBSTETRIC MORALITY.
619
for example, a case of powerless labor,  suitable for the forceps;  if we care-
lessly allow the labor to continue so long as to involve the death of the
child, we are as much responsible for its death as if we had had recourse to
destructive  instruments, instead of delivering it by the forceps.
t ?^ ifuU be Physically ^possible that the child  can be born  alive  then
I hold that the accoucheur's  responsibility for its life ceases entirely—no
blame can rest upon him for its death.   Nor do I  believe that he  can  be
held responsible in the ordinary meaning of the term, although, in the case
supposed, he has to hasten the child's death to secure another life, for which,
so far as delivery is concerned, he is unquestionably, and in the fullest sense
of the word, directly responsible.
   For I would beg you to consider seriously the different position in which
we stand as  regards delivery, towards the child and towards the  mother.
Delivery is essential to the safety of both ; it may be incompatible with the
life of the  child,  but it can always be accomplished before the life of the
mother  is seriously compromised.  Having, therefore,  the command of the
essential condition  of  success, the  full responsibility rests upon us,  that so
far, the  mother's life shall be insured ; and as all responsibility for the child
has ceased, we say that the mother becomes  our sole object.
   It is the  due appreciation of these relative responsibilities in difficult cases
that distinguishes the wise and experienced accoucheur:  he preserves a just
equipoise between them so long as it  is possible to fulfil both, and recognizes
the proper moment when one ceases.    One, I say, not either: for I protest,
as  strongly as my reviewer, against the notion which he  attributes  to us,1
that we  choose which  of the two lives we  shall save, a notion as  false in
theory as it is in practice.   No man  dare make such a choice, for we have
neither the necessary knowledge, nor the right, nor  the authority, to decide
which is the more important life, and best worth preserving.
   And no one ever does make such a choice.   Perhaps the least suspicious
evidence I can adduce is to refer to the cases to which, in my own book, the
operation of craniotomy is said to be applicable.  You will find  that, in all,
the child is either presumably dead, or the labor is mechanically impracticable
with safety to the child.   So that, without hesitation or  limitation,  I would
lay it down as a canon, that craniotomy is never to  be contemplated when a
living child can, by any means compatible with the  safety of the mother, be
delivered "per vias naturales," and  upon this rule  I invariably act.
   This rule happily limits  the number of such painful  cases;  yet, although
not numerous, instances do  occur  in which I believe craniotomy to be not
only necessary and justifiable,  but imperatively demanded, even  though the
child be alive, if  we would not voluntarily  incur  the responsibility of the
mother's peril, and perhaps  death ;  and upon  this class of cases  I  shall
trouble the Society with some  observations in answer to my  reviewer.   He
especially refers to cases of mechanical disproportion from narrowness of the
pelvis, and  from a hydrocephalic head.   Both these  classes, and some others,
involve  merely questions  of  mechanical  disproportion, and  may,  for our
present  purpose, be treated together;  but I shall add a few words separately
on hydrocephalic  children.
  i The reviewer states that " this seems to have been the opinion of the French doctors
who attended the Empress Maria Louisa during her accouchement, for they  consulted  the
first Napoleon as to whether they should spare the mother or child in case they found it
necessary to kill one of  them."   I believe that this is about as true as the phrase
attributed to General Cambronne,—" Les guides meurent mais ne se rendent pas;" or
Wellington's  " Up, Guards, and at them," both of which were  denied  by the  supposed
authors    In truth M. Dubois was too experienced a man to make such a speech; if
anything like it was  made, it was,  probably, a request to  know whether the mother was
to be allowed to rfi>, because the child could not be born  alive.  And let me just remind  the
reviewer, in any case, that the parties were of his own Church. 
620
OBSTETRIC  MORALITY.
  Now in order to meet the question fairly, I shall assume that we have to
deal with the case of a pelvis so narrowed at either brim or outlet that a
living child, even aided by the forceps,  cannot pass, but through which a
mutilated child  can be extracted, without undue risk of injury to the mother;
and it matters little to the argument whether the  difficulty be from deformity
of the bony tissue, from a fixed irreducible tumor, or from  excess of bulk on
the part of the child.   I say I must assume, for the sake of the  argument,
such a case, although I am met at the outset by the objection  on the  part
of the reviewer, that in practice we cannot be sure of such cases, for that
there is little certainty, and  no  uniformity, in the  measurements given  by
authors; that,  in fact, they are not agreed about the  size of the aperture
through which a living child cannot pass.  This is certainly true, though the
difference is not great, and it is a difficulty which would be  seriously felt in
many cases if we had to give an opinion & priori, or before the commence-
ment of labor.   But after labor has commenced, the  position  of the ac-
coucheur is quite changed, and he has acquired  new and decisive means of
forming a correct judgment.   He can compare the size of the aperture with
the size of the  child's head, for they are in close apposition : he has the evi-
dence of what hours  of strong pains can do towards forcing the head down-
wards ; nay, more, he can test the applicability of the forceps, whether they can
be  introduced, and whether, when introduced, he can draw down  the  head.
With these advantages I undertake to  say that no man will find any difficulty
in deciding whether a patient can be delivered without craniotomy or not.
   Let me now  remind you  of the course of a labor of this kind when left to
nature.   During  the first stage no bad symptoms appear,  nor for some time
after the commencement of the second, nor is the child in present  peril; but
after a time somewhat varying and uncertain, indications of constitutional
suffering are developed,—the symptoms of powerless labor, in short,—and
from that moment the mother may be said to be in danger, which is fear-
fully increased by every hour's delay  and suffering.   In process of time
the symptoms become still more  formidable, and involve  so much general
derangement that the evil effects continue after delivery:  and if this be not
effected, the patient  will ultimately die in a state of  coma or convulsion, or,
perhaps, before this  final stage, the walls of the  uterus  may give way whilst
we are waiting,  and death result from the laceration.   If the  woman be
delivered within  a  reasonable time  after the  setting in  of unfavorable
symptoms, they  shortly  disappear, and her recovery  will,  in  almost all
cases, be complete.   If the  labor be  allowed  to  continue, and  exactly in
proportion to the delay, the recovery  will be less favorable, and the danger
after delivery  greater, until we arrive at that point of time when delivery
itself cannot save the mother.  At what period of the labor the death of
the child, which  is inevitable, will occur, it is impossible  to state with any
accuracy.   It  does, doubtless, sometimes take  place  comparatively  early,
perhaps before any very bad  symptoms have set in ; but  I feel little  doubt
that, as a general rule, it is  not mi til a much  later period, in fact not until
the mother is in imminent peril,  it, many cases not until the last stage.
   Now, what is the right and proper thing to be done in  such cases ?   The
child we shall assume to be living, but it  is physically impossible to extract
it alive through  the passages.  The  mother is  in  great  danger,  which  in-
creases rapidly, and  they will inevitably both die if left alone.   We may (at
least for  the present) dismiss the question of baptism,  as  that is impossible,
whether we craniotomise or not, and  there are two courses open  to us— 1.
To  wait until  we may reasonably suppose the child to be  dead, and then
perforate and  deliver, regardless of the consequences to the mother ;  or 2.
To perforate as soon as the bad  symptoms set in, after having assured our-
selves of the impossibility of using the forceps, and so  secure the life of the 
OBSTETRIC  MORALITY.
621
mother.  The reviewer indicates a third method, the Cesarean section, which
I shall  examine presently.  In our choice  of these last two methods the
reviewer and I  are at issue ; the conclusions at which we arrive are diame-
trically  opposite.   He chooses the first, and rejects craniotomy so long as
the child is alive.   " But it will be said," he observes," must the accoucheur
fold his arm and allow both mother and child to perish, when he might pro-
bably save one of them ?  To this we answer, once more, that  he cannot
commit murder ; that he must not do evil in the hope that good may follow;
and that the medical man, like every other  member of society, must be pre-
pared  to encounter in this dim world a great many calamities which he can
neither remedy or alleviate."  Now I have shown that we  do not commit
murder.  I agree fully in the rule that we are not to do evil that  good may
follow,  but the reviewer's use  of it in  this  place is plainly a " petitio prin-
cipii,"  for I deny that we do  evil, that is,  morally, or involving guilt; and
that "doctors have  to encounter many calamities  in this dim world  which
they can neither remedy  or alleviate," is undoubtedly true, but is this a case
in which the doctor can shelter himself under the comfortable conclusion that
 " he can neither  remedy or alleviate it ? "  Is it not quite evident that his
voluntarily refusing  to deliver makes him an active, willing  and  responsible
accomplice in the death of the mother ?
   I have no hesitation  in stating my deliberate  opinion, that the  second
 plan, which has received the sanction of the best and most distinguished men
 in  the  profession, is the  right and the  wise  course to adopt, and the one
 which best adjusts and preserves the balance of our responsibility.  For, in
 the first place, I have proved that the destruction of a child  under such cir-
 cumstances  is not  murder, but justifiable in  law.  Nay,  if you  think  a
 moment, one cannot  say that  the blame of  the child's death  rests upon the
 accoucheur at all, for  that is  inevitable if  he do nothing.   All  he is  justly
 answerable for is of depriving it of life a  few hours before  it would  other-
 wise cease to live.   And for what ?   The  mother  is in  imminent danger,
 and will die  if assistance be withheld, but  she can be saved now.   I say,
 therefore,  if this  assistance be not given, the accusation  of murder (by
 omission) would come with greater force against the party who voluntarily
 allows the mother's life to be imperilled.   Take lower ground, if you like,
 than the abstract question of right.   Granted, if you please, that hastening
 the child's death is an evil: so is the death of the mother : which of the two
 is the lesser  evil, considering that you cannot prevent the .irst, and can pre-
 vent the latter ?                     „,.,-,,   •        -ui <  n  a
   No good man will forget that for all his  deeds he is responsible to trod;
 but for our profesional actions we have the  additional tribunal of professional
 and public opinion.   Narrow the circle still further, and it is clear that each
 of us  is specially answerable to the party who has intrusted us with the lives
 most dear to  him.   The latter has the most direct and deepest interest in
 both the objects of  our care, and  it appears to me  that it  is impossible to
 ignore his right to be a  party to whatever  decision we come to.
  ° Suppose it to be  our  painful duty to announce  to the husband that the
 labor is such that the child cannot be born alive, but that it must be destroyed
  f we hope to save the mother;  nay, that if we wait until it die, the mother
 ,      Tybe so  much the  worse.   Are there many husbands  that  would
 he tate ?  Would  not natural feeling and  common  sense lead him to  decide
 tl^  the  child's  safety  being  impossible, the  mother s safety  should  be
 secured'  If this be the case, the accoucheur who refuses to act must be
 secured .  u i      responsibility he thus incurs towards society.  Admit-

 ^n»w*^^™*™st  be Ms guide'* d°  t  think in a
 cas? like the present he  can always be  at  liberty to ignore  the consciences
 of others. 
G22
OBSTETRIC
MORALITY.
  I have thus endeavored, I hope  not unsuccessfully, to define the position
in which we stand as regards the mother, in cases where the child cannot be
saved.   I have shown the responsibility which has ceased for the life of the
child, has thereby, as it were, doubled in behalf of the mother; that quies-
cence on  our part cannot be considered as a submission to necessity, or to
the  decrees of Providence;  but that, whether  we interfere or not, we are
equally voluntary, intentional, and active  agents.   That in hastening the
death of the child, we in no sense incur the guilt of murder,  nor are we fully
responsible for its death, which, with or without our  interference,  must have
ensued ;  but that if we, by waiting for its death, imperil the mother, we are
in the fullest sense responsible for that result.
  But  at this point I am met by the reviewer with a  quotation from my own
statistics  to  show, that the gain to the mother  is not so great after all; for
that 1  in 5 die after  craniotomy.   No doubt this is  a very large  mortality;
but if  the reviewer had been a medical man, or if he had taken the trouble
to read the next  sentence in  my book, he would have found it explained as
in many cases the result  of  the doctrine he is upholding, viz., the waiting
until the child is dead, and  the consequent increase of peril to the mother.
Iu many eases, doubtless, the delay is voluntary; in others it arises  from
ignorance on the part of the poor,  so  that,  when assistance is  procured, the
patient is too far gone for ultimate safety.   I should be very glad to furnish
a table of cases without complication, in which  the operation was performed
before  the patient was  too far reduced ; but I fear  that I shall not be able
to adduce many.  In Dr. Collins'  Life of Dr. Joseph Clarke are given the
records of his private practice, and I find  that  he performed  the operation
twelve times from mechanical disproportion (including one case of hydroce-
phalus), and all the mothers recovered favorably;  yet the reviewer specially
mentions that, of the same operation performed  in hospital under Dr. Joseph
Clarke, 1 in 3 of the mothers died ; an ample confirmation of the explanation
I have given.
   In Dr. Robert  Lee's "Cases in Midwifery" there are  eighty cases of
craniotomy recorded, under similar  conditions to those I have indicated, viz.,
mechanical disproportion without complication, although  Dr. Lee was not
called  in many of them until too long  a time had elapsed ; but, even so, only
4 died, or 1  in 20.   Dr. Lee's character is a  sufficient guarantee that the
operation was the patient's  only chance, and he expressly regrets that some
of them were not delivered earlier; had they been, probably none would have
died.
   In the record of Mr. Cross' practice, there are 1 cases in which craniotomy
was performed, and all the women recovered.
   Dr.  M'Clintock has met 5  cases in  private practice in which the operation
was required from disproportion, and all the mothers recovered.
   In looking over my own case-book  I find that I have never performed the
operation in  consequence  of mechanical disproportion,  in  my own private
practice ; the only cases being two of excessive  hemorrhage, in which, there
being  no doubt  of the child being dead,  this  operation  was preferred to
turning; and one case of convulsions, in which the  child was  already dead.
But in  consultation I have  had recourse  to  craniotomy in  twenty cases,
shortly after  it became evident, either that the child was  dead, or that it
could  not be born alive ;  of  these,  all the mothers recovered well.   In  four
other  cases  I was called in after the  labor had been so protracted  that the
mother's case was hopeless,  and the  operation did not save them ; these,
therefore, I exclude.
   From these cases, though their number is more  limited than one could
wish, I think we may fairly conclude  that  if the operation  be performed as
Boon as  it is imperatively demanded, and before the mother is run down, it 
                        OBSTETRIC MORALITY.                    623

iSnrlpanttTded+Wit\gr-ater da"ger than raust alwa^s be anticipated from
any great operation, for it appears that out of 124 cases, some of which were
unduly prolonged, only four women died,  or 1 in 31, i.e., 3 per cent.   \av
more Dr. M Chntock showed, at a recent meeting of this Society, that of
the two  modes  of  delivery, by the forceps, and by  craniotomy, the latter
easterns paribus, is  the safer for the mother.
  With  regard  to M. Debreyne's  experience, quoted by the reviewer, that
  it is almost always fatal to the mother," if it be more than  one of the loose
expressions occasionally used  by writers, I  can  only say that  it  speaks
volumes  against M. Debreyne's practice and that advocated by the reviewer,
tor 1 naye shown that the excessive mortality results from unreasonable delav.
  JNow let me say one word upon children with hydrocephalus.  These cases
come under the same law as those of which I have been speaking, i.e  , the
law of disproportion  or of relative  bulk.   The reviewer declaims strongly
against perforating them, because, as he says, such  children have been  born
alive. _ No doubt this is true, but the cases are few; in the greater number
the child is dead, or has been necessarily destroyed.  But their life or death
does  not determine the use of the perforator; if the head  be not too large
to pass through the pelvis, we should no more think of destroying the child
than if it were deformed in any other way: if, on the  other hand, it cannot
pass, it  must be opened for the same reasons as we perform craniotomy in
distorted pelvis.  Probably the reviewer was  not  aware that such cases,
when let alone, involve serious danger to the mother: yet  of seventy cases
collected by Dr. Keith, in sixteen there was rupture of the uterus and death.
The same result followed in five cases related by Dr. R. Lee.
   So far, I  have assumed that we have only a choice between the two
methods  of dealing with these cases : that there  is no  alternative but de-
stroying  the child, or  allowing it to die;  but the reviewer maintains  that
there is,  and, if I understand him, that it  ought in all cases to be the substi-
tute for  craniotomy. He says that " when it has been proved by experience
and to an absolute demonstration, that  a full-sized child cannot be  born
alive, the induction of premature labor ought undoubtedly to be adopted.
The only lawful alternative is the  Caesarean section,  and  this itself is so for-
midable  and dangerous, that,  when it can  be foreseen, and its necessity
avoided  by any lawful and less dangerous means, it is an undoubted duty  to
have recourse to them."  That is, for every present  impracticable labor we
are to have recourse to the Caesarean section ; but for any future ones in the
same woman to the induction of  premature labor.   I perfectly agree  with
the reviewer, that for all cases of obstruction for which I have recommended
craniotomy, and he the Caesarean  section, premature labor  ought to be ad-
vised iu  subsequent pregnancies, and this doctrine he  found in my book,  if
he  read  it.   At the same time, I cannot but congratulate the profession on
finding the Dublin Review an advocate for the induction of premature labor:
it is  a sign  of  progress very encouraging  to us, for the reviewer must be
aware that this conservative  operation  was first proposed by those Pro-
testants, upon whose alleged disregard of infantile life he is so severe ; and
also that for years it was  opposed in France, Italy, and Germany, by the
Roman Catholic clergy. Even  so  late as  1827, M. Capuron, a distinguished
and devout practitioner, characterized it as " Un attentat commis envers les
lois divines et humaines."
  Now let us consider the Caesarean section as a substitute for craniotomy.
  The reviewer bases  his conclusions upon the statistics given in my book.
The entire number stated is 423, of which 231 mothers were saved, and
192 lost  or about  1 in  2|; of 238  children, 167 were saved, and 71  lost.
Let me observe  that, althoueh  I  have collected this number, I am far from
pledging myself to the trustworthiness of the persons by  whom  they  were 
624
OBSTETRIC  MORALITY.
recorded.   The incomplete account of the children also is a great drawback,
as our statistics might be altered if we knew what became of the remainder.
   If we inquire a little further, we find that M. Figueira has collected 790
cases, of which 424 were fatal to the mother, or considerably more than one-
half, but say 50 per cent.
   Again,  Dr. Arneth mentions that M.  Kayser collected and analyzed 338
cases, of which 210  proved fatal to the mothers, or nearly 2 out  of 3, but
say 60 per cent.
   Moreover, if we take the cases which have occurred in Great Britain and
America alone, I find, out of 63 cases, 18 mothers were saved, and 45 lost,
or nearly three-fourths, say 70  per cent.   In 60  cases, where the result to
the child is mentioned, 34 were saved, and 26 lost, or, 1 in  2^.
   Thus we cannot in fairness take the more favorable statistics as a grouna
of our proceedings:  we must either strike an average, or, where that is im-
possible, base our calculations upon the lowest.  Now, according to Figueira,
we shall lose  more than  one-half; according to  Kayser,  two-thirds;  and
according to British  and American experience, nearly three-fourths ; whilst
of the children we may, under similar circumstances, possibly save one-half,
— I say possibly, because, as the  result  to  many of the children was not
noted, it may as well be less as more.
   Let us go a step further.  It is well known that, of late years, the cases
have been more carefully selected  in these countries, and in many ways  have
been managed by previous preparation both of  the patient herself and of
suitable means and appliances, which require time  and  foreknowledge.   To
show this, take the cases that occurred in Great Britain and America before
1830: 35 such cases will  be found in the Table I have given, of  whom 30
died and  only five recovered, or 1 in 7;  i. e., ^ths, or 86  per cent, of the
mothers were lost; more than one-half the children were saved.
   So far, then, we find that a more  minute analysis has not  improved the
mortality after this grave operation : we see that it varies  from one-half to
two-thirds, three-fourths,  and six-sevenths of the  mothers, and about  one-
half of the  children: whilst we found that a careful examination of crani-
otomy reduced  the mortality to 1  in 31.   That is, you lose 1 mother in 31
after craniotomy,  and all the children ; but in the same number by the Caesa-
rean section, you would lose about 16, 20, 22, or 27 mothers, and  save 16
children.   Or, taking the lowest of these figures, and admitting for a moment
the lives to be of equal value, out of 31 cases, or 62 lives, you  save 30,
which is exactly the  number of lives that would be saved by craniotomy, if
my calculations are right.   If  we take the higher numbers, the saving of
life will be reduced respectively to 27, 25, and  20, in 62.   And, moreover,
we should not forget that, whereas craniotomy is  an operation of necessity,
not election, we  shall have voluntarily  chosen this operation, and  have
knowingly incurred this fearful destruction of mothers.  To any person thus
acting, the reviewer's words will cease to be ironically severe, and become
simply descriptive.   "And if we  may sacrifice  one life to  save the other,"
he says, " if we may  sacrifice the  less  important to save the more precious,
we may, of course, occasionally kill the mother to save  the child, because
there are many circumstances in which the life of the latter is much more
precious than that of the former."
   After what I have  said,  I think, we shall hardly be prepared to agree with
the verdict of the reviewer, that if all the circumstances of both operations
were compared impartially, " the advantages would remain on the side of
the Caesarean section, which is  much  the easier and simpler of the two."
Let  us examine  a little  closer into this, as  bearing upon practice.   One
cause of a  high  rate of  mortality after the  Caesarian section is, that the
patients have  often  been  allowed to  remain in labor too  long before the 
OBSTETRIC  MORALITY.
625
 oSpr«tnr v,   ?6 admnta9e has been—and it is essential to success-that the
 and has btl\-       SOmeJtime Previously that  he would have to operate,
 Msitf.nt,  ? 7? m ?me degree  t0 PrePare his Patient> t0 secure Citable
 assistants, and  to  get  ready various matters which are sure to be required.
 vtl.^-T5^ firuSt' lr0m the shock of the operation ; second, from hemor-
 rhage ;  third, and  chiefly, from subsequent peritonitis, and  this latter risk
 will be much increased by bad food, bad air,  and bad nursing generally, but
 especially by the prevalence, at the time, of any epidemic.           7
   JNow, m substituting this operation for  craniotomy, consider the circum-
 stances  in which we must almost necessarily be placed, and see whether they
 are  favorable to success or not.   They appear to me to  combine  every dis-
 advantage of the cases  of hysterotomy on record, with none of the advantage
 possessed  by the operator in them.
   In the first place, so formidable  an operation will naturally be postponed
 to the latest possible moment, on  account of its known  danger which will
 materially diminish the chances of both mother and  child.   Then, as  it is
 quite impossible, in such cases as we have been considering, that the operator
 could anticipate its necessity, he will necessarily be unprovided with thinsrs
 requisite, and with assistants ; nay, it may  be night before he makes up his
 mind, and he  may possibly be in the country,  remote  from  all  qualified
 assistance.   Moreover  these cases  are very much  more frequent among  the
 poor than those in comfortable circumstances, and here we  have  combined
 the drawbacks of bad air, bad food, and injudicious management,  with pos-
 sibly a prevalent epidemic.
   Under these  circumstances, what will be the  probable mortality ?  You
 may unhesitatingly dismiss  the  hope of saving one-third, or one-fourth, or
 even one-seventh of the mothers, and half  the children ;  but can  you, with
 any reasonable  certainty, calculate in saving one-twentieth of the  mothers,
 and one-fourth of the children ? and if not, look at the unfortunate position
 of the accoucheur,—he has sacrificed  so many of the mothers to save so
 small a proportion of the children.  May we not fairly characterize this as
 doing evil that good, and very little good, may arise, which we reprobate
 as strongly as the reviewer.
   But allow me to add that, if we  are to be guided solely by the  desire of
 delivering a living child, at whatever expense to the mother,  I do not see
 how we can limit the  operation  to  the  cases  we have supposed — viz.,
 mechanical disproportion.  There  are  others in  which we fail in saving the
 child by ordinary means, where it might indubitably be born  alive  by means
 of the Caesarian section.   Take,  for example,  a case of prolapse of the
 funis, which you fail in  replacing,  and where  turning  is impracticable,  and
 the  application of the  forceps impossible;  the labor being  natural,  the
 mother will be delivered without risk, but the child will be dead.   Now in
 this  case Caesarian section  would  undoubtedly save the child, but  dare any
 one propose its adoption?  Yet the  principle  is the same, only  pushed a
 little further.
   The reviewer  lays much mistaken stress upon the  Caesarian section  being
 "simpler and easier," which  he would not have done had  his  medical know-
 ledge kept pace  with his theological.  In craniotomy, in  the cases we have
 been considering, no wound  or injury is inflicted upon the mother; a mu-
 tilated child  is forcibly drawn through the passages,  and that is  all.   In
 the Caesarian section, on the other hand, the largest serous cavity in  the
 body, and that by far the more sensitive to morbid action,  is fully laid open,
 the "uterus  is  divided, and  there will be more or less hemorrhage into  the
peritoneum.  After the operation  is over, there  is every probability of an
attack of peritonitis from the exposure  and rough contact with the serous
membrane, and this disease is one of the most  fatal we ever met iu  practice.
       40 
626
OBSTETRIC  MORALITY.
It must be either ignorance or folly to compare the danger of the operative
proceedings of craniotomy with  those  of the Caesarian section, as regards
the mother.   And medical men are aware  of and admit this.   I know a
little  of foreign  obstetric  literature, but I  cannot call to mind a  single
Roman Catholic  writer of eminence who has  recommended this substitution.
I should at this  moment be perfectly willing to  abide  by the  decision of a
jury of French or Austrian obstetricians of  authority on this subject; and,
however decided, I can assure  the reviewer  that he will find no one in this
country to  take  his  advice about the  Caesarian section.1  Any one who
should venture to do  so would, I have  little doubt, find  himself put upon
his defence before the  tribunals  of his country, and in  the hands of a jury
who have wives,  and value  them.
   Allow me to add a  confirmation of the  opinion I have expressed, in the
words of Dr. West, no mean authority, it will be admitted :—" If, then," he
says,  " such and  so many dangers beset this operation, while the causes of
that mortality are, for the  most part, beyond  the power  either of surgical
dexterity or medical  skill  to obviate, and some of them inseparable from
those  processes  which needs must  follow delivery, we may,  I think,  feel
satisfied that the general rule in British midwifery which prohibits the per-
formance of the  Caesarian  section, except where delivery would otherwise
be  altogether impossible, rests  on a far sounder foundation than that of
mere prejudice,  or blind obedience to  the  dicta of men eminent in their
profession."
   I have now gone  pretty fully into  these important questions;  I have
shown that hastening the  death of  a child  that cannot be born alive is not
murder, as the reviewer has been pleased to term it;  but, according to the
law of morals and the law of  the land, justifiable  and right.   I have ex-
pressed my own faith in the safety of the child's soul when baptism is impos-
sible, whether it die ' in utero' or is  destroyed.    I have endeavored to prove
that the responsibility of the accoucheur for  the child ceases when his power
over  it fails ; but that, in  the one essential  particular,  his responsibility for
the mother  does  not  cease, but rather augments, because that condition is
within his own control.  We have seen that  craniotomy is not recommended
in any case  in which the child can be delivered alive, and that, although the
mortality to the mothers is very high where assistance  is  deferred until the
death of the child  has taken place,  it is comparatively small when afforded
in reasonable  time.
   As  to the alternative of the Caesarian section, I  hope  I  have convinced
you that, whatever may.be its mortality, when deliberately  planned and ar-
ranged beforehand, with assistants and all the various  appliances necessary,
yet that, hurriedly performed, with  the patient exhausted  with  prolonged
sufferings, and the operator deprived of the advantages of due preparation,
the mortality  must inevitably be so fearfully  high, whilst the number of chil-
dren  saved  would be so small, that  were we prepared,  as the reviewer is, to
sacrifice so many mothers in our endeavor to save the children, the sum total
of  lives  saved would,  at the best, not be more, but might very probably  be
much less than by the operation of craniotomy.
   There  are  two  or  three  points  of  secondary importance upon which  I
should like to say a few words, if I have not exhausted your patience.   The

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

                       OF THE

          MONTHLY  NURSE.
  [The following pages are extracted, with the sanction of the author, from
a little " Manual for Midwives and Nurses," recently issued by Dr. Churchill
The subjects discussed have already been treated in chapters 3 and 4 of Part
III., but the additional  details  and minutiae  so  clearly  presented in the
" Manual" can hardly fail to prove of value to the young practitioner, when
called upon for the first time to  take  charge of the lying-in room, and to
assumethe responsibility  of giving all the requisite instructions to the nurse.
  Having found it desirable to  arrange our extracts in somewhat different
order from that in which they occur in the " Manual," a few verbal altera-
tions have been rendered  necessary to preserve  their due connection.  With
these exceptions, however, no change whatever has been attempted.]
  Qualifications of a Monthly Nurse.—1. A good nurse ought not only
to be a woman  of irreproachable moral  character, but she ought to have a
deep sense of religion.   This will lead  her to  regard her office as  a  high
vocation, the duties  of which are to be conscientiously performed for His
sake, who entrusted them to  her ; it will support her under fatigue, and in
the midst of scenes  of difficulty, distress, and  sorrow, will lead her to the
only source of  strength,  and comfort, and wisdom.  An irreligious nurse
will generally be more or less inefficient.
  2. She ought to possess a tender sympathy for the sufferings of others;
and, so far from interfering with her usefulness, this will  render her efforts
more diligent and untiring, at the same time that the gentleness and feeling
she manifests will soothe  the patient and acquire her confidence.
  3. A habit of quick yet careful  observation is essential, lest she should
overlook some important symptom, or undervalue some unusual occurrence,
and so lose the earliest  opportunity of affording relief,  or  of  sending for
advice and assistance.
  4. She should possess  a certain amount of education.   A  nurse who can-
not read, cannot be trusted with the  administration  of  medicines without
great risk ; but a degree  of cultivation ensures greater intelligence, and, as
they have abundant  leisure, they have time  for improvement.  I can  also
say, from experience, that a nurse  who can read pleasantly has it in her
power  to beguile many a weary hour for her  patient.
  5. Neatness  and cleanliness should characterize not only  her person and
dress, but the entire sphere of her  duties.   The arrangements of the sick
chamber, of the bed,  of the patient,  and  of the infant, should all be marked
by order, cleanliness, and neatness.  A  slatternly nurse is generally some-
thing  worse.  She should have "a place for everything, and everything in 
630
QUALIFICATIONS AND  DUTIES
   6. As tidiness should be the character of her department, so  quietness
and gentleness should  mark her movements  and actions.   There should be
no hurry, no bustle, no fuss.   As  everything should  have its proper place,
so every duty should  have its proper time and order, that the patient may
neither be flurried nor discomposed.
   7. A scrupulous attention to the directions of the  obstetrician in attend-
ance  should be  regarded as  the  nurse's first duty, on no  account to be
neglected from carelessness, or evaded  at the request of the patient or her
friends.   As she is responsible to him for the faithful execution of his orders,
she is so far answerable for the safety and life of the  patient.   To  practice
any improper concealment towards the  attending  obstetrician is a gross in-
justice to both parties, which  may cost the patient her life, and bring irre-
trievable disgrace upon the nurse.
   8. A nurse should cultivate habits of perfect accuracy and truth towards
the patient, her friends, and the medical attendant: it is quite possible, and
often necessary, to refrain from telling  the whole truth to the  patient, with-
out telling what is untrue.  For the sake of her own health, as well as for
the efficient discharge  of her duties, she should be temperate in eating;  of
early, active habits, and of constant watchfulness, so long as she is in attend-
ance upon a patient.
   Natural  Labor. — The beginning  of labor is dated by the patient from
the time that the uterine contractions become painful; and this is quite cor-
rect, provided that the entire  uterus be engaged, and that the pains recur
regularly.   There is  a kind  of irregular contractions, however, which are
called  " spurious or false pains," from  their teasing the patient without
advancing the labor.   They arise  from various  causes, as  over fatigue, im-
proper  food, constipation, cold,  etc.,  and  you will  know them by their
irregularity, by their  commencing at the fundus, or  top of the womb, and
being of limited extent, by their not being accompanied by mucous discharge
or " shews," nor pushing forward the " bag of the waters," nor dilating the
mouth of the womb.   Whenever you find the pains to possess these charac-
ters, you may be  sure  that they are spurious pains, especially if,  as is often
the case, the patient have not arrived at the  full time ;  and you  had better
recommend rest, bland food, and attention to  the bowels.   If this be not
sufficient, the family physician should, without delay,  be consulted.
   The true pains, on the other hand,  recur at regular intervals, but these
intervals gradually become shorter; in other words, the pains become quicker,
and also stronger.  And  although they begin in  the back, generally, they
spread round to  the front, until the entire womb is contracted and  becomes
hard.  The result of this  contraction is, that the " bag of the waters," as it
is  called,  is pushed by degrees to the  mouth of  the womb, and gradually
dilates it: at the  same time, there  is a  pretty abundant discharge of mucus
from the vagina.   These peculiarities may almost always be  observed, even
at the beginning  of labor, and when you find them, you may be satisfied that
the female is really in labor.
   As the pains change their character  as labor goes on, a convenient dis-
tinction has  been made into  "cutting or grinding pains:" and  "forcing
or bearing down pains ; the former are confined to the first stage of labor,
and are  short, piercing, and not  very  frequent at first;   neither does the
patient  bear  down with them, unless, very improperly, she  be told to do so.
As the  labor goes on they increase, and sometimes occasion as much suffer-
ing as  the pains of the second stage.   They cause the patient to cry out,
and, perhaps, it is better that she should do so, to  a certain extent;  but she
should be encouraged to control  the   expression of pain and restlessness
within reasonable bounds.  A refractory, noisy, restless patient, certainly
suffers more than a quiet submissive one. 
OF  THE MONTHLY  NURSE.
631
  The  forcing or bearing down pains " are very different, and are very well
described  by their name.   The patient is obliged to bear down, she catches
hold of something, stiffens her body, holds her breath, and does most effectu-
ally aid the uterine contractions in expelling the child.   And whereas with
the grinding pains, the skin was cool and the pulse quiet, but  the patient
restless and crying out, during  the bearing down pain she cannot cry out
because she is obliged to hold  her breath ; she lies quiet in order to force •'
her skin becomes hot and bathed in  perspiration, and  her  pulse is  quick!
Thus, by the state of the skin and the cry alone, you will generally know in
what stage the labor is.
  You will remember the division I have made of labor into three stages; as
a general rule, the waters come away about the termination of the first stage,
and so may serve you as a sort of landmark.  Now let us mention the principal
symptoms  which  you meet with in each stage.   I  have just  described the
pains of the first stage — they are cutting, increasingly frequent, gradually
becoming  stronger, rendering  the patient restless  and irritable, often low
spirited, and requiring soothing and encouraging  treatment.   During this
stage,  also, the stomach  often  becomes  irritable, and the  patient may be
troubled with retching or vomiting, which rather does  good than  harm, as
it relaxes the parts and diminishes the resistance.
  During  the  first stage, shivering is apt to occur,  and especially towards
its termination, just as the  head is pressing through the os uteri.   The pulse
and  skin are but little affected, at least not until near its completion.
  If, during this stage, you place your hand  on the  abdomen, you will feel
the womb  very hard during a pain, and somewhat softer, though still harder
than before labor, during an interval.  It is also tilted  forward in order to
place the  child's head in a favorable position  for entering the pelvis.   Fur-
ther information will be obtained by an  internal examination ; but  I had
better first  tell you how this is to be made.   The patient should be placed
on her left side, with the  hips close to the edge of  the bed : then, having
oiled your right forefinger, you pass it (under the clothes) from behind for-
ward, until you arrive at the external orifice, into which you introduce it,
and  direct it rather backwards and upwards until you arrive a* the os uteri,
which  will  feel like a small  ring, and within which you will  find the  mem-
branes protruding.  You must  be very careful not to press too roughly, or
you  will rupture them ; but when they are relaxed, you  can feel the present-
ing  part  through  them.   Thus you may ascertain if the labor be natural,
and  how far it has advanced, judging by the size of the os uteri, and  its
softness or hardness.   If you keep your finger at the os uteri during a pain,
bo as to estimate its force,  and the effect it produces, you may give a shrewd
guess whether  the labor is likely to  be long  or short.  Of course you will
also  notice the state of the vagina, whether it is cool or  hot, moist or dry,
or whether there be any unusual obstruction,  etc., and on withdrawing your
finger, you will observe  the character  and amount of the discharge.  Re-
member, this examination is to be with gentleness and delicacy,  without ex-
posure or pain, and if all be right, it will not be necessary to repeat it during
the first stage.
  During the second stage the pains become longer, stronger, and  more fre-
quent, and are  seconded by the efforts of the patient:  the pulse is quick, the
skin  hot, and the face flushed.   Yomiting sometimes occurs, but  if the  labor
have not been  unusually prolonged, it is neither a bad  sign nor injurious.
The  patient also feels a degree of heaviness or drowsiness, so that it is not
uncommon  for her to doze between  the  pains; and  this should always  be
permitted.  As the  head   passes  downward through  the  lower outlet, it
presses upon  some of the nerves which supply the lower limbs, and causes 
632
QUALIFICATIONS AND  DUTIES
severe cramps in  the thighs or calves of the legs, which may be somewhat
relieved by friction.
  If an internal examination  be  made  during this stage, you will neither
feel the bag of the waters nor the os uteri, as a general rule, for the former
has been  ruptured, and the latter has been drawn upward over the child's
head ; but you will touch  the head (or whatever part presents) directly, and
find it filling some  portion of the  vagina.   During a pain  you will feel it
descend a little, and go  back when the pain ceases ;  but by the frequent
repetition of this process, you will observe the head gradually come  down,
until it  fill the pelvis and press upon the perineum.  At this time the pro-
gress  becomes slower, a great many pains seem to cause  little advance, and
this for two reasons :  first, the head has to be adapted  to the lower outlet
by a change of position and by compression, or moulding, as it is termed;
and secondly (especially in first labor), because it  takes time to dilate the
soft parts.
  After the pressure upon the perineum has  gone on  some time, it begins
to yield,  and you find it bulge  out with each  pain, and  by degrees the
head  begins to appear at  the orifice of the vagina, pressing  forward, then
receding,  but steadily gaining  ground,  until with a stronger pain than usual
or a double one, it passes into the  world, generally with  the back of the
head directed forwards towards  the pubis, and the face of the perineum ;
but this position almost  instantly changes, and the face is turned upwards
(most frequently)  or downwards.   The  next pain after the head  is born,
effects this'; and  presses the shoulders on the perineum,  over which they
pass with much less difficulty and delay than  the  head  ; and are followed
immediately by the body of the child, when the second  stage is completed.
It is important for you to remember this second pressure  upon the perineum,
for if proper attention be not paid,  the perineum, that escaped  injury from
the head, may be torn by the shoulder.
   After  the birth of the child, a short time of rest  occurs, and then the
womb again contracts, and pain is felt, but not so severe as formerly.  This
is for the expulsion of the afterbirth, which is generally  separated from the
womb by the pains, which expel the  child, and only needs a further contrac-
tion to be removed entirely from the uterine cavity.  After the birth of the
child, there is always  more or less  discharge of blood, which continues till
the placenta comes away,  and  then generally,  though not  always, diminishes.
If the interval between the expulsion of the child and  placenta be long, the
latter will be accompanied by  its clots.
   If the patient have had children, the  pains return in an hour  or two, and
continue  at intervals for  a day or more, but they are  seldom very bad, and
after  suckling has been fairly established, they subside.   These are  called
" afterpains," and, though unpleasant, are of great use in expelling any clots
which may be in the womb, and in preventing hemorrhage.   After its con-
tents have  been expelled, the womb contracts, and may be felt as  a hard
tumor at  the lower part of the belly, about as large as the infant's head.
   Duties of Nurse during Pregnancy.—You are  not  to regard preg-
nancy as a diseased state, requiring medical treatment necessarily; on the con-
trary, it is a natural condition, and needs little more than common sense, in
the majority of instances, to conduct it to a  happy termination.  A certain
amount—rather less, perhaps, than at another time—of  exercise should  be
taken;  as the  stomach is irritable, or at  least more  easily disturbed than
usual, some care should be taken  to  avoid those articles of diet likely to dis
agree ;  longings, as  they are  called, may be, to a  certain  extent, gratified,
provided they are not forbidden by common  sense ; and  the dress should  be
comfortable, according to the  season of the year and the weather.   I need
not say that the personal vanity, which seeks gratification  in well-fitting 
OF  THE MONTHLY  NURSE.
633
clothes, must give way to the necessity for freedom, looseness, and  ease in
dress.   The stays, for example, should be altered entirely :  the front bone
or steel  should either be removed or exchanged for one much slighter;  a
gore of elastic should be inserted on  each  side, so as to allow of expansion ;
and  the  breasts  should  be freed from all possibility of  pressure.   If the
patient intend to suckle her  child, she should, every morning and evening,
for about two  months before  her confinement, wash the nipples with soap
and  water, dry them, and then bathe them with equal parts of brandy and
water,  or  brandy and strong green tea: this  will harden the  skin, and
diminish the  probability of sore nipples.   The bowels should  be carefully
regulated,  if necessary,  not by large doses of medicine,  but  by moderate
ones repeated.  Take care and do not mistake :  an irritable condition of the
bowels, with small, frequent motions  for a  proper freedom, is  quite consistent
with large  accumulations,  and requires medical advice.  Powerful  purga-
tives must  never be given to a pregnant woman, for  fear  of bringing on
labor.   Small doses of castor oil, or  Gregory's powder,  or Epsom salts, will
answer in many cases.   The spirits of a pregnant woman are very variable:
it will, of course, be your duty to promote cheerfulness, by suggesting to her
 the  many happy considerations connected with her condition,  and by abstain-
ing  from all unpleasant  histories, etc.  Quiet and cheerfulness, fresh air and
exercise, by promoting the healthy performance of the bodily functions gene-
rally,  will  naturally favor the successful  completion  of pregnancy.  But
 some  deviations from the  natural course  may  occur, some  symptoms may
 arise,  which may indicate that all  is not quite right; and I  wish to caution
 you against the  attempt to treat such yourself.  By so doing you will lose
 time at least,  which, in some cases, may result  in serious consequences.
 Whenever, therefore, any unusual or threatening symptom occurs,  be the
 first to advise that a medical man be consulted : by so doing, you will pro-
 mote your own interest, as well as that of the patient.
   Preparations for Confinement.—At the time you are engaged as nurse,
 you will be also consulted as to certain  preparations for confinement.   If
 possible, you should secure a large airy bed-chamber, a bed  with a comfort-
 able hair mattress, with ample means for order and tidiness : let the patient
 have castor oil in the house, and a sufficient supply of bed linen, napkins, etc.
 A dressed sheepskin, or a large square waterproof cloth, should be provided,
 with diaper for binders, strong pins, etc.   See that the infant's clothes are
 correct__with strings, instead of pins;  and  prefer rather an abundance  of
 inner clothing to external finery.
   Preliminary Duties of  Nurse.—In  most cases you will be  summoned
 oefore the attendance of the accoucheur is considered  necessary, and your
 object should be, on the  one hand, to avoid calling on  him unnecessarily
 early, and, on the other, to make sure that  he is  summoned in time.   In
 order to decide upon this, you  must take into consideration the distance at
 which he lives, the character of the  patient's former labors,  the rate  of pro-
 gress  of the  present labor, and the presentation.   If,  for instance, it be a
 first labor and the presentation natural, you may wait until the waters break,
 or the pains change their character, provided the distance be not consider-
 able   If  the former labors were rapid, you  must send  so much the sooner;
 and if you discover any other presentation  than  the head, you  must send
 instantly, no  matter how little progress may have been made  To ascertain
 this of course you  must make an examination in the way I  have described,
 but' having done so, it will scarcely  be necessary to repeat it as the change
 of pains and of outcry will inform you when the  second stage begins, and the
 doctor should then  be in attendance.                      .
   On your arrival  at the patient's  house, you will ascertain her  present
 state, and not put her to bed, unless for examination, during the  first stage. 
634               QUALIFICATIONS AND DUTIES

