SYNOPSIS OF PRIVATE OBSTETRICAL PRACTICE 
FOR 
FORTY-TWO YEARS PREVIOUS TO JANUARY 1, 1876. 
By WILLIAM INGALLS, M. D. 
[Reprinted from The Boston Medical and Surgical Journal, ,\pril26, 1877.] 
CAMBRIDGE: 
JMntefc at tfje 
1877. Regards of 
William Ingalls, M. I). 
Boston. A SYNOPSIS OF PRIVATE OBSTETRICAL PRACTICE FOR 
FORTY-TWO YEARS PREVIOUS TO JANUARY 1, 1876.1 
BY WILLIAM INGALLS, M. D. 
Soon after the proceedings of the Dublin Obstetrical Society in April, 
1872, were published, I read the Report of Private Obstetrical Practice 
for Thirty-Nine Years, by Fleetwood Churchill, M. D. Pondering this 
report, holding frequent conversations and comparing cases with inti- 
mate professional friends whose duties in large proportion embraced 
this important branch, knowing that I had had in all my forty years of 
general practice a large number of " labor cases," I have imposed upon 
myself the task of gathering together and assorting my experience, in 
the hope that it might be of some interest if not of importance. 
Churchill modestly says in his introduction, " I do not suppose that 
the results of my practice are more favorable than those of other prac- 
titioners, and their only merit is that they were entered in my case- 
book at the time they occurredI believe I may claim perfect 
accuracy for what is recorded." I also claim accuracy for what fol- 
lows, adding this, that I have uniformly omitted to record or make 
notes of those cases which were normal, and of cases which were of no 
special interest. 
The doctrine of compensation or equipoise is frequently illustrated 
in our profession, and especially in the obstetrical branch thereof; for 
we find two or three, of our friends harassed throughout their pro- 
fessional lives by a succession of formidable abnormal cases, which, by 
the bye, they manage for the most part with consummate address, 
while there are others who seem to have rarely encountered any but 
simple cases. 
Within the forty-two years previous to January 1, 1876, two thou- 
sand obstetrical cases were under my care. Below are the records of 
such cases as were of special interest or importance, or which required 
from various causes the application of art. Abortions, premature labors, 
and consultation cases are not included in this number ; an exception, 
however, will be noticed in the record of plural births. 
Variola ; a Case of Delivery on the Seventh Day of the Eruption. - 
The woman and her husband and four of her eidit living children were 
the occupants of the only two rooms which, with a small attic story, com- 
1 Read before the Obstetrical Society of Boston, February 10, 1877. 2 
A Synopsis of Private Obstetrical Practice. 
prised the house. On my arrival I learned that labor began five hours 
before, that my patient was in the seventh day of the eruption of va- 
riola, that she had mild delirium, that three of the children were in 
different stages of the disease, and that there was a great want of light, 
air, and food. Within an hour the whole family was vaccinated, and 
at the end of it the baby was born, and upon its lips, forehead, and 
body there was the characteristic eruption of the disease at about the 
fourth day. As soon as the baby was born it was vaccinated. One of 
the children, five years of age, died on the eighth day of the eruption ; 
all the others recovered, the baby having the disease lightly. 
Scarlatina: Two Cases; One having Scarlatina at the Time of Delivery ; 
the Other associated with the Disease. - Case I. Two children had scar- 
latina simplex, and one had scarlatina anginosa ; the eruption had nearly 
disappeared ; they had been taken care of by the mother, who was at 
full term of pregnancy. Early in the morning of the seventh day of 
the eruption of the disease in her children, the mother was taken with 
vomiting and fever, and from four to six hours after, the eruption made 
its appearance upon her face, breast, and arms. Labor began about 
twelve hours after the vomiting, and the child was born four hours 
after that, covered all over with the scarlet eruption. All the cases 
recovered. 
Case II. In this family there were three children passing through 
the disease when the mother was taken in labor, which was accom- 
plished without untoward event while she and the whole household, 
aside from the sick children, were suffering from scarlatinous throats. 
About twenty-four hours after the birth the baby displayed a perfect 
specimen of the eruption over its whole surface. All recovered, but 
the eldest son suffered for a long time from sequelae of the disease. 
