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THE MODERN  PRACTICE  OF MIDWIFERY,
       A COURSE OF LECTURES

                                            23

OBSTETRICS:^
      DELIVERED AT ST. MARY'S HOSPITAL, LONDON,
    WM.  TYLER SMITh, M.D.,

MEMBER OP THE ROYAL COLLEGE OP PHYSICIANS:
        WITH AN INTRODUCTORY LECTURE ON THE


 HISTORY OF THE  ART OF  MIDWIFERY,

          AND COPIOUS PRACTICAL ANNOTATIONS,

                     B Y

    AUGUSTUS/K. GARDNER, A.M.,  M.D.,

LATE INSTRUCTOR ON OBSTETRICS IN THE N. Y. PREPARATORY SCHOOL OF MEDICINE I
   AUTHOR OF THE " CAUSES AND CURATIVE TREATMENT OF STERILITY," ETC.

          Illustrate bg 212  (SngrgHtrgs.


                 SECOND EDITION.
u». 1  ,
"..vW>
           NEW YORK:
ROBERT  M. DE WITT, PUBLISHER,
       160 & 162 NASSAU STREET. 
                wo.

                IS5?

F.<l>~  no.  6  '> ^8  .   iu
      Kntei.ud Recording to Act of Congress, in the vear 185S, by


              ROBERT M. DE WITT,


In the Clerk's Office of the Distriot Court for the Su.ithdtn District of New York.
W. H. Timkis, PiiMer and Slertotyper.                          n  ... ,
                    "                           *»■ »". Alexakder, Binder. 
                                         TO






                       WALTER CHANNING, M.D., ETC.,





        LATE  PROFESSOR OP OBSTETRICS  IN THE  MEDICAL DEPARTMENT  OF HARVARD




          COLLEGE, BOSTON, MASS., THE EDITOR'S FIRST TEACHER  IN THE ART OF MID-




            WIFERY ;  THE LAST OF FOUR BROTHERS, TO ALL OF WHOM HE HAS BEEN




              INDEBTED FOR INSTRUCTION  IN .ESTHETICS, SCIENCE, AND  RELIGION,






                                        AND TO






                       JOHN W.  FRANCIS,  M.D.,  L.L.D.,





         THE  DISTINGUISHED ANNOTATOR OF DENMAN's MIDWIFERY,  AND THE ACKNOW-




           LEDGED HEAD OF THE ACCOUCHEURS OF NEW YORK, WHOSE NAME  IS PLACED




              IN  THE  FRONT  OF  THIS BOOK,  NOT WITH  THE  EXPECTATION  OF




t              ADDING  TO HIS NUMEROUS  AND WELL-DESERVED HONORS,  BUT




                  TO  TESTIFY  TO  HIS  KINDNESS OF HEART,  AND  ACTIVE




                                 PERSONAL  FRIENDSHIP,







                         Qt&te ESTork  is most rtsptttfulls fcibi'tatefr. 
 
EDITOR'S  PREFACE.
  As the Lectures which form the basis of this volume
approached completion in the  London Lancet, where
they first appeared, I was convinced of their superiority,
and that if collected into a volume, they would consti-
tute  the best body of Midwifery extant.  Propositions
were made for my superintendence of such a work  sup-
plying any deficiencies, and rendering it as complete as
possible—to serve at once as a manual for students and
a reference for  the practitioner.  Accordingly,  it  was
prepared for the press in the fall of 1857, but on account
of the financial revulsion, it was deemed  expedient to
defer its publication till the present summer, and nume-
rous editorial additions  mark the second  revision thus
rendered imperative.  Finally, when nearly stereotyped,
its progress was again arrested  by the delayed appear-
ance of  the London edition with several  new chapters
and  cuts,  requiring the  work  to be  torn in  pieces,
re-paged, etc., in order to place the additions in their
appropriate localities.  I have thought it best, however,
deviating from the English print, to preserve the form
of lectures  in which they originally appeared.   Further
than that, it differs little from the author1 's revised  edi-
tion, except in immaterial expressions and  expletives. 
8
editor's preface.
 [ have carefully avoided making any subtractions from
 the work even when elimination might have been of
 utility.   The  additions  which  have been  made,  are
 inclosed in brackets [ ], and will be found mainly to be
 of a practical nature ; the introductory  lecture and lec-
 ture xxxiv.,  on the  operations upon the os and cervix
 uteri, being the most extended.   I have also endeavored
 to present some instruments of  a less clumsy character
 than  those depicted  by the  author,  the use of which,
 especially the forceps, would seem, in their  own appear-
 ance, to  indicate the reason why they were so little in
 favor with English  obstetricians.   For valuable sugges-
 tions  from Drs. T.  G. Thomas and  Charles A.  Budd,
 the fruit of  their experience as  acceptable teachers of
 this branch of medicine, I must acknowledge my obliga-
 tions.  This work is  here submitted to  the profession,
in the hope that as now issued, it  may not fall under the
general obloquy of  American editions of foreign works.
Certainly  the  enterprising publisher has  spared no
expense in presenting the work in a creditable manner,
and no  little labor  and thought have  been bestowed
upon it by
                                     The Editor.
   New York, 141 East Thirteenth Street,
           September, 1858. 
CONTENTS.
■*►
                                                                    PAGB
Preliminary Lecture,..........11
   LECTURE
     I.—Generation............83
    II.—The External Organs of Generation,.....48
   III.—The Internal Organs of Generation,......62
   IV.—Ovulation,...........76
    V.—Menstruation,..........85
   VI.—Conception,  and the Early Development of the Ovum,   .     .   97
   VII.—The Decidua, Chorion, Placenta, and Umbilical Cord,   .     .  109
  VIII.—Signs  of Pregnancy,.........127
   IX.—Disorders of Pregnancy,    .    .......149
    X.—Disorders of Pregnancy—(continued),......102
   XI.—Causes of Abortion,.........177
   XII.—Treatment of Abortion,........192
  XIII.—Duration of Pregnancy,........210
  XIV.—Molar Pregnancy—Blighted Ova,......223
   XV.—Super-fcetation—Extra-uterine Gestation—Missed Labor,      .  233
  XVI.—The Gravid  Uterus,.........249
 XVII.—The Nervi-Motor Functions of the Uterus,    ....  261
XVIII.—The Fcetus in Utero,.........270
  XIX.—The Bones, Articulations, and Ligaments of the Female Pelvis,  284
   XX.—The Anatomy of the  Fcetal Dead,......309
  XXI.—The Mechanism  of  Labor,........321
 XXII.—The Mechanism  of  Labor—(continued),.....336 
X                             CONTENTS.
                                                                  PAQ8
   LECTURE
    XXIII.—The  Stages of Labor,........346
    XXIV.__The  Management of Natural Labor,......357
     XXV.—Management of  the  Puerperal State......374
    XXVI.—Presentation  of the  Face,.......386
   XXVIL—Pelvic Presentations,........400
  XXVIII.—Transverse Presentations,.......417
    XXIX.—Placental Presentation,......       428
     XXX.—Funis Presentations.........458
   XXXI.—Deformities of the Pelvis,.......471
   XXXII.—Deformities of the Pelvis—(continued),     .... 491
  XXXIII.—Obstructed Labor,.........505
  XXXIV.—Obstructed Labor  from Rigidity of the  Os Uteri,   .    . 518
   XXXV.—Tardy and Precipitate Labors,......533
  XXXVI.—Difficult Labors depending on  the  State of the Ovum,   . 545
 XXXVII.—roST-PARTUM Hemorrhage,.......55C
XXXVIII.—Rupture of toe  Uterus,.......575
  XXXIX.—Inversion of the Uterus,  etc.,......585
      XL.—Puerperal Mania,.........596
     XLI.—Puerperal Convulsions,........605
    XLII.—Puerperal Fever,.........624
   XLIII.—Puerperal Fever—(continued),     .    .    .    .    .     .  634
    XLIV.—Phlegmasia Dolens—Puerperal Arteritis—Sudden  Death
                 in the Puerperal State,......648
     XLV.—The Induction of Premature Labor,.....657
    XLVI.—Turning,...........6Gg
   XLVII.—The Forceps,..........684
  XLVIII.—The Caesarian Section,........>jq%
    XLIX.—Embryotomy,..........i^
       L.—Conclusion,..........ijgg 
   A HISTORY  OF  THE  ART OF  MIDWIFERY,

(Delivered at the N. Y. College of Physicians and Surgeons, Nov. Wth, 1851.)

                BY A.  K. GARDNER.
■***■
               PRELIMINARY LECTURE.