If labor be only beginning, and it the day time, she  had better not remain
in her bedroom, but leave that to  be aired and settled.   Or, if she remain in
her room, it should be kept fresh, and every thing in it arranged in a clean
and orderly manner.   The various things that are likely to be wanted, such
as sheets, napkins, hot and cold water, baby's clothes, etc., should be placed
within reach, and aired, if necessary.   The binder, pins, ligatures, and scis-
sors should all be ready, and the bed properly made up.   All this  may be
done neatly and quietly, without hurry or parade.  Hurry and fuss will agi-
tate and  disturb the patient, and your object should be to cheer, comfort^ and
encourage her.  She will, no doubt, be very glad to  talk to you, and if it be
her first  time, to find  out from you  something about what she has to go
through.   If all be right, you have an opportunity of  encouraging her, but
I would advise you rather to avoid details.   Above  all, neither tell her the
histories  of other patients, nor make promises as to  the period of her being
well;  as  if she once find  out that you have been mistaken, or have been
deceiving her, it will depress her, and she will put  no further trust in any
thing  you tell her.  And further, let me  add a caution  against gossiping,
either with the patient's friends or servants, about any thing you may have
seen or heard in other families ;  it will certainly be  repeated, and  you will
inevitably get into disgrace.   A nurse is  necessarily  a  confidential person,
above a servant, and trusted with many things as a  friend ; and she should
conscientiously regard as sacred all  the information  she  may obtain when
professionally employed.   I  have known  several  excellent women  much
injured by a  neglect of this rule.  A cheerful, kind, and genial  manner,
marked by respect for others, and therefore  for yourself, with orderly, neat
habits, and confidential trustworthiness and  truth, are principal recommen-
dations in a nurse-tender.
   But to return :  on your arrival, you should ascertain that the bowels have
been recently moved,  or if not,  give  medicine or a plain enema  of warm
water or thin gruel, and throughout the  labor take  care  that the patient
pass  water at intervals.   On  the  arrival of  the medical man,  of course the
patient is in his hands, and you receive your orders  from him.  Your chief
duty will be to have everything at hand which  he may want, so that there
may be neither delay nor hurry.
   Management of Labor.—During the first stage of labor there is not
much to be done.   You will probably be called at the beginning, before the
patient is very bad ; and it is not necessary, especially if it be in  the day
time, that she should go to bed immediately, as you will  probably find the
pains stronger and  more frequent while she is sitting up.   She may walk
about the room a little, and  occupy herself, so as  to relieve  the weariness
 of waiting.   You need not interfere  at this period with  her ordinary diet,
but she  is better without stimulants, and you should  make  sure  that the
bowels are freed, if necessary, by a dose of castor oil or an injection.  Quiet
 and cheerful  conversation,  a cool room, mild diet,  slight occupation, and a
hopeful view  of the case, will be all that is necessary until the second stage
 sets in.   She should never be encouraged  to bear down, or "assist herself,"
 as it is termed, until the second  stage begins, and the pains force her to do
 so ; nor is her crying aloud objectionable, unless it be  excessive, and she lose
 all control of herself.
   Preparation of the Bed.—When the  waters  break, unless this occur
 prematurely,  the  patient should, generally,  go to  bed at once ;  but, pre-
 viously,  the bed must be made so as to protect it from  moisture, and to admit
 of the soiled linen being removed at once, and without disturbing the patient,
 and this  is the way you should do it: — Under or over the lower sheet (for
 it does not signify which), you should have placed  a tanned sheepskin, or a
 yard and a half square of oiled silk, or water-proof cloth, at the right side 
OF  THE MONTHLY  NURSE.
635
of the bed, where the hips are  to be, and hanging a little over the side •
upon this the end of a sheet folded twice lengthwise, and upon this again
a sheet folded four times square,  so that, after a labor is  over, this upper
sheet can be easily removed, and if the under one be soiled, it can be drawn
out so as to bring a dry part under the patient/whilst the  soiled portion is
rolled up and pinned.  When the discharge has moderated, say in six or
eight hours, this  sheet and the leather may be removed, and the under sheet
and  bedding will be  found perfectly dry, and may easily be kept so by the
free  use of napkins.
   When the patient is placed on the bed thus made, with her hips close to
its edge, the under portion of her  night dress should be turned up above the
hips, and a folded napkin  or two so placed  as to secure that  the waters or
discharges do not  flood the bed, and make the patient uncomfortable, or
render a change of dress necessary.  Thus arranged, you will find the patient
not  only protected  from discomfort at the time, but afterwards she can be
made quite comfortable,  without fatigue, exposure,  or exertion.
   Position and  Duties of Nurse During  Labor. — During the second
stage of labor your place is on the side of the bed opposite  to the physician.
You can give the patient your hand to pull until the head is  born, when it
is your duty to make steady and firm pressure upon  the uterus as it contracts
and descends;  and this you should  do, not by pressing it directly towards
the spine,  but by enclosing the fundus of the womb in your right hand, and
pressing it downwards towards the pelvis.  Then you will  follow down the
uterus until the child is born, and you will keep up this pressure  until the
binder is applied, and afterwards you can resume it if the doctor wish.  You
should always have a vessel ready to receive the afterbirth.   The most con-
venient thing for this purpose is a small basin.
   During  the  labor, but  especially during the second stage, the patient
suffers more or less  from thirst, and the most suitable drink  will be whey,
milk and water, or weak tea, or a moderate quantity of cold water.  From
a mistaken notion of keeping up the strength, wine and water is sometimes
given ; but I believe this  to be  unnecessary, and  I think it will  rather be
found to increase the heat, and sometimes to interfere with the labor pains.
During the early part of the labor, the patient should be allowed, or rather
encouraged, to take her usual meals;  as the pains  increase, she will lose all
inclination for eating, but  it is  of consequence that she should take  some-
thing occasionally, if the  labor be prolonged, in order to give the stomach
something to do, otherwise, she will, probably, suffer from flatulence.   It is,
especially, the nurse's province,  as I have  already remarked,  to  see that
attention be paid  to the  natural evacuations ;  that  the bowels  are  freed
during the early part of  the labor, and that throughout, afterwards, the
urine  is discharged.  Neglect  of this latter precaution may  lead to very
unpleasant consequences.
   She should keep the room quiet and cool,  and give the patient some cool
drink occasionally, a little thin gruel, milk  and water, whey, or weak tea,
whichever she prefer ; see that the bladder is emptied  at intervals ; should
not  mistake the escape of  "the  waters" for this;  and if the bowels have not
been moved previously, she should give an injection  of warm water or thin
gruel.   She will encourage the  patient more to bear her labor courageously,
by a frank, simple  statement that all is right and going on favorably, than
by fallacious promises of  speedy delivery, which the nurse knows, and the
patient will soon find out,  not to be  true.
   As the pains increase in strength, they compel the patient to  " bear down,"
and  "-enerally she does not need to be told to do this, for she cannot help it
but  it will  be well to  direct her only to do this so long as the pain is severe;
as it declines, it will be of  no use, and only occasion fatigue.   It is usual to 
636
QUALIFICATIONS  AND  DUTIES
fasten a sheet round the bedpost for the  patient to pull, and sometimes to
place a box at her feet for her to push against.   The latter is objectionable
on many accounts : it tends to disturb the position of the hips, which should
be  maintained, and  it may remove the perineum  from the hand of the
obstetrician at the moment when support  is most essential; and I think that
the voluntary rigidity of the thighs and hips, thus occasioned, rather hinders
the escape  of the child's head.   There is  no objection to the  sheet, if care is
taken that  the patient do not draw herself beyond the protected  portion of
the bed.   I think, however,  that the hand of a  person  sitting opposite to
her is still better, as  she can pull as much as she wishes without changing
her position.  Unless under peculiar circumstances,  it is wrong to have any
one  sitting on the bed, or leaning  over the patient, as it adds much to her
heat and discomfort.   As the labor advances, the patient becomes very hot,
and some of the upper bed-clothes may be removed for a time.
  The Binder.—When labor is found to be progressing regularly, the nurse
should see  that half a dozen strong pins, a pair of  scissors,  some ligatures
of threads  or tape or twine, and the binder, are in readiness.   The  latter
should, generally, be about half a yard wide, and from a yard and a half to
two yards  long; but it is  best to  make  the binder according to measure,
taking for  its length  what will go round the woman's hips, with two or three
fingers breadth additional, to allow for  overlapping;  and for its  breadth,
taking from just  beneath  the breast to  the level of the hip joint.   It is
usual to make  the binder of strong diaper or twilled  calico, doubled and
stitched at the edges.  If the lady is  to be confined in the winter,  a very
good binder may be made  of thin "lining flannel," and one fold of  diaper
or twilled  calico.   A strip of calico  stitched  to  the  binder behind and
passed between the legs, below a napkin, and then pinned in front, is useful
in keeping  the binder straight.  Of whatever material it is made, it should
be well washed and  dried before it is required for use.  There are  other
binders ingeniously contrived  with buckles and straps, and cut to fit the
shape, but  I have not found them as  easily put on or removed, nor do I
think that  they make as firm pressure as the simple binder above described.
  Duties of Nurse after the Birth of the Child.—When the child  is
born, and the placenta expelled, the nurse should remove the soiled linen
from the patient, and apply  warm napkins, so  as to make her comfortable
for the time, without exposure or exertion on her part; and having replaced
the bed clothes, which were lightened during the heat of the second stage,
the nurse is at liberty to turn her attention to the infant.
  Application of Binder.—The first thing  to be  done after the  birth of
the child is to apply the binder.   To do  this properly, the nurse should roll
up  about the half of it, and pass it underneath  the  patient to an assistant,
Jvho will unroll it,  and pass  over the end of it to you.   Take care that it is
fairly and  smoothly under the hips; then, drawing it tight over the  lower
part of the abdomen and hips, pin it there first;  and drawing it equally and
firmly over the upper portion,  fasten it  by two or three other pins, so that a
pleasant and comfortable, yet firm, pressure may be  made.
  I may as well mention here the  mode  of making additional pressure, by
pads or compresses.   If this  should be  necessary, fold a napkin in a roll
first, and place that across the abdomen, above the  uterus; then  fold as
many more as may be necessary, in squares, and place them over the uterus:
the former  will prevent the womb from ascending in the abdomen, and the
latter, from enlarging anteriorly.   The  binder is then to be drawn tightly
over the whole.   You will  find that in this way you can make any amount
of pressure you please.  There is  one point I wish  to impress upon you
very strongly, and that is, that this, and  almost every other operation with
which  you are  concerned,  may, and ought to  be  done, with little or no 
OF  THE MONTHLY  NURSE.
637
exposure, or uncovering of the patient.   The neglect of this precaution is
not only an offence against delicacy, but it causes the patient to run great
risk of catching cold, and cold in childbirth is a very serious thing, indeed.
  Subsequent Treatment.—When the doctor leaves the house, the nurse's
first duty is to see that his directions  are  implicitly obeyed.   Remembering
all the  patient has gone  through, it is evident to  common sense, that the
quieter she is kept the better: not more than one or two persons should be
allowed to enter the room, and no running in and out should be permitted.
There should be very little conversation, and that neither in a loud tone, nor
in whispers, for the latter tease  the patient by exciting but not gratifying
her curiosity, and  the former will give a headache.   The room should be
shaded, but not kept too dark, the temperature should be carefully regulated,
and sufficient ventilation secured.
  There are two questions the patient is almost sure to ask, and which you
should  be prepared to answer: first, whether she may change her position,
by turning on  her back,  or on the other  side ?  There can be no objection
to this in ordinary cases ;  but if there be any disposition to flooding she had
better remain as she  is, that  being the  most convenient position ;  or if she
be in a great mess from discharges, she had better wait until this is removed
and she is made more comfortable.
   The second question is, whether she may go to sleep ?  Against this there
is a prejudice amongst nurses, I believe, because in flooding cases the patient
feels  sleepy, and if allowed to sleep without being disturbed by examinations,
and the flooding  continue, she  may faint without its being discovered, and
perhaps die without assistance.   But if the nurse watch over the uterus and
the discharge, so as to ascertain, from time to time, that there is no flooding,
there is no reason why the  patient should not sleep, and certainly there is
nothing which  will refresh her so much.
   Having now mentioned what you  are  to do, let me conclude by a few
cautions as to what you are not to do.
   1.  You are not to  amuse your patients by accounts of the  wonderful and
dangerous cases you have attended, even though  the relation  may be  to
your  own credit.
   2.  You are not to relate anything which may tend to depress your patient,
or render her anxious and uneasy.
   3.  You are not to tell  lies, or make promises, as to her labor being  soon
over, even for the purpose of cheering her; as she will  surely find you out,
and will not afterwards believe you, even  when you tell the  truth.
   4.  You are  not to put her to bed during the first stage,  nor encourage
her to  make bearing down  efforts at an early period, because they will do
no good and will fatigue her.
   5.  You are not to  give hot or stimulating diet or drinks, under the belief
that they will quicken the labor.
   6  You are not to  allow too many visitors in the  room — one or two are
quite enough : hot rooms, hot drinks, many visiters, and useless efforts are
most pernicious, and  may easily convert a natural labor into a tedious one,
if not something worse.                  ,.-,..,        ^ 4
   7   You are not to  keep the patient too hot during the second stage.
   8  You are  not to mistake the dribbling of "the waters" for passing
urine but make sure  that the bladder is emptied at intervals.
   9  You are  to  apply the  binder, remove the soiled linen,  and make the
patient comfortable, without  exposing her to cold.
   Care of the New Born Infant. —When the child has been separated
inji 
638
QUALIFICATIONS AND  DUTIES
tion is fully established.  Before  laying it down, however, tne nurse should
gently and carefully wipe the eyelids, to remove any discharge which may
prove irritating, and see that there is no bleeding from the cord.
  Washing the Infant.—As soon as the nurse is at liberty, her attention
is required by the child, and the first procedure is washing.  This should be
done in warm water—soap is not necessary—in a gentle and handy manner.
It is not advisable to be so particular as to make the process very long, for
the second  washing will be  far more effectual.   The cheesy  matter with
which  the child may be covered, will readily wash off if it be first smeared
with butter, lard, or sweet oil, but if not entirely removed by the first wash-
ing, it will be found dry and falling off in flakes or dust, the next time the
child  is  undressed.   It  is a very common practice to  apply whiskey or
brandy to the infant's head, but this appears a very useless custom, and one
which  may lead to mischief, if a drop of the fluid should splash into the eye.
  Dressing the Infant. —When the washing is finished, the  child should
be gently and thoroughly dried with warm, soft napkins,  before the fire, and
all  its clothes  having been warmed it should be dressed  as speedily as pos-
sible,  and made warm and comfortable.   Do not forget, before you put on
the flannel binder,  to  make  sure that there is no bleeding  from the navel-
string.   A little soft rag should be folded around the remains of the funis,
and turned up  upon the belly ;  over this the flannel binder is placed.   All
the articles of dress that come in contact with the  skin  should be soft, and
all handling performed gently, as is obviously necessary, if you consider the
extremely delicate state of a new born infant.  Strings should be substituted
for pins, wherever it is possible, and  all complicated contrivances avoided ;
it is desirable a baby should  be dressed, or undressed, as easily as possible.
You must be very  cautious with  the  few  pins which are deemed necessary,
not to allow the points to come in  contact with the child; and  with the
strings and bandages, that they be not too tight.  You will  be expected, no
doubt, to give  an  opinion upon  the  important subject  of  caps, and will,
naturally, ask me for mine.   Doubtless, "much may be said on both sides,"
but I confess that I can  see  no  advantage in dispensing with them, but a
saving of expense.  It is not more natural to have the head  uncovered, than
it would be to have the legs so; I am  sure that the absence of caps never
prevented " water in the head," and certainly the infant has one more chance
of  taking cold, to  say nothing of their looking very ugly, without caps.
However, I generally let my patients take their own way,  as I know that
they will  do as they like, whatever I may think ; this only I stipulate, that
the head shall,  at  all  events, be  lightly covered with a flannel shawl for a
week.
  Now, remember,  that as regards dress,  the infant requires softness, loose-
ness, and warmth ; and as regards handling, gentleness and dexterity.
  Physic for the  Infant. — After washing and dressing, comes the ques-
tion of physic and  food.   No doubt, if the mother have plenty of milk, it
will act as a purgative,  and  render medicine unnecessary; perhaps,  even
without it, the child's bowels  might be moved spontaneously: nevertheless,
as few women have milk the first day, and as the retention of the meconium
is apt to gripe the child, and make it uneasy, it is generally advisable to
give a  small teaspoonful  of castor oil: at any rate, if the  bowels  are not
moved in the course of twelve hours.   Sugar and water, or butter and sugar,
are sometimes given to the new born infants, but if any purgative be required,
castor  oil.is far better than such mixtures.
  Food of Infant.—By far the best food for an infant until its mother
can supply its wants, or to make up for her shortcomings  for a week or two,
is equal parts of cow's milk  and water, sweetened; or three parts  of ass's
milk, and one part of water.   But how often should an infant be fed ? When- 
of  the monthly  nurse.
639
ever it is hungry, of course ;  but not,  necessarily, whenever you  think it
hungry  because it cries.   A  new born baby will, probably, require  some-
thing  about every two  hours,  and surprising  as  it may seem, it  is quite
possible, at  this early period, to lay the foundation of orderly habits,  and
quite impossible to overrate their value.   Give  the baby its food every two
hours,  or thereabouts, unless it be asleep :  either its natural food, or milk
and water, with a spoon, or from  a cup or feeding bottle; the latter is the
best, provided  you wash it each time after using it, and remove and cleanse
the teat on  the nipple.   A little experience will show you the proper quan-
tity to give  each time ; and, fortunately, any little exce'ss is remedied bv the
stomach rejecting the surplus.   When " possitting," as it is called, occurs,
or if the stomach be  unusually delicate,  it  is better to give the child less at
a time, and  rather oftener.   If the mother have not milk enough, or if full
nursing  be  too much for her  strength,  you must supply her deficiency by
feeding ; and I think it  will be better to feed the baby at night, so  that she
may get a  good sleep, and let her nurse  it during the day;  after a time,
when she is quite strong, she may reverse this, and feed the child during the
day, if she cannot nurse it altogether, as the most natural, and most conveni-
ent, and most comfortable sleeping place  for  the baby at  night  is in its
mother's arms, at least for some time.   As the  child grows older, a change
of  food will be required, for the same food, if continued long, almost always
disagrees with the child.   During the first month, and  I  am only at present
concerned with this period, the changes need  be very few; but for infants
somewhat older, I may  mention, as varieties in addition to  milk — barley-
water, prepared barley or groats, arrowroot, panada, rusks, and bread jelly.
The latter  is made by pouring boiling  water  on the  crumb of bread  and
squeezing it out again four or five times, and then simmering it gently with
a little water in a saucepan  until it is thick enough to set, which it will do on
cooling.  A spoonful of this jelly, with water  or milk, and sugar,  makes a
very nice food.  Whatever food you give, take care that it is very thin.  No
doubt  a child is " more satisfied" by thick food, just as you are after a heavy
meal, but it is not the more healthy way of feeding for either.
   Subsequent Treatment of Infant. — Having said so much about food,
we must retrace our steps a little.  Yery little  physic will be necessary after
the first dose ;  and the less the better.   Until  the dark green stools (meco-
nium)  have  passed off, and the discharges become yellow, the child is apt to
be  griped and -uneasy, but  this will only last a day or two; the mother's
milk will then be  coming,  and that, at first, acts as a gentle purgative, so
that the bowels will  generally be  moved three or four times a-day,  which
will be sufficient.  You  are not to think it your duty, however, to  give the
child medicine  if it do not come up to this standard ; nor are you to remedy
too great frequency by a dose of castor oil:  in  such a case you should ask
the  medical attendant for  a prescription.   Remember, that  to a young
infant  a purging is much more serious  than a slight costiveness.   In addi-
tion to castor oil, the^nly medicine of which a nurse should have command
(unless ordered by the doctor) is fennel water, which may be given mixed
with water,  or  with the food, if the child suffer from flatulence;  and these
medicines should be kept apart from all others.   Avoid all quack medicim*,
and all tampering with stronger medicines than those I have mentioned, or
vou may incur  a life-long reproach.  I  knew a nurse who, either from care-
lessness  or a wish to relieve the child, gave it a small dose of laudanum and
it was  with difficulty saved from death.   No doubt, young infants suffer from
flatulent pains, and make their sorrows  heard, but you are not at once to
conclude that  they need phvsic ;  a little fennel water, warming the feet, a
warm  flannel to the  stomach,  or a warm  bath, will almost always  afford
relief  When a child  cries violently, without apparent reason, it is not a bad 
640
QUALIFICATIONS  and duties
plan to see if the point of a pin be not the cause.  And if simple means do
not afford  relief in a reasonable time, you  ought to send  for the medical
attendant without  delay; you may lose valuable time, and what will affect
you  sensibly, credit, by trying to cure the case yourself, when it is beyond a
nurse's skill.
   Sleep of Infant.—Next, and nearly equal in importance to the infant's
food, is  its sleep.   Without sleep  an infant cannot thrive ;   and a nurse
should make it a rule never to disturb an infant, not even to show it to the
dearest friends.  You can easily give it a habit  of sleeping at  an early  age,
and  hunger will generally wake it:  the  more it sleeps the better.   When
convenient, after the first few days, the best place  for  it to sleep  is  the
mother's bed,  as it will be sure to be warm there ;  but if you lay it down in
a  cot you should  ascertain that its feet are warm, and  that  it is warmly
covered,  and  secured  against draughts.  As it gets  older, it will remain
longer awake, of course, but you should, as  far as possible, keep to regular
times for sleep, and the midday sleep should be continued  until it is three or
four years old.
   Cleanliness  of  Infant.—Another matter  of great  importance to an
infant is  cleanliness.   I do not  mean  that "rough and tumble" cleanliness
which consists in putting on a clean  frock over  soiled  petticoats, or a clean
pinafore  over a dirty frock ; but that minute cleanliness of  a child's person,
and of its inner as well as its outer garments, which ought to be the aim of
all good nurses.   An infant should be washed most carefully, after being
fed, every morning, and  in a  slighter  degree in the evening, and  its dress
entirely  changed each time.  The water should  be  pleasantly warm,  and
soap will rarely be necessary.   A soft fine sponge or flannel should be used,
and the  operation  performed. with  gentleness  and  quickness.  Take  care
that all the creases and folds of the  skin are cleansed, and every part of the
body which comes in contact with  another  part, as neglect here will surely
lead to scalding and chafing.  After this it must be thoroughly dried  with a
warm soft napkin,  and all the  creases well  powdered.   For this  purpose,
fine starch or hair powder is generally used ;  they answer the  purpose  very
well generally, but there  is a much better powder, called " Lycopodium," or
puff-ball powder, which may be  obtained from the chemists.   If a part be
dusted with this powder, water will pass over  it without dissolving it, or
washing  it off, or wetting the skin.   I have found this most useful  with soft
ohildren, who are  scalded, but especially when  the buttocks' or groins  are
affected.
   Washing and dressing are distressing enough; and when all is finished,
the child is generally ready for a sleep, in which it should always be indulged.
A very careful watch should be kept upon the natural evacuations, so  as not
to allow them to remain  in contact with the  child longer than you can help :
half the cases of chafing  and scalding we meet, arise from the nurse's neglect
in this particular, although they are  ingenious enough in finding  out other
causes.  No napkin  that  has been soiled  by  the bowels should ever be
applied  again until  it has been  washed; and at first,  or with children of
tender skins, no napkin that has ever been wet should be  used more  than
once.  More than twice  they should never be used, even with older children,
and before applying them, you should  see that they are thoroughly dry, and
soft, and warm.   After each movement  of the  bowels, the infant should be
sponged, dried, and dusted, and the latter always after passing water.   In
these operations also, it is curious how early regular habits may be acquired ;
after a month or two, a baby will quite understand what it is " held out"  for;
and such habits promote health  as well as cleanliness.
   Chafing and its  Treatment.—But suppose, in spite of all your care, a
child should chafe, and become sore : you must  bathe  the parts very gently
with milk and water and dry them  carefully, two or three  times a-day, and 
                      OF  THE  MONTHLY NURSE.                 641


 iTtatTonWIot?tSVyCOP°fd!Um, ?o°nWder; if th^ d0 D0t  imPro^ ^n mav
 -ry a lotion of the sugar of lead (20 grains to an ounce of water}  or of the