Rubeola: One Case of Delivery within a Few Hours after the Appear- 
ance of the Eruption. - There seemed to have been no prodromal stage 
in this case : the eruption made its appearance on the mother early in 
the day ; the child was born in the afternoon after an easy labor of 
three hours, and was covered with a ] erfectly developed eruption; 
both recovered. 
Plural Births: Thirty-Three Cases and Sixty-Seven Children; One 
in about Sixty-Two Labors; One Case of Triplets; the Remainder, 
Twins ; Sex of the Children as follows: - 
Male. 
Female. 
Total. 
One case of triplets 
3 
Four cases of miscarriage at four, five, seven, and eight months.... 
8 
Five cases of miscarriage at four, four, five, seven, and eight months 
5 
5 
Five cases at term, one child of each sex 
5 
5 
Eleven cases, all males 
22 
Seven cases, all females 
14 
40 
27 
67 A Synopsis of Private Obstetrical Practice. 
3 
There was, also, one abortion of twins at ten weeks, which was pro- 
duced by an instrument; there was profuse flooding and prolonged 
convalescence. • The triplets lived to be twenty years of age, and for 
aught I know may now be alive at forty. Of the miscarriages three 
were acknowledged to have been induced, one of them by an instru- 
ment ; in the others the means used were concealed; the mothers 
recovered without trouble. In one of the cases at term the male pre- 
sented the left shoulder with head to the left, and was turned and 
delivered; the female followed normally. In three cases the second 
child was born dead; two of them had evidently been so for several 
hours. In many of the cases special notice was taken of the placentae, 
but there are no records. 
Deaths of Mothers: Three Cases. - There were three deaths of 
mothers attributable to or connected with childbirth, each occurring 
within seven days of that event, and there were no other deaths due 
to that cause. 
Case I. S. S., age thirty-eight. This was the sixth single birth in 
eight years. The labor was normal, but the lady was, and remained, 
blanched, and coughed a great deal, having a sense of weight or op- 
pression over the chest. She died on the seventh day after delivery. 
The autopsy was made by Dr. Bowditch. " There was found car- 
tilaginous thickening of the mitral valves of the heart, and a congested 
state of the lungs, . . . slight trace of tubercle, . . . uterus well con- 
tracted, peritoneum and intestines normal." 
Case II. P. S., age twenty-two. Primipara. Upon my arrival I 
was informed by the midwife in attendance that the existing condition 
of things had remained the same for from four to five hours. I found 
a second stage of labor, the os not fully expanded, an oedematous ante- 
rior lip, and a protruding caput succedaneum ; the patient was uncom- 
plaining and almost indifferent, evincing great fatigue rather than 
exhaustion. Having drawn off the urine and succeeded in gently forc- 
ing back the anterior lip, I waited for two or three pains, when, find- 
ing that the head remained stationary, and taking into consideration the 
condition of the patient, I applied the forceps, and having brought the 
head down far enough to cause bulging of the perinaeum, disengaged the 
instrument; after this with the third or fourth pain the head was born, 
the child giving evidence of being alive by gasping and uttering one 
or two feeble cries. There were several minutes (four or five) before 
a shoulder could be brought down ; as soon as this was effected the 
child was born dead. The mother seemed to be going on well up to 
the seventh day, when she suddenly died. Autopsy was not permitted. 
Case III. Mrs. R., age thirty-six. A well-formed and healthy 
woman ; had been delivered by me, successfully, three times. The 
fourth labor went on propitiously up to the moment of the expulsion of 4 
A Synopsis of Private Obstetrical Practice. 
the child, which came quickly with a gush, the placenta following im- 
mediately, and simultaneously a deluge of blood and collapse of the 
mother. Instantly I sprang upon the bed, and, seizing the legs under 
my arms, elevated the pelvis and ordered snow or ice to be brought 
without delay, and had a drachm of fluid extract of ergot and a half an 
ounce of brandy poured down the throat. Resigning my position to 
the husband, I passed my hand within the expanded uterus and with 
the other kneaded it externally ; there was no contracting response. 
Basins of snow arriving, a ball of it was conveyed within the womb, and 
soon after this I was enabled to inject water at a low temperature. 