  Before commencing this series of Lectures  comprising the
whole study of Midwifery, written with great clearness and pre-
cision and with  a fullness unequalled  in any treatise upon this
important branch of medicine, it may be well to  note the gra-
dual advance of the art and science of midwifery  (for it has two
aspects).  Let me therefore beg your attention to a brief epitome
of the  origin and  history of the art  and  science of obstetrics,
from the  earliest records down to the present  time; and, if in
its narration, there be little food for national pride, let us not fail
to notice, that in the brief period since America has vied with the
nations of the earth in ameliorating human woes, her contribu-
tions towards assuaging the pangs of childbirth, equal,  if not
surpass, all those of the rest of the world—let us not fail in this
to see encouragement  for the future; and let all  strive to rival
one  another in the  double  aim of  benefiting  mankind and
exalting the reputation of our  beloved country and its medical
profession.
  From the foundation of the world man  has  been born of
woman;  and notwithstanding that his inventive genius has dis-
covered steam, the great Briareus of the nineteenth century,
and harnessed him  to his chariot, and  sends  the lightning to do
                                                      n 
12
FIRST RECORDED PRESENTATION.
his bidding over the almost boundless extent of the world, yet
we caniiot°hope that any change can be effected in this particu-
lar.  But, although man's entrance into this world was always
in this manner, the art of midwifery was of much  more recent
origin.  That function which it  is the aim of the art of mid-
wifery to facilitate, may  have been effected in the greater num-
ber of cases without the intervention of  foreign aid,  and the
women may at  an early period  have been confined alone; but
childbirth has never, probably,  in the most favorable climate,
and at any  time, been  always   so  easy  and  prompt.   Some
women have been exposed to great  pains  and perils.  Compas-
sion for suffering, a natural pity and a  common lot, brought
around the sufferers those who  had passed through  the  same
trials, ready to assist and counsel.  Those who therein showed
the most  courage and address were sought for at such times, and
these were in great demand.  Tradition hands down from gene-
ration to  generation  the wisdom of each  preceding, and  thus,
probably, the midwife was created, and  a distinct profession
arose, devoted to this calling.
  The first  mention that we  have  of it is, that the ancient
Hebrews employed mid wives to assist  in  the delivery of their
children ; and the first two whose names have descended to pos-
terity, are Shiprah and Puah, who were exercising their profes-
sion  at the time when the Hebrews  were first in captivity in
Egypt, about the period of the  birth of Moses.   Long preceding
that era,  however, we  have an  account of the confinement of
Rebecca and the birth  of Esau  and Jacob.   " And  the  first
came out red,  all over like an hairy garment, and they  called
his name Esau; and  after that came his brother out, and his
hand  took hold  on Esau's heel."  Thus  the first recorded pre-
sentations were  of the  head  in Esau's case—and of the head
and hand in the case of  Jacob.
  Though I have  mentioned that  the  first midwives  whose
names are given,  were at  the time of   the first captivity  in
Lgypt>it; is evident that a distinct class of persons were set
apart for this office anterior to  this period.  For we read that
- Rachel travailed and  had hard labor; and it came to pass
that when she was in hard labor, that the midwife said unto
her, Fear not, thou shalt have this son also :"  and again it is
recorded  of Tamar, the daughter-in-law of Judah, of whom it 
RAPID PROPAGATION.
13
is narrated, " that behold twins were in her womb.   And it
came to pass when she travailed, that the one put out his hand;
and the midwife took and bound upon his hand a scarlet thread,
saying, this came  out first.   And  it  came to pass as  he drew
back "his hand, that behold, his brother came out ... .  And
afterwards  came out his brother  that had the  scarlet thread
upon his  hand."    May not this be most probably  the  first
recorded case of spontaneous evolution in an arm presentation ?
Rachel is the first case  mentioned that died in labor, although
from the above quoted remark of the midwife, it would seem to
be not an unfreqnent occurrence, or at least that death in labor
did sometimes occur.  The narration continues to state, " And it
came to pass as her soul was in departing (for she died) that she
called his name Benoni."
  Some idea of the character of the assistance  afforded by the
midwife maybe judged by  the remark of Rachel to  Jacob, at
the time when she was barren :   " And she said, behold my
maid, Bilhah, go in" unto her, and she shall bear upon  my hues,
that I may also have children  by her."   Again in Exodus,
where the king of Egypt spake to the Hebrew  mid wives, say
ino-  " And when  ye do the office of midwife  to the Hebrew
women, and see them upon  the stools, if it be a son,  then shall
ye kill him," etc., but as they failed to do so, and the king asking
the reason, they replied, " Because the Hebrew women are not
as the Egyptain women ; for they are lively, and are delivered
ere the midwives  come in unto them."  It would thus appear that
art had endeavored to  invent some method for mitigating the
sufferings even at this early period, and that the " Portable
ladies' solace  or  Accoucheur's chair," is no new idea.   Hippo-
crates makes  no  mention of a  chair or any particular form of
bed in natural  confinement, but in a tardy labor he  speaks of
their being placed upon  a  chair  with a hole  in  it, or on an
inclining bed.  In the fifteenth and sixteenth centuries the mid-
wives carried  chairs about with them from house to house, and
similar ones are still in use  in Germany,  and are called  kreia*
stuhl.
   While speaking of the  Bible history of the art of midwifery,
 it mav not be amiss to  mention an instance of the most  rapid
 propagation mentioned  in any work.  After Joseph was settled
 as Governor of Egypt and his father had gone with all his house 
14
BIBLE HISTORY.
to join him, "all the souls of the  house of Jacob  which  came
into  Egypt were three score and  ten," which evidently refers
only to°the males—the descendants, excepting the tribe of Levi,
were numbered by  Moses, the second year after leaving Egypt,
which is variously considered to be from 210 years to 430 years.
The number at this time was  003,350  fighting men  above 20
years of age.   A calculation  is gone into in the Talmud, which
has been very much ridiculed by many.   Allowing for the early
marriages capable of being contracted in a warm  climate, and
ordinary length of  life, it is  found that for this increase it is
necessary that there should  be six children at a birth.   Those
believing this  have been jeered at, because it was stated that
there never was an  instance recorded of  so many human beings
being born  at once.  But, recently, a woman at  Sidney, New
South Wales, was delivered of this number, which has proved
the thing possible,  though none the less miraculous.
  There is  much in the Old Testament upon kindred  topics,
many laws are laid down to the  PentateuA respecting men-
struation  and  its disabilities, purifications therefrom, etc.   Its
particular reference to Bathsheba  is mentioned in  2d Samuel.
Barrenness is called " a closing of  the  womb "  instead  of "a
stricture of the cervix uteri" of  the  modern  nomenclature.
Tho  period of utero-gestation is stated  at nine months, yet in
the Book of Wisdom the following remark occurs relative to the
term of pregnancy; c' and in my mother's womb was  fashioned
to be flesh in the time of ten months."  These ten months must
of necessity be moons or forty weeks or  two-hundred and eighty
days : a term deemed most precise of the duration of utero-ges-
tation.   The words  " untimely birth " are to be found in several
places  as in Job and in the Psalms. Labor pains are noticed in
several passages.   The management of  new-born children is
but alluded to in Ezekiel.  Lactation was much prolonged, for in
the apocrypha a woman says to her son, " I who gave thee suck
three years."
  From this  period to the  birth of  Hippocrates, 458 years
before the birth of Christ, we have no record of the advance of
the art, if any there were.  At this period it would appear that
nature was but little assisted by art.  The  practice was in the hands
of females without information upon  the subject.  Yet Plen-
arete, the mother of Socrates, was a midwife ; and Plato speaks of 
HIPPOCRATES ON OBSTETRICS.
15
midwives and explains their functions and regulates their duties.
The  knowledge  of the anatomy of the parts  was  extremely
imperfect, even to the minds of such individuals as Hippocrates
and Galen themselves.   Conceive, if you can, the books of the
world destroyed, schools of medicine abolished, and the prac-
tice  of midwifery again in the  hands of women,  even of the
intellectual  females  of the present day, and after the lapse of
fifty or a hundred years, imagine its state !   Far  worse was  its
condition 458 years before the birth of Christ.  The traditions
upon which the midwife of those days relied, were founded upon
error, while a century hence  the  learning  of the present day
would in some degree be perpetuated.
  The writings of Hippocrates upon this subject  are three trea-
tises ; De Natura Muliebri, De Mulierum Morbis, and De Super-
fcetione, papers far more profound and embracing a far wider
reach than  we should suppose  probable at this period.  His
theory of conception  and generation was  acknowledged, till
quite a late period, as correct.  According to him conception was
a fermentation of the male and female semen, which he believed
was elaborated in the brain : the sex depended upon  the predo-
minant influence  of  either parent.  Like  Democritus, Hippo-
crates maintained  a locomotive power in the uterus, yet in his
book, De Natura Pueri, he furnishes us with some interesting
cases concerning the ovum and the means by which it may  be
expelled.  He has treated at much length  on difficult  labors,
notices various presentations and  different attachments of the
placenta.    The singular circumstance  that a  child of seven
month's gestation has, according to some, a greater  chance  of
living than one of eight was noticed by him, and he attempts
an unsatisfactory explanation of it. (This question is also moted
in the Medrash Rabbah, or the exposition of Rabbah on the
book of  Exodus, a rabbinical treatise dating from the 3d cen-
tury.  It there states of the mother of Moses, chap. ii. verse  2 :
And the woman conceived and bore a son, and when she  saw
him, that he was a goodly child, she hid him three months."   It
seems that the  executioners of Pharaoh  had spies, who noted
carefully all the pregnant women among the Hebrews, and cal-
culating closely to the date of their delivery, went and took the
child away and destroyed it.   In order, therefore, that the child
could have been concealed three months, it must  have been six 
16
THE RABBINS ON OBSTETRICS.
months and one day old,  says the Medrash, for a child can live
at seven months and not  at  eight.)   The writings attributed to
Hippocrates  treat  at some  length  of difficult  labors,  and
notice  various presentations of the child, and gives many gen-
eral directions.
   At the time of Hippocrates  the  physician and surgeon was
called upon by the midwife only when the woman was in extre-
mis,  for the purpose of delivering, by forcible means, the foetus
which threatened the life of the mother.  If the labor advanced
but slowly, Hippocrates advises that the woman be attached to
the bed, which should be considerably inclined, and then forci-
bly shaken ;  snuff to  be given, and the nostrils to be  closed
when sneezing was excited; fumigations and unctions to the
genital organs, and excitants of all kinds.   In the teachings of
Hippocrates,  he advises the breaking up of the cranium and the
extraction by the hook.  He also counsels  turning when prac-
ticable.—Celsus, who lived at the commencement of the Christ-
ian era, says,  " If the  head present, and the child is supposed
to.be dead, that a hook should be placed in the eye, ear, mouth
or forehead."
  The  deliverance of the placenta was in those early times
effected by the weight of the child, the cord not being cut until
this  was  achieved.   If the cord was  broken by any accident,
weights were  attached to the portion in connection with the pla-
centa, the woman being on a pierced  chair or an inclined bed.
Hippocrates objects very strongly  to drawing upon the cord,
and in order to make the traction as gentle and regular as possi-
ble,  advises that the  child,  or the weight before mentioned,
be placed upon  a  leathern bottle filled with water, and punc-
tured with a few holes, so that the water slowly escaping, the
cord would be gently  drawn upon.  If this  method did not suc-
ceed he gave sternutatories, that by  the sneezing the placenta be
thus detached.
   It is supposed that hysterotomy is of very ancient date, as it
was  called euPpioeknr) and voreooTouoTOKie by the Greeks ;  these
terms are still used by modern writers, but  it is generally consi-
dered that it  was only after the  death of the mother that they
had recourse  to this operation.  Indeed, writers upon  this sub-
ject  give the  ten successful cases of Rousset, published by him
in 1581,  and translated into  Latin in 1661, as  the first cases 
THE CESARIAN OPERATION.
17
where  the  operation was  performed upon  the  living woman.
He has reported ten successful cases, and one woman who was
operated upon six times, and died the seventh, because he could
find no one willing to operate.  This woman was named Godard,
of Milly, in Gatany, and was operated upon by a barber.   One
of the other women, named Ouinville, was also similarly deliver-
ed by  a barber, who  is reported, perhaps as an excuse for the
rashness of the act, to have been drunk at the time.
   The first authentic and successful case is  reported by Michel
Doeren, professor  at  Giessen, and  afterwards at Breslau, and
who died in 1664, which he saw in 1610, operated upon by
Jeremiah Trautman.
   I am, however, convinced that  the Caesarian operation was not
confined to cases where the mother had died, but that very long
before the period mentioned,  it was of not unfrequent occurrence.
I have recently been shown in the Jewish Mishnah, a passage on
this subject.  This very remarkable work is one of the most au-
thentic on record.  It was handed down by tradition for several
hundred years, as is supposed, before the Christian era; but the
various articles of the work, which is now called the Mishnah,
were not collected and written in Hebrew till a.d. 180.  In this
most curious work, upon all  sorts of topics having any reference,
however remote, to the Jewish religion, in the  5th  chapter of
the  treatise " Niddah," section  1st, is the discussion of a law
question.   It relates to the purification of women after delivery ;
and the question  is whether a woman  is unclean who has had
the child  cut from her side,  " yotza-dophan."  This would make
it appear that the operation on the living person was of  much
earlier date than generally supposed, as we would not imagine
such a  question would be debated,  if the  fact  was not known
sometimes to occur.
   After this period, almost a thousand  years passed away with-
out  leaving a  trace  of  the art, and probably without any
improvement.  Paul of Egineta, who lived in the seventh cen-
tury, and who was perhaps the first man-midwife, coincides with
Philomenus, of a somewhat  earlier date, that the whole aim was
to extract the foetus in any  way, and without regard to its life,
by turning, the crochet in the fontanelles, or by dismembering
the child.  Albucasis says the same things of Arabian midwi-
fery of the twelfth century, and describes  various instruments
for  compressing  and breaking  up the head, and others, for 
jg              WONDERS OF THE DARK AGES.