 alPW°P tfmC ^^ Vir-i0l)' f°Ur &"*»■ t0  an <™» <>f dLti led w t
 of fid fntt   '  after^was+hl^.or drying the part.   If you employ the suga
 nni nil  r;T-Gmber th^ ? 1S P°isonous- and be careful where it is kegpt,
 treatment i£ " f^T^ ^^  f°r  feaT  °f mistakes"  If- ™^  this
 consumed                 "* &  ™ ^JS' the  family doctor ou^ht  to be
   Convalescence after  DELivERY.-Let us  now return  to  the patient,
 whom  we left settled after delivery, and  allowed to sleep ; and  trace the
 progress of her  recovery, and the  symptoms which characterize her conva-
 lescence.  I shall treat  the subject under different heads, and describe the
 symptoms as they occur naturally, or as they deviate from their natural  and
 healthy condition ; and under each  head I  shall  speak of your duties
   1.  A very slight  observation will show you that the condition of  the
 patient is much changed after labor.   She  is much more exhausted than  you
 would  expect, from the exertion she has made; she is pale, wearied  and
 as you say, "worn out;" yet, on the other hand, her senses  are too acute!
 and she is painfully affected by light and  noise, which she would  not have
 minded previously.  Her  appetite  is gone, and  the various  secretions are a
 good deal altered.
   Nervous Shock.—This all arises from the shock to  the  nervous system
 and is  independent of both the exertion and the amount of blood lost.
   Nay, this  shock is. sometimes so severe, especially after an operation, as
 to protract the recovery for many weeks, or even, in rare cases, to  prove fatal.
   In ordinary cases no medical treatment is required on account of this state
 of things ; but you must be careful to  allow the patient to rest  until  she
 recovers from it.   Keep the room quiet, cool, and shaded ; forbid visitors, and
 allow no whispering, and little talking, and every day will show an improve-
 ment.
   Even more care, caution, and  stillness will be necessary after operations,
 or when the shock is more severe than usual, and will have to be continued
 longer.   You will also have to carry out the directions of the medical attend-
 ant as  to medicine and  diet, and this you  must always do with scrupulous
 punctuality.   When  directions  have once been given, you  are not at liberty
 to deviate from them, either to gratify the patient or her friends, or in accord-
 ance with  any notion of your own.
   2.  The respiration and circulation remain somewhat hurried after delivery,
 but by degrees  this hurry  subsides  ; and when this is the case, your only
 duty, in reference to it, will be  to  keep the patient cool, comfortable,  and
 tranquil.  Should either the  breathing or circulation become  quicker or
 labored, you must instantly inform the medical  attendant.
   3. Immediately after the  expulsion of the placenta, I have told you that
 the uterus contracts, and if all goes on well, this contraction continues per-
 manent, but increased now and then  by afterpains.  It may be felt as a hard
 tumor in the lower part  of  the abdomen, about the  size of an infant's head,
 and each day it diminishes,  until at  length it sinks into the pelvis, and can-
 not be felt.
   The vagina has been, of course,  very much  stretched by the passage  of
 the child, but it is so elastic that it speedily recovers its natural state.  The
 inner edge of the perineum  is often slightly  torn in first labors ; but  if it be
 not more than this, you will hardly  be able  to discover it the next day, and
it is of no consequence.
  Every day, and more  than  once each day, for the first few days, you will
make a  point of  ascertaining that the uterus is properly contracted  ; for  as
long as  it is so, there  is  little fear of flooding.   But it may  be larger than
      41 
642
QUALIFICATIONS AND  DUTIES
it ought to be from various causes;  and if yon find it so, especially if it be
tender on pressure, you must mention  it to the doctor, and ask directions
from him.
  A fresh binder  should be  applied every morning, and tightened so as to
afford firm support without being painful: it becomes  displaced very soon,
however, and will  require rearrangement three or four times a-day.  You
should always  pay special  attention to this matter, as it is a great vexation
for a lady to find her figure spoiled when she is able to dress and go down
stairs.   The abdomen is so loose for some time, that,  unless artificial pres-
sure be made, it is almost sure to distend from flatulence, and once distended,
you will find it almost impossible to remedy it until the next confinement.
  The external parts  should  be carefully washed with warm water ten or
twelve hours after confinement, and  this should be  repeated daily with every
precaution against cold.  A soiled  sheet folded should be placed under the
hips, and the patient be kept covered.  If you discover more than the slight
laceration I have mentioned, or if there be any unusual inflammation or sore-
ness about the vulva, you should call the attention  of the doctor to it on his
next visit.
  4. After-Pains.—Connected with the condition  of the womb are the after-
pains which result from its  contractions.   You rarely observe them after
the first confinement, and as  rarely are they absent  after subsequent ones.
They commence generally in the course of an hour or two after delivery,
last for  a minute  or two, and  then  subside, to be renewed at intervals.
During, or immediately after each, there is often a  slight increase of the  dis-
charge, or some clots expelled, although the pains are themselves a security
against flooding.   They continue for two or three days, increased for a time
by  suckling, but gradually becoming less frequent  and less severe until they
disappear.
   This is the ordinary form of afterpains, and  so  far from regretting their
occurrence, medical men consider them as beneficial when not  too  severe.
In  some  instances, however, this  is  the case;  they are  as painful as labor
pains,  coming  on very frequently,  lasting some  time, and  depriving  the
patient of rest.  Or, after apparently subsiding, they may recur on the third
or fourth day, and at the same time you may observe the uterus larger than
it ought  to be : after a time you will generally find a clot expelled, and then
the afterpains cease.
   Little  treatment is required if the afterpains are natural and not exces-
sive ; a warm napkin, or piece of flannel over the uterus, will  afford tempo-
rary relief.  In the more severe cases, you had better obtain a prescription
from the medical attendant; or, if you  are acting alone as midwife, you may
give a draught containing from twenty to twenty-five drops of laudanum.
   5. The Lochia.—The discharge of blood which occurs  after delivery,
diminishes in quantity, but continues for  some time: this is called " the
lochia,"  or "lochial discharge," or "cleansings."  At first, it is red  like
blood, but after a  few days it gradually becomes  paler, then yellowish or
greenish, and is called  by nurses  the "green waters."  Occasionally the
blood coagulates in the vagina,  and forms  a large clot, which may require
pains  to  expel it, or  it may  even render passing  water difficult.  When
expelled, it occasions the patient some alarm and  uneasiness ; but this you
may relieve, as it  is of no consequence, and merely indicates that the  dis-
charge has been more  than usual.  The quantity  varies very  much,  and so
does the duration  of the discharge; sometimes it is very scanty, especially
when the  child dies before birth;  and sometimes it ceases in a fortnight,
especially when there is an  abundant secretion of milk.   It ought to be over
in about a month at all events.
   On the other hand, there may be too  much  at  first; or it  may come on
more flush some days after delivery, or on sitting up ; or it may return after 
OF  THE MONTHLY  NURSE.
643
having changed  its character;  and in all these variations  there  mav be
nothing seriously astray ;  but it will only  be right that you should acquaint
the doctor with  the occurrence,  that he may decide whether any treatment
be necessary.
  It will  be  your especial care  that neither by cold nor exposure shall the
discharge be checked.   Napkins, well dried and warm, should be constantly
applied, and  changed  often enough to prevent their becoming wet applica-
tions ; and the binder should be  kept tight so long as the discharge is exces-
sive.   Nor should the patient be  allowed  to make any exertion until the
quantity has moderated  and  the color changed, or else it may so increase
as to amount to flooding.
   6. State of Bowels and Bladder.—Owing partly to the quiet lying in
bed, and  partly to the relaxed state of the  abdomen, the bowels are seldom
moved after delivery until medicine is given ; and the patient will sometimes
allow the urine to accumulate in the bladder.   Occasionally, indeed, when
the second stage of labor has been tedious and difficult, the patient is not
able to pass water at all for some days subsequently.
   Now it is very desirable  that the urine should be passed at moderate
intervals, and you should induce her to try and do so  some time, say  six or
eight hours,  after delivery.   The application  of a  warm  cloth to the vulva
will facilitate this,  and,  applied afterwards,  it will remove any smarting.
If the patient turn on  her  face and  knees, she will sometimes  succeed in
voiding urine, when she  cannot do so in any other position.  If after one
or two moderate efforts  (and you must  never allow much forcing) she is
unsuccessful, you must obtain assistance and have the water drawn  off.
   However  desirable  it  may be that the  bowels  should be moved, I do not
think it wise to effect  this by medicine for twenty-four  or thirty-six hours
after delivery.   This  rest will allow the patient to recover a little, and the
organs to return more or less to their natural state  ; nor have I ever known
any mischief to  arise from waiting so long.   After this time,  if they are not
moved naturally, a dose of castor oil, Gregory's  powder, or the  common
 " black bottle " (senna, salts and ginger),  moderate  in amount, may be given
very early in  the morning.   As a general rule, I think that  pills do not act
satisfactorily when the patient is confined to bed.   If the first dose of medi-
cine produce no  effect, it may  be  repeated, or, what  is perhaps better, an
enema of a pint  of warm  water,  or thin gruel, with a tablespoonful of castor-
oil, or table-salt may  be  given.   In administering  this, you will  have to be
very gentle :  remember that all the parts are very  tender : direct the point
 of the pipe back towards the spine, use very little force, and stop and change
the direction if  the patient complain of pain.   Should she suffer  from piles,
you had better not try the enema.   And  when the  medicine operates, or the
Patient passes water, do  not let  her sit up  :  she must use the bed-pan, and, at
 the most have  her shoulders slightly raised.   To prevent  the patient  re-
ceiving any cold  impression from  the pan, it should  be warmed at the fire
before using it,  or, what is better, should  be cased in flannel.
   Piles  —As  I have referred to piles,  I may as well say a word or two
 about them   They are very common during pregnancy ; and in  some cases
where they did  not exist during pregnancy, they come on after delivery, and
add much to the patient's sufferings.   Sometimes they grow from the orifice
 of the anuS  and are called external piles ; in other cases they  form within
the bowel and  are forced down when the bowels are moved, and remain
outsid T  these are the most painful, as, when down they are grasped by  the
anusTor orifice  of the bowel) and strangulated.   Now when your patient
      lo^-L nf niles it is  your dutv by an examination, to ascertain whether
thevt   xtcrSa\ or n  rn'al  if the fatter they must be returned within  the
bowef™  hteh you can do bv  oiling the points of your fingers, and pressing
 the piles gently, yet  firmly; upwards, until they pass  into the bowel; and 
644
qualifications and  duties
this you must repeat whenever they come down.  If they be external and
very tender, you should foment them twice  a-day,  and apply  a nice  soft
poultice of linseed-meal afterwards : if this  afford but little  relief, two or
three leeches may be applied to them.  When the tenderness has diminished,
a little ointment of galls, smeared over them two or three times a-day, will
generally reduce their size, and hasten their disappearance.
  7. Condition of Breasts.—During the latter part  of pregnancy, as you
know, the  breasts are enlarged, and  even before labor often  secrete a  thin
kind of milk ; but you do not generally find true milk formed  until after
labor.   About the end  of  the  second, or during the third day (sometimes
earlier), the breasts  enlarge and  become hard,  and,  if not  relieved, very
painful, particularly in first confinements.
  This  change may be preceded by a rigor,  or fit of shivering, and accom-
panied by a degree of fever, with quick pulse, hot skin, headache, and thirst:
these symptoms need not alarm you, if you are satisfied that they arise from
the milk.   Let me remark  here, that the occurrence of a rigor in childbed is
a circumstance that always demands particular attention, as it is often the
first symptom of inflammation of the womb, or of some form of that most
dangerous complaint, puerperal fever.  If it be caused by the  coming of the
milk, it need occasion no alarm, but ascertain positively, and without delay,
that this is really the  cause of the rigor.   You may come to this conclusion
if you  find that  the breasts are becoming kind and tender — if the lochia
continue in proper quantity, and  if  there be no pain or  tenderness  of the
uterus.   Whenever you are in  doubt whether this shivering  be dependent
or not upon the state of the breasts, your safest plan is to  call in the assist-
ance of the accoucheur, for the loss of a very few hours in puerperal fever
may place the woman  beyond the  power  of  medicine.   Whenever your
patient takes  a  shivering, therefore, no matter from what cause, attend to
her instantly,  as  it is most desirable to check it.  Put  a hot  jar or hot
blanket to her feet; lay an additional blanket over her shoulders,  and give
her a warm drink of whey, tea, milk and water, or oatmeal  tea.  To this
drink,  a few grains (8 or 10) of nitre, or  half a teaspoonful of sweet spirits
of nitre, or a dessert spoonful of mindererus spirit may be added, if at hand.
   The  true remedy for  the enlargement  of  the breasts  is, of  course, the
application of the child ; but in some cases the increase is so rapid, that the
child can make no impression, especially with first children, or if the nipples
be defective;  and the breasts  go  on increasing, until, by the excessive dis-
tension, inflammation is excited, and an abscess, or "bieling" of the breast,
may be  the result.  In  other cases,  when the infant is put too  often to the
breast before the milk is come, or where the skin of the nipples is very ten-
der, it becomes irritated and inflamed, and either cracks or ulcerates,  giving
rise to  great suffering and  disappointment.   Nay more, unless you  are  very
careful, and even sometimes, in spite of all your care, the inflammation  may
extend  from the nipple into the gland of the breast, and an abscess form.   I
believe this, and  cold from exposure, to be the  two most frequent causes of
this painful and troublesome affection.
   Putting the Child to the Breast.—How soon after delivery ought the
child to be put to the breast ?   If the patient have had children before, and
the breasts contain milk, I should say the sooner the better, after  she is rested
from the fatigue of labor, say in six or eight hours.   If it be  her first child,
and the breasts be enlarged, I generally have the child applied once within
twenty-four hours, and  twice or thrice the next day, if it get  any milk; but
not more, lest the nipples should be irritated.   But if  the breasts are flaccid
and flat, you  had better wait until the second or third  day.  If  the draught
be free, the child strong, and  you are able  to apply it  early enough, and
sufficiently frequently, you will almost certainly avoid milk fever, and the
excessive and painful enlargement  of the breasts; but the condition of the 
OF  THE MONTHLY  NURSE.
645
nipph may, possibly, interfere with the frequent application of the child
As the oreasts increase, the child may make more ample use of them during
the day time, until on the fourth or fifth day its entire nourishment is derived
from the mother.
   If,  however, the breasts become hard and knotty and painful, in  spite of
the efforts of the child, you may afford great relief, and facilitate the flow of
milk,  by rubbing them gently  with a little warm oil —rubbing  them gently,
I say, not as if you were polishing a mahogany table.  In  performing this
simple operation, the patient should lie on her back, and rather toward the
side opposite to the breast that is to be rubbed,  and you should make the
friction with your hand  around the base  of the breast first, and gradually
approach the nipple.  Do not move your hand in a direction from the nipple
towards the base of the gland, but just the reverse.  A small bit of camphor
dissolved in the  oil is a pleasant addition.
   In  this state  of the breasts, a "cire cloth" is  often applied to them, and
with much benefit.   This is nothing more than a piece of soft old linen, the
size of the  breast, and having a hole cut in the centre for the nipple.  On
one side it is spread with olive oil and bee's wax  melted together,  and this
side is applied to the breast.  Although rather a dirty application, it is often
found to be productive of ease  to the  patient, and may be kept on for two
or three days.
   But I should wish here to point out to you a distinction too often for-
gotten.  When the breasts are  enlarged  and knotty from over distension,
rubbing affords great relief; but if they are running on into inflammation,
rubbing will make them worse, and destroy the only chance  of escape from
an abscess.   I have  seen  this mistake and its results over and over again.
The chief distinction for your guidance is, that in over distension the  hard-
ness is equal over the whole breast, there is little or no tenderness,  and the
skin is pale ; whereas in inflammation,  one part of the breast is particularly
tender, and there is  a peculiar hardness there;  the breast  is very painful
when moved, and there is a blush on the skin  of some portion of it.  In
these latter cases the soothing treatment—fomentations, poultices, etc., — ii
the only one likely to be successful.
   Attention to the Nipples.—As regards the nipples, I have  already
mentioned that the skin should be hardened during the  latter months of
pregnancy,  by the application of  spirits and water, after washing with soap
and water, and  drying.   It is a good plan to sponge the nipples with cold
water each time  after suckling, and then to apply brandy and water.  If
you find the nipples becoming tender and raw, or cracked and painful, great
relief may be obtained by the application of a small soft poultice, for a short
time  after suckling, and then from the use of a lotion of alum and water, 01
equal parts of tincture of catechu and water, or strong green tea.   In some
cases, it is advisable to apply a weak solution of lunar caustic, but  this you
had better leave  to the doctor.
   Inflammation and Abscess of the Breasts.—If, notwithstanding the earlj
and careful application of the child, and attention to the nipples, the breasts
should inflame, either from cold, over secretion, or extension of inflammation
from  the sore nipple, what are you to do ?  Not to  rub them, but to foment
and poultice them until you can get advice; but  if you should not be able
to obtain this, six or eight leeches may be applied,  followed by  constant
poulticing,  until either  the inflammation  subsides,  or  suppuration  takes
place  supporting  the  breast by a  sling,  so that it cannot  hang down ;
taking care at the same time, to  keep  the  bowels free.   During this pro-
cess  it is better to confine the patient to a simple, moderate  diet; allowing
broths  if there  be not much fever, but no wine until the abscess is evacu-
ated • and remember that  it is better to have the abscess opened than to let
it break • it will be more completely emptied, will heal sooner, and it niav 
646
qualifications and  duties
happen, that by avoiding the neighborhood of the nipple, the future use of
the breast may be secured.
   Care of Breasts in such as do not Suckle. — But suppose the infant
to be dead, or the patient  unable  or determined not to suckle her child,
what are  you to do ?  You cannot prevent the secretion of milk, and I do
not think that the methods of checking secretion, by cold applications, etc.,
are safe or advisable. But if you remember that the amount of milk secreted
depends partly upon the food taken into  the system, and  partly upon the
amount of milk drawn from the breasts, you will see that you have a safer,
though slower, method of putting an end to it. Diminish the diet, especially
the fluid portion of it, and  take away a little milk occasionally, by the child
or by a breast-pump, just enough to relieve the sense of distention, and you
will  soon  find  that less is secreted, and if you  gradually diminish the
amount you take away, in the course of a  week or two, the patient will not
require this  assistance.   And, at the same time, you may have recourse to
gentle frictions, fomentations, and the cire  cloth.
   Incontinence of Milk. — When the milk runs freely on the application
of the child, scarcely any assistance or interference on  your part will be ne-
cessary ; but, on the other  hand, I have met with a few instances in which
the milk all ran away,  so  that with an ample supply the child was nearly
starved.   In one case, both breasts kept continually leaking without cause;
in other cases, when the rush or draught was excited in one breast, from the
application of the child or any other cause, it not only was felt as usual in
the other,  but the milk  ran  from it as freely as it was drawn from the one in
use.   This may be called "incontinence of milk," and seems to depend upon
some local weakness.  In such cases, I think that astringents applied to the
nipple, and the use of nipple glasses,  are of the greatest benefit.
   Changes in the Milk. — At a more  advanced period of nursing, when
the mother is exposed to various external  influences, you  will find the milk
liable to be affected both as to quantity and quality.   Thus  the exciting or
depressing passions will equally affect the  quantity  of milk ; but they may
do more, they may change  its  quality, and so injure the  child seriously.   I
know an instance of this in two  ladies who, when nursing, were plunged in
grief by the death of a third sister,  and both lost their children shortly after.
Great grief is, therefore, a  strong argument for weaning  the child, or for
substituting feeding  for nursing,  for a  time.  But  those  emotions which
merely check  the  secretion,  are of less consequence; and, in general, when
they cease, the milk  returns.  I need hardly tell you, that the " milk pow-
ders," sometimes given  to increase  the milk, are a delusion, except so far as
they act upon the imagination of the patient and relieve her fears.
   Summary of chief points in respect  to  Management of Convales
cence after Delivery. — I have now gone  over the chief peculiarities of
childbed, their variations,  and  the  management necessary : there remain
still  a few points of management,  upon which it is desirable that I should
say a few words.
   1. Cleanliness.—You cannot be impressed too deeply with the necessity of
cleanliness and  tidiness, not only personal, but general, as regards the sick
room.  The patient should be carefully washed, her hair settled,  and her
night dress and  cap, after  the second  day, changed morning and evening,
the napkins changed twice  a-day or oftener, and  the parts carefully washed
with  warm  water,  and  dried  once a-day.   The  bed-clothes should  be
straightened when tossed, the room dusted and made orderly every morning,
all unnecessary matters removed, and everything kept in its proper place.'
Trifling as such things  may seem, they exert a positive influence upon the
patient, and may thus favor or hinder her convalescence.
   2. Diet. —The diet  of  the patient is of great importance, though I am
not disposed to attribute to it as great an  influence as some have done, nor 
OF  THE MONTHLY  NURSE.
647
have I seen as much mischief arise from deviations from the ordinary rules
as from  other causes ;  still it  is evident that errors in diet, whether as to
quantity or quality, ought to be sedulously avoided.  In general, the patient
should be kept on bland, sloppy diet for five or six days; perhaps your best
guide will be the state of the milk:  when the secretion has been reduced to
the ordinary quantity required  by the child, or in  other word, when the child
is able to  take all its mother  has for it, the diet  may be safely increased, if
in other respects she is going on well.  Whey, milk and water, or weak tea
for ordinary drink ; gruel,  panada, sago, tapioca,  or bread and  milk for
lunch  and dinner; with tea, not too strong, in the evening, will afford suf-
ficient variety;  bread and butter, of course, she  may have.  When the  first
rush of milk has subsided,  about the fifth or sixth day, chicken broth, with
or without  bread or  toast,  as  she pleases, or beef tea, may be allowed for
dinner ;  then chicken panada, chicken roast or boiled, a chop, etc., with a
glass of wine, until she gradually resumes her ordinary diet.  I think wine
agrees  best with the patient for the first few days, but afterwards  she  may
have malt liquor if she prefer it.
   3.  Rest.—Of even greater importance than the diet, is the keeping the
patient in  bed sufficiently long, and for some days  in the  supine  position;
almost all the more serious  attacks of illness I have seen, have resulted from
sitting up  or getting  up too soon.  The labor first, and then the  lying in
bed, render the  system so  sensitive, that a very slight exposure is  sufficient
to give cold.  For three or four days the patient should absolutely be  con-
fined to the horizontal position, and not be allowed to sit up in bed.  Cases
of sudden death have repeatedly occurred from patients sitting up too soon
after delivery.   Then she  may be propped up with pillows or a  bed-chair
during meals, and  occasionally through the day, avoiding fatigue, and not
even permitting this liberty if there have been flooding.
   I turn a deaf ear to all  requests to leave her  bed, even  to have it made,
before the eighth day, and  I have found  the benefit of so  doing.   The bed
can be shaken up very effectually, if the patient be placed  near one edge,
 and then near the  other, while the bed is making;  and this prolonged rest
allows the  organs which have  been so much disturbed, to return  gradually
to their natural condition,  and by the eighth day the  general sensibility is
 so much diminished  that the  patient  is less susceptible  of cold.   On the
 eighth day, then, she may  sit up for an hour, not dressed, for that would
 fatigue  her too  much, but warmly  wrapped up  in petticoats, shawls, and
 dressing gown.   The  next day she may sit up longer, and be more  fully
 dressed, and afterwards she will gradually resume her usual habits  in this
 respect.
   4. Occupation.—Another point of minor importance, but bearing upon
 the patient's comfort, is her occupation during the period of confinement
 after labor.  Of course, for two or three days she is too weak to think about
 anything but her safety and her child, and too much occupied with these to
 need any other.   But as she gets  stronger, the day passes heavily, and the
 ordinary sick-room gossip is hardly sufficient to satisfy any but very ignorant
 or very common minds.  If you are able to read nicely, as you ought to be,
 you may thus be a great comfort to her.  A chapter of The Book, to which
 all turn in sorrow and in suffering, read in the  morning,  after washing and
 dressing will calm and compose  her mind : and occasionally through the
 day  a few pages of an  interesting but not exciting  work, will make the
 time pass  very pleasantly.  For some few days the patient ought not  to
 read herself but  as  she gets  stronger, she  will become  uncomfortable  if
 unoccupied and provided the  bed be  placed sideways to the light,  there can
 be no objection to her reading a little.  When she sits up,  she will, of course,
 be able to find  employment that will not fatigue her. 
 648    qualifications  and duties of  monthly nurse.

   Symptoms adapted to Create  Alarm. — Having thus  treated  pretty
 fully  of the phenomena of childbed, with certain deviations from the common
 course, and the necessary treatment of each, I trust you will find no difficulty
 in the ordinary management of lying-in women;  but as you know that very
 dangerous attacks  occur at this  period, especially when  puerperal fever is
 epidemic, which it is of the highest importance to have checked at the very
 commencement;  and as some of the symptoms I have noticed, have a strong
 resemblance  to  the  beginnings  of  disease,  it may be well to draw your
 attention to  some circumstances which  ought  to excite  your alarm,  and
 induce you to call in assistance as soon as possible.
   1.  The occurrence of  rigors, particularly on the second or third day,  if
 the breasts are not full and hard, aud especially if there be any pain in the
 belly.   I have already spoken of the urgency of this symptom, and told you
 how to distinguish between shivering from the milk and from inflammation.
 If you  cannot fairly attribute it  to  the milk,  you  will not lose a moment in
 sending  for the  doctor ;  if you  delay but a few hours, the patient may be
 past help.  Meantime, however, you may apply a fomentation to  the belly,
 but take care how you do it.   Place a blanket folded lengthways  under the
 patient, and  next to  her body;  then wring  out  flannels  in  hot water,  and
 apply them, but not too wet; then fold the ends of the blanket over all, and
 repeat this in ten minutes.   Not a drop of water should  be  allowed to fall
 on the  bed or night-clothes, and when you finish the fomentation, dry the
 patient thoroughly, and  place a  warm, dry  flannel all over the abdomen.
 Or, instead  of the fomentation, you may apply a poultice of scalded bran
 (in a  flannel bag), or of linseed meal: the latter should be  made thin  and
 sloppy, or it will become  hard, and applied as hot as the patient can bear it.
  2. The occurrence of weakness or fainting,  without special  cause, or after
 haying been raised in bed, is most alarming.   In such a case,  lay the patient
 quite  flat in bed, and give a little wine, but summon the doctor instantly.
  3.  The same treatment will be necessary,  in case of any oppression or
 unusual difficulty of breathing.
  4.  Severe pain in the uterus, extending down the thighs, even if it be only
 an exaggerated after-pain, demands relief; and as it may be more than this,
 viz., the commencement of inflammation, you  had better  obtain assistance,
 especially if it be preceded or accompanied by shivering.
  5.  The sudden stoppage  of the  lochia—especially if  the milk be  not
 abundant, or, on the other  hand,  an  unusually profuse discharge__is  too
 serious a matter to be neglected.   Until you obtain assistance, you may, in
 the former case, safely apply a poultice  to the lower  part of  the abdomen ;
 and in the latter, if the discharge amount to  flooding, after  tightening  the
binder, you may  dip a napkin in  cold water and  apply it  for a  moment to
the external parts.  Do not  make  a slop  about the patient,  and do not let
the wet napkin remain in  contact with  her, as  it does  no good after the first
impression of cold.
  6.  An attack of vomiting or diarrhoea may occur without apparent cause,
or as the consequence of repeated doses of medicine, and it is never to be
overlooked.   If it continue beyond a very short time,  you  had better call in
a doctor.
  7.  If, after repeated and moderate attempts, aided  by the means already
recommended, your patient cannot pass water within ten  or twelve hours,
professional assistance will be  necessary.  Such  cases rarely occur, except
with first children, or where the second stage has been unusually prolonged ;
but when it does happen, you must neither rely upon your  own remedies'
nor allow time to be lost. 
INDEX.
Abdomen, enlargement of
Abdominal labor.......257
Abortion..........190 j
   "     causes........191
   "     ovuline causes.....192
   "     treatment......194
   "     prophylaxis......198
   "     induction of......308
Abscess of breast......609, 645
Accidental hemorrhage.....450
Adhesion of the placenta .... 250-448
After-pains........255, 642
Air in the veins a cause of sudden death. 528
Alarm, symptoms  to create  ....  648
Albuminuria in convulsions  ....  471
Allantois..........128
Amenorrhcea........91
Amnii, liquor........129
Amnion, the.........121
Amputation  of foetal limbs in utero  .   154
      "     knife for......365
Anatomy of the pelvis......35
Anaemia of new-born infant ....   237
Anaesthetics in convulsions  ....   480
      "      in midwifery   ....   243
Apoplectic convulsions.....482
Apoplexy of child at birth  .   .  .  .  237
Appendages, uterine, inflammation of.  567
Areola, mammary, in pregnancy  .  .
Arm presentations.......
          "       statistics ....
          "        treatment.   .  .  .
 Arteries of uterus.......71
 Ascites of fcetus........435
 Asphyxia of new-born infant   .  .  .  237
 Auscultation in pregnancy  ....  162
 Axes of pelvis.......205-354

 Ballottement.........161
Page 1591 Blood, transfusion of
Page
158
420
423
425
Blundell, on vesico-vaginal fistula  .  .
Blunt Hook.........
Bond's placental forceps.....
   "   foroeps........
Bones of the pelvis.......
Borax as an oxytoxic......
Boillaud, on phlegmasia dolens.  .  .
Bowels, state of........
Bozeman, on vesico-vaginal fistula. 497-
Breasts, care of the, in such as do not 1
           suckle......J
   "   condition of......
   "   putting child to.....
   "   inflammation and abscess of. 609-
   "   state of, after delivery  .   .  .
Breech presentations......
         "         statistics   .   .  .
         "         treatment of  .  .
Brennan, on turpentine  .... 563,
Brim of the pelvis.......
     "     "     distortions ....
Bruit placentaire.......
Button shield, Bozeman's.....
Burns on cephalic version  ....
   "   on prolapse of funis ....
   "   on laceration of perineum
   "   on phlegmasia dolens .
   "   ou mammary abscess .  .
 Burrowes on puerperal mania  .
Baudelocque's callipers
      "       cephalotribe ....
Barnes, on placenta praevia ....
   "    on vesico-vaginal fistula  .   .
Bearing down pains of labor   .  .   .
Beatty on vesico-vaginal fistula   .   .
Bed, preparation of.....•
Binder, the.......ffj-
Bladder, state of, after delivery   . 2ob,
Bleeding in puerperal peritonitis  . 561, ob6
   «            "     mania   .  .   .   605
Blisters in      "     feyer .  .  .   .   588
Bloodletting in puerperal convulsions .   4,,
 58
369
462
505
225
501
634
636
643
591,

600,
Caesarian section.......
    "     "    statistics   ....
    "     "    method of operating .
Calculus in the bladder, a cause of ob- \
    structed labor......J
Callipers..........
Calomel in puerperal fever  ....
    «         "     mania ....
Campbell, on puerperal peritonitis
   "     on ephemeral fever .
Canal of the cervix uteri.....
Cannabis indica in tedious labor  .  .
Carunculae myrtiformes.....
Catamenia.........
Carcinoma uteri, a cause of obstructed |
    labor.........J
Cauterization in vesico-vaginal fistula.
Cavity of the pelvis......
    i»     "       distortions of .  .
Cephalsematomata......._
Cephalic version  .   .  .   .  313, 31<
  *                         (649)
45 o
504
365
196
359
 35
265
595
643
-499

646

644
644
-645
257
410
413
415
589
  43
  51
lc,2
499
313
441
515
596
609
601

383
387
395

289

  58
589
605
55 S
 606
  69
 203
  63
 281

 496
  44
  52
 239
-42C 
650
INDEX.
Cephalotribe.........369
Cervix uteri.........69
Cervix uteri, canal of......69
  "     "   during pregnancy  .   .   .  114
Chamberlen's forceps......333
Chafing of infant.......640
Child,  position of, in utero  .  .   .   .  144
Child,  at birth, measurements .   .   .  146
  "       "   weight.....146
  "       "   signs of maturity .   .  147
  "       "   management of   .   .  234
  "       "   still born  ....  237
Child-bed, management of women in .  251
     "    fever........537
Chloroform.........243
     "     in convulsions   ....  480
     "     in puerperal mania .  .   .   606
Circulation  in foetus......150
     "      state  of, after delivery .   .   248
Chorion..........119
Churchill's  forceps.......336
Clarke, John, on inflammation of ute- \  r fi7
     rine  appendages...../
Clarke on malignant puerpe0583   5g5  5gg
     ral fever   ....   J
Clarke, Joseph,  on do......583
Clarke, on  extirpation of uterus .  .   522
Cleanliness of infant......640
     "       "      after delivery.  .   646
Coagiria of  blood in heart a cause  of")
     sudden death......J
 Clitoris..........61
 Coccyx...........39
530
501

554
497
559
499
Coghill's instrument for vesico-vagi
    nal-fistula.......
Cold to abdomen in puerperal perito
    nitis.........
Colles, on vesico-vaginal fistula
Collins,  on puerperal peritonitis   .
Collis, on vesico-vaginal fistula .   .
Complex labor........438
Compound presentations.....427
Conception.........102
Confinement, preparation for  .   .   .  633
Contagion of puerperal fever  .   .   .  546
Convalescence, abnormal.....253
       "       after natural labor, 247, 641
Convulsions.........467
     "     hysteric......467
     "     epileptic......468
     "     apoplectic......482
Copland,  on uterine phlebitis  .  .   .  577
     "    on puerperal fever.  545, 582, 584
Corpus  luteum of menstruation ...    85
     "    "    of pregnancy .  .  107-109
Cranioclasm  .........   380
Craniotomy........   .   361
     "     forceps.......366
     "     obstetric arguments for   .   617
Crotchet..........364
Croton  oil in tedious labor  ....   265
Crural phlebitis........590
Cullerier, on recto-vaginal fistula .  .   508
Cupping, dry,  in tedious labor .  .  .   266
Cusack, on puerperal peritonitis  .  .   560
Cutting pains of labor......225 !
Cystocele, vaginal, a cause  of ob-")  oq-
     structed labor......J
Dalton, on corpus luteum   .   .   .  85, 109
   "   on foetal circulation .   .   .   .  152
   "   on formation of decidua   .   .  118
Davis, forceps........336
  "   bone forceps......366
  "   on phlegmasia dolens   .   .   .  594
Death of foetus, signs of.....188
  "   sudden  ........  523
Decidual cotyledons......116
Decidua..........115
Deformities of pelvis......49
Denman, on phlegmasia dolens .  .  .  591
Dessault, on vesico-vaginal fistula .  .  495
Development, laws of......153
Dewees' wire crotchet......195
Diameters of foetal head.....146
Diet after delivery.......646
     "    of pelvis......45, 46
Distortions of pelvis......49
     "       "     effects of,  on labor.  292
Double monsters.......436
Douglass, on puerperal fever  .   .  .   584
Dressing infant........638
Dry cupping in tedious labor  .   .  .   266
Duges, on puerperal convulsions   .  .   471
   "          "     hysteritis .   .  .   565
   "   on  inflammation of uterine ")  r--
           lymphatics   .   .  .   .  /
Duplay,  on puerperal hysteritis    .  .   566
Duration of pregnancy.....167
Dysmenorrhcea........95
       "       neuralgic.....95
       "       inflammatory   ...   97
       "       mechanical  ....   98
Earle, on vesico-vaginal fistula .   .   .  497
Edwards, on placenta praevia  .   .   .  460
Elythroplastie........504
Emansio mensium.......93
Embryo, the development of.  .   . 134, 153
Embryulcia.........361
Emetics in puerperal peritonitis   .   .  563
    "         "      mania.  .   .   .  605
Enteric gastro fever......578
Ephemeral fever........606
Epileptic convulsions......468
Ergot of rye........262
     "     to cause premature labor .  308
Erysipelas and puerperal fever .  .  .  543
External organs of generation ...    60
Extirpation of the inverted uterus .  .   521
Extra-uterine pregnancy.....180
Extremities, inferior, presentation   .   417
      "      superior     "      .  .   420

Face presentations.......403
     "     "       statistics ....   406
     "     "       treatment  ...   408
Fallopian tubes........73
False pains.........630
Feet, turning by the......314
Ferguson, on puerperal  peritonitis   .  561
     "           "      hysteritis.  .  566
     "     on uterine phlebitis  .   .  .  576
 Ferriar, on phlegmasia dolens  .   .  .  594
     "   on puerperal mania   .   .  .  605
I Fever, puerperal.......5?.7
   "   gastro-enteric  ....     .578 
INDEX.
651
Fever, ephemeral.......606
First position of child......215
  "  stage of labor......225
Fi>tula, vesico-vaginal.....493
   "    recto-vaginal......507
Flooding.........449, 464
Foetal life, physiology of.....149
Foetal circulation.......150
    "      heart, sounds of  ,  .  .   163
    "      head, diameters of   . 146, 211
Foetus, changes in, after birth .  .  .   153
   "    amputation  of  limbs  of, in ")  .,..
           utero....../
   "    development of.....153
   "    measurements of.....146
   "    movements of......161
   "    nutrition of......49
   "    pathology of......187
   "    position of, in utero ....   144
   "    signs of death of.  ....   188
   "    viability of.......147
   "    weight of, at birth  ....   146
Foot presentations.......417
Force  expulsive, uterine .....   203
Forceps, placental.......196
   «    the.........331
   "       statistics.....338, 353
   "       suitable cases for   .   .  .   343
   "       mode of operating  .   .  .   346
   "       after treatment  ....   351
Forehead towards the pubis ....   408
       "       statistics.....409
       "       treatment.....409
Fourchette, the........63
Fourth position of child.....218
Funic pulsation and souffle  ....   165
Funis umbilicalis.......127
   "   presentation of......438
   "   prolapse of.......438
   <<     "     statistics.....438
   a     "     treatment.....441
Galvanism in tedious labor ....
    "    to cause premature labor  .
Gastro-enteric fever......
    a    a       treatment   .  .   .
Generation.........
    "    external organs of   .  .   .
    "    internal organs of   .  .   .
Gestation..........
    "    term of.......
Glandulae nabothi.......
Gooch, on puerperal fever   .'   ,  .   •
   i<          "    mania  .   .  • 600-
Gordon, on puerperal peritonitis  .   .
   "    on inflammation of uterine")
             appendages   .   .  .   /
Graafian vesicles.......
Grinding pains of labor.....
Guthrie, on phlegmasia dolens  .  .   .
Hemorrhage
 265
 309
 578
 581
 102
  60
  66
 154
 167
  69
 584
-603
 558

 568

  74
 225
 595

 449
1. accidental.....450
  treatment.....452
  internal.....454
2. unavoidable  ....  455
  treatment.....457
3. after delivery   ...  464
Hemorrhage, treatment.....465
     "       secondary.....465
Hemorrhage umbilical.....239
Hall, M., on convulsions.....470
     "   on puerperal mania  .  .  .   604
Haunch bone........36
Hayn's perforator.......363
Hayward, on vesico-vaginal fistula   .   497
Head, version by.......313
Hernia, vaginal........289
Hey, on puerperal peritonitis  .  .  .   561
Hip-bone..........36
Hobart, on vesico-vaginal fistula .  .   497
Hodge's forceps........357
Holmes's perforator......364
   "    on puerperal fever ....   548
Horner, on lacerated perineum.  .  .   594
Hour-glass contraction.....446
Hunter, W., on puerperal mania  .  .   600
Huckle bone.........39
Hull, on phlegmasia dolens ....   513
Hulme, on puerperal peritonitis   .  .   558
Huston's forceps.......356
Hydrocephalus of foetus.....435
Hymen..........62
   "   imperforate.......290
Hysteric convulsions......467
Hystetritis puerperal......564
      "    treatment......566
Hysterotomy........383

Ilium, os..........36
Imperforate os uteri......279
Incontinence of milk......646
Indian hemp as an oxitoxic  ....   265
Induction of premature labor  .  .  .   296
     "    mode of operating  .   .  .   306
     "    of abortion......308
Inertia of uterus.......261
Infant, care of, new born.....637
   "   physic for.......638
   "   food for .   .......638
Inflammation of lymphatics .  .  .  .   577
       "     of peritoneum ....  556
       "     of uterine appendages .  567
       "     of breasts  .... 609, 645
       "     of uterine veins  .  .  .  572
Innominatum, os.......3o
Internal hemorrhage......454
Internal organs of generation  ...   66
Interstitial foetation.....183, 485
Instrumental labor.......331
Introductory observations   ,  .  .  .   33
Inversion of the uterus.....515
     "      terminations   .  .  •  •  519
     "      treatment.....520
Ischium, os.........^6

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

Kane, on kiesteine.......^
Keith, on sudden death.....ob\
Kennedy. E., on  vesico-vaginal )  ^-_^)-y
     fistula.......S
Kiesteine..........lb5 
652
INDEX.
Labia majora........61
  "   minora........61
Labium, sanguineous tumor of .  .   .   290
Labor, abnormal.......191
  "    natural.......222, 630
  "    tedious........257
  "    unnatural.......257
  "    powerless.......274
  "    management of, natural  . 229, 634
  "    obstructed.......278
  "    premature .......190
  "    stages of......202, 631
  "    symptoms of.....223, 224
  "    with convulsions.....467
  "     "  distortion.....292
  "     "  flooding......449
  "     "  inversion of uterus  .  .   515
  "     "  lacerations.....484
  "     "  malposition.....403
  "     "  malpresentation   .  .  .   403
  "     "  prolapse of funis  .  .  .   438
  "     "  retained placenta  .  .  .   443
Laceration of the perineum ....   509
Lacerations..........484
Lallemand, on vesico-vaginal fistula  .   497
Lee, R., on puerperal peritonitis  .  .   559
  "        hysteritis......564
  "         inflammation of  uterine1  ,---
             lymphatics ....  J
  "        uterine phlebitis   .  .  .   574
  "        phlegmasia dolens .  .  .   592
Lee, on placenta praevia.....459
Lever, the.........323
Ligaments, the round......74
Liquor amnii........129
     "      excess  of......270
     "      premature escape of .  .   271
Lochia, the......250, 256, 642
Low fever of childbed......537
Lymphatics of uterus......71
     "      uterine  inflammation of  .   577

M'Clintock, on vesico-vaginal fistula .   501
     "     on sudden death.   .  .  .   529
Machinery of parturition.....203
     "       expulsive force   .  .  .   203
     "       passage of pelvis, etc.  .   205
     "       child.......211
Mackenzie,  on phlegmasia dolens .  .  596
     "      on prolapse of funis  .  .   441
Malignant puerperal fever  ....   581
Mal-position of child......403
Mal-presentation.......403
Mammary abscess.......609
     "    sympathies in pregnancy  .   158
Mania, puerperal.......599
   "  lactea........600
Maturity  of child.......147
Meatus urinarius.......62
Mechanism of parturition   ....  203
     "    of head in 1st position .  .  215
     "       2d position.....216
     "       3d position.....217
     "       4th position    ....  218
 Meigs, on hysterotomy.....387
   "   on placenta praevia   ....  463
   "   prolapse of funis.....441
 Meigs, on sudden death.....530
Meigs, on puerperal fever   ....   550
Meigs's embryulcia instruments  .  .   367
Membrana decidua.......115
Membranes, toughness of   ....   271
Menorrhagia.........98
Menstruation........77
     "      commencement of .  .  78,82
     "      cessation of ...  .      81
     "      condition  of uterine or-"l  ,gg
              gans  during  ...  J
     "      excessive......98
     "      final cause of  ...  .    87
     "      difficult and painful  .  .    95
     "      non-appearance of.  .  .    91
     "      suppressed.....93
     "      vicarious......94
     "      arrest of, in pregnancy  .   156
Mercury in puerperal peritonitis  .  .   562
Milk in breasts of pregnant female  .   159
  "the..........251
Mons Veneris........60
Monsters..........435
Monthly  nurses, duties of  ...  .   629
Morality, obstetric.......613
Morning sickness.......157
Mucous membrane of uterus   ...    69
Murphy, on convulsions.....470
Murray, on puerperal peritonitis  .  .   558
Muscular structure of uterus  .   .  .   203