Pressure upon the abdominal aorta momentarily checked the flowing of 
blood, but it seemed to me there was little left within the body that 
could come away. Dr. Arnold, who arrived fifteen minutes before the 
death, has kindly sent me his notes of the case, from which I make the 
following extracts: - 
" A remarkable feature was the irregular contraction of the uterus : 
sometimes it seemed to have contracted quite firmly, as was evinced by 
the small, rounded tumor and the hard, firm walls, and again to dilate to 
the size of one four months pregnant, while digital examination found 
the walls of the uterus soft and spongy. This contraction and dilata- 
tion occurred irrespective of the compression of the aorta. Although 
during the continued compression of the aorta but little blood was lost, 
she still sank." 
There had been no contraction of the womb up to the moment of the 
first introduction of the hand of Dr. Arnold, but in two or three min- 
utes, by our united efforts of kneading and compressing the aorta, the 
contractions mentioned in his notes took place. The time from the 
birth of the child, which is alive and well, to the death of the mother 
was one and a half hours. I may mention that perchloride of iron was 
sent for, but it failed to arrive. 
Two Cases of Obstinate and Protracted Rigidity of the Os. - There 
were two cases worth mentioning, in which this condition was observed 
in primiparae; both were strong, muscular women, having black hair 
and dark complexions : - 
Case I. Mrs. S., age thirty-nine. I was called to this case early 
in the morning, and was told that the pains, which were of great strength 
and severity, began twelve hours before, and still continued. Natural 
evacuations had taken place within two hours. Upon taking a pain I 
found it almost impossible to reach the os, which was well up in the 
hollow of the sacrum, but eventually made it out, closed, hard, firm, 
and unyielding; the hard, rounded body behind the anterior segment 
of the uterine wall indicated a head presentation ; there was little 
moisture of the vagina ; the abdomen was not pendulous. I ordered 
nourishment and afterwards opium. Returning five hours later, I A Synopsis of Private Obstetrical Practice. 
5 
learned that there had been but slight effect from the opium. Taking 
a severe pain, I found that the condition of things seemed not to have 
changed in the slightest degree ; and it Was the same after eight hours 
from this time, although opium had been given more freely. There 
was no lack of courage, patience, or strength. The patient now sat in 
a warm hip-bath for thirty minutes, after which the vagina was filled 
with warm sweet-oil. Tartrate of antimony was given ; there was no 
nausea, but after a while a copious alvine dejection. I now made an 
attempt by manipulation over the abdomen to change the position of 
what I believed to be the head of the child, so that, if successful, the 
os should come forward within easier reach of the finger. I signally 
failed. Venaasection and inhalation of ether were peremptorily declined. 
I he husband and I were the only persons in attendance; a spring 
freshet had surrounded the house, which was built on piles, with water 
and ice to the depth of three feet, the storm was raging, and for these 
reasons counsel was not readily attainable and I was forced to go 
through with the scene as best I might, alone. 
After about forty-eight hours had elapsed since the beginning of 
these hard pains, recurrent on an average every five minutes, without 
producing apparent effect, there seemed to be a moderate increase of 
vaginal mucus and a little less hardness of the os, which was, to a 
trifling degree, more readily accessible, so that I warrantably felt en- 
couragement. From this hour labor went on with perfect regularity ; 
but twenty-four hours elapsed before the birth of the child, which was 
born alive, he and his mother doing well. 
Seventy-two hours is a long time for a woman to be under the 
suffering of such pains as those of labor, and if she maintain her 
strength and good nature to the end as did this one, we can but remark 
the fact as unusual. It should be borne in mind that these, from the 
beginning, were not the "irregular," "flighty," "aggravating" pains 
which occur before labor fairly begins, but I emphasize the fact that 
they were downright, hard, contracting pains. 
Case II. Mrs. C., age twenty-two. In this case the strong pains 
began sixty hours, and the os gave symptoms of yielding ten hours, 
before the birth of the child. In almost all respects this was like the 
first case. Venaesection and inhalation of ether were refused. The 
mother and child did well. 