extracting it.   Among them is  a species of forceps with  teeth
which he terms a " misdach," for the purpose of crushing the head
and enabling it to pass; he also gives a plate of a single and dou-
ble hook, and a knife for cutting off the head.   Ambrose 1 are s
work, dated 1579, gives plates of various  modifications of the
same instruments.
  From this period, these and similar instruments were in gene-
ral use, and more attention seems  to have been given to the
general subject.   Ignorance is  always credulous, and  it is not
to be wondered at, that a great  number of ridiculous cases and
extraordinary tales have come down  to us.   Among those most
credible are reports of children born in  pieces, by the  anus,
through the abdomen, and by vomiting, which seemed most
wonderful  to the reporters of  those days, but which  we now
recognize  to  have  been extra-uterine  pregnancies.   Massa, a
Venetian, reports a woman, aged 60, who was supposed to have
had  dropsv,  that  was  confined,  after  fifteen months,  with a
o-irl, without eyes or arms, which defects and delay were  attri-
buted  to   her  advanced age.   Jules  Crassus gives  several
instances of children born  after eleven months' pregnancy, but
admits that these instances  are uncommon.
   It is  evident that from  this  date  more attention was paid to
the subject, from the reports of writers more credible; Diomede
Cornarus,  physician  to the Emperor Maximilian II., speaks of
deafness having occurred after labor, etc.
   By the  following data the gradual growth of the obstetric art
 may be seen.
   Aristotle first notes the importance of the menstrual flux, and
 affirms that, with very rare exceptions, women are barren who
 have never menstruated.   He also treats of the signs of preg-
 nancy and divides labors into natural and unnatural.   Celsus
 first recommends " turning " in all cases of unnatural presenta-
 tion.   Pliny considers footling cases  unnatural, and thinks that
 twelve children could be born  at a birth.   Aristotle's  credulity
 stops at five.  Galen seems to have been the first to understand
 the anatomy of the viscera of the female pelvis.  Pliny divides
 the uterus into the fundus  and neck and describes the os tinea? •
 notices the derangement of the digestive organs attendant upon
 pregnancy; ascribes to the  undue  union of the ossa pubis the
 main cause of difficult parturition.
   Among the Arabians, Serapion treats upon the disorders inci- 
INVENTION OF THE FORCEPS'.
19
dent to pregnancy.   Rhazes directs how to puncture the mem-
branes with the nail  or a sharp-pointed instrument when they
retard labor.
  Coming down to brighter days, we arrive at the period when,
by the discovery of  the vectis, the first  impulse was  given to
midwifery, and  from whence  its subsequent progress  com-
menced.   Although  claimed by many for Celsus, its real disco-
very or invention is undoubtedly due to Henry Roonhuysen, of
Holland.   Although its introduction was of great advantage to
the art of that  day, this  instrument, in its various modified
forms, is now scarcely used by practitioners, for, employed as a
means of traction, it is far inferior to the forceps, and its origi-
nal employment as a lever is so dangerous, that it is  very pro-
perly in  a great degree discarded  in  actual practice.   For a
considerable  time it was in very common use,  and till with-
in a few years, there were m'any who spoke very highly of its
utility in  changing  the positions of  the  head—an  alteration
which is now very generally believed  to be due, oftener to the
powers  of nature  than to the  manipulations  of the  accou-
cheur.
   In the invention  of  the vectis  the forceps were half dis-
covered ; for it is supposed that from this hint, Dr. Hugh Cham-
berlain, some time  before 1647, constructed  the original of the
various modifications and fashions now in use, each of which is
so highly vaunted by its possessor, although a similar instru-
ment is described by Avicenna.   Judging  of  the success of
physicians of past days, with  those of the present, it may well
be suspected, that the result depends  more upon the skillfulness
of the hands which hold the instrument, than upon any peculiar
shape or fashion of the iron.
   Since  this time but few instruments  have been invented for
obstetrical operations: one, the  cephalotribe, by Baudelocque,
Jr.,—a most formidable but exceedingly useful instrument, which
I have seen several times used in the cases of the rickety pelves
of Europe, with great success by Professor  Dubois.   It will I
trust, be  many years before disease shall be so common in this
country as to require its assistance.  It is an exceedingly useful
instrument.  Another instrument  is of more recent  invention,
of this country, I think.   It is a revival of an ancient  attempt
to pass a band over the head for the purpose of traction, and is 
20               EARLY OBSTETRIC WRITINGS.