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

Obliquity of uterus.......272
Observations,  preliminary   ....    33
Obstetric morality.......613
     "   operations......296
Obstructed  labor.......278
Oldham's vertebral  hook.....366
Operations, obstetrical.....296
Opiates in  puerperal convulsions  .  .  479
     "      "      mania ....   605
Organs of generation.....35-77
Osborn,  on craniotomy.....368
    "    on hysterotomy.....387
    "    on symphyseotomy ....   398
 Os tincse..........69
 Os uteri..........69
     "   minute or imperforate  .  .  . 279 
INDEX.
653
Os uteri, rigid........266
Outlet of the pelvis......45, 209
Ovaries, the........74-77
     "    disease of, a cause of ob-\  0Q.
            structed labor  .   .  .  /  zm
     "    physiology of.....77
     "    during menstruation.  .  .    84
     "      "    pregnancy   .  .  .   108
Ovarian foetation.......181
Ovum, the..........129
Oxytoxics..........262

Paget, on sudden death.....533
Pains, spurious.......224, 630
   "  cutting........225
   "  grinding......•  .  .  225
Parophrosyne puerperarum ....  600
Parturient  female,  management  of,")  „.-
     after delivery....../
Parturition.........199
     "     classification of  ...  .  200
     "     mechanism of .  .   .   .  .  203
Pathology of fcetus.......187
Pelvis...........35
   "  the true........43
   "  the false........42
   "  joints of.......39-41
   "  axes of the.......205
   "  brim of the.......43
   "  canal of the.......205
   "  diameters......43, 45, 46
   "  difference between male and female. 46
   "  deformities of.....49, 292
   '*  abnormally large.....50
   "       "     small.....51
   "  cavity of........44
   "  outlet of........45
   "  external measurement of .   .  .   47
   "  internal       "         ...   48
   "  passages  of.......205
   "  planes of........206
Perforations of  intestines, a cause of")  _„r
     sudden death......J
Perineum, the........63
           rigidity of......290
Peritoneum, inflammation of   .   .  .  556
Peritoneal fever........537
Peritonitis, puerperal......556
     "     morbid anatomy ....  559
     "     treatment......561
Phlebitis, uterine.......572
     "    crural.......590
Phlegmasia dolens.......590
       "       pathology.....593
       "       treatment.....597
Physiology of the uterus and ovaries. 77-199
     "     of generation.....77
     «     of foetal life.....149
Piles...........643
Placenta, the........120
     "    extraction of.....235
     "    retention of......443
     "    praevia  .......  445
Placental souffle........162
     a    forceps.......196
Plug, the, in hemorrhage.....452
     «<     in vesico-vaginal fistula.  .  505
Plural births .....     ...  428
Podalic version.......314
Polypus uteri........
Positions..........
Powerless labor........
      "      treatment.....
Pregnancy, signs of......
     "     duration of.....
     "     extra-uterine.....
     "     spurious......
     "     twin.......
Pregnant women, general condition  .
Preliminary observations.....
Premature labor........
     "    "     induction of  .  .  .
Presentation of face......
     "       of breech.....
     "      of inferior extremities
     "      of superior extremities  .
     "      of hand or arm with head
     "      of feet and hands .  .  .
Presentations........
Prolapse of funis.......
Pseudo-pregnancy.......
Pubis, os..........
Puerperal fever........
       "      contagion.....
       "      1. peritonitis   .  .  .
       "      2. hysteritis  ....
       "      3. inflammation of ap-")
                    pendages .  .  J
       "      4. uterine phlebitis
       "      5. inflammation of
                    uterine  lym-
                    phatics .  .
       "      6. gastro-enteric fever
       "      7. malignant fever
       "         hysterics  ,
Puerperal mania  ....
Pulsations of foetal heart .   ,
       "          funis .
Pulse, state of, after birth   ,
Purgatives in puerperal peritonitis
-319
 283
 202
 274
 276
 155
 167
 180
 174
 167
 156
  33
 190
 296
 403
 412
 417
 420
 427
 428
 201
 438
 174
  37
 537
 546
 656
 564

 567
 572

 577

 578
 581
 564
 599
 163
 165
 254
 563
Quickening.........160
Radford, on galvanism in tedious labor.
    "    on placenta praevia   .   .  .
Radford's forceps.......
Ramsbotham, on face presentations  .
       "     on puerperal fever  .  .
Recto-vaginal fistula......
       "    "      treatment .   .  .
Respiration, condition of, after delivery.
Retention of the placenta   ....
       "      statistics.....
       "      treatment.....
Rigby, on uterine hemorrhage .   .  .
   "   on puerperal fever
Rigidity of cervix uteri.....
   "    treatment.......
Roberton, on puerperal fever   .   .
Roonhuysen, on the lever   ....
Round ligaments,  the......
Rupture of uterus.......
       "      statistics.....
Sacro-coccygealjoint  .  .
Sacro-iliac synchondrosis
265
460
336
403
549
507
508
248
443
444
445
453
551
266
267
549
324
 74
484
484

 40
 39 
R54
INDEX.
Sacrum, os.........38
Salivation of pregnancy.....157
Sanguineous tumor of labium  .   .   .  290
Scalp tumor of........239
Scanzoni, on puerperal fever   .   .   .  544
Scarlatina, a cause of sudden death  .  535
Scirrhus uteri, a cause of  obstructed ")  oqi
    labor........./
Secondary hemorrhage.....465
Second stage of labor......227
Second position of child.....216
Sexes, relative proportion of   .   .   .  148
Share bone.........37
Shock to nervous system,  a cause of")  r2fi
    sudden death....../
Sickness, morning.......157
Sigault, on symphyseotomy ....  397
Signs of pregnancy......155
Simpson, on turning......315
    "   on puerperal fever.  .   .   .  643
    "   on cranioclasm.....380
    "   on puerperal convulsions   .  471
    "   on placenta prasvia   .   .   .  459
    "   on vesico-vaginal fistula .   .  499
Sims, on vesico-vaginal fistula .   .   .  497
  "   on sleep of infant.....640
Smellie's forceps.......336
    "   perforator.....361-363
Smith, Tyler, on abolition of cranio-")  „-K
               tomy.....J 375
    "       on puerperal fever  .   .  553
    "       on convulsions   .   .   .  470
Sore nipples.........608
Spermatozoa.........103
Spontaneous evolution......421
Spurious pregnancy......174
Stages of labor.......202, 225
Sterility..........171
Still born child........237
Stolz, on Caesarian section ....  392
Sudden death........523
       "    1. from syncope  .   .   .  523
       "    2. idiopathic asphyxia  .  525
       " *   3. shock......626
       "    4. air in the veins.   .   .  528
       "    5. coagulum  in the  heart. 530
       "    6. disease of the heart  .  531
       "    7. obstruction  or rup- "|
                  ture of pulmonary [■ 533
                  arteries  ...  J
       "    8. general dropsy.   .   .  534
       "    9. perforation of intestine. 535
       "   10. scarlatina  ....  535
Superfoetation........177
Suppressed menstruation.....93
Suture, in vesico-vaginal fistula   .   .  497
Symphyseotomy.......397
Symphysis pubis.......40
Syncope of newborn  infant .  .   .   .  237
    "     a cause of sudden death .   .  523

Tartar emetic in puerperal peritonitis .  563
    "     "   in inflamed breasts .   .  611
Tedious labor........257
    "      causes and treatment.   .  261
    "      statistics......257
Third position of child.....215
Third stage of labor......229
Thomas, on re-position of the funis   .  442
Tonnelle, on puerperal nysteritis  .   .  665
    "    on uterine phlebitis  .   .   .  574
Toughness of membranes, a cause of")  n71
    tedious labor......j
Tractor vectis of Ogden.....325
Transfusion.........455
Trask, on placenta praevia  ....  464
Tubal foetation........182
Tubes, fallopian........73
Tumor of scalp........239
Tumors in the pelvis......282
Turning..........309
   "     statistics.......310
   "    object of the operation   .   .  312
   "  1.  cephalic version  .  .   .313, 317
   "  2.  podalic version.....314
   "     by external manipulation   .  318
Turpentine in puerperal peritonitis   .  563
    "          "     fever ...  589
Twin births.........428
  "   pregnancy......167, 428
Tyre, on phlegmasia dolens ....  594

Umbilical cord........127
       "      pulsation of the .   .   .  165
       "      hemorrhage of the  .   .  239
       "      vesicle......120
Unavoidable hemorrhage.....455
Unnatural labor.......257, 403
Undilatable os uteri......266
     "    vagina.......281
Urethra..........    62
   "   orifice of.......62
Urine, in convulsions......471
Utero-gestation.......111,154
Uterine appendages, inflammation of .  567
   "   phlebitis.......572
   "   lymphatics, inflammation of .  577
   "   phlebitis.......572
   "   contractions......203
   "   souffle........162
Utero-gestation........m
Uterus...........67
  "    arteries of the......71
  "   muscular coat......69
  "   mucous lining......69
  "   vessels and nerves of...   .    71
  "    changes  induced by gestation  .  114
  "    double........72
  "   inertia of.......261
  "   inflammation of.....564
  "    obliquity of.......272
  "   physiology of.....77-199
  "   rupture of.......484
  "   after delivery......248
  "   inversion of.......515
Uva ursi in tedious labor   ....  265

Vagina, orifice of.......62
   "   structure of......64
   "   narrow  or undilatable  .   .   .  281
   "   state of, after delivery .   .   .  248
Vagina, closure of vesico-vaginal fistula. 504
Vaginal examination  .   .  . 226, 230, 631
   "    cystocele.......  287
   "   hernia........289
Vectis, the.........323 
INDEX.
655
f ectis, the, cases suitable   ....   326
   "       mode of operation  .  .  .   328
Veins, uterine, inflammation of.  .  .   572
Venesection in puerperal peritonitis .   561
Version..........309
   "   in convulsions......480
Vesicles, Graafian, the.....74
Vesico-uterine fistula......506
Vesico-utero vaginal fistula ....  507
Vesico-vaginal fistula......493
       "       treatment.....495
Vesicula alba........120
Vestibulum.........62
Vicarious menstruation.....94
Vidal de Casis on vesico-vaginal fistula. 504
Vines, on puerperal convulsions   .   .  478
Voillemier, on puerperal fever .  .   .  584
Vomiting in puerperal mania  .  .   .  605

Washing infant........638
Water-douche in tedious labor  .  .   .  266
Weight of child........146
Weid...........606
White, on phlegmasia dolens   .  .   .  594
Wire crotchet........195
Wright,  M. B., on cephalic version   . 314
THE END. 
 
        HENEY    C.   LE^l'S
                          (LATE LEA & BLANCHARD's)

CLASSHniBlD   O^T.A.ILOa XJE3
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leU^rs.   Address,                               HENRY C.  LEA,

                               Nos. 706 and 708 Sansom  St..  Philadelphia,  Pa. 
4              Henry C. Lea's Publications—(Dictionaries).
JJUNGLISON  (ROBLEY), 31. D.,
         Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia.

    MEDICAL   LEXICON;  A Dictionary  of  Medical Science:  Con-
       taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology,
       Pathology,  Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical
       Jurisprudence, and Dentistry.  Notices of Climate and of Mineral Waters;  Formulae for
       Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of
       the Terms,  and the French and other  Synonymes; so as  to constitute a French as well as
       English Medical Lexicon.  Thoroughly Revised, and very greatly Modified and Augmented
       In one very large  and handsome royal octavo volume of 1048 double-columned pages, in
       small type; strongly done up in extra cloth, $6 00; leather, raised bands, $6 75.
  The object of the  author from the  outset has  not been  to make  the work a mere lexicon or
dictionary  of terms, but to afford, under each, a condensed view of its various medical relations,
and thus to render the work an epitome of the existing  condition  of medical science.   Starting
with this view, the immense demand which has existed for the work has enabled him, in repeated
revisions, to augment its  completeness and usefulness, until at length it has attained the position
of a recognized and standard  authority wherever the language is spoken.  The mechanical  exe-
cution of this edition will be found greatly superior to that of previous impressions.   By enlarging
the size of  the volume to  a royal octavo, and  by the  employment of a  small but clear type, on
extra fine paper, the additions have been incorporated without materially increasing the bulk of
the volume, and the matter of  two  or three ordinary octavos has been compressed into the space
of one not  unhandy for consultation and reference.
  It would be a work of supererogation  to bestow a
word  of praise upon this Lexicon.   We can  only
wonder at the labor expended, for whenever we refer
to its pages  for information we  are seldom disap-
pointed in finding all we desire, whether it be in ac-
centuation, etymology, or  definition of terms.—New
York Medical Journal, November, 1865.
  It would be mere waste of words in us to express
our admiration of a work which is  so  universally
aud deservedly appreciated.  The most admirable
work of its kind in the English language.  As a book
of reference  it is invaluable to  the medical  practi-
tioner, and in every instance that we have  turned
over its pages for information we have been charmed
by trie clearness of language and the accuracy of
detail with which each abounds.  We can most cor-
dially and confidently commend it to our readers.—
Glasgow Medical Journal,'January, 1866.
  A work to which there is no equal in the English
language.—Edinburgh Medical Journal.
  It is something more than a dictionary, and some-
thing less than an encyclopaedia.  This edition of the
well-known work is a great improvement on its pre-
decessors.  The book is one of the very few of which
it may be said with truth that  every medical  man
should possess it.—London Medical Times, Aug. 26,
1865.
  Few works of the class exhibit a grander monument
of patient research and of scientific lore.  The extent
of the sale of this lexicon is sufficient to testify to its
usefulness, and to the great service conferred by Dr.
Robley Dunglison on the profession, and indeed on
others, by its issue.—London Lancet, May 13, 1865.
  The old edition, which is now superseded by the
new, has been universally looked upon by the medi-
cal profession as a  work of immense research and
great value.  The new has  increased usefulness ; for
medicine, in  all its branches, has been making  such
progress that many new terms and subjects have re-
cently been introduced : all of which may be found
fully defined in the.present edition.  We know of no
other  dictionary in  the English  language that can
bear a comparison with it in point of completeness of
subjects and accuracy of statement.—N. ¥. Drug-
gists'  Circular, 1865.
  For many  years Dunglison's Dictionary has  been
the standard  book of reference with most practition-
ers in this country, and we can certainly commend
this work to the renewed  confidence and regard of
our readers. — Cincinnati Lancet, April, 1865.
  It is undoubtedly the most  complete and useful
medical dictionary hitherto published in this country.
—Chicago Med. Examiner, February, 1665.,
  What we take to be decidedly the best medical dic-
tionary in the English language. The present edition
is brought fully up to the advanced state of science.
For many a long year "Dunglison" has been at our
elbow, a  constant companion  and friend, and we
greet him in his replenished and improved form with
especial satisfaction.—Pacific Med. and Surg. Jour-
nal, June 27, 1865.
  This is, perhaps, the book  of all others which the
physician or surgeon should have <tfi his shelves.  It
is more needed at the present  day than a few years
back.—Canada Med. Journal, July, 1865.
  It deservedly stands  at  the  head,  and cannot be
surpassed  in excellence.— Buffalo Med. and Surg.
Journal, April, 1865.
  We  can" sincerely commend Dr. Dunglison's work
as most thorough, scientific, and accurate.  We  have
tested it by searching its pages for new terms, which
have abounded so much of late in medical nomen-
clature, and our search  has been successful in every
instance.  We have been particularly struck with the
fulness of the synonymy and the accuracy of the de-
rivation of words.  It is as necessary a work to every
enlightened physician  as Worcester's  English Dic-
tionary is to every one who would keep up his know-
ledge  of the English tongue to the standard of the
present day.  It is, to our mind, the most complete
work  of the kind with which we are acquainted.—
Boston Med. and Surg.  Journal, June 22, 1S6.3.
  We  are free to confess that we know of no medical
dictionary more complete; no one better,  if so well
adapted for the use of the student; no one that may
be consulted with more satisfaction  by the medical
practitioner.—Am. Jour. Med. Sciences, April, I860.
  The value of the^present edition has  been greatly
enhanced by the  introduction  of new  subjects and
terms, and a more complete etymology and accentua-
tion, which renders  the work  not only satisfactory
and desirable, but  indispensable to'the  physician.__
Chicago Med. Journal,  April, 1S65.
  No intelligent member of the profession can or will
be without it.—St. Louis Med. and Surg. Journal.
April, 1865.                                   '
  It has the rare merit that it certainly has no  rival
in the  English language for  accuracy and extent
references.— London Medical Gazette.
TTOBLYN  [RICHARD D.),  M.D.
    A  DICTIONARY OF  THE. TERMS  USED IN MEDICINE AND
      THE  COLLATERAL  SCIENCES.  A new American  edition, revised, with  numerous
      additions, by  Isaac  Hays, M.D., Editor of the "American Journal of the  Medical
      Sciences."   In one large royal 12mo. volume of over 500 double-columned pages; extra
      cloth,  $1 50 ; leather, $2  00.
  It is the best  book of definitions we have, and  ought always to be upon the student's table.— Southern
Med.. 4*d Swrg. Journal. 
Henry C. Lea's Publications—(Manuals).                  5
JS^EILL [JOHN), 31. D.,  and   CjMTH [FRANCIS  G.), 31. D.,
                                             Prof, of the Institutes of Medicine in the Univ. of Penna.

    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, extra cloth, $4 ; strongly bound
       in leather, with raised bands, $4 75.
  The Compend of Drs. Neill and Smith is incompara-
bly the most valuable work of its class ever published
in this country. Attempts have been made in various
quarters to squeeze Anatomy, Physiology, Surgery,
the Practice of Medicine, Obstetrics, Materia Medica,
and Chemistry into a single manual; but the opera-
tion has signally failed in the hands of all up to the
advent of "Neill and Smith's" volume, which is quite
a miracle of success.  The outlines of the whole are
admirably drawn and illustrated, and the authors
are eminently entitled to the grateful consideration
of the student of every class.—N. 0. Med. and Surg.
Journal.
  This popular favorite with the student is so well
known that  it requires no  more at the hands of a
medical editor than the annunciation of a new and
Improved edition.  There is no sort of comparison
between this work and  any other on a similar plan,
and for a similar object.—Nash. Journ. of Medicine.
  There are but few students or practitioners of me-
dicine unacquainted with the former editions of this
unassuming though highly instructive work.  The
whole science of medicine appears to have been sifted,
as the gold-bearing sands of El Dorado, and the pre-
cious facts treasured up in this little volume. A com-
plete portable library so condensed that the student
may  make it his constant pocket  companion.—West-
ern Lancet.
   To compress the whole science of medicine in less
 than 1,000 pages is an impossibility, but we think that
 the book before us approaches as near to it as is pos-
 sible.  Altogether, it is the  best of its class, and has
 met with a deserved success. As an elementary text-
 book for students, it has been useful, and will con-
 tinue to be employed in the examination of private
 classes,  whilst it will often be  referred.to by the
 country practitioner.—Va. Med. Journal.
  As a handbook  for students it is invaluable, con-
taining in the most condensed form the established
facts and principles of medicine and its collateral
sciences.—N. H. Journal of Medicine.
  In the rapid course of lectures, where work for the
students is heavy, and review necessary for an exa-
mination, 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 sound-
est  doctrines and  the latest improvements  and  dis-
coveries are explicitly, though concisely, laid  before
the student.  Of course it is useless for us to recom-
mend it to all last course students, but there is a class
to whom we  very sincerely commend this cheap book
as worth its weight in silver—that class is the gradu-
ates in medicine of more than ten years' standing,
who have not studied medicine since.   They wili
perhaps find out from it that the  science is not ex-
actly now what it was when they left it off.—The
Stethoscope.

  Having made free use of this volume in our exami-
nations of pupils, we can  speak from experience in
recommending it as an admirable compend for stu-
dents, and especially useful to preceptors who exam-
ine 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 examined.   A work
of  this sort should be in the  hands of every one  who
 takes pupils into his office with a view of examining
 them; and this is unquestionably the best of its class.
 Let every practitioner who h as pupils provide himself
with it, and he will find the labor of refreshing his
knowledge so much facilitated that he will be  able to
 do  justice to his pupils at very little cost of time  or
 trouble to himself.—Transylvania Med. Journal.
TUDLOW [J.L.), M.D.,
    A  MANUAL  OF  EXAMINATIONS  upon  Anatomy,  Physiology,
      Surgery,  Practice of Medicine, Obstetrics, Materia Medica,  Chemistry, Pharmacy, and
      Therapeutics.  To which is added a Medical Formulary.  Third edition, thoroughly revised
      and greatly extended and enlarged.   With  370 illustrations.   In one handsome royal
      12mo. volume of 816 large pages, extra cloth, $3 25; leather,  $3 75.         v

  The arrangement of this volume in the  form of question and answer renders it especially suit-
able for the office examination of students, and for those preparing for graduation.

  We know of no better companion for the student
during the hours spent in the lecture-room, or to  re-
fresh  at a glance, his memory of the various topics
crammed into his head by the various professors to
whom he is compelled to listen.—Western Lancet.
  As it embraces the whole range of medical studies
It is necessarily  voluminous,  containing 816 large
duodecimo pages.  After a somewhat careful exami-
nation of its contents, we have formed a much more
favorable opinion of it than we are wont to  regard
»uch works. Although well adapted to meet the wants
of the student in preparing for his final examination,
it might be profitably consulted by the practitioner
also, who is most apt to become rusty in the very kind
of details here given, and who, amid the hurry of his
daily routine, is but too prone to neglect the study of
more elaborate  works.  The possession of a volume
of this kind might serve as an inducement for him to
seize the moment of excited curiosity to inform him-
self on any subject, and which is otherwise too often
allowed to pass unimproved.—St. Louis Med. and
Surg. Journal.
 mANNER  [THOMAS HAWKES),  M.D.,

    A  MANUAL OF CLINICAL  MEDICINE AND  PHYSICAL DIAG-
      NOSIS   Third  American, from the  second enlarged and revised  English edition.  To
      which is added The Code of Ethics of the  American Medical Association.   In one hand-
      some volume 12mo.  (Preparing for early publication.)

  Thi< work, after undergoing a very thorough revision at the hands  of the author, may now be
     IJro annear shortly.  The title scarcely affords  a proper idea of the  range of subjects em-
3e11n theTolume as7it contains  not  only very full details  of dtagnostic symptoms property
 ,   -La  ri,,t also a laree amount of information on matters of every day practical importance
noTusuan^tkched upon in the sv^matV work,  or scattered through many different volumes. 
6                  Henry C. Lea's Publications—{Anatomy).
 QRAY [HENRY),  F.R.S.,
         Lecturer on Anatomy at St. George's Hospital, London.

   ANATOMY,  DESCRIPTIVE   AND  SURGICAL.    The  Drawings  by
       H. V. Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital;  the Dissec-
       tions jointly by the Author and Dr. Carter.   Second American, from the second revised
       and improved London edition.  In one magnificent imperial octavo volume, of over  800
       pages, with 388 large and elaborate engravings on wood.   Price in extra cloth,  $6  00;
       leather, raised bands, $7 00.
  The author has endeavored in this work to cover a more extended range of subjects than is cus-
tomary in the ordinary text-books, by giving not only the  details necessary for  the student,  but
also the application of those details in the practice of medicine and surgery, thus rendering it both
a guide for the  learner, and an admirable work of reference for the active practitioner.   The en-
gravings form a special feature in the work, many of them being the size of nature, nearly all
original, and having the names of the various parts printed on the body of the cut,  in place of
figures of reference, with descriptions at the foot. They thus form a complete and splendid series,
which will greatly assist the student  in obtaining a clear idea of Anatomy, and  will also serve to
refresh the memory of those who may find in the exigencies of practice the necessity of recalling
the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with
a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of
essential use to  all physicians who receive students  in  their offices, relieving  both preceptor and
pupil of much labor in laying the groundwork of a thorough medical education.
  Notwithstanding its exceedingly low price, the work will be found, in every detail of mechanical
execution, one of the handsomest that has yet been  offered to the American profession; while .the
careful scrutiny of a competent anatomist has relieved it of whatever typographical errors existed
in the English edition.
  Thus it is that book after book makes the labor of
the student  easier than before, and  since we have
seen Blanchard & Lea's new edition of Gray's Ana-
tomy, certainly the finest work of the kind now ex-
tant, we would fain hope that the bugbear of medical
students will lose half its horrors, and this necessary
foundation of physiological science will be much fa-
cilitated and advanced.—N. O. Med. News.

  The various points illustrated are marked directly
ou the structure; that is, whether it be muscle, pro-
cess, artery, nerve, valve, etc. etc.—we say each point
is distinctly marked by lettered engravings, so that
the student perceives at once each point described as
readily as if pointed out on  the subject by the de-
monstrator.  Most of the illustrations are thus ren-
dered  exceedingly satisfactory, and to the physician
they serve to refresh the memory with great readiness
and with scarce a reference to the printed text.  The
surgical application of the various regions is also pre-
sented with force and clearness, impressing upon the
student at each step of his research all the important
relations of the structure demonstrated.—Cincinnati
Lancet.
  This is, we believe, the handsomest book on Ana-
tomy as yet published in our language, and bids fair
to become in a short time the standard text-book of
our colleges and studies.  Students and practitioners
will alike appreciate this book.  We predict for it a
bright career, and are fully prepared to endorse  the
statement of the  Londoji Lancet, that "We are  not
acquainted with any work in any language which
can take equal rank with the one before us." Paper,
printing, binding, all are excellent, and we feel that
a grateful profession will not allow the publishers to
go unrewarded.—Nashville Med. and Surg. Journal.
 CjMITH [HENRY H), M.D.,     and   TJORNER [ WILLIAM E.), 31.D.,
   Prof, of Surgery in the Univ. of Penna., &c.          Late Prof, of Anatomy in the Univ. ofPenna., &c-

   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.   $4 50.
  The plan *f this  Atlas, which renders it so pecu-1 the kind that has yet appeared; and we must add
liarly convenient for the 6tudent, and its superb ar- | the very beautiful manner in which it is "got up "'
tistical execution, have been already pointed out. We  is  so creditable to the country as to be flattering to
must congratulate the student upon the completion  our national pride.—American Medical Journal.
of this Atlas, as it is the most convenient work of I
E
VRNER [WILLIAM E.), M.D.,
SPECIAL  ANATOMY AND  HISTOLOGY.   Eighth edition, exten-
  sively revised and modified.  In two large octavo volumes of over 1000 pages, with more
  than 300 wood-cuts;  extra cloth, $6 00.
gHARPEY [ WILLIAM), M.D.,    and    Q UAIN [JONES §• RICHARD).

   HUMAN  ANATOMY.  Revised, with Notes and Additions, by Joseph
      Leidf, M. D., Professor of Anatomy in the University of Pennsylvania.  Complete in two
      large octavo volumes, of about 1300 pages, with 511 illustrations; extra cloth, $6 00.
  The very low price of this standard work, and its completeness in all departments of the subject,
should command for it a place in the library of all anatomical students.

  ALLEN [J. M.),  M.D.

    THE PRACTICAL  ANATOMIST;  or, The Student's Guide in the
      Dissecting Room.  With 266 illustrations.  In one very handsome royal 12mo. volume,
      of over 600 pages; extra cloth, $2 06.
  One of  the most useful works upon the subject ever written.—Medical Examiner 
Henry C.  Lea's  Publications—(Anatomy).
 ^yiLXOX [ERASMUS), F.R.S.

   A SYSTEM  OF  HUMAN ANATOMY, General and  SpeciaJ.   A new
      and revised American, from the last and enlarged English edition.   Edited by W. H. Go-
      erecht, M, D., Professor of General and Surgical Anatomy in the Medical College of Ohio.
      Illustrated with three hundred  and ninety-seven engravings on wood.   In one large and
      handsome octavo volume, of over 600 large pages; extra cloth, $4 00; leather, $5 00.
  The  publisher trusts that the well-earned reputation of this long-established  favorite  will  be
more than maintained by the present edition.  Besides a very thorough revision by the author, it
has been most carefully examined by the editor, and the efforts of both have been directed to  in-
troducing everything which increased  experience in its use has suggested as desirable to render it
a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana-
tomy.   The amount of additions which it has thus received may be estimated from the fact that
the present edition  contains over one-fourth  more matter than the last, rendering a smaller type
and an enlarged page requisite to keep the volume within a convenient size.  The author has not
only thus added largely to the  work, but he has also made alterations throughout, wherever there
appeared the opportunity of improving the arrangement or style, so as to present every fact in its
most appropriate manner, and to render the whole as clear and intelligible as possible. The editor
has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased
the number of illustrations, of which  there are about one hundred and fifty more in this edition
than in the last, thus bringing distinctly before the eye of the student everything of interest or
importance.
 T>Y THE SAME AUTHOR.

   THE  DISSECTOR'S MANUAL;   or, Practical and Surgical Ana-
       tomy.  Third American, from the last  revised and enlarged English edition.  Modified and
       rearranged by William Hunt, M. D., late Demonstrator of Anatomy in the University of
       Pennsylvania.  In one large and handsome royal 12mo. volume, of 582  pages, with  J 04
       illustrations; extra cloth,  $2  00.
 JJODGES,  (RICHARD 31.),  31. D.,
J-J-      Late Demonstrator.of Anatomy in the Medical Department of Barnard University.
   PRACTICAL  DISSECTIONS.   Second  Edition,  thoroughly revised.   In
      one neat royal 12mo. volume, half-bound,'$2 00.   (Just Issued.)
  The object of this work is to present to the anatomical student a clear and concise description
of that which  he is expected  to observe in an ordinary course of dissections.  The author has
endeavored to omit unnecessary details; and to present the subject in the form which many years'
experience has shown him to be the most convenient and  intelligible  to the student.  In the
revision of the present edition,  he has sedulously labored to render the volume  more worthy of
the favor with which it has heretofore been received.
 1IJACLISE [JOSEPH).

    SURGICAL  ANATOMY.   By Joseph Maclise, Surgeon.  In _one
      volume, very large imperial quarto; with-68 large and splendid plates, drawn in the best
      style and beautifully colored, containing 190  figures, many of them the size of life; together
      with copious explanatory letter-press.   Strongly and handsomely bound in extra  cloth.
      Price $.14 00.
  As no complete work of the kind has  heretofore  been published in the English language, the
present volume will supply a want long felt in this country of an accurate and comprehensive
Atlas of Surgical Anatomy, to which the student and practitioner can at all times refer to  ascer-
tain the exact relative positions of the various  portions of the human frame towards each  other
and to the surface, as well as their abnormal deviations.  The importance of such a work to the
student, in the  absence of anatomical material, and to practitioners, either for consultation in
emergencies or to refresh their recollections of  the dissecting room, is evident.   Notwithstanding
the large size, beauty and finish of the very numerous illustrations, it will be observed that the
price is so low as to place it within the reach of all members of the profession.
  We know of no work on surgical anatomy which  refreshed by those clear and distinct dissections,
oon compete with it.—Lancet.
  The work of Maclise on surgical anatomy is of the
highest value.  In some respects it is the best publi-
cation of its kind we have seen, and is worthy of a
place in the library of any medical man, while the
student could scarcely make a better investment than
this.—The Western Journal of Medicine and Surgery.

  No such lithographic  illustrations of  surgical re-
gions have hitherto, we think,  been given.  While
the operator is shown every vessel and nerve where
an speration is contemplated, the exact anatomist is
which every one must appreciate who has a particle
of enthusiasm. The English medical press has quite
exhausted the words of praise, in recommending this
admirable treatise.  Those who have any curiosity
to gratify, in reference to the perfectibility of the
lithographic art in delineating the complex mechan-
ism of the human body, are invited to examine our
specimen copy.  If anything will induce  surgeons
and students to patronize a book of such rare value
and everyday importance to them, it will be a survey
of the artistical skill exhibited in these fac-similes of
nature.— Boston Med. and Surg. Journal.
JT   '  Professor of Anatomy and Physiology in Dartmouth Med. College, X. B.
   HUMAN HISTOLOGY,  in its relations to Anatomy, Physiology, and
      Pathologv:  for the use of medical students.  With four hundred and thirty-four illustra-
      tion*.  In one handsome octavo volume of over 600 pages, extra cloth.   $3 to. 
Henry C. Lea's Publications—(Physiology).
MARSHALL [JOHN), F. R. S.
        Professor of Surgery in University College, London, &c.
   OUTLINES  OF  PHYSIOLOGY, HUMAN AND COMPARATIVE.
     With Additions by Francis Q-urnev  Smith, M. D., Professor of the Institutes of Medi-
     cine in the University of Pennsylvania, Ac.   With numerous  illustrations.   In one large
     and handsome octavo volume, of about 1000 pages.  (Just Ready.)
  We may now congratulate him  on having com-
pleted the latest as well as the best summary of mod-
ern physiological science, both human and compara-
tive,  with  which we are acquainted.   To  speak  of
this work in the terms ordinarily used on such occa-
sions would not be agreeable to ourselves, and would
fail to do justice to its author.  To write such a book
requires a varied and wide range of knowledge, con-
siderable power of analysis, correct judgment, skill
in arrangement, and conscientious spirit.  It must
have entailed great labor, but now that the task has
been fulfilled, the book will prove not only invaluable
to the student of medicine and surgery, but service-
able to all candidates in natural science examinations,
to teachers in schools, and to the lover of nature gene-
rally.  In conclusion, we can only express the con-
viction that the merits of the work wili command for
it that  success which the ability and  vast labor dis-
played  in its production so well deserve.—London
Lancet, Feb. 22, 186S.
  If the possession of knowledge, and peculiar apti-
tude and skill in expounding it, qualify a man to
write an educational work, Mr. Marshall's treatise
might be reviewed favorably without even  opening
the covers.  There are few, if any, more accomplished
anatomists and physiologists than the distinguished
professor of surgery  at University College; and he
has long enjoyed the  highest reputation as a teacher
of physiology, possessing remarkable powers of clear
exposition and graphic illustration.  It is only re-
markable that Mr. Marshall has allowed so  long a
time to elapse'before  producing a text-book after his
own heart.  The plan of this  book differs in many
respects from that of existing educational books ;
the science of  human physiology being treated in
wider and more constant reference to chemistry,
physics, and  comparative anatomy and physiology.
There can be no question, we think, that this is the
most satisfactory, philosophic, and fruitful mode of
teaching physiology.   We have rarely the pleasure
of being able to recommend a text-book so unreserv-
edly as this.—British Med. Journal, Jan. 25, 1868.
c
ARPENTER  [ WILLI'AM  B.), M. D., F. R. S.,
     Examiner in Physiology and Comparative Anatomy in the University of London.

 PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with their chief appli-
   cations 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 additions, by Francis Gurney Smith, M. D., Professor of the Institutes of
   Medicine in the University of Pennsylvania, Ac.   In one very large and  beautiful octavo
   volume, of about  900 large pages, handsomely printed;  extra cloth, $5 50 ;  leather, raised
   bands, $6 50.
                                             We doubt not it is destined to retain a strong hold
                                           on public favor, and remain the favorite text-book in
                                           our colleges.—Virginia Medical Journal.
  The highest compliment that can be extended to
this great work of Dr. Carpenter is to call attention
to this, another new edition, which the favorable
regard of  the profession has called for.  Carpenter is
the staudard authority on physiology, and no physi-
cian  or medical student will regard his library as
complete without a copy of it.—Cincinnati Med. Ob-
server.
  With Dr. Smith, we confidently believe ""that the
present will more than sustain  the enviable reputa-
tion  already attained by  former  editions, of being
one of the fullest and most complete treatises on the
subject in the English language."  We know of none
from the pages of which a satisfactory knowledge of
the physiology of the human organism can be as well
obtained,  none better adapted for the use of such as
take up the  study of physiology in its reference to
the institutes and practice of medicine.—Am. Jour.
Med. Sciences.
  We have so often spoken in terms of high com-
mendation of Dr. Carpenter's elaborate work on  hu-
man physiology that, in announcing a new edition,
it is unnecessary to add anything to what has hereto-
fore been said, and especially is this  the case since
every intelligent physician is  as well aware of the
character and merits of the work as we ourselves are.
—St. Louis Med. and Surg. Journal.

  The above is the title of what is emphatically the
great work on physiology; and we are conscious that
it would be a useless effort to attempt to add any-
thing to the reputation of this invaluable work,  and
can only say to all with whom  our opinion has  any
influence, that it ia. our authority.—Atlanta Med.
Journal.
B
Y THE SAME AUTBOR.
    PRINCIPLES OF  COMPARATIVE  PHYSIOLOGY.  New Ameri-
      can, from the Fourth  and Revised London  Edition.  In  one large and handsome octavo
      volume, with over three hundred beautiful illustrations.  Pp.752.  Extra cloth, $5  00.
  As a complete and condensed treatise on its extended and important subject, this work becomes
a necessity to students of natural science, while the very low price at which it is offered places it
within the reach of all.