Three Cases of Convulsions. - The following are the only cases of 
convulsions I have witnessed, and the notes of them are transcribed in 
full : - 
Case I. L. V., age thirty, third labor, dark haired, and somewhat 
above medium size. Labor normal and hygienic surroundings appar- 
ently good ; the placenta followed the child in about three minutes, and 
five minutes after that the woman, lying nearly on her left side, be- 6 
A Synopsis of Private Obstetrical Practice. 
came violently convulsed ; in a short time, having come out of that con- 
dition, she drank some water and soon had a second convulsion, less 
severe than the first, and again a third, quite moderate, which was 
the last. With the exception of the water which she was allowed 
to drink there was almost nothing done for her, for the good reason 
that there was nothing available with which to do anything, except 
never-absent mustard, which was plentifully rubbed on her feet, legs, 
and back. Mother and child did well. 
Case II. A. P., age thirty-five, primipara. This tall and thin, 
black-haired woman had a normal delivery, the placenta following the 
child within five minutes; twenty-five minutes after this, while lying 
nearly on her left side, she was seized with a violent convulsion, 
which having passed, she fell into a quiet, and peaceful condition and 
remained so for nearly two hours, undisturbed. She now had another 
convulsion, seemingly of greater severity than the first, on the subsi- 
dence of which, finding her pulse hard and incompressible, I took from 
her arm many (the record says forty) ounces of blood, at the same 
time having her seated in a chair with her feet in a hot foot-bath. 
While she was in this position there was a third and less severe attack, 
after which we replaced her in bed, where she slept quietly for nearly 
an hour and a hall ; she then had the fourth convulsion, which was 
moderate and the last. 
At about this time Dr. G. H. Lyman was driving by the house, and 
I invited him in, and he gave me kindly encouragement to expect a 
recovery. Mother and child did well. 
The hygienic surroundings of the wooden house were not good; it 
had been built and occupied many years, and, as is the case with about 
nine tenths of the farm-houses in the country, the earth on one side 
was saturated with the thrown-out household slops. 
Case III. J. S., primipara, age twenty-one. A tall and rather 
large-framed woman, of nervo-sanguine temperament; was going on 
normally with the labor, when, after the head of the child began to ex- 
pand the perinaeum and slowly but perceptibly to advance, regularly 
and propitiously, I perceived her eyes rolling upwards and a moderate 
" hunching " ot the right shoulder, as she lay nearly on her left side. 
Quickly stepping into the next room for my forceps, I found the patient 
upon my return in a well-developed convulsion, and also placed by our 
most excellent nurse - bless her - in an admirable position for the use 
of instruments, and a deep pitcher of hot water on the floor, into which 
I plunged the instruments for a moment and then, immediately, by 
their aid drew forth the child ; in a few minutes the placenta fol- 
lowed. There were but two other convulsions, each less severe than the 
previous one. There was a profuse haemorrhage afterwards, but by 
the time of the arrival of Dr. H. G. Clark, who had been sent for, A Synopsis of Private Obstetrical Practice. 
7 
there seemed to be no important indication for serious apprehension of 
an unfavorable result. Mother and child did well, and have remained 
so these eight years. 
In none of these three cases were there any premonitory symp- 
toms leading me to anticipate trouble of any kind at the birth. In 
the first two no anaesthetic was used ; ether was administered in the 
third case for about one hour, and the attack took place while the 
patient was under its influence. The hygienic surroundings, so far as 
I know, were unexceptionable. It will be seen that in the first of this 
series of cases almost literally nothing was done for the restoration of 
the patient; in the second much was done; and in the third that was 
done which, I suppose, was what any obstetrician would have felt cer- 
tain was the proper thing to do. I must be pardoned for the few words 
interposed about the nurse ; they and more are in my notes. To have 
a kindly, cool, and handy nurse, one who is willing and knows what to 
do at the right moment, is next to having, in an emergency, a strong, 
friendly, and reliable brother practitioner by one's side. 
Nineteen Cases of Accidental Ante-Partum Hemorrhage., Immediate 
and Remote. - One case of profuse haemorrhage immediately preceding 
labor is recorded as follows : S. S., aged thirty-six, third labor. A del- 
icate woman, bearing children in rather quick succession, early one 
morning walked from her bedroom to her kitchen, which was on the 
same floor, and while standing for a minute or two giving directions 
7 CT CT CT 
had a gush of blood from the uterus, in quantity represented as amount- 
ing to at least a pint and a half. She was immediately clasped by the 
cook and quietly drawn back to her bed, upon the side of which she sat, 
being disinclined to get into it, as she did not feel particularly faint. 