called a fillet, if I correctly remember.  It will probably never
be of any great use.  Valuable modifications of various instru-
ments are referred to in future pages.
  About this period the illustrious Harvey, in England, and con-
temporaneously the renowned Ambrose Pare, in France, by their
genius  still farther advanced the art and drew attention to it.
Pare wrote largely upon monstrosities both human and compara-
tive, giving thirteen causes for them, including divine wrath.  He
divided labors into riatural and preternatural, classing under the
former those cases in which the child presented with the head
and was delivered coincidently with the discharge of the waters.
The  preternatural  includes all others, in all  which cases  he
advises  turning.  Guillimeau, his pupil, records cases of rup-
tured uteri under his own observation.
  Harvey's work De Gencratione gives detailed accounts of expe-
riments made under royal patronage with a view to the elucida-
tion of the subject of generation.  In it he attempts to detect the
nature  of conception, and follows the daily change in the hen's
egg during incubation.  His examinations are minute and origi-
nal.  He discovered that the chick originated  from the cicatri-
cula of the ovum, and the punctum saliens to be the heart.   These
and many other investigations entitle  him to  be mentioned with
high respect among  those who have  advanced the obstetric
science.
  About this time, 1663, the ignorant midwife was supplanted by
the man of scientific attainments, as will be hereafter mentioned.
  In 1640, an essay on foetal life was written  by Ny mm anus and
a treatise on the diseases of women and children by Sennertus.
Mauriceau, in 1666, gave to the world his system of midwifery,
more ample in its details and richer in practical information than
any  preceding  work.   It  was  translated  into English  and
published by the Chamberlains.
  From  the general introduction of the  forceps into obstetric
practice  about the year 1700,  one very  happy result  was
achieved.  Previous to  this time physicians, as I have before
said, were only called to women in  labor to correct the blun-
ders committed by the ignorant women  in  attendance, and as
this was generally after hope itself had almost fled, he was gene-
rally considered as the messenger of death.    But the preten-
tions of the possessors of this new instrument to greatly abridge 
EARLY  OBSTETRIC TEACHINGS.
21
the duration of labor when it was natural, and to save life when
difficult, changed the habits of the people.   Every  woman
almost,  was delivered with the  forceps.   The consequence was,
that the theoretical knowledge  of the physician soon became
practical;  what had  been for so long mere chance, quickly
advanced to  the dignity  of  an art.   Vigorous  and educated
minds began to be interested about it;  labors  were classified
and instruments were used only in cases  especially requiring
them.   Nature was no longer interfered with, but assisted when
her powers failed.  The mechanism of labor then first began to
be understood.  Previous to this period  it was supposed that
the child during utero-gestation retained  a sitting position in its
mother's womb, and that a short time before confinement,  it
therein  turned a somerset  in order to bring the head in the usual
position for delivery.
  Astruc thus describes this prevalent opinion :  " In this state,
the infant has his head upwards and his feet towards the orifice
of  the  uterus,  with  his  face  towards his mother's abdomen.
During the first six months he remains in this situation, his head
being towards his mother's navel, for his  feet are, during that
time, specifically heavier than the head ;  but this part begins at
length to grow faster, in proportion, than  any other ;  wherefore,
its superior weight turns the head  downwards towards  the ori-
fice of the  uterus, just as we see a ball of lead joined to a piece
of cork, by its specifical weight to sink, whilst the  cork floats
on  the  surface, or  keeps the  superior parts.  This change of
situation of the infant is owing to the speedy  growth  of the
brain.   He is thus turned about fifteen days or three weeks
before the  delivery, which the inidwives,  nay,  the mothers, per-
ceive at that  time, wherefore  they say that the belly has then
fallen."
  It was then supposed to present, with the long diameter of the
head to the  short diameter of the  pelvis,  either the occiput or
sinciput to the sacrum.  Sir Fielding Ould was  the  first writer
who corrected this latter opinion, and stated that the face was
turned in the first part of its progress to one side or the other
of the  pelvis, "so as to have the  chin  directly on  one of the
shoulders."  Dr. Smellie, in 1752,  began to  teach in England.
It is reported of him that he had at his  door a paper  lantern
placed,  upon which was written, " Midwifery taught here for 
22
OBSTETRICS TAUGUT IN  AMERICA.
 five shillings."  He corrected the error of the  twisting of the
 neck, but generally agreed with Ould.
   He also contributed materially to  the mechanical improve-
 ment of instruments, was the  first who accurately determined
 the shape and size of the pelvis, and the head of the foetus, and
 pointed out the whole progress of parturition.
   From this period, general attention was  given by the profes-
 sion to the  study of midwifery.   The art was regularly intro-
 duced as a branch of education in the medical schools.  Nume-
 rious establishments were devoted to practical  instruction of
 students  in surgery and  mid wives.   The illustrious  Ruysch of
 Holland, prepared two cabinets of preserved foetuses of all ages,
 sizes and conditions (afterwards sold  to Russia)  perhaps never
 equalled.   By his writings and labors he greatly^ advanced the
 science.  Maubray, 1723, was the first teacher of the science in
 England,  and opposed the use of  instruments.   Dioneis reports
 cases of ruptured uteri.  Gregory the younger,  gave a course
 of instruction in Paris in 1733, he gave the first correct idea of
 the nature of retroversion of the  uterus.  Manningham a simi-
 lar course, and  a clinique at  his own house in London at the
 same time, having  established  the  first hospital for lying-in
 women  in England.   De Lapeyronie, first  surgeon to Louis
 XV., created two  chairs for obstetric teaching,  one for sages-
 femmes and one in the college  of  surgery.  The  faculty of
 medicine  instituted a similar  chair.    In  1697,  Van  Hoorn
 in Sweden, established a similar  professorship for midwives at
 Stockholm.   In 1737, a hospital and practical  school  was
 established at Strasbourg, the first institution of the kind created
 for students.   Similar institutions were established all  over
 Europe, and among them in  Rome, in 1789, by Pope Pius VI.
 and in St. Petersburg, in 1797, by the Empress Federowna.
  The  publication of Dr. William Hunter's great work  on the
 gravid  uterus in 1775 forms an era in our science.  It is unsur-
 passed  in  the accuracy of its  drawings  and the style of their
delineation at the present day.   In it  he portrays the membrana
decidua and reflexa which are his own discoveries.
  Not behindhand in the march of improvement, Dr. Shippen of
of Philadelphia, pupil  of Dr. W. Hunter, first
                                          gave public
                                        -e  year 1762.
ret class often pupils increased to two hundred  and fifty
instruction in midwifery in the New World in the vear 1762 
PROPOSITION  OF SYMPHYSIOTOMY.
23
before his death.  In  1767, the medical school in New York,
under the direction  of King's,  now Columbia  College, was
founded with Dr. V. B. Tennant, professor of obstetrics.
  In 1756, the subject of the induction of premature labor as a
substitute for craniotomy, the csesarian section and other similar
subsequent dangerous  operations,  was first  made a matter  of
discussion.  The  usefulness of the operation was soon allowed,
but the mortality soon rendered the matter a questio vexata, not
only for the physicians, but for the D.D.'s of the Sorbonne.
  It  is curious to see how similar questions  were  frequent
stumbling-blocks in the schools of France,  where  a very large
majority of  the  children under discussion were generated in
immorality, and then to  observe with what  clearness the great
English  teachers,  Denman, Clarke, Burns,  and  others, have
investigated  these apparently similar questions.
  Whatever may have been the queries, no  objections are now
urged against this operation, which  is occasionally practised  by
all the celebrated accoucheurs of the present time.
  In  the year 1768 the plan of dividing the ossa pubis was pro-
posed by Sigault, of France, for the purpose of  increasing the
antero-posterior diameter, and  thus  safely delivering the  child.
It is astonishing with what enthusiasm this operation, now every-
where reprobated, was received  by the profession throughout
the world, and  more particularly in France.   Calm investigation
was out of the question, and  the operator and inventor were
everywhere received with the most distinguished  honors.   Not-
withstanding that the patient,  who had  previously been  deliv-
ered  by  craniotomy, barely escaped with her  life, and received
a serious injury of the bladder, on the strength of this one case
the medical  faculty of Paris voted  medals  to Sigault  and  his
assistant Le Roi, and a pension to  the former and his unfortunate
patient.   In no future case  was  the success equal to this,  the
first.   " Every operation had its  victim,"  says Hull, " not-
withstanding it was sometimes performed upon women whose
pelves were slightly deformed, and had previously been delivered
without  extraordinary assistance."  In  England, this plan was
first seriously examined by the Hunters and  Dr. Denman, who
reported against it.  Indeed, subsequent examination has proved
that the  division of the ossa pubis does not  sensibly enlarge  the
antero-posterior diameter, and  the whole matter seems to have 
24       CLASSIFICATION OF OBSTETRIC  PRESENTATIONS.
 been verv much like the question  once proposed to a  learned
 academy, and long and  profoundly debated by them, why  a
 bowl filled to its utmost capacity with water would yet admit  a
 fish to be placed therein without displacing its contents.  Symphy-
 siotomy  has, however, done  one good thing.   It has taught
 the profession to be certain of facts, and  to reason upon them,
 and  act, also, afterwards.  Has the  lesson been received ?  or is
 every new theory and medicine—homoeopathy or cod liver oil—
 received as soon as promulgated ?
   A somewhat similar operation, called not after  its inventor, but
 by its reviver in 1829, is Catolica's operation, which differs from
 symphysiotomy in  not dividing the cartilage, but the body and
 ramus of the pubes on each side between the two foramina ovales,
 as was  recommended  by Aitken in 1785.  A more scientific
 appellation would  be bi-pubiotomy, were  a  name desirable for
 an operation which is not recommended  by a single successful
 result.
   While these  foolish proceedings  were  being enacted, there
 were some attending to the true interests of the art, and  by a
 curious coincidence, Saxtroph, of Copenhagen, and Solayres de
 Renhac, of Montpelier, in 1771, published  each  an essay which
 agreed in the assertion, that the long diameter of the head,  con-
 trary to all previous teachings, entered the pelvis parallel to one
 of its oblique diameters, the sagittal suture running in a line from
 the sacro-iliac synchondrosis behind to the foramen ovale in front
 and generally from the right sacro-iliac  synchondrosis to the left
 foramen ovale.
   From  this small beginning have  proceeded  those  improve-
 ments in midwifery which have rescued it from empiricism, and
 almost transformed an art into a science.
  Baudelocque, in the year 1791, methodically arranged the posi-
 tions and presentations of the child, making  twenty-two presen-
 tations and seventy-four positions.  This classification, modified
as ,t  has been by various subsequent writers, among  them  and
the most  conspicuous, Naegele of Heidelberg, is at the bottom of
the present system of teaching throughout the world   No prac
titioner who pretends to science at the present  day, denie  the
great importance of a knowledge of the position, as well a   he
 part presenting.  All operations are based upon  this know  die
for as formerly the  forceps were put  on to the head in any man 
RECENT OBSTETRIC APPLIANCES.
25
ner which wa9 the most, convenient, at  the present  day their
application is in accordance with established  rules, each depend-
ing upon the position of the head.
  In  1791,  Frederick William Voigtel published  a volume, I
think the first on the subject, upon the " toucher" and the signs
of pregnancy shown by it.
  In 1S07, the first addition to the obstetric art from America was
made by the discovery of the peculiar virtues of Ergot in excit-
ing uterine contractions, by Doctor John Stearns, late of this city.
The general virtues of this very valuable medicine were  for a
long period but little known to the mass of practitioners, and its
use confined to the younger members of the profession, and those
of the elder who have sided in its favor.  Many and long were
the controversies respecting its virtues.   Its value as a medicine
in various diseases of women is  still under investigation.  In
1818, Mr. Mayer, of  Geneva, first applied  auscultation  to the
diagnosis of pregnancy—a discovery of very great value to the
accoucheur, but a branch to which too little  attention is paid by
the profession generally.
  Another operation still, and fully stated in Lecture xxxiv, is the
division of the os and cervix uteri in cases of obstinate rigidity,
and where the urgency of the case demands the active interfer-
ence  of the attending  physician.   When this matter shall be
fairly brought to the attention  of  the profession, I venture  to
predict that it will take its place as  one  of  the rarely required
but possible and justifiable obstetric operations.
   Of many recent additions  to  the appliances of obstetric sur-
gery  I can but  merely allude, as their exact value cannot be
fully estimated till time has stamped them  with  its seal; they
are,  however, more fully  mentioned  in the following  pages.
They are the colpeurynter, the sponge  tent,  the douche, where-
with  to produce premature delivery ; the uterine sound to diag-
nosticate the  interior  condition  and size   of the  uterus;  the
measurement of tumors etc.; the speculum used in connection
with  obstetrics to facilitate the tamponing of the os uteri and the
vagina, in cases of haemorrhage ; and in general the improve-
ment of  the forceps, tractor  or vectis, craniotonry forceps, and
other instruments, in effect almost equally their  recreation, and
greatly diminishing the mortality of parturient females.
   Finally, within the  remembrance of all, the  application of 
2Q                ANESTHESIA  INTRODUCED.