 JXY THE SAME AUTBOR.

    THE  MICROSCOPE  AND  ITS  REVELATIONS.   Illustrated  by
      four hundred and thirty-four beautiful engravings on wood.   In one large and very hand-
      some octavo volume, of 724 pages, extra cloth, $5 25.
 JZIRKES (WILLIA3I SENHO USE), M. D.,     ■  >

    A  MANUAL  OF PHYSIOLOGY. .  A new American from the third
      and improved London edition.  With two hundred  illustrations.  In one large and hand-
      some royal 12mo. volume.   Pp. 586.   Extra cloth, $2 25; leather, $2 75.
  It is at once convenient in size, comprehensive in
de«i»n, and concise in statement, and altogether  well
adapted for the purpose designed.—St. Louis Med.
wad Surg. Journal.

  The physiological reader will find it a mest excel-
lent guide in the study of physiology in its most ad-
vanced and  perfect form.   The author has shown
himself capable of giving details sufficiently ample
in a condensed and concentrated shape, on a science
in which it is necessary at once to be correct and not
lengthened.—Edinburgh Med. and Surg. Journal. 
Henry C. Lea's  Publications—(Physiology).
J)ALTON [J  c.), M.D.,
         Professor of Physiology in the College of Physicians and Surgeons, New York &c

    A  TREATISE  ON  HUMAN  PHYSIOLOGY, Desired for the u«e
      o  Students and Practitioners of Medicine.   Fourth edition, evisedwhh nearly three hun









£sap r re^%£w                         incorporax ^uitpr

Srttr^SS^^^                ^ ""J °f the text in Such  a ™ SnotessSIly
and convenience of the rt^            «' *° *? M they haVe been found a,laPted to the want*
a^addiHor,=rtVl t0he.reader-  • ;   •   Seve™l new illustrations are introduced,  some of them
as additions, others as improvements or corrections of the old.   Although all narts of the book
^Zreed'n theTrond l™ ™**?™>»- ^ «"**"* nUmber ^ad^ons and  hang's we -e
required in the Second Section, on the Physiology of  the Nervous System."
  The advent of the first edition of Prof. Dalton's
Physiology, about eight years ago, marked a new era
in the study of physiology to the American student
1 T« H of n.iltrtntn /.i.;if..i______      .   .   ....
Dnder  Dalton's  skilful management, physiological
science threw off the long, loose, ungainly garments
of probability and surmise, in which it had been ar-
rayed by most artists, and came among us smiling
and attractive, in the beautifully tinted and closely
fitting dress of a demonstrated science.  It was a
stroke of genius, as well as a result of erudition and
talent, that led Prof. Dalton to  present to the world
a work on physiology at once brief, pointed, and com-
prehensive, and which exhibited plainly in letter and
drawings the basis  upon which the conclusions ar-
rived at rested.  It is no disparagement of the many
excellent works on physiology, published  prior to
that of Dalton, to say that none of them, either in
plan of arrangement or clearness of execution, could
be compared with his for the use of students or gene-
ral practitioners of medicine.  For this purpose his
book has no equal in the English language.— Western
Journal of Medicine, Nov. 1867.
  A capital text-book in every way. We are, there-
fore, glad to see it in its fourth edition.  It has already
been examined at full length in these columns, so that
we need not now further advert to it beyond remark-
ing that both revision and enlargement have been
most judicious.—London Med.  Times and Gazette,
Oct. 19, 1867.
  No better  proof of the value of this admirable
work could be produced  than the fact that it has al-
ready reached a fourth edition in the short space of
eight years.  Possessing in an  eminent  degree the
merits of clearness and condensation, and being fullv
brought up to the present level of Physiology, it i"s
undoubtedly one of the most reliable text-books
upon this science that could be placed in the hands
of the medical student.— Am. Journal Med. Sciences,
Oct. 1867.

  Prof. Dalton's work has such a well-established
reputation that it does not stand in need of any re-
commendation.  Ever since its first appearance it has
become the highest authority in the English language;
and that it is able to maintain the enviable position
which it has taken, the rapid exhaustion of the dif-
ferent successive editions is sufficient evidence.   The
present edition, which is the fourth, has been  tho-
roughly revised, and enlarged  by the incorporation
of all the many important advances  which  have
lately been made in this rapidly progressing science.
—N.  Y. Med. Record, Oct. 15, 1S67.
  As  it stands, we esteem it the very best of the phy-
siological text-books for the student, and  the most
concise reference and guide-book for the practitioner.
—N.  Y. Med. Journal, Oct.  lSt>7.
  The present edition of this now standard work fully
sustains the high reputation of its accomplished au-
thor.   It is not merely a reprint, but has been faith-
fully revised, and enriched by such additions as the
progress of physiology has rendered desirable. Taken
as a whole, it is unquestionably the most reliable aud
useful treatise on the subject that has been issued
from  the American  press.—Chicago Med.  Journal,
Sept.  1867.
D
UNGLISON [ROBLEY), 31. D.,
     Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia.
HUMAN  PHYSIOLOGY.   Eighth edition.   Thoroughly revised  and
  extensively modified and enlarged, with five hundred and thirty-two illustrations.  In two
  large and handsomely printed octavo volumes of about 1500 pages, extra cloth.  $7 00.
TEH31ANN[C.  G.)

   PHYSIOLOGICAL  CHEMISTRY.   Translated from the second edi-
     tion by George E. Day, M. D., F. R. S., Ac, edited by R. E. Rogers, M. D., Professor of
     Chemistry in the Medical Department of the University of Pennsylvania, with illustrations
     selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates.  Com-
     plete in two large and  handsome octavo volumes, containing 1200 pages, with nearly two
     hundred illustrations, extra cloth.  $6 00.
B
Y THE SAME AUTHOR.
 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 Professor Samuel Jackson, M. D., of the University of Pennsyl-
    vania.  With illustrations on wood.   In one very handsome octavo volume of 336 pages
    extra cloth.  $2 25.
mODD  [ROBERT B.), M.D.  F.R.S., and £>OW3IAN (TV), F.R.S.

   THE  PHYSIOLOGICAL  ANATOMY  AND  PHYSIOLOGY  OF
     MAN.  M'ith about three hundred 1 urge and beautiful illustrations on wood.'  Complete in
     one large octavo volume of 950 pages, extra cloth.  Price $4 75. 
10                Henry  C. Lea's Publications—(Chemistry).
 ~DRANDE [ WM. T), D. C.L.,  and  ffA YLOR [ALFRED S.), M.D., F.R.S.


   CHEMISTRY.  Second  American  edition, thoroughly revised  by  Dr.
      Taylor.   In one handsome 8vo. volume of 764 pages, extra cloth, $5 00 ; leather, $(> 00.
      (Just Issued.)
                               From Dr. Taylors Preface.
  "The  revision of the second  edition, in  consequence of the death of my lamented colleague,
has devolved entirely upon myself.   Every chapter, and  indeed every page, has  been revised,
and numerous additions made in all parts of the volume.   These additions have been  restricted
chiefly to subjects having some practical interest, and they have been made as concise as possible,
in order  to keep the book within those limits which may retain for it the character of a Student's
Manual "—London, June 29, 1867.
  A book that has already so established a reputa-
 tion, as has  Brande  and Taylor's Chemistry, can
 hardly need a notice, save to mention the additions
 and improvements of the edition.  Doubtless the
 work will  long remain a favorite text-book in the
.schools, as well as a convenient book of reference for
 all— N. Y.  Medical Gazette, Oct. 12, 1867.

  For this reason we hail with delight the republica-
 tion, in a form which will meet with general approval
 and command public attention, of this really valua-
 ble standard work on  chemistry—more particularly
 as it has been adapted with »uch care to the wants of
 the general  public. • The well known scholarship  of
 its authors,  and their extensive researches for many
 years'in experimental chemistry, have been long ap-
 preciated in the scientific world, but in this work they
have been careful to give the  largest possible amount
of information with the most sparing use of technical
terms and phraseology, so as to furnish the reader,
 "whether a student of medicine,  or a man of the
world, with a plain introduction to the science  and
practice  of chemistry."—Journal of Applied Chem-
istry, Oct. 1867.
I   This second American edition of an excellent trea-
 tise on chemical science is not a mere republication
 from  the English  press, but  is  a revision and en-
 largement of the original, under the supervision of
 the surviving  author, Dr. Taylor.   The favorable
 opinion expressed  on the  publication of the former
 edition of this work is fully sustained by the present
 revision, in which Dr. T. has increased the size of
 the volume, by an addition of sixty-eight pages.—Am.
 Journ. Med. Sciences, Oct.  1S67.
   The Handbook in Chemistry of the  Student.—
 For clearness of language, accuracy of description,
 extent of information,  and freedom from pedantry
 and mysticism, no  other text-book comes into com-
 petition with it.—The Lancet.
   The authors set out with the definite  purpose of
 writing a book which  shall be intelligible  to any
 educated man.  Thus* conceived, and worked out in
 the most sturdy, common-sense  method, this book
 gives  in the clearest and most summary inerhod
 possible all the facts and doctrines of chemistry.—
 Medical Times.
f>0 WMAN [JOHN E.), M.  D.
PRACTICAL HANDBOOK  OF MEDICAL  CHEMISTRY.  Edited
   by C L.  Bloxam, Professor of Practical Chemistry in King's College, London.  Fourth
   American, from the fourth and revised English Edition.  In one neat volume, royal 12mo.,
   pp. 351, with numerous illustrations, extra cloth.  $2 25.
  The fourth edition of this invaluable text-book of
Medical Chemistry was published in England in Octo-
ber of the last year.  The Editor has brought down
the Handbook to that date, introducing, as far as was
compatible with the necessary conciseness of such a
work, all the valuable  discoveries in the science
which have come to light since the previous edition
was  printed.  The work is indispensable to every
student of medicine or enlightened practitioner.  It
is printed in clear  type, and the illustrations are
numerous and intelligible.— Boston Med. and Surg.
Journal.
B
Y THE SAME AUTHOR.
INTRODUCTION  TO  PRACTICAL  CHEMISTRY, INCLUDING
    ANALYSIS.   Fourth American, from the fifth and revised London edition.  With numer-
    ous illustrations.  In one neat vol., royal 12mo., extra cloth.   $2 25.  (Just Issued.)

                                            It is by far the best adapted for the Chemical student
                                            of any that has  yet fallen in our way.—British and
                                            Foreign Medico-Chirurgical Review.
                                             The best  introductory work on the subject with
                                            which we are acquainted.— Edinburgh Monthly Jour.
  One*of the most complete manuals that has for a
long time, been given to the medical student.—
Athencsum.
  We regard it as realizing almost everything to be
desired in an introduction to Practical Chemistry.
QRAHAM [THOMAS), F.R.S.
 THE  ELEMENTS  OF  INORGANIC   CHEMISTRY,  including the
    Applications of the Science in the Arts.  New and much enlarged edition, by Henry
    Watts and Robert Bridges, M. D.  Complete in one large and handsome octavo volume
    of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra  cloth'
    $5  50.

Part II., completing the work from  p. 431 to end, with Index, Title Matter, Ac, may be hod
    separate, cloth backs and paper sides.  Price $3 00.'

                                            afford to be without this edition of Prof.  Graham's
                                            Elements.—Silliman's Journal, March, 1S58.
                                              From Prof. Wolcott Gibbs, N. Y. Free Academy.
                                              The work is an admirable one in all respects, ana
                                            its republication here cannot fail to exert a positive
                                            influence upon the progress of science in this country.
   From Prof. E. N. Borsford, Barvard College.
  It has, in its earlier and less perfect editions, been
familiar to  me, and the excellence of its plan and
the clearness and  completeness of its discussions,
have long been my admiration.
  No reader of, English works on this science can 
Henry C. Lea's Publications—(Chemistry.  Pharmacy, d-c).    11
JprO WNES [GEORGE), Ph. D.

    A MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical and
       Practical.   With one hundred and ninety-seven illustrations.  Edited by Robert Bridges,
       M. D.  In  one large royal 12mo. volume, of 600 pages, extra cloth, $2  00 ;  leather, S2
  We know of no treatise in the  language, so well
calculated to aid the student in becoming familiar
with the numerous  facts in the intrinsic science on
which it treats, or one better calculated as a text-
book for those attending Chemical lectures. * * * *
The best text-book on Chemistry that has issued from
our press.—American Medical Journal.

  We again  most cheerfully recommend it as the
best text-b >< >k» for students in attendance upon Chem-
ical lecture^  ti.at we have  yet examined.—III. and
Ind. Med. and Surg. Journal.

  A  first-rate work  upon a  first-rate subject.—St.
Louis Med. and Surg. Journal.

  No  manual of Chemistry  which we have  met
comes so near meeting the wants of the beginner.—
Western Journal of Medicine  and Surgery.
                                          50.
  We know of none within the same limits which
has higher claims to our confidence as a college class-
book, both for accuracy of detail and scientific ar-
rangement.—Augusta Medical Journal.
  We know of no text-book on chemistry that  we
would sooner recommend to the student than this
edition of  Prof.  Fownes' work.—Montreal Medical
Chronicle.
  A new and revised edition of one of the best elemen-
tary  works on chemistry accessible to the American
and English student.—N. Y. Journal of Medical and
Collateral  Science.
  We unhesitatingly recommend it to  medical stu-
dents.—N.  W. Med. and Surg. Journal.
  This is a  most excellent text-book for class instruc-
tion in chemistry, whether for schools or colleges —
Silliman's Journal.
ABEL AND BLOXAM'S HANDBOOK OF CHEMIS-
  TRY, Theoretical, Practical, and Technical. In one
  vol. 8vo. of 662 pages, extra cloth, $4 50.
GARDNER'S MEDICAL CHEMISTRY.  1 vol. 12mo.,
  with wood-cuts; pp. 396, extra cloth,  $1 00.
KNAPP'S TECHNOLOGY; or Chemistry Applied to
  the  Arts,  and to Manufactures. With  American
  additions, by Prof. Walter  R. Johnson.  In two
  very handsome  octavo volumes, with 500  wood
  engravings, extra cloth, $6 00.
 J>ARRISH [ED WARD),

          Professor of Materia Medica in the Philadelphia College of Pharmacy.

   A  TREATISE  ON PHARMACY.   Designed as  a Text-Book  for the
       Student, and as a Guide for the Physician and Pharmaceutist.   With many Formulse and
       Prescriptions.  Third Edition, greatly improved.   In one handsome octavo volume, of 850
       pages, with several  hundred illustrations, extra cloth.   $5 00.

   The immense amount of practical information condensed in  this volume may be estimated from
 the fact that the Index contains about 4700 items.   Under the head of Acids there are 312 refer-
 ences ;  under Emplastrum,  36;  Extracts,  159;  Lozenges, 25; Mixtures, 55;  Pills, 56 j  Syrups,
 131;  Tinctures,  138 ; Unguentum,  57, &c.
  We have examined this large volume with a good
 deal of care, and find that' the author has completely
 exhausted the subject upon which he treats ; a more
 complete work, we think, it would be  impossible to
 find.  To the student of pharmacy the  work is indis-
 pensable ; indeed, so far as we know, it is the only one
 of its kind in existence, and  even to the physician or
 medical student who can  spare five dollars to pur-
 chase it, we feel sure the practical information he
 will obtain will more than compensate him for the
 outlay.—Canada Med. Journal, Nov. 1864.
  The medical student and the  practising physician
 will find the volume of inestimable worth for  study
 and reference.—San Francisco Med.  Press,  July,
 1864.
  When we say that this book is in some  respects
 the best which has been published on the subject in
 the English language for a great many years, we do
 not wish it to be understood as very extravagant
 praise.  In truth, it is not so much the best as the
 only book.—Tlie London Chemical News.
  An attempt to furnish anything like an analysis of
 Parrish's very valuable and elaborate Treatise on
 Practical Pharmacy would require more space than
 we have at our disposal.  This, however, is not so
 much a matter of regret, inasmuch as it would be
 difllcult to think of'any point, however minute and
apparently trivial, connected with the  manipulation
of pharmaceutic substances or  appliances which has
not been clearly and carefully discussed in this vol-
ume.  Want of space prevents our enlarging further
on this valuable work, and we must conclude by a
simple expression of our hearty appreciation of its
merits.—Dublin Quarterly Jour, of Medical Science,
August, 1S64.
  We have in this able and elaborate work a fair ex-
position of pharmaceutical science as it exists in the
Dnited States ;  and it shows that our transatlantic
friends have given the subject  most elaborate  con-
sideration, and have brought their art  to a degree of
perfection  which, we believe, is scarcely to be  sur-
passed anywhere.  The book is, of course, of more
direct value to the medicine maker than to the physi-
cian ;  yet Mr. Parrish has not failed to introduce
matter in  which the prescriber is quite as much
interested as the compounder of remedies.  In  con-
clusion, we can only express our high opinion, of the
value of this work as a guide to the pharmaceutic,
and in many respects to the physician, not only in
America, but in other parts of the world.—British
Med. Journal, Nov. 12th, 1864.

  The former editions  have been  sufficiently long
before the medical public to  render  the merits of the
work well known.  It is certainly  one of the most
complete and valuable works on practical pharmacy
to which the student, the practitioner, or the apothe-
cary can have access.—Chicago Medical Examiner,
March, 1864.
 DUNGLISON [ROBLEY),  M.D.,
■*-*      Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia.
   GENERAL THERAPEUTICS  AND  MATERIA MEDICA;  adapted
       for a Medical Text-Book.  With Indexes of Remedies and of Diseases and their Remedies.
       Sixth edition, revised and improved.  With one  hundred and ninety-three illustrations  In
       two large and handsomely printed octavo vols, of about 1100 pages, extra cloth.  $6 50.

 T>Y THE  SAME  AUTHOR.
^NEW  REMEDIES.  WITH  FORMULA  FOR  THEIR  PREPARA-
       TION AND ADMINISTRATION.   Seventh edition,  with extensive additions.   In  one
       very large octavo volume of 770 pages, extra cloth.   $4 00. 
•12    Henry C. Lea's Publications—(3Iat.3Ied.and Therapeutics).
 OTILLE [ALFRED), M.D.,
kD     Professor of Theory and Practice of Medicine in the University of Penna.

   THERAPEUTICS  AND MATERIA MEDICA; a Systematic Treatise
      on the Action and Uses of Medicinal Agents, including their Description and  History.
      Third edition, revised and enlarged.  In two large and handsome octavo volumes  of about
      1700 pages, extra cloth, $10; leather, $12.   (Now Ready.)
  That two large editions of a work of such magnitude should be  exhausted in a few  years, is
sufficient evidence  that it has supplied a want  generally felt by the profession, and the unani-
mous commendation bestowed upon it by the medical press, abroad as well as at home, shows
that the author has successfully accomplished his object in presenting to the profession a system-
atic treatise suited to  the wants of the practising physician, and unincumbered with details
interesting only to the naturalist  or the  dealer.  Notwithstanding  its enlargement, the present
edition has been kept at the former very  moderate price.
                           From the Preface to the Third Edition.
   Although the second edition of this  work had for many months been out of print, the author
preferred to delay a new issue of it,  rather than  omit anything which appeared to be substantially
valuable among the recent advances of the science  and art of Therapeutics.  The subjects  now
treated of for the first time, are :  Chromic Acid ; Permanganate of Potassa ; The Sulphites
of  Soda, etc. ; Carbolic  Acid;  Nitrous Oxide; Rhigolene ; and  Calabar Bean.   The
article on Bromine has beep prepared entirely anew; and that on Electricity very materially
enlarged by an account of the most recent improvements in electrical apparatus, and in the appli-
cation of this agent to the cure of disease.  The  additions which have been mentioned, with
much new matter  besides, which will be found under the more important titles, occupy nearly
one hundred pages.
  April, 1868.
  A few notices of former editions are subjoined.
  We have placed first on the list Dr.  Stille's great
work on Therapeutics. When the first edition of this
work made its appearance nearly five years ago, we
expressed our high sense of its value as containing a
full and philosophical account of the existing  state
of Therapeutics.  Erom the opinion expressed.at that
time we have nothing to retract; we  have,  on the
contrary, to state that the introduction of numerous
additions has rendered the work even more complete
than formerly. We can cordially recommend to those
of our readers who are interested in Therapeutics a
careful perusal of Dr. Stille's work.—Edinburgh Med.
Journal, 1865.
  An admirable digest of our  present knowledge of
Materia Medica and Therapeutics.—Am. Journ. Med.
Sciences, July, 1860.
  Dr. Stille's splendid work on therapeutics and ma-
teria medica.—London Med. Times, April 8, 1865.
  We think this work will do much to obviate the
reluctance to a thorough investigation of this  branch
of scientific study, for in the whole range of medical
literature treasured  in the English tongue, we  shall
hardly find a work written in a style more clear and
simple, conveying forcibly the facts  taught, and yet
free from turgidity and redundancy.  There is a fas-
cination in its pages that will insure  to it a wide po-
pularity and  attentive perusal, and a degree of use-
fulness not often attained through the influence of a
single work. The author has much enhanced the
practical utility of his book by passing briefly over
the physical, botanical, and commercial history of
medicines, and directing  attention chiefly to their
physiological action,  and  their application  for the
amelioration or cure of disease.—Chicago Med. Jour-
nal, March, 1860.

  It has held from its appearance in ,1860, the plarce
it so well deserves, that of the best treatise on Thera-
peutics in the  English language.   A considerable
amount of new matter has been added to this edition
without increasing its bulk, and its general appear-
ance is all that could be  desired of a work which
should find a place in the  hand library of every stu-
dent and  physician.—Boston Med. and Surg. Jour-
nal, Dec.  15, 1864.
 riRIFFITH [ROBERT E.), M.D.

    A  UNIVERSAL  FORMULARY,  Containing the  Methods of  Pre-
      paring and Administering Officinal and other Medicines.  The whole adapted to Physicians
      and Pharmaceutists.   Second edition, thoroughly  revised,  with numerous additions, by
      Robert P. Thomas, M.D., Professor of  Materia Medica in the Philadelphia College of
      Pharmacy.  In  one large and handsome octavo volume of 650 pages, double-columns.
      Extra cloth, $4  00; leather, $5 00.
  In this volume, the  Formulary proper occupies over 400 double-column  pages, and contains
about 5000 formulas, among which, besides those  strictly medical, will be found numerous valuable
receipts for the preparation of essences, perfumes, inks, soaps, varnishes, &c. &o.  In addition to
this, the work contains a vast amount of information indispensable for daily reference  by the prac-
tising physician and apothecary, embracing Tables of Weights and Measures, Specific Gravity,
Temperature for Pharmaceutical Operations, Hydrometrical Equivalents, Specific, Gravities of some
of the  Preparations  of the Pharmacopoeias, Relation between  different Thermometrical  Scales,
Explanation of Abbreviations used in Formulae, Vocabulary of Words used in Prescriptions, Ob-
servations on the Management of the Sick Room, Doses of Medicines, Rules for the Administration
of Medicines,  Management of Convalescence and Relapses, Dietetic Preparations not  included in
the Formulary, List of Incompatibles, Posological Table, Table of Pharmaceutical Names whioh
differ in the Pharmacopoeias, Officinal Preparations and Directions,  and Poisons.
  Three complete and extended Indexes  render the work especially adapted for immediate consul-
tation.  One,  of Diseases and  their  Remedies, presents under the head of each  disease the
remedial agents which have been  usefully exhibited in it, with reference to the formulae containing
them—while another of Pharmaceutical and Botanical Names, and a very thorough General
Lndex  afford  the means of obtaining at once any information desired.  The Formulary itself is
arranged alphabetically, under the heads of the leading constituents of the prescriptions.
  This is one of the most useful books for the prac-
tising physician which has been issued from the press
of late  years, containing a vast variety of formulas
for the  safe and convenient administration of medi-
cines, all arranged upon scientific and rational prin-
ciples,  with  the quantities stated  in full, without
signs or abbreviations.—Memphis Med. Recorder.
  We know of none in our language, or any other, so
comprehensive in its details.—London Lancet.

  One of the most complete works of the kind in any
language.—Edinburgh Med. Journal.
  We are not cognizant of the existence ef a parallel
work.—London Med. Gazette. 
Henry  C. Lea's Publications—(Mat. 3Ied.and TJierapeutics).    13
JpEREIUA  [JONATHAN), M.D., F.R.S. and L.S.

    MATERIA  MEDICA  AND  THERAPEUTICS;  being  an Abridg-
      ment of the late Dr. Pereira's Elements of Materia Medica, arranged in conformity with
      the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemists and
      Druggists,  Medical and  Pharmaceutical  Students, <fcc.   By F. J. Farre. M.D.,  Senior
      Physician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia ;
      assisted by Robert Bentley, M.R.C.S., Professor of Materia  Medica and Botany to the
      Pharmaceutical  Society  of Great Britain; and by Robert Warington,  F.R.S., Chemical
      Operator to the Society of Apothecaries.   With numerous  additions and references to the
      United States Pharmacopoeia,  by Horatio C. Wood, M.D.,  Professor  of Botany in  the
      University of Pennsylvania.   In one large and handsome octavo volume  of 1040 closely
      printed pages,  with 236  illustrations, extra  cloth,  $7 00; leather,  raised bands, $S 00.
      (Just Issued.)  ■
                                                poeia, none will be more acceptable to the student
                                                and practitioner than the present.  Pereira's Materia
                                                Medica had long ago asserted for itself the position <>f
                                                being the most' complete work on the subject in the
                                                English language.  But its very  completeness stood
                                                in the way of its success.  Except in the way of refer-
                                                ence, or to those who made a special study of Materia
                                                Medica, Dr. Pereira's work was  too full, and its pe-
                                                rusal required an amount of time which few had  at
                                                their disposal.  Dr. Fane has very judiciously availed
                                                himself of the opportunity of the publication of the
                                                new Pharmacopoeia, by bringing  out an abridged edi-
                                                tion of the great work.  This edition of Pereira is by
                                                no means a mere abridged re-issue, but contains ma-
                                                ny improvements, both in the descriptive and thera-
                                                peutical departments.  We can  recommend it as a
                                                very excellent and reliable text-book.—Edinburgh
                                                Med Journal, February, 1866.
  The task of the American editor has evidently been
no sinecure, for not only has he given to us all that
is contained in the abridgment useful for  our pur-
poses, but by a careful and judicious embodiment of
over a hundred new remedies has increased the size
of the former work fully one-third, besides adding
many new illustrations, some of which are original.
We unhesitatingly say that by so doing  he has pro-
portionately increased the value, not only of the con-
densed edition, but has extended the applicability of
the great original, and has  placed his medical coun-
trymen under lasting obligations to him.  The Ame-
rican physician  now has all that is  needed  in the
shape of a complete treatise on materia  medica, and
the medical student has a text-book which, for prac-
tical utility and  intrinsic worth, stands unparalleled.
Although of considerable size, it is none  too large for
the purposes for which it has been intended, and every
medical man  should, in justice to himself, spare a
place for it upon his book-shelf, resting assured that
the more he consults it the better he will be satisfied
of its excellence.—N. Y. Med. Record, Nov. 15, 1866.
  It will fill a place which no other work can occupy
In the library of the physician, student, and apothe-
cary.—Boston Med. and Surg. Journal,  Nov. 8, 1866.
  Of the many works on Materia Medica which have
appeared since the issuing of the British Pharmaco-
  The reader cannot fail to be impressed, at a glance,
with the exceeding value of this work as a compend
of nearly all useful knowledge on the materia medica,
We are greatly indebted  to Professor Wood for his
adaptation of it to our meridian. Without his emen-
dations and additions it would lose much of its value
to the American student.   With them it is an Ameri-
can book. — Pacific Medical and Surgical Journal,
December,  1866.
 TpLLIS (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.  The
      whole accompanied with a few brief Pharmaceutic and Medical Observations.  Twelfth edi-
      tion, carefully revised and much improved by Albert H. Smith, M. D.  In one volume 8vo.
       (Nearly Ready.)
  We endorse the favorable opinion which the book
has so long established for itself, and take this occa-
sion to commend it to our readers as one of the con-
venient  handbooks of the office and library.—Cin-
cinnati Lancet,  Feb. 1S61.
  The work has  long been before the profession, and
Its merits are well known.  The present edition con-
tains many valuable additions, and will be found to
be an exceedingly convenient aud useful volume for
reference  by  the medical  practitioner. — Chicago
Medical Examiner, March, 1864.
  The work is now so well known, and has been so
frequently noticed in this Journal as the successive
editions appeared, that it is sufficient, on the present
occasion, to state that the editor has introduced into
the eleventh edition a large amount of new matter,
derived from the current medical and pharmaceutical
works, as well as  a number of valuable,presciiptioiis
furnished from private sources.  A very comprehen-
sive and extremely useful  index has also been mip-
plied, which facilitates  reference to the particular
article the  prescriber may wish to administer; and
the language of the Formulary has been made to cor-
respond with the nomenclature of the new national
Pharmacopoeia.—Am. Jour. Med. Sciences, Jan. 1S64.
flARSON  (JOSEPH), 31.D.,
\J     Professor of Materia Medica and Pharmacy in the University of Pennsylvania, &c.

   SYNOPSIS  OF  THE  COURSE  OF   LECTURES   ON MATERIA
      MEDICA  AND PHARMACY, delivered in the University of Pennsylvania.  With three
      Lectures on the Modus Operandi of Medicines.   Fourth and revised edition, extra cloth,
      $3 00.   (Now Ready.)        _____
ROYLE'S  MATERIA MEDICA  AND  THERAPEU-
  TICS; including the Preparations °' th« Pha""a-
  copceias of London, Edinburgh, Dublin, and of the
  United States. With many new medicines   Ed  ed
  by Joseph Cars..*, M D.  With ninety-eight^ illus-
  trations.  In one large octavo volume of about 700
  pages, extra cloth. *3 00.
PHRISTISON'S DISPENSATORY; or, Commentary
  on the Pharmacorccias of Great Britain and the
  rrnitPd States.  With  copious additious, and 213
  5S^-cod-engravings. By R. BoLK.FKi.nGR.FFiTH,
  M L>  In one very handsome octavo volume of over
  1000 pages, extra cloth. *4 00.
CARPENTER'S  PRIZE  ESSAY ON  THE USE  OF
  Alcoholic Liquors in Hkat.th and Disease.  Now
  edition, with a Preface by D. F. Condie, M.D., and
  explanations of scientific words.  In one neat 12mo.
  volume, pp. 17S, extra cloth.  60 cents.
De JONGH  ON THE THREE KINDS OF COD-LIVER
  Oil, with their  Chemical and Therapeutic Pro-
  perties.  1 vol. 12ino., cloth.  75 cents.
MAYNE'S DISPENSATORY AND THERAPEUTICAL
  Rfmembrancer.   With every Practical Formula
  contained in the three British Pharmacopoeias.
  Edited  with the addition of the Formulae ot  the
  U  S  Pharmacopoeia, by R. E. Griffith, M. D.   In
  one 12uio. volume, 300 pp., extra cloth.  70 cents. 
14                Henry C. Lea's Publications—(Pathology).
 QROSS (SAMUEL D.),  31. D.,
          Professor of Surgery in the Jefferson Medical College of Philadelph in.

   ELEMENTS  OF  PATHOLOGICAL  ANATOMY.    Third  edition,
       thoroughly revised and greatly improved.  In one large and very handsome octavo volume
       of nearly 800 pages, with about three hundred and fifty beautiful illustrations, of which a
       large number are from original drawings ;  extra cloth.  $4 00.
  The very beautiful execution of this valuable work, and the exceedingly low price at which it
is offered, should command for it a place in the library of every practitioner.
  To the student of medicine we would say that we
know of no work which we can more  heartily com-
mend than Gross's Pathological Anatomy.—Southern
Med. and Surg. Journal.
  The volume commends itself to the medical student;
it will repay a careful perusal, and should be upon
the book-shelf of every American physician.—Charles-
ton Med. Journal.
  It contains much new matter, and brings down our
knowledge of pathology to the latest period.—London
Lancet.
TONES [C. HANDFIELD), F.R.S., and  SIEVEKING [ED. H),  M.D.,

  Assistant Physicians and Lecturers in St. Mary's Hospital.
MANUAL OF  PATHOLOGICAL ANATOMY.    First  American
edition, revised.  With three hundred and ninety-seven handsome wood engravings.  In
one large and beautifully printed octavo volume of nearly 750 pages,  extra cloth, $3 50.
  Our limited space alone restrains us from noticing
more  at length the various subjects treated of in
this interesting work; presenting, as it does, an excel-
lent summary of the existing state of knowledge in
relation to pathological anatomy, we cannot  too
strongly urge upon the student the  necessity of a tho-
rough acquaintance with its contents.—Medical Ex-
aminer.
  We have long had need of a hand-book of patholo-
gical anatomy  which should  thoroughly  reflect  the
present state of that science.  In the treatise before
us this desideratum is supplied.  Within the limits of
a moderate octavo, we have the outlines of this great
department of medical  science  accurately  defined,
and the most recent investigations presented in suffi-
cient detail for the student of pathology.  We cannot
at this time undertake a formal analysis of this trea-
tise,  as it would  involve a  separate and  lengthy
consideration Of nearly every subject discussed ; nor
would such analysis be advantageous to the  medical
reader.  The work is of such a character that every
physician ought to obtain it, both for reference and
study.—N. Y. Journal of Medicine.
  Its importance to the physician cannot be too highly
estimated, and we would  recommend our readers to
add it to their library as soon as they conveniently
can.—Montreal Med. Chronicle.
POKITANSKY [CARL). M.D.,
        Curator of the Imperial Pathological Museum, and Professor at the University of Vienna.
  A  MANUAL   OF  PATHOLOGICAL  ANATOMY.    Translated  by
     W. E. Swaine,  Edward Sieveking, C. H. Moore, and Q. E. Day.  Four volumes octavo,
     bound in two, of about 1200 pages, extra cloth.   $7 50.
GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY.
  Translated, with Notes and Additions, by Joseph
  Leidt, M. D.  In one volume, very, large imperial
  quarto, with 320 copper-plate figures, plain and
  colored, extra cloth.  $i 00.
SIMON'S GENERAL PATHOLOGY, as conducive to
  the Establishment of Rational Principles for the
  Prevention and  Cure of Disease.  In one octavo
  volume of 212 pages, extra cloth.  $1 25.
 WILLIAMS [CHARLES J. B.),  M.D.,
          Professor of Clinical Medicine in University College, London.

   PRINCIPLES OF  MEDICINE.   An Elementary Yiew of the Causes,
       Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics,
       or the preservation of health.  A new American, from the third and revised London edition.
       In one octavo volume of about 500 pages, extra cloth.  $3 50.
  The unequivocal favor with which  this work has
been received by the profession, both in  Europe and
America, is one among the many gratifying evidences
 which might be adduced as going to show that there
 is a steady progress taking place in the science as well
 as in the art of medicine.—St. Louis Med. and Surg.
 Journal.
   No work has  ever achieved  or maintained a more
 deserved  reputation.— Virginia  Med. and Surg.
 Journal.
  One  of the best works on  the subject of which U
 treats in our language.
  It has already commended itself to the high regard
 of the profession ; and we  may well say that  we
 know of no single volume that  will  afford  the source
 of so thorough a drilling in the principles of practice
 as  this.  Students aud  practitioners should make
 themselves intimately familiar with its teachings—
 they will find their  labor and study most amply
 repaid.—Cincinnati Med. Observer.
  There is no work in medical  literature which can
 fill the place of this one.  It  is the  Primer of the
 young practitioner, the Koran of the scientific one.—
Stethoscope.
  A text-book to which no other in our language is
comparable.—Charleston Med. Journal.
  The lengthened analysis we have given of Dr. Wil-
liams's Principles of Medicine will, we trust, clearly
prove to our readers his  perfect  competency forthe
task he has undertaken—that of imparting to  the
student, as well as to the more  experienced  practi-
tioner, a knowledge of those general principles of
pathology on which  alone a correct practice  can be
founded.   The absolute  necessity  of such a work
must be evident  to  all who pretend to  more than
mere empiricism.  We must conclude by again  ex-
pressing our high sense of the immense benefit which
Dr. Williams has conferred ou medicine by the pub-
lication  of this work.  We are certain that in  the
present state of our knowledge his Principles of Medi-
cine could not possibly  be  surpassed.  While  we
regret the loss which many of the rising generation
of practitioners' have sustained by his resignation of
the Chair  at University College,  it is comforting to
feel that his writings must long  continue to exert a
powerful influence on the practice of that profession
for the improvement  of which he has so assiduously
and successfully labored, and in  which he  holds so
distinguished a position.—London Jour, of Medicine 
Henry C. Lea's Publications—(Practice of Medicine).          15
JJ1LINT  [A USTIN),  M. D.,
-*-       Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. Y.

   A  TREATISE   ON   THE   PRINCIPLES  AND   PRACTICE   OF
       MEDICINE ;  designed  for the use of  Students and  Practitioners of Medicine.   Second
       edition, revised and enlarged.  In  one large and  closely printed octavo volume of nearly
       1000 pages ; handsome extra cloth,  $6 50; or strongly bound in leather, with raised bands,
       $7 50. (Just Issued.)