Thirty minutes after the gush of blood I found her in the position above 
mentioned, cool and collected, assuring me that she had not lost blood 
to any amount since the first moment, and that she had had no pain. 
It was soon expedient for me to make a careful examination, and I 
found that with the exception that the os was patulous, readily admit- 
ting the end of the finger, everything was normal. There being no 
haemorrhage and the mind of the patient reliant, I awaited develop- 
ments. Not many minutes elapsed before pains began, and the labor 
went on with perfect regularity, and a healthy female child was born 
in about one hour, the placenta following in five or six minutes. Mother 
and child did perfectly well. 
Of nine women, three were primiparae, two had had one previous 
labor, three had had four previous labors, and one had had nine ; each 
had flowing about four weeks after conception, the time being reck- 
oned back from that of the delivery, which was at term, and in no case 
was there any special trouble. 
In three other cases there was a flow three consecutive times at the 8 
A Synopsis of Private Obstetrical Practice. 
monthly intervals next preceding delivery, and in one case a flow four 
weeks previous to delivery; in each of these cases mother and child 
did well. Nineteen cases are accounted for, and in all of this series 
the report is reliable; I mention this because there seems to be so 
strong a disposition in pregnant women, or in those who have recently 
passed through the ordeal of childbirth, to exaggerate in their relation 
of what they have experienced, and we are told tales of great hardship 
and many hair-breadth escapes. In the first case I could but be appre- 
hensive for a while of having to conduct it through the dangers of a 
placenta praevia. I know of no solution of the cause of the haemorrhage 
but this, that an edge of the placenta must have started away from the 
uterine surface ; it was carefully inspected at the proper time, but noth- 
ing unusual presented. The other cases seemed to be of the kind we 
read about, of deviations in the regularity of the' menstrual function, 
and that would appear the more probable from the fact of the periodic- 
ity of the discharge. During the flow and for several days after its 
cessation, the principal treatment relied upon and peremptorily insisted 
upon was absolute rest. 
Fifteen Cases of Post-Partum Ilcemorrhage.-Under this caption 
the case which was related under that of Deaths of Mothers is not in- 
cluded, because the birth of the child, that of the placenta, and the 
flooding were as nearly simultaneous as was possible, and therefore the 
haemorrhage can hardly be said to have been post-partum. There are 
fifteen cases, of which there are special notes, which properly come 
under this head; in six of them flooding occurred on account of inertia 
of the womb following prolonged and exhausting labor; in seven, on 
account of a too rapid labor; in one it took place three hours, and in 
one eight days after the birth of the child, and upon the last two cases 
are the following comments : - 
The labor in the case mentioned last but one was attended by the 
mother of the patient, and she called for my assistance because her 
daughter was getting pale and restless. I learned that the child was 
born about three hours before my arrival; that the afterbirth followed 
in about three minutes, " a little aid having been given." The patient, 
blanched and restless, had a sighing respiration and an irregular pulse. 
The womb was expanded to the size of the new-born child's head : the 
os was loosely closed around a string of membrane about the size of an 
ordinary untied skein of silk, and at the moment of examination there 
was but a moderate flow of blood through it. The shred of membrane 
having been removed, a finger was insinuated within the womb, which 
was occupied by a large clot, and when this began to come away con- 
traction of the organ followed, and there was no further trouble. 
The cause of the haemorrhage in the case in which it occurred eight 
days after the birth of the child is unaccountable, for the labor was nor- A Synopsis of Private Obstetrical Practice. 
9 
mal, the health of the lady had been good, suitable and sufficient nour- 
ishment had been taken and enjoyed, the nurse was faithful, and all the 
surroundings were of the best. I arrived thirty minutes after the first 
moment of alarm, and found the patient breathing slowly, but not in a 
labored or sighing manner, the pulse soft and slow, the skin normal to 
the touch. The uterus seemed not to be expanded, or if it were it was 
to a limited extent; there was a moderate flow of blood from the womb 
through the os, of which I convinced myself by digital examination, 
exercising the greatest circumspection. In the bed was a large clot, 
which the nurse said escaped from the vagina just before I came to the 
bedside. 1 gave a drachm of fluid extract of ergot, and afterwards 
brandy. In about one hour from the first alarm the bleeding ceased, 
but during two hours fainting continued intermittinglv, and from that 
time there was a gradual recovery of tone and complete restoration 
to health. The occurrence took place in the forenoon of a hot July 
day. The nurse thought the fainting took place before the haemor- 
rhage. 