anesthesia to our art has driven  away the suffering and the fears
from many minds.  Early used by Simpson of Edinburgh and
.tron-ly recommended by that  distinguished  physician, it  has
been received with much distrust in this country.  The wife  ot
Longfellow, our distinguished poet, was the first in America to
e-ay its wondrous virtues under the  direction of Dr. Bigelow,
Senior, of Boston.  Its use in that city is now very general, but
exceedingly limited in New York, although not a single unfortu-
nate case has been reported that I have heard of.
  Having been myself among the earliest,  if  not the first, phy-
sician in New York to administer chloroform in labor [see cases
reported by  me, in the voluminous work published in Boston by
Dr. Channing, Professor  of  Obstetrics  in Harvard University,
entitled " A  Treatise  on ^Etherization in Child-birth,"  with
reports of 5S1 cases], and having continued ks use until the pre-
sent time, I  feel entitled, from personal experience, to commend
its administration in almost every case of labor, as well in simple
and natural  as in difficult and instrumental.
  The religious objections made against its use, that it nullifies
the curse "  I will greatly multiply thy sorrow and thy concep-
tion ;  in sorrow thou shalt bring forth children," reminds one of
similar discussions respecting craniotomy in olden time, of which
the distinguished Astruc thus speaks :  'v Reason itself and daily
practice affirm that the  mother's  (life) should be saved at  the
expense  of  the child's; wherefore  when authority, reason  and
example concur in the determination of any affair whatsoever,
we should always submit thereto.   Yet some divines and phy-
sicians of no small note maintain that the infant's life should be
rather preserved, that he should not die in original sin, which is
washed away by baptism.  But as the weight of their arguments
is chiefly built on a religious circumstance, the difficulty may
be removed in most cases by administering this sacrament to the
infant in the mother's womb, whether any part of its body presents
itself to our view, or whether it does not, so  that the  baptismal
water may be  conveyed immediately on  this part  by the  help
of  a syringe, breaking its  membranes if they intervene ; which
practice should be put in execution in all  difficult births, before
the extraction of the infant is attempted.   For it is authorized
by able divines  and  daily example:  wherefore rejecting  the
second, we should acquiesce in  the decision of the first pan." 
       OBSTETRIC WRITERS OF THE NINETEENTH CENTURY.      27

   The great value of anaesthesia in  many cases of  operative
 midwifery, few will pretend to deny, and already a large number
 of medical men throughout the country approve of its moderate
 use  to mitigate the sufferings of this state.   This  number I
 think is greatly increasing, and before this generation has passed
 away, we will  probably see labor  rendered painless  an  every
 day occurrence.  Should it be so, the  art of midwifery will have
 advanced more rapidly in  this than in the famous eighteenth
 century, its golden epoch.
   The nineteenth century has  been prolific in writings.  Not to
 remention Baudelocque and Naegeld, the writings of Moreau,
 Cazeaux, Chailly (Honore),  Colombat, Velpeau, Capuron, Dubois
 in France; Kiwisch, Bauer  and  others in Germany; Rigby,
 Ramsbotham, Gooch, Blundell, Murphy,  Churchill,  Simpson,
 Collins, Lee, Hardy,Bennet,Tyler Smith, AVest, Lever, Oldham
 and many  others in Great Britain;  Dewees, Bard, Francis,
 Meigs, Channing,  Trask, Oilman in  this country, have added
 much to the reliableness of obstetric knowledge.  Add to this
 the  frequent reports  of cases and monographs in the numerous
 journals, the debates in scientific associations, and it may readily
 be seen that  the  science is not at a  stand-still, but advancing
 with a rapidity equal to any branch of the  healing art.
   During the dark  ages, and  probably from the beginning of
 the world, as I have previously said, the care of women in child-
 bed appertained exclusively to their  own  sex.   Even Paul of
 iEgineta, who is styled the first male  practitioner of midwifery,
 in the 7th century, it is probable, had  little  if any practice.  As
 late as 1552, Dr. Veit, in Hamburg, was publicly branded for
 having attended as a midwife in female garb.
   Dr. Atwood was  the first physician in New York, who dared
 advertise  himself as a man-midwife  before the revolution  in
 1762.
   During all this season the most gross empiricism and the most
 iuperstitious practices reigned in this branch of medicine.  The
 nost simple precepts of hygiene were consecrated by religious
 ceremonies, which greedy priests, in those days of credulity and
 ignorance, easily multiplied.  Every woman among the Greeks
 and  Romans  at  the time she first  noticed  her pregnancy,
 vent to the temple of Diana and deposited  her girdle, and took
afterwards garments suitable to her new condition. 
28          INEFFICIENCY OF FEMALE OBSTETRICIANS.

  Although Juno and Lucina presided in a general manner over
labor and child-bearing, particular divinities were invoked at
every stage, and for every accident in the course of this func-
tion.  Mena, who appears to be the same  as Diana, preserved
women from floodings during pregnancy and childbirth.  Vows
were made to Postversa and Prorsa, when the  child presented
in an unusual and dangerous manner.
  During this period  we can  learn little of the duties  of the
midwife.  This individual  seems to  have been a remarkable
busybody.   It is  highly probable that she  did too much rather
than too little.   She  busied herself about  everything  which
interested women, and was the oracle respecting everything rela-
tive to their outward embellishment, the color  of the skin, the
shape, the breasts,  and all sequelae, probably numerous enough,
of confinement.  She  made marriages, procured  abortion, and
cured sterility ; in short, the Cleopatras, Aspasias  and  Agno-
dices of Ancient Greece, were very similar and probably more
ignorant than the infamous Restells and Costellos of  our day.
  At the present time there is  a proposition mooted—springing
from the same high source which advocates woman's rights, the
Bloomer costume, and other similar nonsensical theories—to give
again the portion of the healing art of which I am treating, if not
the  whole domain of medicine, to the  females.   I have pointed
out  some of  the absurdities  of former days, when entirely under
the  direction of women, and have gradually traced the  subse-
quent ameliorations,  most, if not all of which, have been made
since the time of Louis XIV., when Julien Clement, first as an
accoucheur,  attended Mad'lle Lavalliere, selected by her, as it is
reported, because she wished her confinement kept a secret.
  The student of the history of midwifery will  in vain seek  to
find a single instance recorded  of any useful practical discovery
made by the midwife.  They perpetuated  the errors  of the
time—they have not in a single instance, up to the present day,
scarcely excepting Mesdames Lachapelle and Boivin, been the
authors of a solitary improvement in the art.
  In  the practice, their success stands in  no better light.  In
1820 it was stated—and the remark has never been refuted—by
the then Professor of Midwifery of the University of New York,
Dr. John W. Francis, a gentleman whose deference for the sex
is only equalled by the excellence of his judgment and the cer- 
              DUTIES OF  CONSCIENTIOUS PHYSICIANS.           29