                            From the Preface to the Second Edition.
  Four months after the publication of this treatise, the author was notified that a second edition
was called for.  The speedy exhaustion of the first edition, unexpected in view of its large size,
naturally  intensified  the desire to make the work  still  more acceptable to practitioners and
students of  Medicine; and, notwithstanding  the brief  period allowed for a revision, additions
have been made which, it is believed, will enhance the practical utility of the volume.
  We are happy in being able once more to commend
this work to the students and practitioners of medicine
who seek for  accurate information conveyed in lan-
guage at once clear, precise, and expressive.—Amer.
Journ. Med. Sciences, April, 1867.
  Dr. Flint, who has been known in this country for
many years, both  as an author and teacher, who has
discovered truth, and pointed it out clearly and dis-
tinctly to others, investigated the symptoms and na-
tural history of disease and recorded its language and
facts, and devoted  a  life  of  incessant study  and
thought to the doubtful or obscure in his profession,
has at length, in his ripe scholarship, given this work
to the profession as a crowning gift.  If we have spoken
highly of its value to the profession and world ; if we
have said, *all considered, it is the  very best work
upon medical practice in any language; if we have
spoken of its excellences in detail, and given points
of special value, we have yet failed to express in any
degree our present estimate of its value as  a guide in
the practice of medicine.  It does not contain too much
or too little ; it is not positive where doubt should be
expressed, or hesitate where truth is known.  It is
philosophical and speculative wheYe  philosophy and
speculation are all that can at present be obtained,
but nothingis admitted to the elevation of established
truth, without the most thorough investigation.  It
is truly remarkable with what even hand  this work
has been written, and how it all shows the  most care-
ful thought and untiring study.  We conclude that,
though it may yet be susceptible of improvement, it
Btill constitutes the very best which human knowledge
can  at present  produce.   "When knowledge is in-
creased," the work  will doubtless be again revised;
meanwhile we shall accept it as the rule of practice.
—Buffalo Med. and Surg. Journal, Feb. 1867.
  He may justly  feel proud of the high honor con-
ferred on him by the demand for a second edition of
his work in four months after the issue of the first.
No American practitioner cau afford to do without
Flint's Practice.—Pacific Med.'and Surg.  Journal,
Feb. 1867.
  Dr. Flint's book is the only one on the practice of
medicine that can benefit the young practitioner.—
Nashville Med. Journal, Aug. 1866.
  We consider the book, in all its essentials,  as the
best  adapted to the  student of any of our  numerous
text-books on this subject.—.ZY Y Med. Journ., Jan.'67.
  Its terse conciseness fully redeems it from being
ranked among heavy and common-place works, while
the unmistakable way in which Dr. Flint gives his
own views is quite refreshing, and far from common.
It is a book of enormous research; the writer is evi-
dently a man of observation and large experience;
his views are  practically sound and theoretically
moderate, and we have no hesitation in commending
his magnum opus to our readers.—Dublin Medical
Press and Gircxdar,  May 16, 1866.
  In the plan of the work and the treatment of indi-
vidual subjects there is a freshness and an originality
which make it worthy of the study of practitioners
as well as students.  It is, indeed, an admirable book,
and highly creditable to American  medicine.  For
clearness and conciseness in style, for careful reason-
ing upon what is known, for lucid distinction between
what we know and what we do  not know, between
what nature does in disease and what the physician
can do and should, for richness in good clinical ob-
servation, for independence of statement and opinion
on great points of practice, and for general sagacity
and good judgment, the work is most  meritorious.
It is singularly rich in good qualities, and free from
faults.—London Lancet, June 23, 1866.

  In following out such a plan Dr.  Flint  has  suc-
ceeded most admirably, and gives to his readers a
work  that is not only very readable, interesting,
and concise, but in every respect calculated to mci-t
the requirements of professional men of every class.
The student has presented to him,  in  the plainest
possible manner, the symptoms of disease, the prin-
ciples which should  guide him in its treatment, and
the difficulties which have to be surmounted in order
to  arrive at a  correct diagnosis.  The. practitioner,
besides having such aids, has offered to him the  con-
clusion which  the experience of the professor has
euabled him to arrive at in reference to the relative
merits of different therapeutical agents, aud different
methods of treatment.   This  new work will add not
a little to the well-earned reputation of Prof. Flint as
a medical teacher.—N. Y. Med. Record, April 2, 1866.

  We take pleasure in recommending to the profession
this valuable and practical work on the practice of
medicine, more particularly as we have had  oppor-
tunities  of appreciating from  personal observation
the author's preeminent merit as a clinical observer.
This work is undoubtedly one of great merit, and we
feel confident that it will have an extensive circula-
tion.— The N. 0. Me§. and Surg. Journal, Sept. 1866.
 T)VNGLISON. FORBES, TWEED IE, AND  CONOLLY.
    THE  CYCLOPAEDIA  OF  PRACTICAL  MEDICINE:  comprising
       Treatises  on the Nature and Treatment of'Diseases,  Materia  Medica and Therapeutics,
       Diseases of Women and Children, Medical Jurisprudence, <fec. Ac.  In four large super-royal
       octavo volumes, of3254 double^olumned pages, strongly and handsomely bound m leather,
       $15 ;  extra cloth, $11.
  *** This work contains no less than four hundred and eighteen distinct  treatises, contributed
by sixty-eight distinguished physicians.
  The  most complete work on practical medicine
extant, or at least in our language.—Buffalo Medical
and Surgical Journal.
  For reference, it is above all price to every practi-
tioner.— Western Lancet.
  One of the most valuable medical publications of
the day.  As a work of reference it is invaluable.—
Western Journal of Medicine and Surgery.

  It has been to us, both as learner and teacher, a
work for ready and frequent.reference, one in which
modern English medicine is exhibited in the most ad-
vantageous light.—Medical Examiner.
BARLOW'S  MANUAL  OF  THE  PRACTICE  OF
  MEDICINE   With  Additions by D. F. Condie,
  jU  l vol. Svo., pp. 600, cloth.  $2 50.
HOLLAND'S  MEDICAL  NOTES  AND  REFLEC-
  TIONS.  From the third and enlarged English edi-
  tion.  In  one  handsome octavo volume of abou;
  500 pages, extra cloth.  $3 50. 
16        Henry C. Lea's Publications—(Practice of 3Iedieine).
 ZTARTSHORNE (HENRY), 31. D.,
-*—*-     Professor of Hygiene in the University of Pennsylvania.

   ESSENTIALS OF THE  PRINCIPLES  AND  PRACTICE  OF MEDI-
       CINE.   A handy-book  for Students and Practitioners.  In one  handsome royal 12mo.
       volume of 418 pages, clearly  printed on small type, cloth, $2 38;  half bound,  $2 63.
       (Just Issued.)
  The very cordial reception with which this work  has met shows that the author has fully suc-
ceeded in his attempt to condense within a convenient compass  the essential points of scientific
and practical  medicine, so as to meet the wants not only of the student, but also of the practi-
tioner who desires to acquaint himself with the results of recent  advances in medical science.
  As a  strikingly terse, full, and comprehensive em-
bodiment in a condensed form of the essentials in
medical science and art, we hazard nothing in saying
that it is incomparably in advance of any work of the
kind of the past, and will staud long in the future
without a rival.  A mere glance will, we think, im-
press others with the correctness of our estimate.  Nor
do we believe there will be found many who,  after
the most cursory examination, will fail to possess it.
How one could be able to crowd so much that is valu-
able, especially to the student and young practitioner,
within the limits of so small a book, and yet embrace
and present all that is important  in a well-arranged,
clear form, convenient, satisfactory for reference, with
so full a table of contents, and extended general index,
with nearly three hundred formulas  and recipes, is a
marvel.— Western Journal of Medicine, Aug. 1867.

  The little book before us has this quality,  and we
can therefore say that all students will find it an in-
valuable guide in their  pursuit of clinical medicine.
Dr. Hartshorne speaks of it as "an unambitious effort
to make useful the experience of twenty years of pri-
vate and hospital medical practice, with its attendant
study and reflection." That the effort will prove suc-
cessful we have no doubt, and in his study, and at
the bedside, the  student will find Dr. Hartshorne a
safe and accomplished companion.   We speak thus
highly of the volume, because it approaches more
nearly than any similar manual lately before us the
standard  at which all such books  should aim — of
teaching much, and suggesting more.  To the student
we can heartily recommend the work of our transat-
lantic colleague, and the busy practitioner, we are
sure, will find in it  the  means of solving many a
doubt,  and  will rise from the perusal of its pageH,
having gained clearer views to guide him  in his daily
struggle with disease.—Dub. Med. Press,  Oct. 2, 1S67.
  Pocket handbooks  of medicine are not desirable,
even when they are as carefully and elaborately com-
piled as this, the latest, most complete, and most ac-
curate which we have seen.—British Med. Journal,
Sept. 21, 1S67.
  This work of Dr. Hartshorne must not be confound-
ed with the medical manuals so generally to be found
in the hands of students, serving them at best but as
blind guides, better adapted to lead them  astray than
to any useful and reliable knowledge.  The work be-
fore us presents a careful synopsis of the essential
elements of the theory of  diseased action, its causes,
phenomena, and results, and of the art of healing, as
recognized by the most authpritative of our profes-
sional writers  and teachers. A very careful and can-
did examination of the volume has convinced us that
it will be generally recognized as one of the best man-
uals for the use of the student that has yet appeared.
—American Journal Med. Sciences, Oct.  1867.
 JJfATSON (THOMAS),  31. D., Sfc.

     LECTURES   ON   THE   PRINCIPLES   AND   PRACTICE  OF
       PHYSIC.   Delivered  at King's College, London.   A new American, from the last revised
       and enlarged English  edition, with Additions, by  D.  Francis Condie,  M. D., author of
       "A Practical Treatise on the Diseases of Children," Ac.   With one hundred and eighty-
       five illustrations  on wood.   In one very large and handsome volume, imperial octavo, of
       over  1200 closely printed pages in small type;  extra cloth, $6  50;  strongly bound  in
       leather, with raised bands, $7  50.
  Believing this to be a work which should lie on the table of every physician, and be in the hands
of every student, every  effort has been made to condense the vast amount of matter which it con-
tains within a convenient compass, and at a very reasonable pr.ice, to place it within reach of all.
In  its present  enlarged form, the work contains  the  matter of at least three ordinary octavos,
rendering it one of the cheapest works now offered to the American profession, while its mechani-
cal execution makes it an exceedingly attractive volume.
DICKSON'S ELEMENTS OF MEDICINE; a Compen-
  dious View of Pathology and Therapeutics, or the
  History and Treatment of Diseases.  Second edi-
  tion, revised. 1 vol. 8vo. of 750 pages, extra cloth.
  $1 00.
W H AT TO OBSERVE AT THE BEDSIDE AND AFTER
  Death in Medical Cases. Published under the
  authority of the London Society for Medical Obser-
  vation.  From the second London edition.  1 vol.
  royal 12mo., extra cloth. $1 00.
LAYCOCK'S   LECTURES  ON  THE PRINCIPLES
  and Methods  op Medical  Observation and Re-
  search.  For the  use of advanced students and
  junior practitioners. In one very neat royal 12mo.
  volume, extra cloth.  $1 00.
M. D.
J) ARC LAY (A.  W.

    A MANUAL  OF MEDICAL DIAGNOSIS; being an Analysis  of the
      Signs and  Symptoms of Disease.   Third American from the second  and revised  London
      edition.  In one neat octavo volume of 451 pages, extra cloth.  $3 50.
  A work  of  immense  practical utility.-~iyO»don
Med. Times and Gazette.
  The book should be in the hands of every practical
man.—Dublin Med. Press.
I
DULLER (HENRY WILLIAM), M. D.,
      Physician to St. George's Hospital, London.

ON  DISEASES  OF   THE  LUNGS  AND  AIR-PASSAGES.   Their
    Pathology, Physical Diagnosis,  Symptoms, 3rd  Treatment.  From the second and revised
    English edition.   In one  handsome  octavo volume of about 500 pages, extra cloth,  $3 50.
    (Now Ready.)
  Dr. Fuller's work on diseases of the chest was so
favorably received, that to many who did not know
the extent of his engagements, it was a matter of won-
der that it should be allowed to remain three years
out of print. Determined,  however, to improve it,
Dr. Fuller would  not consent to a mere reprint, and
accordingly we have what might be with perfect jus-
tice styled an entirely new work from his pen, the
portion of the work treating of the heart  and great
vessels being excluded.  Nevertheless, this volume is
of almost equal size with the first.—London Medical
Times and Gazette, July 2C, 1S67. 
Henry C. Lea's Publications—(Practice of 3Iedicine).        17
 TfLINT (A USTIN).  31. D.,
"*■       Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, X. Y.

   A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA-
      TION OF THE CHEST AND THE  DIAGNOSIS OF  DISEASES AFFECTING  THE
      INSPIRATORY ORGANS.  Second and revised edition.  In one handsome octavo volume
      of 595 pages, extra cloth, $4 50.  (Just Issued.)
  Premising this observation of the necessity of each
stuTlent and practitioner making himself acquainted
with auscultation and percussion, we may state  our
B
                                            American medicine.—Atlanta Med. and Surg. Jour-
                                            nal, Feb. 1867.
                                              The chapter on Phthisis is replete with interest;
                                            and his remarks on the diagnosis, especially in the
                                            early stages, are remarkable for their acumen arid
                                            great practical value.  Dr. Flint's style is clear and
                                            elegant, and the tone of freshness and originality
                                            which pervades his whole work lend an additional
                                            force to  its thoroughly practical  character, which
                                            cannot fail to obtain for it a place as a standard work
                                            on diseases of the respiratory system.—London
                                            Lancet, Jan. 19, 1867.
                                              This is an admirable book.  Excellent in detail and
                                            execution,  nothing better could be desired  by the
                                            practitioner.   Dr.  Flint enriches  his  subject with
                                            much  solid and not a little original observation.—
                                            Banking's Abstract, Jan. 1867.
F THE SAME AUTHOR.    „              ----

A PRACTICAL TREATISE  ON  THE DIAGNOSIS,  PATHOLOGY,
   AND  TREATMENT OF DISEASES OF THE HEART.   In one neat octavo volume of
   nearly 500 pages, with a plate; extra cloth, $3 50.
honest opinion that Dr. Flint's  treatise is one of the
most trustworthy guides which  he can consult.  The
style is clear and distinct, and  is also concise, being
free from that tendency to over-refinement and unne-
cessary minuteness which characterizes many works
on the same subject.—Dublin Medical Press, Feb. 6,
1867.

  In the invaluable work before us, we have a book
of facts  of nearly 600 pages,  admirably arranged,
clear, thorough, and lucid on all points, without pro-
lixity; exhausting every point  and topic touched ; a
monument of patient and long-continued observation,
which does credit to its author,  and reflects honor on
  We question the fact of any recent American author
in our profession being more extensively known, or
more d>-sisrvedly esteemed in  this country than Dr.
Flint.   We willingly acknowledge his success, more
particularly in the volume on diseases of the heart, in
making an extended personal clinical study available
for purposes of illustration, in connection with cases
which have been reported by other trustworthy ob-
servers.—Brit, and For. Med.-Chir. litview.
fJHA31BERS  (T. K.), 31. D.,
^      Consulting Physician to St. Mary's Hospital, London, &c.

  THE  INDIGESTIONS; or, Diseases of the Digestive Organs Functionally
      Treated.  Second American, from the second and revised English Edition.  In one hand-
      some octavo volume of over 300 pages, extra cloth, $3 00.  (Now Ready.)
                                              and practical skill—that his success as a teacher or
                                              literary expositor of the medical art consists; and the
                                              volume before us is a better illustration than its au-
                                              thor has  yet produced of the rare degree in which
                                              those combined qualities are at his command.  Next
                                              to the diseases of children,  there is no subject  on
                                              which the young practitioner is oftener consulted, >>r
                                              on which the public are more  apt to form their
                                              opinions of  his professional skill, than the various
                                              phenomena of indigestion. Dr. Chambers comes most
                                              opportunely and effectively to Ms assistance. In fact,
                                              there are few situations in which Ihe commencing
  He is perhaps the most vivid and brilliant of living
mefdical writers; and here he supplies, in a graphic
series of illustrations, bright sketches from his well-
s*tored portfolio.   His isan admfrable clinical book,
like all that he publishes, original, brilliant, and in-
teresting.  Everywhere he is graphic, and his work
supplies numerous practical  hints of much value.—
Edinburgh Med. and Surg. Journal, Nov. 1S67.
  Associate with this the rare faculty which  Dr.
Chambers has of infusing an enthusiasm in his sub-
ject, and we have in this little work all the elements
which make it a model of its sort.  We have perused
it carefully; have studied every page; our interest
in the subject has been intensified as we proceeded,
and we are enabled to lay it down with unqualified
praise.—N. Y. Med. Record, April 15, 1S67.
  It is in the combination of these qualities—clear and
vivid expression, with thorough scientific knowledge
practitioner can  place himself in which Dr. Cham-
bers' conclusions on digestion will not be of service.
—London Lancet, February 23,1867.

  This is one of the most valuable works which it
has ever been our good fortune to receive.—London
Med. Mirror, Feb. 1867.
B
RINTON  (WILL1A31),  M.D.,  F.R.S.
LECTURES  ON THE DISEASES OF THE  STOMACH;  with an
Introduction on its Anatomy and Physiology.   From the second and enlarged London edi-
tion.   With illustrations on wood.   In one handsome octavo volume of about 300 pages,
extra cloth.  $3 25.   (Just issued.)
                                          The most complete work in our'language upon the
                                         diagnosis and treatment of these puzzling and impor-
                                         tant diseases.—Boston Med. and Surg. Journal, Nov.
                                         1865.
  Nowhere can be found a more full, accurate, plain,
arm instructive history of these diseases, or more ra-
tional views respecting their pathology and therapeu-
tics.—^ m. Journ. of the Med. Sciences, April, 1S65.
TJABERSHON (S.  O.),  M.D.
H
PATHOLOGICAL AND PRACTICAL  OBSERYATIONS ON DIS-
  EASES of the ALIMENTARY CANAL, (ESOPHAGUS  STOMACH, CAECUM AND
  INTESTINES.  With illustrations on wood.  In  one handsome octavo volume of 312
  pages, extra cloth.  $2 50.    ^^_________________

UDSON  (A.), 31.D., 31 R.I.A.,
     Physician to the Meath Hospital.
LECTURES ON THE  STUDY OF FEYER.   In one vol. 8vo.   (Pub-
  lishing in the  "Medical News and Library" for 1867 and 1868.) 
18        Henry C.  Lea's  Publications—(Practice of 3fedin'ne).
 ROBERTS  ( WILLIAM),  31. D.,
-*■*'     Lecturer on Medicine in the Manchester School of Medicine, &c.

   A  PRACTICAL  TREATISE  ON  URINARY  AND  RENAL  DIS-
       EASES, including Urinary Deposits.  Illustrated by numerous cases and engravings.   In
       one very handsome octavo volume of 516 pp., extra cloth.  $4 50.   (Just Issued.)
  In carrying out this design, he has not only made | sive work on urinary and renal diseases, considered
good use of his own practical knowledge, but has
brought together from various sources a vast amount
of information, some of which is not generally pos-
sessed  by the profession in this country.  We must
now bring our notice of this book to a close, re-
gretting only that we are obliged to resist the temp-
tation of giving further extracts from it. Dr. Roberts
has already on several occasions placed before the
profession the results of researches made by him on
various points connected with the urine, and had thus
led  us to expect from him something good—in which
expectation we have been by no means disappointed.
The book is, beyond question, the most comprehen-
                                               in their strictly practical aspect, that we possess
                                               the  English language.—British  Medical  Journal,
                                               Dec. 9, 1S65.
                                                We have read this book with much  satisfaction.
                                               It will take its place beside the be»t treatises in our
                                               language upon urinary  pathology and therapentics.
                                               Not the least of its merits is that the author, unlike
                                               some other book-makers, is contented  to withhold
                                               much that he is well qualified to discuss in order to
                                               impart to his volume such a strictly practical charac-
                                               ter as cannot fail to render it popular among British
                                               readers^—London Med.   Times and Gazette, March
                                               17, 1866.

  „% " Bird on Urinary Deposits," being for the present out of print, gentlemen will find in the
above work a trustworthy substitute.
MORLAND  ON  RETENTION IN THE BLOOD OF
  THE ELEMENTS  OF THE  URINARY SECRE-
  TION.  1 vol. Svo., extra cloth. 75 cents.
BLOOD AND URINE (MANUALS ON).  By  J. W.
  Grifpth, G. 0. Reese, and A. Markwick.  1 vol.
  12mo , extra cloth, with plates,  pp. 460.. $1 25.
BUDD ON DISEA'SES OF THE LIVER.  Third edition.
  1 vol. Svo., extra cloth, with four beautifully colored
  plates, and numerous wood-cuts.  pp. 500.  $4 00.
  TONES (C.  HANDFIELD), M. D.,
U      Physician t: St. Mary's Hospital, &c.

   CLINICAL   OBSERVATIONS
      DISORDERS.   Second American Edition.
      extra cloth, $3  25.  (Just Issued.)
  Taken as a whole, the  work before us furnishes a I
short but reliable account of the pathology aud treat-
ment of a class of very common but certainly highly
Obscure disorders.  The advanced student will find it
a rich mine of valuable facts, while the medical prac-
titioner will derive from it many a suggestive hint to
aid liim in the diagnosis of ''nervous cases," and in
determining the  true  indications for their ameliora-
tion or cure.—Amer. Journ. Med. Sci., Jan. 1867.
  ON  FUNCTIONAL  NERVOUS
,  In one handsome octavo volume of 348 pages,

  We must  cordially recommend it to the profession
of this country as supplying, in a great measure, a
deficiency which  exists in the  medical literature of
the English language.—New York Med. Journ., April,
1867.

  The volume is a most admirable one—full of hfnta
and practical suggestions. — Canada Med. Journal,
April, 1867.
HARRISON'S ESSAY  TOWARDS A  CORRECT
  THEORY  OF THE NERVOUS  SYSTEM.   In  one
  octavo volume of 292 pp.  $1 50.
SOLLY ON THE HUMAN BRAIN : its Structure, Phy-
  siology, and Diseases.  From the Second and much
  enlarged London edition.  In one octavo volume of
  500pages, with 120 wood-cuts; extra cloth.  $2 50.
BUCKNILL AND TUKE'S MANUAL OF PSYCHO-
  LOGICAL  MEDICINE;  containing  the History,
  Nosology, Description, Statistics, Diagnosis, Patho-
  logy, and Treatment of Insanity.   With a Plate.
  In one handsome octavo volume, of 536 pages, extra
  cloth.  $4 25.
VLADE (D.  D.), M.D.
DIPHTHERIA; its Nature and Treatment, with an account of the His-
   tory of its Prevalence in various Countries.   Second and revised  edition.  In one neat
   royal 12mo. volume, extra cloth.  $1 25.  (Just issued.)
SMITH ON CONSUMPTION ; ITS EARLY AND RE-
  MEDIABLE STAGES.  In one neat octavo volume
  of 2o4 pages, extra cloth.  $2 25.
SALTER ON ASTHMA; its Pathology, Causes, Con-
  sequences, and Treatment.  In one volume octavo,
  extra cloth. $2 50.
BUCKLER ON FIBRO-BRONCHITIS AND RHEU-
  MATIC  PNEUMONIA.  In one octavo vol., extra
  cloth, pp. 150.  $1 25.
FISKE FUND PRIZE  ESSAYS.—LEE ON THE EF-
  FECTS  OF  CLIMATE  ON TUBERCULOUS DIS-
  EASE.   AND WARREN ON THE INFLUENCE OF
  PREGNANCY  ON THE DEVELOPMENT OF TU-
  BERCLES.  Together in one neat octavo volume
  extra cloth, $1 00.
HUGHES' CLINICAL  INTRODUCTION  TO AUS-
  CULTATION AND OTHER MODES OF PHYSICAL
  DIAGNOSIS.  Second edition.  One volume royal
  12mo., extra cloth, pp. 304. $1 25.
WALSHE'S PRACTICAL TREATISE ON THE DIS-
  EASES OF  THE HEART AND GREAT VESSELS.
  Third American, from  the third revised and mucn
  enlarged London edition.  In one handsome octavo
  volume of 420 pages, extra cloth.  $3 00.
' YONS (ROBERT D.), K. C. C.

 A TREATISE  ON  FEVER;  or, Selections from a Course of Lectures
    on Fever.  Being part of a Course of Theory and Practice of Medicine.  In one neat octavo
    volume, of 362 pages, extra cloth.   $2 25.
CLYMER ON FEVERS;  THEIR DIAGNOSIS, Pa-
  thology and Treatment.  In one  octavo volume
  of 600 pages, leather.  *1  75.
TODD'S CLINICAL LECTURES ON CERTAIN ACUTE
  Diseases. In one neat octavo volume, of 320 pages,
  extra cloth   4i2 50
LA ROCHE ON YELLOW FEVER, considered in its
  Historical, Pathological, Etiological, and Therapeu-
  tical Relatious. Including a Sketch of the Disease
  as it has occurred in Philadelphia from 1699 to 1S54,
  with an examination of the connections between it
  and the fevers known under the same name in other
  parts of temperate as well as in tropical regions.
  In  two large and  handsome octavo  volumes,  of
  nearly 1500 pages, extra cloth, *7 00.
LA ROCHE ON PNEUMONIA ; its Supposed Connec-
  tion,.Pathological, and Etiological, with Autumnal
  Fevers, including an Inquiry into the Existence and
  Morbid  Agency of Malaria. In one handsome oc-
  tavo volume, extra cloth, of 500 pages.  Price $3 00. 
Henry  C. Lea's Publications—(Venereal Disease*, etc.).        19
 T? UMSTEA D (FR EE31A N J.), 31. D.,      %
-*-*   Proff.iKor.of Venereal Dise.ases at the Col. of Phys  and Surg., New York, &c.

   THE  PATHOLOGY   AND  TREATMENT  OF  VENEREAL  DIS-
       EASES.   Including the results of recent investigations upon the subject.  A new and re-
       vised edition, with illustrations.  In one large and handsome  octavo volume of 640 pages,
       extra cloth, S5 00.   (Lately Issued.)
  During the short time which has elapsed since the appearance of this work, it has assumed the
position of a recognized authority on the subject wherever the language is spoken,  and its transla-
tion into Italian  shows that its reputation is not confined to our  own tongue.  The singular clear-
ness with which the modern doctrines of venereal  diseases are set forth renders  it admirably
adapted to the student, while the fulness of its practical  details and directions  as to treatment
makes it  of great value to the practitioner.  The few notices subjoined will show the very high
position universally accorded to it by the medical press of both hemispheres.
  Well known as  one  of the best authorities of the  which has long been felt in English medical literature.
present day on the subject.—British and For. Med.
Chirnrg. Review, April, 1866.
  A regular store-house of  special information.—
London Lancet, Feb. 24, 1866.
  A remarkably clear and full systematic treatise on
the whole subject.—Land. Med. Times and Gazette.
  The best, completest, fullest monograph on  this
subj ect in our language.—British American Journal.

  Indispensable in a medical library.—Pacific Med.
and Surg. Journal.
  We have no doubt that it will supersede in America
every other treatise on Venereal.—San. Francisco
Med. Press, Oct. 1S64.
  A perfect compilation  of all that is worth knowing
on venereal diseases in general.  It fills up a  gap
(1ULLERIER (A.),          and
^      Surgeon to tlie Hdpital du Midi.
—Brit, and Foreign Med.-Chirurg Review, Jan., '65.
  We have not met with any which so highly merits
 our approval and praise as the second edition of Dr.
 Bumstead's work.—Glasgow Med. Journal, Oct. 1864.
  We know of no treatise in  any language which is
 its  equal in point of completeness and practical sim-
 plicity.—Boston Medical and  Surgical Journal,
 Jan. 30, 1S64.
  The book  is one which every practitioner should
 have in his possession, and, we may further say, the
 only book upon the subject which he should acknow-
 ledge as competent authority.—Buffalo Medical and
 Surgical Journal, July, 1S64.
  The best work with which we are acquainted, and
 the most convenient hand-book for the busy practi-
 tioner —Cincinnati Lancet, July, 1S64.
                                               T>UMSTEAD  (FREEMAN J),
                                              -*-*    Professor of Venereal Diseases in the College of
                                                         Physicians and Surgeons, N. Y.

AN   ATLAS  OF  VENEREAL  DISEASES.    Translated  and  Edited   by
    Freeman J. Bumstead.   To be issued  in five parts, at Three Dollars each, making a large
    imperial 4to. volume  of over 300 pages, double-columns, with 26 plates, containing about
    150 figures, beautifully colored, many of them the size of life.
  Parts I , II ,  III., and IV. are now ready.
  Part V. will be issued in October, 1868.
  As the successor of Ricord in the great Venereal Hospital of Paris, M.  Cullerier  has enjoyed
special advantages for the present undertaking, and his series of illustrations, though only recently
finished, is already recognized as the most complete and comprehensive that has yet appeared on
this subject.  In reproducing these plates every care has been had to preserve their artistic finish
and accuracy, and they are confidently presented as equal to anything that has yet been produced
in this country.  The reputation of Dr. Bumstead as a writer and syphilographer is too well known
to require other guarantee for the fidelity of the translation or the value of the additions introduced.
  Anticipating a very large sale for this work, it is offered  at the very low price of Three Dol-
lars a Part, thus placing it within the reach of all who are interested in this department of prac-
tice.  Gentlemen desiring early impressions of the plates would do well to  order it without delay.
  ##* A specimen of the plates and text sent free by mail, on receipt of 25 cents.
  This is a very handsome edition  in English of a
well-known and highly valued French publication.
That Dr. Bumstead, the author of by far the best and
most  popular treatise on venereal  diseases in the
English language, should think it proper to translate
and edit this one, speaks more highly in its favor than
anything that can be said.   It is a judgment ex ca-
thedra.  The translation is an excellent one.   The
plates in the first Part represent blennorrhagia and
its complications, swelled testicle, and gonorrhceal
ophthalmia. They are  admirably and artistically^ex-
ecuted.  Indeed they are superior to any illustrations
of the kind hitherto executed in this country   The
notes  added by Dr. Bumstead enhance the value of
the work.   The  whole  getting-up of  this publication
is of rare excellence, and most creditable to all con-
cerned.—^4m. Journ. of Med. Sciences, April, 1868.
  A magnificent work, in the best style of artistic
illustration.—Chicago  Med. Journal, April, 1S6S.
  We  desire now especially to call  the attention of
the profession to the appearauce of this magnificent
work   The  plates in chromo-lithography  are  most
admirably executed, and compare very favorably in
distinctness and brilliancy with the  originals, as we
know from personal examination.  The appearance of
the work in parts places it within the reach of all, and
when completed it will be a most valuable accession
to our literature.— N.  Y. Med. Journal, April, 1868.
  This is probably the handsomest work of its class
ever published in this country.— Boston Med.  and
Surg. Journal, April 15, 1868.
  The two parts thus published are illustrated by
plates, than which none superior have been issued
from the press; in fact, in this  country, no more
magnificent work  has ever been published.  Infinite
credit is due the publisher  and translator that  they
should have placed before  the profession, in such a
style, so valuable a production.—St. Louis Med. Re-
porter,  May, 1S6S.
  This is one  of  the most elegantly published and
valuable works that have been reprinted and edited
in this country, relating to the loathsome, though im-
portant, class of venereal diseases.  The author and
editor are alike men of experience and eminent abi-
lity aud  we  freely commend the product  of their
labors to the general patronage of the profession.—
Chicago Med. Examiner, May, 1S68.
L
ALLEMAND  AND  WILSON.
A  PR VCTICAL  TREATISE  ON  THE  CAUSES,  SYMPTOMS
   AND TREATMENT OF SPERMATORRHOEA.  By M. Lallemand.  Translated, and
   edited bv Henry J. McDocgall.   Fifth American edition.   To which .s added-----ON
   |kE^e^ OF THE VESICULA SEMINALES. and their associated organs.  With
   s, .',-iai reference to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane.
   liv Mabhis Wilson, M.D.  In one neat octavo volame, of about 400 pp., extra cloth, $2 * o. 
20         Henry  C. Lea's Publications—(Diseases of the Skin).
  JfyriLSON (ERASMUS), F.R,S.,

     ON DISEASES OF THE  SKIN.   With Illustrations on wood.   Sev-
        enth American, from the sixth and enlarged English edition.   In one large octavo volume
        of over 800 pages, $5.   (Now Ready.)

   A  SERIES  OF  PLATES   ILLUSTRATING  "WILSON   ON  DIS-
       EASES OF THE SKIN;" consisting of twenty beautifully executed plates,  of which thir-
       teen are exquisitely colored,  presenting the Normal Anatomy and Pathology of the Skin,
       and embracing accurate representations of about one hundred varieties of disease, most of
       them the size of nature.   Price, in extra cloth, $5 50.
  Also, the Text and Plates, bound in one handsome volume.   Extra cloth, $10.
                       From the Preface to the Sixth English Edition.
  The present edition has been carefully revised, in many parts rewritten, and our attention has
been  specially directed  to the  practical  application and  improvements of treatment.  And, in
conclusion, we venture to remark that if an acute and friendly critic should discover any differ-
ence between our present opinions and those announced in former editions, we  have only to ob-
serve that science and knowledge are progressive, and  that we have done our best to move onward
with the times.
  The  industry and care with which the author has revised the present edition are shown by the
fact that the volume has been enlarged by more than a hundred pages.  In its present improved
form it will therefore doubtless retain the position which it has acquired as a standard and classical
authority, while at the same time it has additional claims on the attention of the profession as
the latest and most complete work on the subject in the English language.
  Such a work as the one before us is a most capital
and acceptable help.  Mr. Wilson has long been held
as high authority in this department of medicine, and
his book on diseases of the skin has long been  re-
  We can safely recommend it to the profession as
the best work on the subject now in existence in
the English language.—Medical Times and Gazette.

  Mr. Wilson's volume is an excellent digest of the
actual amount of knowledge of cutaneous diseases;
it includes almost every fact or opinion of importauce
connected with the  anatomy and pathology  of the
skin.—British and Foreign Medical Review.
  These plates are very accurate, and are executed
with an elegance aud taste which are highly creditable
to the artistic skill of the American artist who executed
them.—St. Louis Med. Journal.
  The drawings are very perfect, and the finish and
coloring artistic and  correct; the volume is an indis-
pensable companion  to the book  it illustrates and
completes.—Charleston Medical Journal.
garded as one of the best text-books extant on the
subject. The present edition is carefully prepared,
and brought up in its revision to the present time In
this edition we have also included the beautiful series
of plates illustrative of the text, and in the last edi-
tion published separately. There are twenty of these
plates, nearly all of them colored to nature, and ex-
hibiting with great fidelity the  various groups of
diseases treated  of in the body of the work.—Cin-
cinnati Lancet,  June, 1863.
  No one treating skin  diseases should be without
a  copy of this  standard work.— Canada Lancet.
August, 1863.
Df THE SAME AUTHOR.                 —

   THE  STUDENT'S BOOK  OF  CUTANEOUS MEDICINE  and Dis-
       eases of the skin.  In one  very handsome royal 12mo. volume.  $3 50.  (Lately Issued.)
T£Y THE SAME AUTHOR.                ____

   HEALTHY SKIN;   a Popular  Treatise on  the  Skin  and  Hair, their
       Preservation and Management.  One vol. 12mo., pp. 291, with illustrations, cloth.  $1 00.