These two are the only cases of post-partum flooding which have 
occurred later than one hour after delivery of the child; the other 
thirteen cases all happened and ceased within the hour, and do not de- 
mand any special mention. 
Two Cases: One of Puerperal Hysteria, one of Puerperal Mania, 
or, as Churchill thinks it should be called, Puerperal Insanity. - I deem 
it of importance to report these two cases, one following the other, that 
they may be compared or contrasted. They are the only cases of the 
kind which I have witnessed. 
J. I., age thirty, temperament sanguine, previous health uniformly 
good, was delivered of her second child on the 14th of February, 1847, 
the birth being perfectly natural, and for twenty-four hours everything 
went on propitiously. Early in the morning of the 15th a violent 
thunder-storm arose, and one particular flash of lightning, which shat- 
tered a tree hard by, seemed to my patient to have exploded in a lumi- 
nous ball in her bed, between her husband and herself. On the follow- 
ing afternoon, having been called to her, it was reported to me that she 
had been alone for the greater part of the day, and that for an hour 
previous to my visit the symptoms which I then observed had been 
manifest: these were restlessness, a face of scarlet, a quick, hard pulse, 
skin hot to the hand, eyes glistening, mild delirium, with intervals 
of momentary consciousness, in which she spoke the words "head," 
" lightning," " expect to die." I immediately took from the back of 
the neck a large quantity of blood by means of cups, applied cold to the 
head, sinapisms to the extremities and spine, and gave small and re- 
peated portions of tartrate of antimony, the Rasorian plan. After a 
few hours the high grade of excitement was subdued, but the condition 10 
A Synopsis of Private Obstetrical Practice. 
of tlie patient was anything but promising. There was variety in her 
symptoms. At one time there would be for an hour or more an utter 
listlessness, succeeded, perhaps, by four or five hours of a disconnected 
jumble of occurrences which had happened recently and remotely : a 
scene would be described in part, and, as though it were a part of the 
same, another would be interposed, and so on in the same strain of 
voice, without emphasis, the diction being always good and refined. 
From and after the expiration of the few hours mentioned above there 
was no febrile excitement, but there was insomnia, which opium in 
small and in large doses proved itself unable to overcome, and after 
due trial it was laid aside. Each day was a repetition of the preceding, 
the baby was utterly unnoticed, and this condition endured for thirteen 
days and nights. On the morning of the fourteenth day from the 
attack, although nourishment and moderate stimulation had been ad- 
ministered throughout, my patient was found to be sinking rapidly, 
as shown by coldness of the extremities, the failing and faltering pulse, 
the sighing, the whispering utterance, drooping eyelids, and tremulous- 
ness of the hands, and also by our inability to arouse her consciousness. 
At this point I gave, regularly, every five minutes, one teaspoonful of 
the richest egg-nog made with brandy, so that she swallowed about ten 
drops of the stimulant with each spoonful. At the expiration of about 
an hour of this treatment I had the satisfaction of feeling the pulse im- 
prove and of seeing the countenance begin to manifest some intelli- 
gence ; a little further on there was evidence of a disposition to sleep, 
and this was permitted. On the sixteenth day convalescence was fully 
established, and on the seventeenth, the baby having been put to the 
breast three times, milk was yielded, and the health of both mother 
and child was fully restored. 
Puerperal Mania. - D. P., primipara, age twenty-six ; temperament 
phlegmatic ; for eighteen hours after normal delivery was in as promis- 
ing a condition as one could wish, mentally as well as physically. At 
this time she awoke after having had what appeared to be a comfortable 
hour's sleep, previous to which she had suckled her babe, there having 
been a secretion of milk for three weeks. Two hours after this point 
of time I saw and examined the patient, first having learned from 
her attendant that quite soon after awaking there seemed to be a fixed 
expression of countenance, the complexion not changed, a slow and 
waving motion of hands and arms, an absolute want of response upon 
being spoken to, these symptoms lapsing at about the end of an hour 
into those in which I found her, and which were those of any ma- 
niac : exhibiting superhuman strength ; unceasingly uttering the most 
profane and obscene language at the height of her voice ; showing 
neither redness nor pallor of face ; her actions purposeless or but mo- 
mentarily fixed ; regardless of her baby and all around her. The pulse A Synopsis of Private Obstetrical Practice. 