 tainty of his statements, that " the bills of mortality in London
 and Dublin attest, that one in seventy of those women perish in
 childbirth who are in the  hands of midwives, whilst  from  the
 accounts of the lying-in  hospitals in those very cities which are
 under the care of male attendants, parturition is fatal to less
 than one half the number—nor indeed is the process of parturi-
 tion so free from difficulties as is by many imagined.  We learn,
 from the last reports  under the authority of Mr. Hey, of the
 Leeds Infirmary, that of 827 cases of Midwifery, one hundred
 and fifty were such as required manual aid, either with regard
 to the expulsion  of the placenta or child.  I hope it is not irre-
 verent to females to assert, that  the acts of resolution and firm-
 ness  which such occurrences impose, are  less  fitted  to  their
 delicacy than to the hardihood of the other sex."
   It is truly not  a matter of wonder that it should be generally
 supposed that any old woman was capable of taking the charge
 of a lying-in woman, when  it is seen how lightly the subject is
 treated by the profession itself.  Many physicians seem to think,
 that the  only utility to be derived from  their presence in the
 puerperal chamber, is the subsequent  fee, and I am inclined to
 think with them.  Their practice is an "expectant" practice in
 more than one particular.  They are willing to  allow a woman
 to remain with the head  impacted,  or retained by the perinaeum
 for scores of hours,  practising one  only of Blundell's excellent
 instructions, viz., wait.  This fatal  delay is not the consequence
 of a settled  conviction of the general  inadvisability of opera-
 tions, or  in  conformity with  any opinions in regard to  "  med-
 dlesome  midwifery^," but solely from an utter ignorance of the
 true state of things, or from an extreme timidity respecting all
 interference with nature.  It is from these causes that we find
 so many  cases of vesico  and recto-vaginal fistulas, which are, I
 will venture to say, rarely, if ever,  the result of an injury  from
 the forceps, as proved by statistics on a future page.  While the
attendant physician is slumbering  in  his comfortable  rocking-
chair, the impacted head is effecting those disorganizations, the
responsibility  of  which  he afterwards endeavors to fling off
his shoulders, by  ascribing this awful result to the forceps.
  Far be it from  me  to  urge or advocate the frequent  use of
instruments, but  I  wish  to direct  the public attention  to the
 cause of  the injurious results which are so willingly  ascribed to
their use.  I think that accurate statistics of the two above men- 
 30       PROPRIETY  OF INSTRUMENTAL INTERFERENCE.

 tioned injuries, as well as rupture of the uterus during labor,
 will show that these  very much preponderate  when forceps
 have not been used.  And allowing; that where  instruments
 were used these sad results occurred in consequence, were they
 not preferable  to the grave ?
   So much has been said against instrumental interference, that
 there is little danger, that in this community unnecessary opera-
 tions will be performed, and so universal is the antipathy to such
 a  resort, that it seems to me that these resources of art are  too
 little called upon, and thereby much unnecessary suffering per-
 mitted, and  much  injury done  to the women, and children's
 lives unnecessarily sacrificed.
   I have been sometimes inclined to think, when seeing the  lit-
 tle efforts made to resuscitate the  still-born babe in the Parisian
 hospitals, that  they thought a  life  which,  for  a long series
 of years afterwards, was to be at the expense of the state, was
 scarcely  worth  the  trouble of saving; and it sometimes seems
 as if physicians  here  thought  it  perhaps  better humanity, to
 allow children  to perish  impacted in the pelvis, or  from  the
 effects  of ergot wrongly administered,  rather  than to deliver
 them by  instruments, and allow them to live a life afterwards to
 be exposed to hunger, cold and filth, finally to  be swept away
 by the yearly recurring cholera infantum or  the  wasting mar-
 asmus.
  The aim of the  physician is clearly stated by Ramsbotham, to
 strive,  " equally to  escape the imputation of haste and  indiscre-
 tion on the one  hand, and of delay and indecision on the other;
 yet let us ever bear  in mind, that more injury may possibly
 accrue from  too  long  delay than arise from premature assis-
 tance."
  In similar terms speak the great mass of the  teachers  of  the
 world.   The great want of the  profession in this particular, is
knowledge of the subject.  What  if the finger can pass freely
 around the sides of  the  head, and the pelvis  seems sufficiently
spacious ? if the long diameter of the head of the foetus is present-
 ing to the short diameter of the pelvis, human interference is
demanded.  The  diagnosis therefore of the position is  equally
important as that of the presentation.
  The next want of the profession  is decision, and here I may
 again quote from  the celebrated preface of the American edition
 of Denman's Introduction to Midwifery.  "Nowhere are promp- 
DANGERS  THREATENING THE  PROFESSION.
31
titude and decision more required; in no situation is the man of
science  more  distinguishable  from the mere  pretender;  in no
situation is the conduct of the physician more  the object of pre-
sent attention  or of subsequent criticism.   In the lying-in cham-
ber no opportunity is afforded for  qualification or deliberation.
The case demands immediate  assistance, and  it  is vain to tem-
porize ; vacillation and delay, always dangerous, may here prove
fatal. The student's mind must be thoroughly prepared, else the
imputation of  ignorance will attend his hesitation and confusion.
Firmness and  decision, founded on accurate and precise know-
ledge, will alone secure to him present confidence  and future
approbation."
  Two dangers  now menace the practice  of  midwifery in this
country, either of which threatens to do it an irreparable injury.
The  one which particular!}' concerns us is  the carelessness and
inefficiency of the profession itself.  The  students at graduation
know little  or nothing of the subject.   Practically, they are
entirely ignorant of its simplest forms.  They have no methodized
habits, no illustrative  reminiscences  to  throw light upon the
obscurities which may occur in their subsequent practice.  The
student  may graduate without ever having attended at the bed-
side of a parturient woman.   After the first few cases, in which
he is sufficiently alarmed, but which, fortunately, pass by suc-
cessfully, he concludes that all the talk of position, presentation,
rotation, and  such  like  terms, is  all nonsense, or at the  best,
theoretical, and  he joins the  "expectant" practitioners, trusts
to the vis medicatrix naturae, confidently expects that spontane-
ous evolution  will always occur, and by a dull inactivity, result-
ing  from  ignorance, loses the child, and  not unfrequently the
mother  also, and injures the  reputation  of the profession, the
capabilities and  attainments of which he does not understand.
  The  next great danger springs from  the love  of mammon.
Ignorance  and presumption, which thrive upon ignorance and
credulity, when  " fools rush in where angels fear to tread."
  The dark ages seem to be again reviving.  Hand in hand with
the  infinitesimals and the water wonder-worker,  comes the
hard-faced midwife, tinctured with  both  theories  (for theory
means absurdity now, and professor is a term  applied to moun-
tebanks and  quacks).   We  have lecturers and lecturesses, and
female  colleges,  where  the very  large  and  highly  intelligent 
32
QUACKERY IN  OBSTETRICS.
 classes are taught how to  get  children, and especially how  not
 to get them.   The Woman's Rights Convention cannot see why
 women should bear children more than men, and while waiting-
 some plan to equalize this matter, they refuse to bear them them-
 selves.
   From these fields of literature come the midwives, with reck-
 less rashness, not like our  Californian adventurers, themselves to
 incur any perils for the sake of gold, but to allow the unfortu-
 nates who confide in  them to run  any risk, and to suffer any
 calamity which their temerity  and ignorance might cause.  Wet
 sheets and globules are poor substitutes for science and practical
 skill.
   Quackery, gentlemen, is rife in every  branch of the profes-
 sion, and revolutionary opinions are being expressed in various
 of its domains—the province of midwifery threatens  to secede
 from the union by which she is bound to  medicine and surgery.
 Shall we allow such an act to be  accomplished, to the manifest
 detriment of  all parties concerned ?   Against such a result we
 must arm ourselves by fresh acquisitions ; we must rub off  the
 rust from our old learning, and by constant study and watchful-
 ness be ever ready to maintain the dignity,  integrity and efficiency
 of the healing art.  What the  future may be, depends upon  us.
 The present is ours, the past is ours also; for medicine is not a
 science of yesterday, nor the dream of any wild schemer, but one
 originating in antiquity,  practised by the  Redeemer, handed
 down, enriched and improved, through centuries, to be perfected
 only in eternity.  The greatest minds  of  the  earth have given
 the admiration  of their  youth, their manhood  has improved,
 ornamented and simplified, and their old age has relied upon it.
The vegetable and mineral kingdoms are  closely allied, and kin-
dred sciences give to it their strong support.  This is  the  lofty
fabric planned by the Great Architect, founded upon a rock  of
adamant, which has resisted the storms of  time, the floods of per-
secution and ridicule, the stormy gusts of  passion and envy, and
remains not only unscathed, but whose fair proportions are daily
more colossal and finished.  This is the glorious edifice that you
 would tear down, to build upon its ruins a flimsy structure of
ephemeral materials and  shapeless construction, " the baseless
fabric of  a vision, to melt away, leaving not a rack behind." 
               W.  TYLER SMITH

                          ON THE

THEORY  ^lISTD  PRACTICE

                           OF


          OBSTETRICS.


                      ---------<»»


                      LECTURE  I.

                   GENERATION.