J\fELIGAN (J. MOORE),  M.D.,M.R.I.A.,

    A  PRACTICAL  TREATISE   ON  DISEASES   OF   THE  SKIN.
       Fifth American, from the second  and enlarged Dublin  edition by T. W. Belcher, M. D.
       In one neat royal 12mo. volume of 462 pages, extra cloth.  $2 25.  (Just Isstied.)
  Of the remainder of the work we have nothing be-
yond unqualified commendation to offer.  It is so far
the most complete one of its  size that has appeared,
and for the student there can be none winch can com-
pare with it in practical value. All the late disco-
veries in Dermatology have been duly noticed, and
their value justly estimated ; in a word, the work is
                                               This instructive little volume appears once more.
                                              Since the death of its distinguished author, the study
                                              of skin diseases has been considerably advanced, and
                                              the results of these investigations have been added
                                              by the present editor to the original work of Dr. Neli-
                                              gan. This, however,  has not so far increased its bulk
                                           —  as to destroy its reputation as the most convenient
luliy up to the times, and is thoroughly stocked with ; manual of diseases of the skin that can be procured
most valuable information.—New York Med. Record,  hy the student.—Chicago Med. Journal, Dec. 1S66.
Jan. 15, 1867.
B
Y THE  SAME AUTHOR.
ATLAS  OF  CUTANEOUS   DISEASES.   In  one  beautiful  quarto
   volume,  with  exquisitely colored plates, Ac, presenting about  one hundred varieties  of
   disease.  Extra cloth, $5 50.
  The diagnosis of eruptive disease, however, under
all circumstances, is very difficult.  Nevertheless,
Dr. Neligan has certainly, "as far as possible," given
a faithful and accurate representation of this class of
diseases, and there can be no doubt that these plates
will be of great use to the student and practitioner in
drawing a diagnosis as to the class, order, and species
to which  the particular case may belong.  While
looking over the "Atlas" we have been induced to
examine also the "Practical Treatise," and we  are
inclined to consider it a very superior work, com-
bining accurate verbal description with sound views
of the pathology and  treatment of eruptive diseases.
—Glasgow Med. Journal.
  A compend which will very much aid the practi-
tioner in this difficult branch of diagnosis.  Taken
with the beautiful plates of the Atlas, which are re-
markable for their accuracy and  beauty of coloring,
it constitutes a very valuable  addition to the library
of a practical man.—Buffalo Med. Journal.
 JJILLIER  (THOMAS),  M.D.,
■*■-*-      Physician to the Skin Department of University College Hospital, &c.
   HAND-BOOK  OF SKIN  DISEASES, for Students and Practitioners.
      In one neat royal 12mo. volume of about 300 pages, with two plates;  extra cloth, $2 26.
      (Just Issued.) 
Henry  C. Lea's Publications—(Diseases of Children).
21
(JONDIE (D. FRANCIS), 31. D.
   A PRACTICAL TREATISE ON THE  DISEASES  OF  CHILDREN.
      Sixth edition, revised and augmented.   In one large octavo volume of nearly 800 closely-
      printed pages, extra cloth, §5  25 ;, leather, $6  25.   (Now Ready.)
                                 From t/ie Author's Preface.
  In preparing for the press this sixth edition of his treatise on the Diseases of Children, the great
aim of the author has been to  present a  complete and faithful exposition of the pathology and
therapeutics of the maladies incident to  the earlier stages of existence.  The entire work has
undergone a careful and thorough revision ;  while in the different sections has been incorporated
every important  observation in reference to the diseases of which they treat, that has been re-
corded since the  appearance of the last edition.  Every effort has been made, and every available
source of information sought after, to render the treatise a reliable and useful guide to the actual
state of medical knowledge in reference to all those diseases which either exclusively or most usu-
ally occur between birth and puberty—diseases which  form, in some degree, a class apart from
those of the adult—and demand for  their cure a particular plan of treatment.
  Dr. Condie has  been one of those who have per-; days by wandering through its pages, and at the same
formed such a service satisfactorily, and, as a result,
his popular, comprehensive, and practical work has
received that  high compliment of approval on the
part of his brethren, which several editions incontes-
tably  set forth. The present edition,  which  is the
sixth, is fully up to the times in the discussion of all
those points in the pathology and treatment of infan-
ti)<'. diseases which have been brought forward by the
German and French teachers.   As a whole, however,
the work is the best American one that we have, and
in its special adaptation to American practitioners it
certainly has no equal.—New York Med. Record,
March 2, 1868.
  No other treatise on this subject is better adapted
to the American physician.  Dr. Condie has long stood
before his  countrymen as one peculiarly pre-eminent
in this department  of medicine His work has been
bo long a standard for practitioners and medical stu-
dents that we do no more now than refer to the fact
that it has reached its sixth  edition.  We are glad
once more to  refresh the impressions of our  earlier
time to be able to recommend it to the youngest mem-
bers of the profession, as well as to those who have
the older editions on their shelves.—St. Louis Med.
Reporter, Feb. 15, 1868.

  The work of Dr. Condie  is unquestionably a very
able one. It is practical in its character, as its title
imports; but the practical precepts recommended in
it are based, as all practice 6hould be, upon a familiar
knowledge of disease.  The opportunities of Dr. Con-
die for the practical study of the diseases of children
have been great, and his work is a proof that they have
not been thrown away.  He has read much, but ob-
served more ; and we think that we may safely say
that the American  student cannot find, in his own
language, a better book  upon the subject of which it
treats.—Am. Journal Medical Sciences.

  We pronounced the first edition to he 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.
 1XTEST (CHARLES), M.D.,
          Physician to the Hospital for Sick Children, &c.

   LECTURES  ON  THE   DISEASES  OF  INFANCY  AND  CHILD-
      HOOD.' Fourth American from the fifth revised and enlarged English edition.   In one
      large and handsome  octavo  volume of  656 closely-printed pages.   Extra cloth,  $4 50;
      leather, $5 50.   (Just issued.)
  This work may now fairly claim the position of a standard authority and medical classic.  Five
editions  in  England, four in America, four in Germany, and translations in French, Danish,
Dutch and Russian, show how fully it has met the wants of the profession by the soundness of its
views and the clearness with which they are presented.   Few practitioners, indeed, have had the
opportunities  of observation and experience enjoyed by the Author.  In his Preface he remarks,
"The present edition embodies the results of 1200 recorded cases  and of nearly 400 post-mortem
examinations, collected from between  30,000 and 40,000 children, who, during the past twenty-
six years, have come under my care, either in public or in private practice." The universal favor
with which the work has been received shows that the author has made good use of these unusua]
advantages
  Of all the English writers on the diseases of chil-
dren, there is no one so entirely satisfactory to us as
Dr. West.  For years we have held his opinion as
judicial, and have regarded him as one of the highest
living authorities in the diflicult department of medi-
cal science in which he is most widely known.  His
writings are characterized by a sound, practical com-
mon sense, at the same time that they bear the marks
of the most laborious study and  investigation.  We
commend it to all as a most reliable adviser on many
occasions when many treatises on the same subjects
will utterly fail to help us.  It is supplied with a very
copious general index, and a special index to the for-
mula scattered throughout the work.— Boston Med.
and Surg. Journal, April 26, 1866.
  Dr West's volume is, in our opinion, incomparably
the best authority upon the  maladies of.children
that the practitioner can consult.  Withal, too—a
minor matter, truly, but still not one that should be
neglected—Dr.  West's composition possesses a pecu-
liar charm, beauty and clearness of expression, thus
affording the reader much pleasure, even independeu
of that which arises from the acquisition of valuable
truths.—Cincinnati Jour, of Medicine, March, 1S6H.
  We have long regarded it as the most scientific and
practical book on diseases of children which has yet
appeared in this country.—Buffalo Medical Journal.
  Dr. West's book is the best  that has ever been
written  in the English language on the diseases  of
infancy  and «hildhood.—Columbus Review of Med.
and Surgery.
  There  is no part of the volume, no subject on which
it treats  which does not exhibit the keen perception,
the  clear judgment, and the sound reasoning of the
author  It  will be found a most useful guide to the
voung'practitioner, directing him in his management
of children's diseases  in the clearest possible manner,
and enlightening him  on many a dubious pathological
point, while the older one will find in it many a sug-
gestion and practical  hint of great value.— Brit. Am.
Med. Journal.
D
E ^iZ^^S ^sUy of Pennsylvania, to.

   TRFVTISE  ON   THE  PHYSICAL  AND  MEDICAL  TREAT-
  MENT OF CHILDREN.  Eleventh edition, with the author's last improvements and cor-
  rections.   In one octavo volume of 548 pages.  $2 80. 
22         Henry C. Lea's Publications—(Diseases of Women).
 rTHOMAS  (T. GAILLARD),3I.D.,
 -*-      Professor of Obstetrics, to in the College of Physicians and Surgeons, N. Y., to.

   A  PRACTICAL  TREATISE ON  THE DISEASES OF WOMEN.   In
       one large and handsome octavo volume of over 600 pages, with 219 illustrations, extra
       cloth, $5; leather, $6.  (Now Ready.)
                                      From the Preface.
   " This work was undertaken with the conviction that a  treatise, such as that which the Author
has aimed to prepare, was needed as a text-book for the American  student, and  as a book of
reference for the busy practitioner,
   " No department of medicine has made greater advances within the last few years than Gyne-
cology ;  yet the record of its progresses, for the most part,  to be found only in special monographs,
journals, transactions of societies, &c, and is thus  inaccessible to the mass of the  profession in
this country.  It has,  therefore, seemed to the author  that a  volume  which should, within  a
limited space,  present the latest aspect of the subject in  a systematic form, could scarcely fail to
prove  useful, while his  position for the last thirteen  years as  a  teacher in  this department has
encouraged him, in the hope that his familiarity with the needs of the student may, to some extent,
have fitted him to undertake the task."
  The best text-book for students, and a perfect vdde
 mecum to the gynecologist.—N. Y. Journal of Obstet-
 rics, May, 1868.
  We have recently been almost flooded by works
 from American sources on the allied subjects of ob-
 stetrics and gynecology. Nor has quantity alone been
 the most noticeable feature connected with them, for
 their quality has invariably been of the highest.  Dr,
 Thomas's work is no exception to this rule; it is pre-
 eminently sound and practical, evincing much re-
 search and great clinical experience.  It is  further
 illustrated by upwards of two hundred engravings,
 some of them of great value.—London Med. Times
 and Gaz., April 25, 1868!
  The book of Prof. Thomas is well  calculated to do
 away with this latter objection,  and to  accomplish
 more towards the establishment of a rational system
 of uterine therapeutics than  any other work of its
 size in  any language.  We have rarely read any trea-
 tise upon a medical topic that  has given us better
 satisfaction, or impressed us with the fitness of an au-
 thor for the proper performance of a most responsible
'task.  It is perhaps unnecessary for us to commend the
 work  most heartily to every one who  is or  may be
 liable to treat uterine diseases.—N.  York Medical Re-
 cord, April 15, 1868.
  A work which will certainly add  to the reputation
 ofits author, and come into general use in this coun-
 try as  a  text-book.  The style is exceedingly clear
 and concise, and the views expressed eminently prac-
 tical and scientific.—Quarterly  Journ. of Psychol.
 Medicine, April, 1868.
  The work is concise and practical, avoiding the dis-
 cussion of unsettled questions, but giving a judicious
 resume  of known  facts.—Chicago Med. Journal,
 April, 1868.
  We are led to believe that it is the best work that
 has yet appeared on the diseases of women.   There
  tabout it a precision and accuracy, a fulness and
BROWN  ON  SOME DISEASES OF WOMEN  AD-
  MITTING OF SURGICAL TREATMENT.   With
  handsome illustrations.  One volume 8vo., extra
  cloth, pp. 276. $1 60.
ASHWELL'S PRACTICAL TREATISE ON THE DIS-
  EASES  PECULIAR TO WOMEN.  Illustrated by
  Cases derived from Hospital and Private Practice.
  Third American, from  the Third and revised  Lon-
  don edition.  In one octavo volume, extra cloth,
  of 528 pages.  $3 50.
RIGBY ON THE CONSTITUTIONAL TREATMENT
  OF FEMALE DISEASES.  In one neat royal 12mo."
  volume, extra cloth, of about 250 pages.  SSI 00.
DEWEES'S TREATISE ON THE DISEASES  OF FE-
completeness, a clearness and simplicity, to be found
in no other  book on the  same subject within our
knowledge;  its  views on uterine pathology are, to
our mind, more  consonant with reason and common
sense than any  other we have seen.  Enjoying fine
opportunities in  an extensive field of observation. Dr.
Thomas, as an author, has fully sustained his high
reputation as a  teacher. . We  have  no hesitation in
strongly recommending it to the profession as the best
exposition yet published of the subjects of which U
treats.—Atlanta Med. and Surg. Journal, April, '68.
  In no work with which we are acquainted, is there
to be found so full and complete an exhibit of the im-
proved means of diagnosis of the obscure subjects of
gynecology,  or  of their  more enlightened therapy.
Did our space permit, we should be glad to go into an
extended review of the  work before us, giving not
merely an outline of the subjects  treated of, but full
extracts from the text itself.   As it is, we can only
recommend our  readers  to buy it, feeling convinced
they will be  amply repaid for the-outlay.—Leaven-
worth Medical Herald, May, 1868.

  Indeed, we' do not know a better study in briefer
space, not for medical students merely, but for prac-
titioners, who may really wish to have light upon an
obscure pathway, to be  trained in the thorough in-
vestigation of diseases  peculiar to  women,  than is
herein to be  found.—Western  Journal of Medicine,
May, 1868.

  It is a masterly risumi of what is known, by an
experienced  and honest observer.  The  Profession
is indebted to Prof. Thomas for thus tabulating tfhe
much that has been accepted as valuable and reliable
in gynecology, but this is not  by any meaus  all the
merit of the  work ; we have his  ample experience,
given in his  opinions on pathology and treatment,
which carry conviction by the  confidence we feel that
they are the candid opinions of an honest and compe-
tent observer.—Humboldt Med. Archives, April, 1868.
  MALES.   With illustrations.  Eleventh Edition,
  with the Author's last improvements and correc-
  tions.  In  one* octavo volume of 536 pages, with
  plates, extra cloth, $3 00.
COLOMBAT DE L'ISERE  ON  THE  DISEASES OF
  FEMALES.  Translated by C. D. Mkigs, M. D.  Se-
  cond edition.  In one vol.  8vo, extra cloth, with
  numerous wood-cuts. pp. 720.  $'! 75.

BENNETT'S  PRACTICAL  TREATISE ON INFLAM-
  MATION' OF THE UTERUS, ITS  CERVIX  AND
  APPENDAGES, and on its connection with Uterine
  Disease.  Sixth American, from the fourth and re-
  vised  English edition.   1 vol. 8vo., of about 500
  pages, extra cloth.  $3 75.
flHURCHILL  (FLEETWOOD), 31. D., 31. R. I. A.

   ON  THE DISEASES  OF  WOMEN;   including  those  of  Pregnancy
      and Childbed.  A new American edition, revised by the Author.  With Notes and Additions,
      by D. Francis Condie, M. D., author of " A Practical Treatise  on the Diseases of Chil-
      dren."  With numerous illustrations.  In one large and handsome octavo volume of 768
      pages, extra cloth, $4  00; leather, $5  00.
JDY THE SAME AUTHOR.                  ----

  ESSAYS  ON  THE  PUERPERAL  FEYER,  AND  OTHER  DIS-
      EASES PECULIAR  TO WOMEN.  Selected from the writings-of British Authors previ-
      ous to the close  of the Eighteenth  Century.  In one neat octavo volume of about 450
      pages, extra cloth.  $2 50. 
Henry  C. Lea's Publications—(Diseases of Women).
23
jyEST (CHARLES), 31.D.
    LECTURES  ON THE  DISEASES  OF  WOMEN.   Third American,
      from the Third London edition.   In one neat octavo volume of about 550 pages, extra
      cloth.  $3  75; leather, $4 75.  (Now Ready.)
  The reputation which this volume  has  acquired  as  a standard book of reference in its depart-
ment, renders it only necessary to say that the present edition has received a careful revision at
the hands of the author, resulting in a considerable increase of size.  A few notices of previous
editions are subjoined.
  The manner of the author is excellent, his descrip-
tions graphic and perspicuous, and his treatment up
to the level of the time—clear, precise, definite, and
marked  by strong common  sense. — Chicago  Med.
Journal, Dec. 1861.
  We cannot too highly recommend this, the second
edition of Dr. West's excellent lectures on the dis-
eases of  females.  We know of no other book on this
subject from which we have derived as much pleasure
and instruction.  Every page gives evidence of the
honest, earnest, and diligent searcher after truth. He
is not the mere compiler of other men's ideas, but his
lectures  are the result often years' patient investiga-
tion in one of the widest fields for women's diseases—
St. Bartholomew's Hospital.  As a teacher, Dr.  West
is simple and earnest in his language, clear and com-
prehensive in his perceptions,  and logical in his de-
ductions.—Cincinnati Lancet,  Jan. 1862.
  We have thus embodied, in this series of lectures,
one of the most valuable treatises on the diseases of
the female sexual system unconnected with gestation,
in our language, aad one which cannot fail, from the
lucid manner in which the various subjects  have
been treated, and the careful discrimination used in
dealing only with facts, to recommend the volume to
the careful study of every practitioner, as affording
his safest  guides to practice within our knowledge.
We have seldom perused a work of a more thoroughly
practical character than the one before us. Every
page teems with the most truthful and accurate  infor-
mation,  and we  certainly do not know of any  other
work from which the physician, in  active  practice,
can more readily obtain advice of the soundest cha-
racter upon the peculiar diseases which have been
made the  subject of elucidation.—British Am. Med.
Journal.
  We retnrn the author our grateful thanks for the
vast amount of instruction he has afforded us.  His
valuable treatise needs no eulogy on our part.  His
graphic diction and truthful pictures of disease all
speak for themselves.—Medico-Chirurg. Review.
  Most justly esteemed a standard work.....It
bears evidence of having been carefully revised, and
is well worthy of the fame it has already obtained.
—Dub. Med. Guar. Jour.
  As a writer, Dr. West stands, in our opinion, se-
cond only to Watson,  the "Macaulay of  Medicine;"
he possesses that happy faculty of ciothing instruc-
tion in easy garments; combining  pleasure with
profit, he leads his pupils, in spite of the ancient pro-
verb, along a royal road to learning!  His work is one
which will not satisfy the extreme on either side, but
it is one that will please the great majority who are
seeking truth, and one that will convince the student
that he has committed himself to a candid, safe, and
valuable guide.—N. A. Med.-Chirurg Review.
  We must now conclude this hastily written sketch
with the confident assurance to our readers that the
work will well repay perusal.  The conscientious,
painstaking, practical physician is apparent on every
page.—JV. Y. Journal of Medicine.
  We have to say of it, briefly and decidedly, that it
is the best work on the subject in any language, and
that it stamps Dr. West as the farils, princeps of
British obstetric authors.—Edinburgh Mud. Journal.
  We gladly recommend his lectures as in the highest
degree instructive to all who are interested in ob-
stetric practice.—London. Lancet.

  We know  of no treatise  of the kind so complete,
and yet so compact.—Chicago Med. Journal.
T>Y  THE SAME AUTHOR.                 ----
  AN ENQUIRY  INTO  THE PATHOLOGICAL  IMPORTANCE  OF
      ULCERATION OF  THE OS UTERI.  In one neat octavo volume, extra cloth.  $1  25.
M
B
  EIGS (CHARLES D.), M. D.,
       Late Professor of Obstetrics, to. in Jefferson Medical College, Philadelphia.
WOMAN:   HER  DISEASES AND  THEIR  REMEDIES.   A Series
    of Lectures to his Class.  Fourth  and Improved  edition.  In one  large and beautifully
    printed octavo volume of over 700 pages, extra cloth, $5 00 ; leather, $6  00.

Y THE SAME AUTHOR.
ON  THE  NATURE,  SIGNS,  AND  TREATMENT  OF  CHILDBED
   FEVER.  In a Series of Letters addressed to the Students of his Class.  In one handsome
   octavo volume of 365 pages, extra cloth.   $2 00.
 TTODGE  (HUGH L.),  M.D.              ',,„,-
JUL     Emeritus Professor of Obstetrics, to., in the University of Pennsylvania.
    ON  DISEASES PECULIAR TO WOMEN;  including Displacements
       of the Uterus.  With  original illustrations.   Second  edition, revised  and enlarged   In
       one beauUfully printed octavo volume of 531 pages, extra cloth.  $4 50.   {Now Ready.)
  rr^eed, although no part of the volume is not emi-  the, day-one ^-e^accoucheur ami £=
nently deserving of perusal and  study we think that  ™°»£  "^ lt\TivL its perusal with new ideas,
the nine chapters devoted to  this subject are espe-  ^*^e^1,lfn^t h m into Tmore rational practice
ciallv so, and we know of no more:valua.ble™^  ' £ .-Ird to many a suffering female who may have
^X^^T^^ ^U=  »ft**J> his hauds.-^ Am^em
bV this partIf the work. We cannot but regard it as  Journal, Feb. 1861.
one of the most original and most practical works of I


 CilUrSON (SIR JAMES Y.), M.D.

   rTTXICVL  LECTURES  ON  THE  DISEASES  OF  WOMEN.  With
       numerous illustrations. Iu one octavo volume of over 500 pages.  Second edition, preparing. 
24               Henry C. Lea's Publications—(3Iidwifery).
JJODGE  (HUGH L.), M.D.,
         Emeritus Professor of Midwifery, to. in the University of Pennsylvania, to.

   THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.   Illus-
      trated with large lithographic  plates containing one hundred and fifty-nine figures from
      original photographs, and with numerous wood-cuts.   In one large and beautifully printed
      quarto volume of 550 double-columned pages, strongly bound in extra cloth, $14.  (Lately
      publislted.)
  The work of Dr. Hodge is something more than a
simple presentation of his particular views in the de-
partment of Obstetrics; it is something more than an
ordinary treatise on midwifery; it is, in fact, a cyclo-
paedia of midwifery.  He has aimed to embody in a
single volume the whole science and art of Obstetrics.
An elaborate text is combined with accurate and va-
ried pictorial illustrations, so that no fact or principle
is left unstated or unexplained.—Am. Med.  Times,
Sept. 3, 1864.
  We should like to analyze the remainder of this
excellent work, but already has this review extended
beyond our limited space.  We cannot conclude this
notice without referring to the excellent finish of the
work.  In typography  it is not to be excelled; the
paper is superior to what is usually afforded by our
American cousins, quite equal to the best of English
books.  The engravings  and lithographs are  most
beautifully executed.  The  work recommends itself
for its originality, and is in every  way a most valu-
able addition to those on the subject of obstetrics.—
Canada Med. Journal, Oct. 1864.
  It is very large, profusely and elegantly illustrated,
and is fitted to take its place near the works of great
obstetricians.  Of the American works on the subject
it is decidedly the best.—Edinb. Med. Jour., Dec. '64.

  **#  Specimens of the  plates and  letter-press will  be forwarded to any address, free by mail,
on receipt of six cents in  postage stamps.

 /J1ANNER  (THOMAS H),
  We have examined Professor Hodge's work with
great  satisfaction; every topic is elaborated  most
fully. The views of the author are comprehensive,
and concisely stated.   The rules of practice are judi-
cious, and will enable the practitioner to meet every
emergency of obstetric complication with confidence.
—Chicago Med. Journal, Aug. 1864.

  More time than we have had at our disposal  since
we received the great work of Dr. Hodge is necessary
to do it justice.   It is undoubtedly by far the  most
original, complete, and carefully composed treatise
on the principles and practice of Obstetrics which has
ever been issued  from the American press.—Paeifie
Med. and Surg. Journal, July, 1S64.

  We have read  Dr. Hodge's  book with great  plev
sure, and have much  satisfaction in  expressing our
commendation of it as a whole.  It is certainly highly
instructive, and in the main, we believe, correct. The
great attention which the author has devoted to the
mechanism of parturition, taken along with the con-
clusions at which he  has arrived, point, we think,
conclusively to the fact that, in Britain at least, the
doctrines of Naegele have been too blindly received.
—Glasgow Med. Journal, Oct. 1864.
M.D.
ON THE  SIGNS AND- DISEASES  OF  PREGNANCY.   First  American
   from the Second and Enlarged English Edition.  With four colored plates and illustrations
   on wood.   In one handsome octavo volume of about 500 pages, extra cloth, $4  25.   (Now
   Ready.)
  The very thorough revision the work has undergone
has added greatly to its practical value, and increased
materially Its efficiency as a guide to the student and
to the young practitioner.—Am. Journ. Med. Sci.,
April, 1868.
  With the immense variety of subjects treated  of
and the ground which they are made to cover, the im-
possibility of giving an extended review of this truly
remarkable work must be apparent.  We have not a
single fault to find with it, and  most  heartily com-
mend it to the careful study of every physician who
would not only  always be sure of his diagnosis  of
pregnancy, but always  ready to  treat all the nume-
rous  ailments that are, unfortunately for the civilized
women of to-day, so commonly associated with the
function.— N. Y. Med. Record,  March 16, 1868.

  We have much pleasure in calling the attention of
our readers to the volume produced by Dr.  Tanner,
the second edition of a work that was, in its  original
state even, acceptable to the profession.  We recom-
mend obstetrical students, young and old, to have
this volume in their collections.  It contains not only
a fair statement of the signs, symptoms, and diseases
of pregnancy, but comprises in addition much inter-
esting relative matter that is not to be found in any
other work that we can name.—Edinburgh Med.
Journal, Jan. 1868.
  In its treatment of  the signs  and  diseases of preg-
nancy it is the most complete book we  know of,
abounding on every page with matter valuable to the
general practitioner.—Cincinnati  Med. Repertory,
March, 186S.
  This is a most excellent work, and should he on the
table or in the library of every practitioner.—Hum-
boldt Med. Archives,  Feb. 1868.
  A valuable compendium, enriched  by his own la-
bors, of all that is known on the signs and diseases of
pregnancy.—St. Louis Med. Reporter, Feb. 15, 186S.
MONTGOMERY (W. F.), M.D.,
        Professor of Midwifery in the King's and Queen's College of Physicians in Ireland.

  AN  EXPOSITION  OF  THE SIGNS  AND SYMPTOMS OF PREG-
     NANCY.  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 of nearly 600 pages, extra cloth.   $3 75.
MILLER (HENRY), M.D.,
       Professor of Obstetrics and Diseases of Women and Children in the University of Louisville.

  PRINCIPLES  AND  PRACTICE  OF OBSTETRICS, &c;  including
     the Treatment of Chronic Inflammation of the Cervix and Body of the Uterus considered
     as a frequent cause of Abortion.  With about one hundred illustrations  on wood.  In one
     very handsome octavo volume of over 600 pages, extra oloth.  $3-75.
RIGBY'S SYSTEM OF MIDWIFERY.  With Notes
  and Additional Illustrations.   Second American
  edition.  One volume octavo, extra cloth, 422 pages.
  $2 50.
DEWEES'S  COMPREHENSIVE  SYSTEM OF  MID-
  WIFERY.  Twelfth edition, with the author's last
  improvements and corrections.  In one octavo vol-
  ume, extra cloth, of 600 pages. $3 50. 
Hexry C. Lea's Publications—(3Iidwifery).              25
IfEIGS (CHARLES D.),  31. D.,
        Lately Professor of Obstetrics, to., in the Jefferson Medical College, Philadelphia
  OBSTETRICS:  THE  SCIENCE  AND  THE  ART.    Fifth  edition,
     revised.  With one  hundred and thirty  illustrations.   In one beautifully printed  octavo
     volume of 760 large  pages.  Extra cloth,  $5 50; leather, $6  50.   (Just Issued.)
 The original edition is already so extensively and
favorably known to the profession  that no recom-
mendation is necessary; it is  sufficient to say, the
present edition  is very much extended, improved,
and perfected.  Whilst the great practical talents and
unlimited experience of the author render it a most
valuable acquisition to the practitioner, it is so con-
densed as to constitute a most eligible and excellent
text-book for the student.— Soutliern Med. and Surg.
Journal, July, 1867.
  It is to the student that our author has more par-
ticularly addressed himself; but to  the practitioner
we believe it would be equally serviceable as a book
of reference   No work that we have met  with  so
thoroughly details everything  that falls to the lot of
the accoucheur to perform.  Every detail, no matter
how minute  or  how trivial, has found a  place.—
Canada Medical Journal, July, 1867.
  This very excellent work on the science and  art of
obstetrics should be in the hands of every student and
practitioner. The rapidity with which the very large
editions have been exhausted is the best test of its
true merit  Besides,  it is the production of an Ame-
rican who has probably  had more experience in this
branch than any other living practitioner of the coun-
try.—St. Louis Med.  and Surg. Journal, Sept. ls>67.
  He has also carefully endeavored to be minute and
clear in his details, with as little reiteration as possi-
ble, and beautifully combines the relations of science
to art, as far as the different classifications will admit.
—Detroit Review of Med  and Pharm., Aug. 1S67.
  We now take leave of  Dr. Meigs.  There are many
other and interesting points in his book on which we
would fain dwell, but are constrained to bring our ob-
servations to a close.   We again heartily express our
approbation of the labors of Dr Meigs, extending oVer
many years, and culminating in the work before us,
full of practical hints for the inexperienced, and even
for those whose  experience has been considerable.—
Glasgow Medical Journal, Sept. 1S67.
UAMSBOTHAM (FRANCIS  H), M.D.
THE   PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC   MEDI-
    CINE 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.,
    Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia.   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 200 large and beautiful figures.  $7 00.
                                               To the physician's library it is Indispensable, while
                                             to the student, as a text-book, from which to extract
                                             the material for laying the foundation of an education
                                             on obstetrical science, it has no superior.—Ohio Med.
                                             and Surg. Journal.
                                               When we call to  mind the toil we underwent in
  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.
acquiring a knowledge of this subject, we cannot but
envy the  student of the present day the aid which
this work will afford him.—Am. Jour,  of the Med.
Sciences.
 riHURCHILL  (FLEETWOOD),  M.D., M.R.I.A.


   ON  THE  THEORY AND  PRACTICE  OF MIDWIFERY.   A new
      American from the fourth revised and enlarged London edition.   With notes and additions
      by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Chil-
      dren," <fcc.   With one hundred and ninety-four illustrations.  In one very handsome octavo
      volume of nearly 700 large pages.  Extra cloth, $4 00; leather, $5 00.
  In adapting this standard favorite to the wants of the profession in the United States, the editor
ha6 endeavored to insert everything that his experience has shown him would be desirable for the
American student, including  a large number of illustrations.   With  the sanction of the author,
he has added, in'the form of an appendix, some  chapters from a little  "Manual for Midwives and
Nurses " recently issued by Dr. Churchill, believing  that the details  there presented can hardly
fail to prove of advantage to the junior practitioner.  The result of all these additions is that the
work now contains fully one-half more  matter than  the last American edition, with nearly one-
half more illustrations; so that, notwithstanding the use  of a smaller type, the volume  contains
almost two hundred pages more than before.
  These additions render the work still more com-
plete and acceptable than ever; and with the excel-
lent style iu which the  publishers have presented
this edition of Churchill, we can commend it to  the
profession with great cordiality and pleasure.—Cin-
cinnati Lancet.
  Few works on this branch of medical science  are
equal to it, certainly none excel it, whether in regard
to theory or practice, and in one respect it is superior
to all others, viz., in its  statistical information, and
therefore, on these grounds a most valuable work for
the physician, student, or lecturer, all of whom will
flud in it the information which they are seeking.—
Brit. Am. Journal.
  The present  treatise is very much  enlarged and
amplified beyond the previous editions but nothing
has been added which could be well dispensed with.
An examination of the table of contents shows how
thoroughly the author has gone over the ground, and
the care he has taken in the text to present the sub-
jects in all their bearings, will render this new edition
even more necessary to the obstetric  student  than
were either of the former editions at the date of their
appearance.  No treatise on obstetrics with which we
are acquainted can compare favorably with this, in
respect to the amount of material which has  been
gathered from every source.—Boston Med. and Surg.
Journal.

  There is no better text-book for  students, or work
of reference and study for the practising physician
than this.  It should adorn and enrich every medical
library.—Chicago Med. Journal. 
26
Henry  C. Lea's Publications—(Surgery).
 QROSS  (SAMUEL  D.), 31.D.,
         Professor of Surgery in the Jefferson Medical College of Philadelphia.

   A  SYSTEM OF  SURGERY:  Pathological,  Diagnostic,  Therapeutic,
       and .Operative.  Illustrated by upwards of Thirteen Hundred Engravings.  Fourth edition,
       carefully revised, and improved.  In two large and beautifully printed royal octavo volumes
       of 2200 pages, strongly bound in leather, with raised bands.   $15 00.
  The continued,favor, shown by the exhaustion of successive large  editions of this great work,
proves that it has successfully supplied a want felt by American practitioners and students.  Though
but little over six years have  elapsed since its first publication, it has already reached its fourth
edition, while the care of the author in its revision  and correction  has kept it in a constantly im-
proved shape.  By the use of a close,  though very legible  type,  an unusually large  amount of
matter is condensed in its  pages, the two volumes  containing as much as four or five ordinary
octavos.   This, combined with the most careful mechanical execution,  and its very durable binding,
renders it one of the cheapest works accessible to the profession.  Every subject properly belonging
to the domain of surgery is treated in detail, so that the student who possesses this work may be
said to have in it a surgical library.
  It must long remain the most comprehensive work
on this important part of medicine.—Boston Medical
and Surgical Journal, March 23, 1865.
  We  have compared it with most of our standard
works, such as those of Erichsen, Miller, Fergusson,
Syme, and  others, and we must, in  justice to our
author, award it the pre-eminence.  As a work, com-
plete in  almost every detail, no matter how minute
or trifling, and embracing every subject known in
the principles and practice of surgery, we believe it
stands without a rival. Dr. Gross, in his preface, re-
marks "my aim has been  to embrace the whole do-
main  of surgery, and to allot to every subject its
legitimate claim to notice;" and, we  assure our
readers, he has kept his word.  It is a work which
we can most confidently recommend to our brethren,
for its utility is becoming the more evident the longer
it is upon the shelves of our library.—Canada Med.
Journal, September, 1865.
  The first two editions of Professor Gross' System of
Surgery are so well known to the profession, and so
highlyprized, that it would be idle for us to speak in
praise of  this  work.— Chicago Medical Journal,
September, 1865.
  We  gladly indorse the favorable  recommendation
of the work, both as regards matter and style, which
we made when noticing its first appearance.—British
and Foreign Medico-Chirurgical Review, Oct. 1865.
  The most complete work that has yet issued from
the press on the science and practice of surgery.—
London Lancet.
  This system of surgery is, we predict, destined to
take a commanding  position in our surgical litera-
ture, and be the crowning glory of the author's well
earned fame.   As an authority on general surgical
subjects, this work is long to occupy a pre-eminent
place, not only at home, but abroad.  We have no
hesitation in pronouncing it without a rival in our
language, and equal to the best systems of surgery in
any language.—N. Y. Med. Journal.
   Not only by far the best text-book on the subject,
as a whole, within the reach of American students,
but one which will be much more than ever likely
to be  resorted to and regarded as a high authority
abroad.—Am. Journal Med. Sciences, Jan.  1865.
   The work contains everything, minor and major,
operative and diagnostic, including mensuration and
examination, venereal diseases, and uterine manipu-
lations and operations.  It is a complete Thesaurus
of modern ourgery, where the student and practi-
tioner shall not seek in vain for what they desire.—
San Francisco Med. Press, Jan. 1S65.
  Open it where we may, we find sound practical in-
formation conveyed in plain language.  This book is
no mere provincial or  even national system of sur-
gery, but a work which, while very largely indebted
to the past, has a strong claim on the gratitude of the
future of surgical science.—Edinburgh Med. Journal,
Jan. 1865.
  A glance at the work is sufficient to show that the
author and publisher have spared no labor in making.
it the most complete "System of Surgery" ever pub-
lished in any country.—St. Louis Med. and Surg.
Journal, April, 1865.
  The third opportunity is now offered during our
editorial life to review, or rather to indorse and re-
commend  this great American  work on  Surgery.
Upon this last edition  a great amount of labor has
been expended, though to all others except the author
the work was regarded in its previous", editions as so
full and complete as to  be hardly capable of improve-
ment. Every chapter has been revised; the text aug-
mented  by nearly two hundred pages, and a con-
siderable number of wood-cuts have been introduced.
Many portions have been entirely re-written, and the
additions made to the text are principally of a prac-
tical character.  This  comprehensive  treatise upon
surgery has undergone revisions and enlargements,
keeping pace with the progress of the art and science
of surgery, so that whoever is in possession of this
work may consult its pages upon any topic embraced
within the scope of its  department, and rest  satisfied
that its teaching is fully up to the  present standard
of surgical knowledge.   It is also so comprehensive
that it may truthfully be said to embrace all that is
actually known, that is really of any  value in  the
diagnosis and treatment of surgical diseases and acci-
dents. Wherever illustration will add clearness to the
subject, or make better or more lasting impression, it
is not wanting; in this respect the work is eminently
superior.—Buffalo Med. Journal, Dec. 1864.
  A system of surgery  which we think unrivalled in
our language, and which will indelibly associate his
name with surgical science.  And what, in our opin-
ion, enhances the value of the work is that, while the
practising surgeon will find all that he requires in it,
it is at the same time one of the  most valuable trea-
tises which can be put  into the hands of the student
seeking to know the principles and practice of this
branch  of the profession which he designs subse-
quently to follow.—The Brit. Am. Journ., Montreal.
 r>Y THE SAME AUTHOR.                  ----

   A  PRACTICAL  TREATISE  ON  THE  DISEASES,  INJURIES,
      AND MALFORMATIONS OF THE  URINARY BLADDER, THE PROSTATE GLAND,
      AND THE URETHRA.  Second edition, revised and much enlarged, with one hundred
      and eighty-four illustrations.  In one  large and very handsome octavo volume, of over nine
      hundred pages, extra cloth.   $4 00.
  Whoever will peruse the vast amount of valuable
practical information it contains will, we think, agree
with us, that there is no work in the- English  lan-

 DY THE SAME AUTHOR.                  ----

   A  PRACTICAL  TREATISE  ON   FOREIGN   BODIES  IN  THE
      AIR-PASSAGES.   In  one  handsome octavo  volume,  extra cloth,  with illustrations
      pp. 468.  $2 75.
guage which can make any just pretensions to be He
equal.—N. Y. Journal of Medicine. 
Henry C. Lea's Publications—(Surgery).                27
J?RICHSEX (JOHX),
-tv      Professor of Surgery in University College, London.