11 
could not be examined, the temperature of the skin was pleasant to 
the touch, and there was no perspiration. This bad condition went 
on to worse if possible ; the habits became filthy, and, the family not 
being able to take care of her, at the end of the second day removed 
her to an asylum, where, I was told, she died at the end of three 
weeks. Her mother had at this time seven living children, one of the 
daughters having been, at the age of twenty, for a short time insane ; 
no other case of insanity had manifested itself in the family so far as 
known. Treatment was attempted, but was not carried out. 
Two Cases of Breech Presentation. - These cases require no partic- 
ular comment save this, that they were in the third and fourth labors of 
the same woman ; the first and second labors were normal. 
One Case of Hydrops Amnii. - There was an enormous outflow of 
liquor amnii, a deluge ; it was in the evening, and I could not tell 
whether it was bluish or greenish ; it was one or the other. The baby 
was born with a double harelip and fissure of the palate. I watched 
the child for twelve years, but the mother was obdurate, and would not 
permit intervention of the surgical art. Let us hope that if an operation 
had been performed it would have been successful. 
Still Births: Nine Cases. - A. P., age twenty-three, primipara; 
large and well formed ; uniformly in good health. About the middle of 
the seventh month of pregnancy the patient had noticed an irregularity, 
or a nodulated or unsymmetrical form of the abdomen, and this condi- 
tion obtained throughout. At term, during the day, there were slight 
and occasional pains ; in the evening regular and dilating pains came on 
about every ten minutes ; the presentation could not be determined ; 
the pains having ceased at midnight, the patient slept from that time 
until eight o'clock, when they returned. ' At twelve M. the os, dilatable, 
was the size of a silver dollar; presentation still obscure; the head, ex- 
ternally, could be felt in the right iliac fossa. External cephalic ver- 
sion was attempted, but without success ; the waters had not escaped. 
After a cool consideration of the state of the case, - the increasing 
fatigue, the severity of the pains, the hopelessness of a spontaneous rec- 
tification of the position of the child, th,e reasonable apprehension that 
there would be some abnormal presentation, an arm, for instance, - 
version was decided upon and performed under chloroform. At this 
time success attended adroit external manipulation in so far that the 
head was brought up to the level of the umbilicus, and this enabled me 
to reach a foot quite cleverly without being obliged to carry the hand 
high up within the womb ; by this means legs, body, and arms were ex- 
tracted ; not so the head. Rotation brought the face towards the pubes, 
which process probably may have been assisted by one blade of the 
forceps, which was applied and moderate force used ; the other blade 
being introduced could not be properly locked; the death of the child 12 
A Synopsis of Private Obstetrical Practice. 
took place during this process. [My mental observation at this mo- 
ment was that the rotation to the position indicated would have taken 
place at any rate, and that no justifiable force for the purpose of pre- 
venting it would have done so.] Chloroform was now suspended, and 
the patient slept for half an hour. This description is in exact accord- 
ance with what was done. I must here add that the importance of 
knowing with accuracy the presenting part, or what might become the 
presenting part upon the impending rupture of the membranes before 
proceeding to the operation of version, was keenly felt. The fingers, 
the membranes intervening, assisted the external manipulation, and.by 
the time the head reached the height of the umbilicus the waters broke, 
and upon the immediate introduction of a part of my hand towards the 
left side of the mother the foot was reached. 
Anaesthesia being again induced, an attempt was made to perform 
craniotomy with a trephine craniotome, but the instrument did not work 
well. At last a blunt hook was introduced within the child's mouth, and 
by the aid of external pressure of the strong hands of an assistant, the child 
being turned well backwards towards the back of the mother, together 
with traction by the hook, the head was delivered about an hour and a 
half from the commencement of version. The lower maxilla was fract- 
ured. The perinseum was torn through one half; it healed kindly, and 
gave little trouble. The patient made a good recovery, with the excep- 
tion of a sensation of loosening cf the pelvic synchondrosis, which was 
remedied by wearing a stout belt. The child, a male, weighed eleven 
and one half pounds. 