  Gentlemen :—In this, the first Lecture of  a Course on the
Theory and Practice of  Obstetrics, it is proposed to draw atten*
tion to some general considerations concerning the reproduction
and development of living beings.  Beginning with matters re-
lating to the most simple modes by which the propagation of
animals can be effected, we may ascend  to the  study of the
higher forms of reproduction, until we arrive at the generation
of the human species.  It will  be  found, as we  proceed, that
there  are no races  so low in the scale of creation but that tho
history of their generative  phenomena  is calculated to throw
light upon the same functions in classes of the highest rank .in
the animal kingdom.   This circumstance must  plead as my
excuse for attempting to deal, at the commencement, with the
elements or principles of generation.
  At the very threshold of this subject, we are met by the long-
agitated question of Spontaneous or Equivocal Generation.
Can  any form of animal life be produced upon the globe we
inhabit, out of dead inanimate matter, or indeed otherwise than
                          3                         ** 
34
SPONTANEOUS GENERATION-
—INFUSORIA.
 as part of a procession or series of living organisms, every genera-
 tion of which must depend for its existence upon the generations
 that have preceded it ?   In  former times, many facts connected
 with the generation of the humbler forms  of living  matter
 seemed altogether inexplicable;  and naturalists and physiologists
 were driven  to a belief in the doctrine that, under special  cir-
 cumstances, such as the decomposition of animal and vegetable
 structures, some of the lower forms of animal existence might be
 developed spontaneously.   The progress of knowledge  has,
 however, steadily diminished the number of these mysteries:
 and it may be said that, in  recent days, the last stronghold of
 the  believers in spontaneous generation has been the condi-
 tions under which the Infusoria and Entozoa can be produced.
   From  any vegetable  infusion, under  certain  regulations as
 regards  light, air, and  temperature,  myriads of microscopical
 infusoria are called  into existence.  The same infusions  uni-
 formly produce  the  same animalcules, and the lowest forms of
 infusorial life are those which first appear.  The results are  the
 same when water, which has  been boiled or distilled, is used ;
 and observers of eminence  have declared that  they have seen
 the debris of  vegetable matter, while undergoing decomposition,
 transformed into infusoria.  Others have  believed that  animal-
 cules may be produced, by  the action of electricity, from silica
•and similar inorganic matters.   It may, however, be said, at the
 present  time, with regard to  infusoria, that the difficulties  in
 the  way of explaining their almost omnipresence have disap-
 peared, and that their production, except under natural circum-
 stances,  can be satisfactorily disproved.
   The different modes of propagation in the infusoria have been
 investigated, and it is known that in their most simple form,  the
 perfect infusoria, and in other cases the germs, are almost innu-
 merable, and of  well-nigh unextinguishable vitality.    One
 animalcule, the Monas crepusculus, is 2~o of a line in diameter;
 and it is remarked  by Professor  Owen  that  a  single drop of
 water may contain no less than  five hundred  millions of these
 minute  beings.   The drop evaporated, this  vast  population,
 greater in number than the  living inhabitants of the world,  be-
 come dry and preserve their  latent life in the air  and in the dust
 of the earth, to be revivified on the occurrence of the conditions
 necessary to  their existence.   Not a mote of the sunbeam but is 
ANIMALCULES.
35
peopled with  these animalcular  organisms.   Their power of
resisting destructive agencies is not one of their least wonderful
properties.  They live in water under ice, or inclosed in vesicles
in the ice itself.   Fontana revived  some specimens of Rotifera
after they  had been  exposed to the sun for upwards  of two
years in dry sand; and Spallanzani and  Schultze have revived
them after  four years of  desiccation.   Other animalcules, in
drying, burst, and liberate  myriads of germs, which preserve
their vitality  under  almost' every conceiveable  circumstance.
These  and similar  facts show that no particle of air, dust or wa-
ter can be taken which does not contain infusoria or their germs,
thus rendering it  almost certain  that the vegetable infusion
does nothing  more than favor  the restoration  of  dried ani-
malcules,  or the development of their  invisible germs.   But
the cxperimentum crucis  respecting the spontaneous  generation
of the infusoria  has been applied  by  Schwann and Schultze.
The access  of air, which  no doubt contains  infusoria or their
germs, is known to be necessary to the  production  of  animal-
cules in vegetable infusions.   One of these experimenters passed
the air employed through caustic  potash and through strong sul-
phuric acid ; and the other through iron tubes heated to redness,
the infusions used having been previously boiled.   Under these
conditions no  infusoria were produced, though a rapid develop-
ment of animalcules occurred on  the admission of air  to simi-
lar  infusions, when no such precautions  were observed.
  As regards  the Entozoa, the presumptive evidence in favor of
their spontaneous generation was  still more conclusive than in
the case of the infusoria.  Entozoa are  found in situations to
which they could not  be supposed to have access by any natural
means. The Cysticercus  celhdosoe is found in the anterior cham-
ber of the eye, in the choroid plexus, and in the substance of
the heart.   The Trichina spiralis infests the voluntary muscles,
and the Strongylus gig as the parenchyma of the kidney.   A di-
plostomum in  the aqueous humor  has itself been found  to be
infested with parasitic animalcules.  Entozoa have been detected
in the foetus in utero,  in the blood, and in the eggs of oviparous
animals. Such facts  appear to present insuperable  difficulties
to the  explanation of  the  existence of entozoa in their  special
habitats, unless  upon the supposition that.they  are produced
spontaneously. It came  to be known that many of  the higher 
36
ENTOZOA.
forms of entozoa possess  complicated organs of generation, and
produced ova and embryos in abundance, which themselves be-
came the subject  of observation.   For a time, however, this
knowledge only increased the difficulty.  How could  entozoa
reach the foetus, or enter the  eye,  when their ova were known
to greatly exceed the diameter of the capillary vessels ?
   It was at last discovered,  that  the  entozoa, particularly  in
their embryo forms, possess a special boring  apparatus, which
had been noticed by John Hunter in some species, by means of
which they are able to make their way through the solid tissues
of the body with extraordinary facility, producing little or no
disturbance in their progress,  and leaving no traces of their ope-
rations behind  them.  It was also found that  a vast variety of
special provisions  existed for the diffusion and localization of
these creatures. The numbers, too, of  the ova of some of the
entozoa are immense.  A single specimen of the Tcenia serrate,
an entozoon  which  infests the dog,  will produce twenty-five
millions of ova! while a mature female of the Ascaris  lumbri-
coidcs  will contain upwards of sixty millions !  Many of them
pass through several phases  of existence in  different  animals
before  they arrive at the perfect  state, provision being  made
for their transfer from one animal to another.  It is believed
that in every species of  tape worm,  two animals, are at least
necessary for their complete development, and  of these two ani-
mals, the one generally stands  in the relation  of food,  or prey
to the other.   Thus  the  scolex, er  embryo head, of the Tcenia
crassicolis, is found in the mouse, while the perfect taenia infests
the intestines of the cat.   The mouse is  of course the  means of
introducing  the embryo  of the taenia  into  the larger  animal.
The power of the entozoa in resisting destructive agents  is even
greater than the infusoria.  Some of these worms of complicated
structure remain alive after being  boiled a  considerable time;
others  are reanimated  after being frozen  for several  weeks.
Their ova have still greater powers of self-preservation.  These and
similar facts respecting their numbers, modes of generation, indes-
tructibility, and powers of penetrating animal tissues, appear suffi-
cient to explain all the seeming mysteries respecting the entozoa
without resorting to the theory of spontaneous generation.
  The most simple form  of animal  life  is that  met with in the
Gregarinae, a genus of microscopic  entozoa  found in  the inter- 
SIMPLEST TYPE OF REPRODUCTION.
37
ruL l
nal organs of worms and insects.  The Gregarina consists essen-
tially of a single cell, or of a cell-wall with its contained-fluid,
and a central nucleus.  (Fig. 1.)  It moves by  contraction of
its cell-wall, and only differs from a vegetable cell
in its contractility, and its solubility in  acetic acid.
In  the  simplest infusoria, the  polygastrian  ani-
malcules, a class below the entozoa in the animal
series, the same monadiform organization is found;
and throughout the  infusoria, although many addi-
tions, in the shape of cilia, and internal organs oc-
cur, the type  of a cell, with  a central nucleus, or
nuclei, is  preserved.  This  central portion consists
of hyaline matter, of an amber colour, which is sup-
posed to be fatty  in character, and is believed  to
bear a resemblance to the  spermatic  particles of
higher  animals.  The Chlamydomonas may be cited as one of
the simplest of the infusoria.  (Fig.  2.)
  The primary and most  simple type of reproduc-
tion, that which is  found in these unicellular, mo-
nadiform animalcules, is that of spontaneous fission,
or Fissiparous Generation, as it is called. In this
mode of reproduction, in the most simple forms of
infusoria, a single  unicellular animalcule  divides
into two or more cells, which, after their division,
become similar to the parent cell.  The first infusorial animal-
cule  ever known,  the  Vorticella convallaria,  discovered  by
Leeuwenhoeck nearly two  hundred years ago, multiplies itself
in this  manner.  Sometimes  the fissure takes place longitudi-
nally, at others transversely (Fig 3,) a notch first appearing at
Gregarina.
Jfto.2.
Fig. 3.
 A, B, C. Longitudinal fissure of elongated infusoria. D, E, P. Transverse fission of oval ani-
malcules.

the  point  of subsequent division, which enlarges  until  the
separation is nearly completed, when the two  cells struggle, by 
38
FISSIPAROUS GENERATION.
means of their cilia, until they are free from  each other, and
swim off  as independent  animalcules.  In  some  infusoria  the
fission consists in a simple division of one cell into  two.   In
others, they divide, but still remain connected  in groups, as a
chain or in a spherical  mass.   The latter  is the case with  the
 Volvox globator,  a well known animalcule.  Instances are met
with in which the division of succeeding generations are regular
multiples  of each other,  as two, four, eight, and  so on.  This
occurs for instance, in  the Chlamydomonas.  (Fig. 4.)  In  the

                           Fig. 4.
             A, B, C.  Multiple fission of Chlamydomonas. n, Nuclei.