   THE SCIENCE AXD  ART OF SURGERY; being a Treatise on Sur-
      gical Injuries, Diseases, and Operations.  New and  improved American, from  the  Second
      enlarged and carefully revised London edition.   Illustrated with  over four hundred wood
      engravings. "In one large and handsome octavo volume of 1000 closely printed pages; extra
      cloth, $6;  leather, raised bands, $7.
  We are bound to state, and  we do so without wish- ' as one of the very best, if not the best  text-book)'
lng to draw invidious  comparisons,, that the work of surgery with which we were acquainted, permits us
Mr. Erichsen, in most respects,  surpasses any that to give it but a passing notice totally unworthy of its
has preceded it.  Mr. Erichsen's is a practical work, merits.  It may be confidently asserted,  that no work
combining a due proportion of the "Science and  Art on the science and art of surgery has ever received
of Surgery."  Having' derived no little instruction more universal commendation or occupied a higher
from it, in many important branches of surgery, we
can have no hesitation in recommending it as a valu-
able book alike to the practitioner and the student.
— Dublin Quarterly.
                                             position as a general text-book on surgery, than this
                                             treatise of Professor Erichsen.—Savannah Journal of
                                             Medicine.
                                              In fulness of practical detail and perspicuity of
Gives a  very admirable practical view of the sci- ! 6tyle, convenience of arrangement and soundness of
eoce and art of surgery.—Edinburgh Med. and Surg
Journal.
  We recommend it as the best compendium of sur-
gery in our language.—London Lancet.
  It is, we think, the most valuable practical work
on surgery in existence, both for young and old prac-
titioners.—Nashville Med. and Surg. Journal.
                                              discrimination, as well as fairness and completeness
                                              of discussion, it is better suited to the wants of both
                                              student and practitioner than any of its predecessors.
                                              —Am. Journal of Med. Sciences.
                                                After careful and fre.quent perusals of Erichsen's
                                              surgery, we are at a loss fully to express our admira-
                                              tion of it.  The author's style is eminently didactic,
                                              and characterized by a  most admirable directness,
  The limited time we have to review this improved ' clearness,  and compactness.—Ohio Med. and Surg.
edition of a work, the first issue of which we prized Journal.
T)Y THE SAME  AUTHOR.   (Ready in June.)

  ON   RAILWAY,  AND  OTHER   INJURIES  OF  THE  NERVOUS
      SYSTEM.   In small octavo volume.  Extra cloth,  $1 00.
  We welcome this as perhaps the most practically
useful treatise  written for  many  a day.—Medical
Times.
  It will serve as a most useful aud trustworthy guide
to the profession in general, many of whom may be
consulted in such  cases; and  it will, no doubt, take
its place as a  text-book on the subject of which it
treats.—Medical Press.
 MILLER (JAMES),
J-'J-     Late Professor of Surgery in the University of Edinburgh, to.
   PRINCIPLES  OF SURGERY.   Fourth American, from the third and
      revised Edinburgh edition.  In one  large and very  beautiful volume  of 700 pages, with
      two hundred and forty illustrations on wood,  extra cloth.   $3 75.
B
   Y THE SAME AUTHOR.                   ----

   THE  PRACTICE  OF  SURGERY.   Fourth American, from the last
      Edinburgh edition.  Revised by the American editor.  Illustrated by three hundred and
      sixty-four engravings  on wood.  In  one large octavo volume of nearly 700 pages, extra
      cloth.   $3 75.
  It is seldom  that two volumes have ever made so I acquired.  The author is an eminently sensible, prac-
profound  an impression  iu so short a time  as the | tical, and well-informed  man,  who knows exactly
"Principles" and the "Practice" of Surgerv by Mr.  what he is talking about and exactly how to talk it.—
Miller or so richly merited the reputation they have | Kentucky Medical Recorder.
 -piRRIE ( WILLIAM). F. R. S E..
JU      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 th«
      Pennsylvania Hospital, Ac.  In one very handsome octavo volume of 780 pages, with  316
      illustrations, extra cloth.  $3 75.
&ARGENT (F.  W.), M.D.
ON BANDAGING AND OTHER OPERATIONS  OF  MINOR SUR-
  " GERY  New edition, with an additional chapter on Military Surgery.  One handsome royal
    12mo. volume, of nearly 400 pages, with 184 wood-cuts   Extra cloth,  $1 75.
                                              We cordially commend this volume as one which
                                            the medical student should most closely study; and
                                            to the surgeon in practice it must prove itself instruct-
                                            ive on many points which he  may have forgotten.—
                                            Brit.  Am. Journal, May. 1S62.
  Exceedingly convenient and valuable to all mem-
bers of the protessiou.-C/ucai'w Medical Examiner,
May, 1862.
  The very best manual of Minor Surgery we have
seen —Buffalo Medical Journal.
MALGAIGNES OPERATIVE SURGERY.  With nu-


  ^"rilX«« ^' of *ear* 6°° PP- *2 5°-
SKEY'S OPERATIVE SURGERY. In one very hand-
  some octavo volume,  extra cloth, of over 650 pages,
  with about 100 wood-cuts.  $3 25. 
28                 Henry C.  Lea's  Publications—(Surgery).

JT)RUITT (ROBERT), M.R.C.S., frc.

  THE  PRINCIPLES AND  PRACTICE  OF  MODERN  SURGERY.
      A new and revised American, from the eighth enlarged and improved London edition. Illus-
      trated with four hundred and thirty-two wood-engravings.  In one very handsome octavo
      volume, of nearly 700 large and closely printed pages.  Extra cloth, $4 00;  leather, $5 00.

  Besides the careful revision of the author, this work  has  had the advantage of very thorough
editing  on the part of a competent surgeon to adapt it more completely to the wants of the Ameri-
can student and practitioner.  Many illustrations have been introduced, and every care has been
taken to render the mechanical execution unexceptionable.   At the very low price afBxed, it will
therefore be found one  of the most attractive and useful volumes accessible  to the American
practitioner.
  All that the surgical student or practitioner could
desire.—Dublin Quarterly Journal.
  It is  a most admirable book.  We do not know
when we have examined one with more pleasure.—
Boston Med. and Surg. Journal.
  In Mr. Druitt's book, though containing only some
seven  hundred pages, both the principles and  the
practice of surgery are treated,  and  so clearly and
perspicuously, as to elucidate every important topic.
The fact that twelve editions have already been called
for, in  these  days of active competition, would of
itself show it to possess marked  superiority.  We
have examined the book most thoroughly, and  can
say that this success is well merited.   His book,
moreover,  possesses  the  inestimable advantages of
having the subjects perfectly well arranged and clas-
sified, and of being written in a style at  once clear
and succinct.—Am. Journal of Med. Sciences.
  Whether we view  Druitt's Surgery as  a guide to
operative procedures, or as representing the latest j
BRODIE'S CLINICAL  LECTURES  ON  SURGERY.
  1 vol. 8vo., 350 pp.; cloth, $1 25.
BARWELL'S  TREATISE ON DISEASES OF THE
  JOINTS.  With illustrations.  1 vol. 8vo., of about
  500 pages ; extra cloth, $3 00.
COOPER'S LECTURES  ON THE PRINCIPLES AND
  Practice op Surgery.  In one very large octavo
  volume, extra cloth, of 750 pages.  $2 00.
GIBSON'S INSTITUTES AND PRACTICE OF SUR-
  qery.  Eighth edition, improved and altered. With
  thirty-four plates.  In two handsome  octavo vol-
  umes, about 1000 pages, leather, raised bands. $6 50
JONES'  PRINCIPLES  AND  PRACTICE OF OPH-
theoretical surgical opinions, no work that we are at
present acquainted with can at all compare with it.
It is a compendium of surgical theory (if we may use
the word) and practice in itself,  and well deserves
the estimate placed upon it.—Brit. Am. Journal.
  Thus enlarged and improved, it will continue to
rank among our best text-books on elementary sur-
gery.—Columbus Rev. of Med. and Surg.
  We  must close this brief notice of an admirable
work by recommending it to the earnest attention of
every medical student.—Charleston Medical Journal
and Review.
  A text-book which the general voice of the profes-
sion in both England and America has commended as
one of the most admirable  "manuals," or, "vade
mecum," as its English  title  runs, which can  be
placed in the  hands of the student.   The merits of
Druitt's  Surgery are too well known to every one to
need any further eulogium from us.—Nashville Med.
Journal.
  THALMIC MEDICINE AND SURGERY.  With one
  hundred and seventeen illustrations.  Third and
  revised American, with Additions from the second
  London edition.  In one handsome  octavo volume
  of 455 pages, extra cloth.  $3 25.
MACKENZIE'S PRACTICAL TREATISE  ON  DIS-
  EASES AND INJURIES OF THE EYE.  From the
  fourth revised and enlarged London  edition.  With
  Notes and Additions by Addixei.l Hewson, M. D.,
  Surgeon to Wills Hospital, &c. &c. In one very
  large and  handsome octavo volume of 1027 pages,
  extra cloth, with plates and numerous woodcuts'
  $6 50.
JLJA3IILTON (FRANK H), M.D.,
         Professor of Fractures and Dislocations, to. in Bellevue Hosp. Med. College, New York.

   A PRACTICAL  TREATISE   ON  FRACTURES AND  DISLOCA-
      TIONS.   Third edition, thoroughly revised.   In one  large and handsome octavo volume
      of 777 pages, with 294 illustrations,  extra cloth, $5  75.   (Just Issued.)

  The demand which has so speedily exhausted two  large editions of this work shows that the
author has succeeded in supplying a want,  felt by the profession at large, of an exhaustive treatise
on a frequent and troublesome class of accidents.  The unanimous voice of the profession, abroad
as well as at home, has pronounced it the  most complete work to which the surgeon can refer for
information respecting all details of the subject.  In the preparation of this new edition, the
author has sedulously endeavored to render it worthy a continuance of the favor which has been
accorded to it, and the experience of the recent war has afforded a large amount of material which
he has sought to turn to the best practical account.
  In fulness of detail, simplicity of arrangement, and
accuracy of description, this work stands unrivalled.
So far as we know, no other work on the subject in
the English language can be compared with it. While
congratulating  our  trans-Atlantic brethren on  the
European reputation which Dr. Hamilton, along with
many other American surgeons, has attained, we also
may be proud that,  in the mother tongue, a classical
work has been produced which need not  fear compa-
rison with the standard treatises of any other nation.
—Edinburgh Med. Journal, Dec. 1866.

  The credit of giving to the profession the only com
plete practical treatise on fractures and  dislocations
in our language during the present century, belongs
to the author of the work before us, a distinguished
American professor of surgery; and his book adds
one more tothelistof excellent practical works which
have emanated from  his country, notices of which
have appeared from time to time in our columns da-
ring the last few months.—London Lancet. Dec. 13.
1866.
  These additions make  the work much more valua-
ble, and it  must be accepted as the most complete
monograph  on the subject, certainly in our own, if
not even in any other  language.—American Journal
Med. Sciences, Jan. 1867.
  This is the most complete treatise on the subject in
the English language.—Banking's Abstract, Jan.lS6J.
  A mirror of all that is valuable in modern surgery.
Richmond Med. Journal, Nov. 1866. 
Henry C. Lea's Publications—(Surgery).               29
rTOYNBEE (JOSEPH), F.R.S.,
-"■      Aural Surgeon to and Lecturer on Surgery at St. Mary's Hospital.
  THE  DISEASES OF THE  EAR:  their Nature, Diagnosis, and Treat-
      ment.  With one hundred engravings on wood.  Second American  edition.   In one very
      handsomely printed octavo volume of 440 pages;  extra cloth, §4.
  The appearance of a volume of Mr. Toynbee's, there-
fore, in which the subject of aural disease is treated
in the most scientific manner, and our knowledge in
respect to it  placed fully %n a par with that which
we possess respecting most other organs of the body,
is a matter for sincere congratulation. We may rea-
sonably hope that henceforth the subject of this trea;
tise will cease to be among the opprobria of medical
science.—London Medical Review.
  The work, as was stated at the outset o^our notice,
is a model of its kind, and every page and paragraph
of it are worthy of the most thorough study.  Con-
sidered all in all—as an original work, well written,
philosophically elaborated,  and happily illustrated
with cases and drawings—it is by far  the ablest mo-
nograph that has ever appeared on the anatomy and
diseases of the ear, and one of the most valuable con-
tributions to the art and science  of surgery in the
nineteenth century.—N. Am. Med.-Chirurg. Remiew.
 T A URENCE (JOHN Z.), F. R. C. S.,   and   MOON (ROBERT C),
1J     Editor of the Ophthalmic Review, to.             ±Y±  H™** Surgeon to theSouthwark Oph-
                                                             thalmic Hospital, &c.

   A HANDY-BOOK  OF   OPHTHALMIC  SURGERY,  for the  use  of
      Practitioners.  With numerous illustrations.   In one very handsome octavo volume, extra
      cloth.   $2 50.  (Just Issued.)
  No book on ophthalmic surgery was more needed.
Designed, as it  is,  for the wants of the busy practi-
tioner, it is the  neplus ultra, of perfection.   It epito-
mizes all the diseases incidental to the eye in a clear
and masterly manner, not only enabling the practi-
tioner readily to diagnose each variety of disease, but
affording him the more important assistance of proper
treatment.  Altogether this is  a work which ought
certainly to be  iu the hands of every general practi-
tioner.—Dublin Med. Press and Circular, Sept. 12, '66.
  We cordially recommend this book to the notice of
our readers, as containing an excellent outline of
modern  ophthalmic surgery.— British Med. Journal,
October  13, 1866.
  Not only, as its modest title suggests, a "Handy-
Book" of Ophthalmic Surgery, but an excellent and
well-digested rtsume of all that is of practical value
in the specialty.—New  York  Medical Journal, No-
vember, 1866.

  This object the authors  have accomplished in a
highly satisfactory manner, and we know no work
we can more highly recommend to the ".busy practi-
tioner" who wishes to make himself acquainted with
the recent improvements in ophthalmic science. Such
a work as  this was much wanted at this time, and
this want Messrs. Laurence and Moon have now well
supplied.—Am. Journal Med. Sciences, Jan. 1867.
 TAWSON (GEORGE), F. R. C. S., Engl.
J-J      Assistant Surgeon to the Royal London Ophthalmic Hospital, Moorfields, to.

   INJURIES  OF  THE  EYE,  ORBIT, AND  EYELIDS:  their Imme-
     diate and Remote Effects.  With about one hundred illustrations.   In one very hand-
     some octavo volume, extra cloth, S3 50.   (Now Ready.)
  This work will be found eminently fitted  for the general practitioner.  In cases of  functional
or structural diseases of the eye, the  physician who has not made ophthalmic surgery a special
study can, in most instances, refer  a patient to some competent practitioner.   Cases  of injury,
however, supervene suddenly and usually require prompt assistance, and a work devoted espe-
cially to'them cannot but prove essentially useful to those who may at any moment be called upon
to treat such  accidents.  The  present volume, as the work of a gentleman of large experience,
may be considered as eminently worthy of confidence for reference in all such emergencies. •
  It is an admirable practical book in the highest and l fulness of practical knowledge.  We  predict for Mr,
best  sense of the phrase.  Copiously illustrated by  Lawson's work a great and well-merited success,
excellent woodcuts,  and with well-selected, well-  We are confident that the profession,  and especially,
described cases, it is written  in  plain, simple lan-
guage, and  in a style the transparent  clearness and
frankness, so to speak, of which, add  greatly to its
value and usefulness.  Only a master of his subject
could so write ; every topic is handled with an ease,
decision  and  straightforwardness, that  show the ; and Gazette, May 18, 1867
skilful and highly educated surgeon  writing from
as we have said, our country brethren,  will feel
grateful to him for having given them in it a guide
and counsellor fully up to the most advanced state of
Ophthalmic Surgery, and of  whom they can make a
trusty and familiar friend.—London Medical Times
 MORLAND (W.  W.), M.D.

   DISEASES OF  THE URINARY ORGANS;  a Compendium of their
      Diagnosis  Pathology, and Treatment.  With illustrations.  In one large  and handsome
      octavo volume of about 600 pages, extra cloth.  $3 50.
  Taken as a whole we can recommend Dr. Norland's I of every medical or surgical pracutioner.-iJrtf. and
compendium^avery desirable addition to the library | For. Med.-Chir. Review, April, 18o9.
PURLING (T.B.),  F.R.S.,

  Suraeon to the London Bospital, President of the Bunterian Society, to.
PEVCTICAL  TREATISE  ON  DISEASES   OF  THE  TESTIS,
ciPFRMATIC CORD  AND SCROTUM.  Second American, from the second and enlarged
English edition.   In'one handsome octavo volume,  extra cloth,  with  numerous illustra-
tions,  pp. 420.'  $2 00. 
30               Henry C. Lea's Publications—(Surgery).
^yALES (PHILIP S.), 31. D., Surgeon U.S.N.
   MECHANICAL  THERAPEUTICS:  a Practical Treatise on Surgical
       Apparatus,  Appliances, and  Elementary Operations :  embracing Minor Surgery,  Band-
       aging, Orthopraxy, and the Treatment of Fractures  and Dislocations.   With six hundred
       and forty-two illustrations on wood.  In one large and handsome octavo volume of about
       700 page's: extra cloth, $5 75;  leather, $6 75.   (Now Ready.)

  A Naval Medical Board directed to examine and report upon the merits»of this volume, officially
states that " it should  in our opinion  become a standard work in the  hands  of every naval sur-
geon;'' and. its adoption for use in both  the Army and Navy of the  United States is sufficient
guarantee of its adaptation to the needs of every-day practice.
   The title of this book will give a reasonably good
 idea of its scope, but its merits can only be appreci-
 ated by a careful perusal of its text.  No one who un-
 dertakes such a task will have any reason to com-
 plain that the author has not performed his duty, and
 has not taken every pains to present every subject in
 a clear, common-sense, and  practical light.  It is a
 unique specimen of literature in its way, in that,
 treating  upon such  a variety of subjects, it is as a
 whole so completely up to the wants  of the student
 and the  general practitioner.  We  have never seen
 any.work of its kind that can compete with it in real
 utility and extensive adaptability.   Dr. Wales  per-
 fectly understands what may naturally be required
 of him in the premises, and in the work before us has
 bridged over a very.wide gap which has always here-
 tofore existed between the first rudiments of surgery
 aud practical surgery proper.  He has emphatically
 given us a comprehensive work for the beginner ; and
 when we say of his labors, that in their particular
 sphere they leave nothing to be desired, we assert a
 great deal to  recommend the  book to the attention of
 those specially concerned.  In conclusion,  we would
 state, at the risk of reiteration, that this is the most
 comprehensive book on the subject that we have seen ;
 is the best that can be placed in the hands of the stu-
 dent in need of a first book on surgery, and the most
 useful that can be named for such general practition-
 ers who, without any special pretensions to surgery,
 are occasionally liable to treat surgical cases.—N. Y.
 Med.  Record, March 2, 1S68.
   It is certainly the most complete and thorough work
 of its kind in the English language.  "Students and
 young practitioners of surgery will find it invaluable.
 It will prove especially useful to inexperienced coun-
 try practitioners, who  are continually  required to
 take charge of surgical cases,  under  circumstances
 precluding them from the aid of experienced surgeons.
 —Pacific Med. and Surg. Journal, Feb. 1868.
   This is a most complete and elegant work of 673
 pages, and is certainly well deserving of the  com-
 mendation  of every American surgeon.  This work,
 besides its usefulness as a reference for practitioners,
 is mast admirably adapted as a text-book for students.
 Its 642 illustrations in wood-cuts, represent every man-
 ner of surgical appliance, together with a minute de-
 scription of each, the name of its inventor, and its prac-
 tical utility in mechanical surgery. There is, perhaps,
 uo work  in the English language so complete in the
 description and detail of surgical  apparatus and ap-
 pliances as this one.  The entire work entitles the au-
•thor to great credit for his clear and distinct style as
 a writer, as well as  for his  accuracy of observation
 ajid great research in the field of surgery.  We ear-
 nestly recommend every member of the profession to
 add a copy of it to his library, with  the assurance
 that he will find some useful  suggestion in the treat-
 ment  of almost every surgical case that may come
 under his  observation.—Humboldt Med.  Archives,
 Feb. 1868.
  It is the completestbook on these subjects we know
 of, and it cannot fail to be  exceedingly useful to the
 busy practitioner, especially to the busy country phy-
 sician who has thrown upon his care something of
 surgery in its various details, with all manner of gene-
 ral practice, and, therefore, may often  wish to refresh
 himself as to the most convenient and elegant modes
 of dressings and manipulations.—Cincinnati Lancet
 and Observer, Jan. 1868.
  We have examined Dr. Wales' book  with much
 care, and believe that his  labor will  greatly benefit
 the practitioner of surgery.  It seems to us especially
 beneficial to the country medical  practitioner who is
 surgeon,  physician, and  obstetrician, as occasion re-
 quires.   We commend the work to our readers  as a
 most useful one.—NashvilCe Med. and Surg. Journal,
 Jan. 1868.
  The title  of the above work is sufficiently indica-
 tive  of its contents.   We  have  not seen for a  Jong
 time (in the English language) a treatise equal to thin
 in extent,  nor one which is better adapted to the
 wants of  the general student and practitioner.   It is
 not to the surgeon alone that this book belongs ;  the
 physician has frequent opportunities to fill an emer-
 gency by such knowledge  as is  here  given.  Every
 practitioner should make purchase of  such a book—
 it  will last him his lifetime.—St. Louis Med. Re-
porter, Feb. 1868.
  A useful book is always a necessary one, and  that
 this  book is eminently one of that character, needs
 but a glance at its pages to  show. It certainly de-
 serves  a  place in the library of every physician.—
 Leavenworth Med. Herald, Feb. 1S68.
  The book seems  to be complete in  every respect,
 and  is  a  welcome addition to our shelves.—Boston
 Med. and Surg. Journal, Jan. 9, IS68.
  In  our  opinion it is a good book, and  one which
 every student and practitioner needs in his library.
 Especially would its value be appreciated by the sur-
geon whose field  of practice is anywise remote from
 the larger cities.—Chicago  Med. Journal, Jan. 1S6S.

  This volume will be a useful acquisition to a large
 number of the working members of the medical pro-
 fession in this country.  Practitioners will find mate-
 rial aid and encouragement in its pages which they
could nowhere else obtain,  to the same extent, in so
convenient a form.— Am.  Journal Med. Sciences
Jan.  1868.                                     '

  He must be a blockhead indeed who, after study-
ing this portion of the book before us, fails to adapt
himself to the emergency  of any case, for we find
here  described pretty much  every contrivance  ever
devised, and we can hardly conceive of that combi-
nation  of circumstances which would  deprive us  of
all these  means of assistance, and the  absence of one
or more of the usual aids would only stimulate  the
ingenuity to devise some other  plan of relief —Nrw
 York Med. Journal, May, 186S.
ASHTON (T.  J.)

 ON  THE   DISEASES,  INJURIES, AND  MALFORMATIONS   OP
     THE RECTUM AND ANUS; with remarks'on Habitual ConstipationSecond AmeriPaf
     from the fourth and enlarged London edition.  With handsome illustrations   In onverv
     beautifully printed octavo volume of about 300 pages.   $3 25.   (Just Issued.)
  We can recommend this volume of Mr  Ashton's in
the strongest terms, as containing all the latest details
of the pathology and treatment of  diseases connected
with the rectum.—Canada Med. Journ., March, 1866.
  One of the most valuable special treatises that the
physician  and surgeon  can have in his library.__
Chicago Medical Examiner, Jan.  1866.
nelrance nf ?if "?d WhlCh, haS elaPsed since the ap-
pearance of the former American reprint, and  the
numerous editions published in England, are the best
arguments we ca* offer of the merits, and of the ute
 essness of-any commendation on our part oI bo?k
^ady «0ofa™'ably known to our readers -Cton
Med. and Surg. Journal, Jan. 2.3, 1866.      *08t0n 
Henry  C. Lea's Publications—(3Iedical Jurisprudence, &c).   31
 WAY LOR (ALFRED  S.), 31. D.,
 J-      Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital.

   MEDICAL  JURISPRUDENCE.    Sixth  American,  from  the   eighth
      and revised London edition.  With Notes and References to American Decisions, by Cle-
      ment B. Penrose, of the  Philadelphia Bar.   In one large octavo volume of 776  pages,
      extra cloth, $4 50 ;  leather, $5 50.   (Just Issued.)
  Considerable additions have been made by the editor to this edition, comprising some important
sections from the author's larger work, " The Principles and Practice of Medical  Jurisprudence,"
as well as references to American  law and  practice.   The notes of the former editor, Dr. Harts-
horne, have likewise been retained, and the whole is presented as fully worthy to maintain the
distinguished position which the work has  acquired as a leading text-book and  authority  on the
subject.
  A new edition of a work acknowledged as a stand-
ard authority everywhere within the range  of  the
English language.  Considering the new matter intro-
duced,  on trichiniasis  and other subjects, and  the
plates representing the crystals of poisons, etc., it may
fairly be regarded as the most compact, comprehen-
sive, and practical work on  medical jurisprudence
which has issued  from  the press, and the one best
fitted for students.—Pacific Med. and Surg. Journal,
Feb.'1867.

  The sixth edition of this popular work comes to us
in charge of a new editor, Mr. Penrose, of the Phila-
delphia bar, who has done much  to render it useful,
not only to the medical practitioners of this country,
bnt to those of his own profession.  Wisely retaining
the references of the former American  editor,  Dr.
Hartshorne, he has added many valuable notes of his
own.  The reputation of Dr. Taylor's work is so well
established, that it needs no recommendation.   He is
now the highest living authority on all matters con-
nected with, forensic medicine, and every successive
edition of his valuable work gives fresh assurance to
his many admirers that he will continue to maintain
his well-earned position. No one should, iu fact, be
without a text-book on the  subject, as he does  not
know but that his next case may create  for him an
emergency for its use.  To those who are  not the  for-
tunate possessors of a reliable, readable,  interesting,
and thoroughly practical work upon the subject, we
would earnestly recommend this, as forming the best
groundwork for all their future  studies of  the more
elaborate treatises.—New York Medical Record, Feb.
15, 1867.
  The present edition Of this valuable manual is a
great improvement on those which have preceded it.
Some admirable instruction on the subject of evidence
and the duties and  responsibilities of medical wit-
nesses has been added by the distinguished author,
and some fifty cuts, illustrating chiefly the crystalline
forms and microscopic structure of substances used
as poisons, inserted.   The American editor has also
introduced several chapters from Dr. Taylor's larger
work, "The Principles and Practice of Medical Juris-
prudence," relating to trichiniasis, sexual malforma-
tion, insanity as affecting civil responsibility, suicidal
mania, and life insurance, &c, which add considerably
to its value.  Besides this, he has introduced nume-
rous references to cases which  have occurred in this
country.  It  makes thus by far the best guide-book
in this department of medicine for students and the
general practitioner  in our language.—Boston Med.
and Surg. Journal, Dec. 27, 1866.
  Taylor's Medical Jurisprudence has  been the text-
book in our colleges  for years, and .the present edi-
tion, with the valuable additions made by the Ameri-
can editor, render it the most standard work of the
day, on the peculiar province of medicine on which
it treats.  The American editor, Dr. Hartshorne, has
done his duty to the text, and, upon the whole, we
cannot but consider this volume the best .and richest
treatise on medical jurisprudence in our language.—
Brit. Am, Med.1 Journal.
w
INSLOW  (FORBES),  M.D., D. C.L., Sfc.    '

ON  OBSCURE  DISEASES  OF  THE  BRAIN AND DISORDERS
 OF THE MIND;  their incipient Symptoms,  Pathology, Diagnosis,  Treatment,  and Pro-
 phylaxis.  Second American, from the third and revised English edition.  In one handsome
 octavo volume of nearly 600 pages, extra cloth.  $4 25.   (Just Issued.)
  Of the merits of Dr. Winslow's treatise the profes-
sion has sufficiently judged.  It has taken its place in
the front rank of the works upon the special depart-
ment  of practical medicine to which it pertains.—
Cincinnati Journal of Medicine, March, 1S66.
  It is an interesting volume  that will amply repay
for a  careful peru>al by all intelligent readers.—
Chicago Med. Examiner Feb. 1866.
  A work  which, like the present, will largely aid
the practitioner in recognizing and  arresting the first
insidious advances of ce.rebral and  mental disease, is
one of immense practical value, and demands earnest
attention and diligent study on the part of all who
have  embraced the medical profession, and have
thereby undertaken responsibilities in which  the
welfare and happiness  of individuals and  families
are largely involved.  We shall therefore close this
brief aud  necessarily very imperfect notice of Dr.
Winslow's great and classical work by expressing
our conviction  that it is long since so important and
beautifully written a volume  has issued from  tha
British medical press.  The details  of the manage-
ment of confirmed cases of insanity more  nearly in-
terest those who have made mental diseases their
special study,  but Dr. Winslow's masterly exposi-
tion of the early symptoms, and his graphic descrip
tions of the insidious advances of incipient insanity,
together with his judicious observations on the treat-
ment of disorders of the mind,  should, we repeat, be
carefully  studied by ail who  have  undertaken  the
responsibilities of medical practice.—Dublin Medical
  It is the most interesting as well as valuable book
that we have seen for a long time.  It is truly fasci-
nating.—Am. Jour. Med. Sciences.
  Dr. Winslow's work will undoubtedly occupy an
unique position in the medico-psychological litera-
ture of this country.—London Med. Review.
L
EA  (HENRY C.)

 SUPERSTITION  AND  FORCE:  ESSAYS  ON   THE  WAGER  OF
   LAW, THE WAGER  OF  BATTLE,  THE ORDEAL, AND TORTURE.  In  one hand-
   some volume royal 12mo., of 406 pages; extra cloth, $2  50.
  The copious collection of facts by which Mr. Lea has
illustrated his subject shows in the fullest manner the
constant conflict and varying success, the advances
and defeats, by which the progress of humane legisla-
tion has been  and is still marked.  This work fills up
with the fullest exemplification and  detail the wise
remarks which we have quoted above.  As a book of
ready refereuce on  the subject it is  of  the highest
value.— Westminster Review, Oct. 1SU7.
  When—half in spite of himself, as  it appears—he
Bkerchc- a sceue or character in the history of legalized
error aud cruelty, he betrays so artistic a feeling, and
a humor so fine and good, that he makes us regret it
was not within his intent, as it was certainly within
his power, to render the whole of his thorough work
more popular in manner.—Atlantic Monthly, Feb. '67.
  This is a book of extraordinary research. Mr.  Lea
has entered into his subject con amore;  and a more
striking record of the cruel superstitions of our un-
happy Middle Ages could not possibly have been com-
piled. ... As a work of curious inquiry ou certain
outlying points of obsolete law,  "Superstition  and
Force" is one of the most remarkable books we have
me; with.—London Athenasum, Nov. 3, 1866. 
32
Henry C. Lea's Publications.
INDEX   TO   CATALOGUE.
 Abel and Bloxam's Handbook of Chemistry
 Allen's Dissector and Practical Anatomist
 American Journal of the Medical Sciences
 Abstract, Half-Yearly, of the Med.  Sciences
 Anatomical Atlas, by Smith and Horner
 Ashtou on the Kectum and Anus
 Ash well on Diseases of Females
 Brinton on the Stomach
 Barclay's Medical Diagnosis .
 Barlow's Practice of Medicine
 Barwell on the Joints  .
 Bennet (Henry) on Diseases of the Uterus
 Bowman's (John E.) Practical Chemistry
 Bowman's (John E.) Medjcal Chemistry
 Brande & Taylor's Chemistry
 Brodie's Clinical Lectures on Surgery .
 Brown on the Surgical Diseases of  Women
 Buckler on Bronchitis  .
 Bucknill and Tuke on Insanity
 Budd on Diseases of the Liver
 Bumstead on Venereal  .
 Bumstead and Cullerier's Atlas of  Venereal
 Carpenter's Human Physiology  .
 Carpenter's Comparative Physiology
 Carpenter on the Microscope
 Carpenter on the Use and Abuse of Alcohol
 Carson's Synopsis of Materia Medica .
 Chambers on the Indigestions
 Christison and Griffith's Dispensatory
 Churchill's System of Midwifery .
 Churchill on Diseases of Females
 Churchill on Puerperal Fever
 Clymer on Fevers.....
 Colombat de l'Isere on Females, by Meigs
 Condie on Diseases of Children
 Cooper's (B. B.) Lectures on Surgery .
 Cullerier's Atlas of Venereal Diseases
 Curling on Diseases of the Testis .
 Cyclopedia of Practical Medicine .
 Dalton's Human Physiology .
 De Jongh on Cod-Liver  Oil  .    .    .
 Dewees's System of  Midwifery
 Dewees on Diseases of Females
 Dewees on Diseases of Children  .    .
 Dickson's Practice of Medicine
 Druitt's Modern Surgery
 Dunglison's Medical Dictionary  .
 Dunglison's Human Physiology  .
 Dunglison on New Remedies
 Dunglison's Therapeutics and Materia Medica
 Ellis's Medical Formulary, by Smith .
 Erichsen's System of Surgery
 Et-ichsen on Nervous Injuries
Flint on Respiratory Organs .
 Flint on the Heart.....
 Flint's Practice of Medicine .
 F>>wnes's Elementary Chemistry .
 Fuller on  the Lungs, &c.
 Gardner's Medical Chemistry
 Gibson's  Surgery.....
 Gluge's Pathological Histology, by Leidy
 Graham's Elements of Chemistry .
 Gray's Auatomy.....
 Griffith's (R. E.) Universal Formulary .
 Griffith's (J. W.) Manual on the Blood, &c.
 Gross on Urinary Organs
 Gross on Foreign Bodies in Air-Passages
 Gross's Principles and Practice of Surgery
 Gross's Pathological Anatomy   .   ".
 Hartshorne's Essentials of Medicine  .
 Habershon on Alimentary Canal .
 Hamilton on Dislocations and fractures
 Harrison on the Nervous System ,
 Hoblyn's Medical Dictionary
 Hodge on Women.....
 Hodge's Obstetrics.....
 Hodge's Practical Dissections
 Holland's Medical Notes and Reflections
 Horner's Anatomy and Histology
 Hudson on Fevers,      ....
Hughes on Auscultation and Percussion
Hillier's Handbook of Skin Diseases
Jones's ;T. W.) Ophthalmic Medicine and Surg
PAGE
  11
   6
   1
   3
   6
  30
  22
  17
  16
  15
  2S
  22
  10
  10
  10
  2S
  22
  IS
  18
  18
  19
  19
Jones and Sieveking's Pathological Anatomy
Jones (C. Handfield) on Nervous Disorders
Kirkes' Physiology     ....
Knapp's Chemical Technology
Lea's Superstition and Force
Lallemand and Wilson on Spermatorrhoea
La Roche on Yellow Fever  .
La Roche on Pneumonia, &c.
Laurence and Moon's Ophthalmic Surgery
Lawson on the Eye     ....
Laycock on Medical Observation  .
Lehmann's Physiological Chemistry, 2 vols
Lehmann's Chemical Physiology  .
Ludlow's Manual of Examinations
Lyons on Fever.....
Maclise's Surgical Anatomy .
Malgaigne's Operative Surgery, by Brittan
Marshall's  Physiology ....
Markwick's Examination of Urine
Mayne's Dispensatory and Formulary
Mackenzie on Diseases of the Eye
Medical News and Library  .
Meigs's Obstetrics, the Science and the Art
Meigs's Lectures on Diseases of Women
Meigs on Puerperal Fever
Miller's System of Obstetrics
Miller's Practice of Surgery .
Miller's Principles of Surgery
Montgomery on Pregnancy  .
Morland on Urinary Organs .
Morland on Uraemia
Neill and Smith's Compendium of Med. Science
Neligan's Atlas of Diseases of the Skin
Neligan on Diseases of the Skin
Prize Essays on Consumption
Parrish's Practical Pharmacy
Peaslee's Human Histology  .
Pirrie's System of Surgery  .
Pereira's Mat. Medica and Therapeutics, abri
Quain and Sharpey's Anatomy, by Leidy
Ranking's Abstract     ....
Roberts on Urinary Diseases .
Ramsbotham on Parturition .
Reese on Blood and Urine
Rigby on Female Diseases
Rigby's Midwifery.....
Rokitansky's  Pathological Anatomy  .
Royle's Materia Medica and Therapeutics
Salter on Asthma.....
Sargent's Minor Surgery
Sharpey and Quain's Anatomy, by Leidy
Simon's General Pathology  .
Simpson on Females    ....
Skey's Operative Surgery
Slade on Diphtheria    ....
Smith (H. H.) and Horner's Anatomical Atlas
Smith (Edward) on Consumption .
Solly on Anatomy and Diseases of the Brain
Stille's Therapeutics
Tanner's Manual of Clinical Medicine
Tanner on Pregnancy
Taylor's Medical Jurisprudence   .
Thomas on Diseases of Females  .
Todd and Bowman's Physiological Anatomy
Todd on Acute Diseases .
Toynbee on the Ear
Wales on Surgical Operations
Walshe on the Heart
Watson's Practice of Physic .
West on Diseases of Females
West on Diseases  of Children
West on Ulceration of Os Uteri   .
What to Observe in Medical Cases
Williams's Principles of Medicine
Wilson's Human Anatomy  .
Wilson's Dissector
Wilson on Diseases of the Skin  .
Wilson's Plates on Diseases of the Skin
Wilson's Handbook of Cutaneous Medicine
Wilson on Healthy Skin
Wilson on Spermatorrhoea
Winslow on Brain and Mind 
 
 
 
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