There now follows an outline of four cases of babies born dead, who 
must have ceased to live within a short time previous to their birth. The 
first was born thirty minutes after my arrival at the bedside ; the prog- 
ress during this half hour was in all respects perfectly natural; the cord 
was around the neck once, and was easily disengaged; the child never 
breathed ; there were two living, healthy children by the parents of 
this one. 
The second was a first-born. The second stage of labor was some- 
what protracted, but otherwise normal, the advance of the head being 
steadily progressive. 
The third was as much like the second as could well be. 
The fourth was a third child ; the cord was twice around the child's 
neck, and was unusually strained; it was cast off at the first possible 
instant but the child did not breathe. 
These children were born of healthy parents whom I had known in- 
timately for several years, and were plump and well formed. Children 
have since been born to the mothers of all but the third. I need not 
say that all devices were put in operation in the hope of revivifying the 
little ones. One case of still birth from prolapsus of the cord should 
be added to this category. A Synopsis of Private Obstetrical Practice. 
13 
There are three cases of children born putrid, of two of which no 
history could be learned ; of the third the mother declared that she had 
been struck upon the abdomen accidentally by a broom handle three 
weeks previous to her delivery, which was at full term; the labor was 
natural; the placenta was much thicker than any one I have ever 
seen, and it weighed more than four pounds. The patient said she had 
suffered nausea during the three weeks, had performed her household 
duties, and had been well enough. She rapidly recovered from her 
confinement, as also did the other two. 
Phlegmasia Dolens: Two Cases. - Case I. Two cases of this affec- 
tion have fallen under my charge. The first was after the birth of the 
second child of the lady who had the haemorrhage at the onset of her 
labor. Fourteen days after her normal delivery, suddenly, great pain 
seized the whole of the left leg, followed shortly by swelling of the 
part, which in about forty-eight hours involved the whole limb up to 
the groin, and no higher at any time. In the fourth week the swelling 
began to subside, in the seventip week the patient could walk, and at 
the end of three months there was no trace of the disease. 
Case II. The second case was that of a little woman, anaemic to a 
great degree, who was suddenly taken in labor at term, and whose child 
was born within half an hour. She had habitually an utter distaste for 
meats, and I might almost say for anything that would yield good nour- 
ishment. Nevertheless, by care and watchfulness the case went on sat- 
isfactorily until the tenth day, when she besought me to let her get up ; 
I reasoned with her, and charged her not to attempt to do so. At my 
visit the next day I found my patient in a high grade of fever, suf- 
fering agony in the calf of her left leg, which was already swollen, 
tense, and shining. Having done what I could to alleviate her condi- 
tion, I sought and found out the cause of the trouble, which was this : 
within an hour of my previous visit the nurse prevailed upon her by 
saying, " The doctors were forever wanting women to lie in bed for a 
month, and it was all nonsense ; all my ladies get up on the tenth day, 
and there is no reason why you should not; so now get up and walk 
around your bed just once," and the little lady did get up and walk 
around her large French bedstead once, and within two hours her suf- 
ferings began. After two or three weeks I was discharged, and I can- 
not say anything more about the case save this, that the swelling in- 
vaded the whole limb, and the other was not affected. The nurse was 
retained. 
Craniotomy.-In 1840 there was one case which, in my judgment, 
required craniotomy, and it was performed. Counsel was sent for, but 
there was so long a delay that I proceeded alone and accomplished the 
object. The mother recovered. I cannot venture to give the particulars 
of the case from memory, and I regret that I am unable to find the little 
book in which the record of it was made. 14 
A Synopsis of Private Obstetrical Practice. 
The sum of the cases I have recorded is as follows: - 
Delivery during variola 1 
" " scarlatina 2 
" " rubeola 1 
Plural births 33 
Deaths of mothers within seven days 3 
Rigid os 2 
Convulsions. 3 
Flooding, ante par turn 19 
" post partum 15 
Puerperal hysteria 1 
" mania 1 
Hydrops amnii 1 
Breech presentations.. 2 
Dead born, including one from prolapsus of cord 9 
Phlegmasia dolens 2 
Craniotomy 1 
96