process of fission, the nucleus is  always the first part to divide,
and it  is this cleavage of the nuclear portion which rules the
segmentation  of  the whole cell.   In these simple organisms,
the sperm and germ-force reside in the nucleus or nuclear par-
ticles—every nucleated infusorial cell, multiplying in this way,
being from its birth, as it were,  impregnated  and ready to pro-
pagate its kind by fission.  No  diminution of the reproductive
force is caused by successive fissions, each generation of purely
fissiparous animalcules having the  same powers as its  progeni-
tors.  Many  infusoria  multiply by other modes of generation as
well as by fission, but the rate of increase by this means alone is
very great.   The Paramcecium aurelia, if  well fed, divides
every  twenty-four hours, its progeny in successive generations
continuing to divide in  the same  ratio.  In  this way, in the
course of four weeks, one animalcule will  produce upwards of
two  hundred and fifty  millions of new beings. This fissiparous
mode of generation is  found not only in Infusoria  and Entozoa,
but in Polypi, Medusae, and Annulata.   It is in  the  Infusoria
also  that the first acts of parturition are observed.  In  the Lox-
odes Bursaria, four or five cells  are formed in  the interior of the
animalcule,  which  are  gradually  developed  into  embryos.
These embryos make their way slowly through the tissues of the
parent  and escape externally.  No  aperture or channel exists 
GEMMIPAROUS GENERATION.
39
previously, and the situation of the parturient escape of the em-
bryo seems entirely to depend upon  accident.   (Fig. 5.)  At
whatever part of the parent organism the embryo is developed

                           Fig. 6.
 A, B. Formation of germs and embryos in Loxodes Bursaria.  C. The process of parturition.
D, E. Free moving embryos.

there a way is made for its escape.  Sometimes two or three
embryos  are escaping  from different parts of the parent at the
same time.  From this simple beginning, the extrusion of the
ova and  embryo goes on in the animal series, until it reaches
the complexity and difficulty  witnessed in the higher mam-
malia and in the human species.
  The next form of reproduction met with in the animal kingdom
is Gemmiparous Generation, in  which the offspring  arise
from the  parent in the shape of gemmae, or buds, which acquire
a similar organization of the parent animal, and separate to as-
sume an  independent existence.  In the Hydra viridis for in-
stance, a prominence first  appears upon the surface of the ani-
mal, which gradually assumes  the form of a  miniature polyp.
It contains a cavity, which, in  the first instance, communicates
with the  stomach of the parent Hydra.  An oval aperture, sur-
rounded  with tentacles, is developed  at its free  extremity.  At 
40
REPRODUCTION OF POLYPS.
first the food digested in the stomachal cavity of the parent sup-
plies the gemmule, but, after a time, the young polyp begins to
catch food, and contributes to the support of itself and parent.
At length its connection with the parent polyp becomes slender,
and it separates altogether.  (Fig. 6.)  Another mode of gem-

                           Fig. 6.
                                         o
             A, B, C. Polypoid Acalephs, giving off gemmas or buds.

miparous generation is  where, as in the sponges, small free
gemmules, or buds, are separated from the body of the parent
animal, and  become  developed into  perfect individuals.   The
part of the body from which gemmation takes place indifferent
animals is very various.  In some, it may occur at any part of
the surface of the body ; in others the gemmules are formed in
the digestive cavity, and extruded from the oval aperture.  In
the medusae, the gemmae arise from  the ovaries, stomach, pro-
boscis, and tentacles.  In other other cases, as in the Alcyoni-
dium elegans, an Alcyonian zoophyte, the tubercles which con-
stitute the gemmae, or buds, are produced in particular strips of
tegumentary membrane.  In some of the gemmiparous animals,
new creatures  may  be  multiplied to  almost any  extent by
mechanical division.   The Hydra viridis may be divided lon-
gitudinally or transversely into several parts, and each fragment
will become a perfect polyp ; or if a wound is made in the body
of the animal, a new polyp sprouts from the site of injury. The
gemmiparous form of generation is met  with in a  large variety
of animals.   It exists in the Infusoria, Entozoa, Polypi, Medusae
Annulata, and Tunicata.  In the Nereis, and in some of themy-
riapoda, gemmation forms an important part of the reproduc-
tive process.  In the former, a constriction first appears in the
tail of the animal, immediately behind which the head of  a new
nereis is developed, and  the posterior division becomes separ-
ated from the anterior, or parent nereis, as a perfect  animal.
 
CONJUGATE GENERATION.
41
  The earliest traces of a dioecious mode of reproduction in ani-
mals, in which two individuals are engaged in the production of
offspring, is met with  in  the  humble Gregarina already men-
tioned.   These microscopical entozoa propagate not only by fis-
sion, but by a process termed conjugation.  In the latter mode
of generation, two of the  elongated cells or animalcules are said
by Stein and other observers to approach  each other; the two
ends which are in  opposition become flattened, so that the two
conjoined animalcules  resemble a single Gregarina in shape.  A
complete fusion of the granular contents of the two individuals
takes place, and from the joint mass a number of small bodies
are produced, which are believed to be the embryos  of this
monadiform entozoon.   (Fig. 7.)   Other instances  of Conju-
                           Fig. 7.
Conjugation of Gregarinae. A. single Gregarina. B, C, D. Two animalcules in a state of conjuga-
 tion. E, F, G. Formation of embryos. H. Free embryos.
gate Generation have been observed by Kolliker, Siebold, and
Cohn.  This mode of generation appears to be quite wanting in
anything  of  an  ordinary sexual character.  The  conjugating
Gregarinae appear  to  be precisely similar  to  each other, and
their reproduction seems  to be by a kind of duplicate fission.  It
is, however, impossible not to be struck with the similarity of
the process of conjugation, and the union of the sperm cell and
germ cell in the higher animals, to which sex has been added in
the scheme of reproduction.  In the latter case, the sperm and 
42
HERMAPHRODITE GENERATION.
germ cells unite  to  produce, by division and subdivision,  the
particles forming the germ mass, and out of which the embryo
is  evolved.   As soon as  sexual  generation  commences, two
kinds of cells are required in the process  of reproduction—one
produced in the ovarium, the other in the testes.  In the lower
classes these two organs are frequently found upon the same in-
dividual, constituting complete hermaphrodite generation.  In
other instances  the individuals are  hermaphrodite, but the mu-
tual congress of two or more animals  is necessary for fertiliza-
tion.  In the higher classes, hermaphrodism disappears, and the
ovarium and testes,  with the sperm and germ cell, belong to
different animals and sexes.
  The present seems to be the  proper place for  making some
general remarks on the subjects of Fissiparous and Gemmiparous
generation, and the relation of these processes to the  acts of re-
production in the higher animals.  The principle of fission is not
limited to animals in which it constitutes the chief mode of gen-
eration.  It extends in a  certain degree to the higher forms of
animal reproduction.   In oviparous animals and mammalia it
may be  said that the dehiscence  of  the ovule  or  of the  im-
pregnated ovum, from  the ovarium,  is  a kind  of fission.  A
still closer analogy to the phenomena of  fission is found  in  the
early changes in the interior of  the  mammalian ovum after
impregnation and indeed of the ovum of all animals multiplying
by sexual generation.  (Fig. 8.) These changes are similar to those

                          Fig. 8.
Development of Ascaris acuminata by repeated fission of the germ celL  Type of development in
 all animals produced from ova.

which have been referred to as occurring in the unicellular infu-
soria. That which will hereafter have to be described as the sez- 
SEXUAL GENERATION.
43
mentation or cleavage of the yelk, consists in the division and
subdivision of the embryo cell, and is almost identical with the
multiple fission of the Chlamydomonas an analogy first pointed
out by the late Dr. Martin Barry.  The  only difference is, that
in the Chlamydomonas and Gregarina the divisions and subdi-
visions produce independent and  perfect animals ;  whereas  in
the mammalian ovum the fission results in a mass of germ cells,
intended to pass on to higher developments.  In animals, the sub-
jects of sexual generation, the male element is  also formed by
the rupture of the primary germ cells secreted by the testes, and
the  conversion of  their  nuclear  matter into  spermatozoa,
which may in fact be  considered  as secondary germ cells.  It
may also be said that the human fabric is the result of the fis-
sion, an innumerable number  of times repeated, of the single
fertilized embryo cell; the multitudes of cells produced by the
rupture and fission of generation after generation of cells, and
by the  conversion  of. their nuclei in turn into parent cells,
being converted by plastic morphological forces, into bone, mus-
cle, nerve, blood, and the other elements of which  the body is
composed.  The similarity of the ciliated epithelial cell of the
mucous membranes to the ciliated unicellular infusoria is very
palpable.  It  is of  myriads of such cells, modified  in infinite
ways, that the human organism is constructed.  In this way we
can to a certain extent realize  the idea of Buffon, when he said
that all animal and vegetable bodies were aggregations  of ani-
malcules ; or the more positive remark of Oken, that the higher
animals and man himself, were agglomerations  of infusoria.
   Generation  byr means of buds or gemmae is still  more exten-
sive than reproduction by fission.   In gemmiparous animals, re-
productive nuclei are scattered throughout the structures and
tissues of  the parent organisms;  it is a fission occurring, not, as
it were, in the whole animal, but in particular parts.  The mode
of reproduction by generation extends higher than  fissiparous
generation, being found, as we  have said, as high as the Tunicata,
and it is concerned in Alternate Generation, which is found
amongst insects.  But the principle is not lost at the point when
it ceases to be a mode of generation.  It is concerned in the re-
production of  lost parts. In gemmiparous generation, animals
are formed, not from ova, or from the fission of primary repro-
ductive cells,  but from secondary  or  derivative germ cells, 
44
VIRGIN PROCREATION.
placed in reserve in the tissues of animals.  In the triton or the
lobster, in which the tail or claw is reproduced, the new forma-
tion occurs from derivative germ cells placed in the tail or claw
—that is,  a  reserve of derivative germ  cells, not used  in the
general development, is deposited in different parts of the body.
In mammalia, the extremities of the foetus are always  formed
by budding or gemmation.   It  is believed by some observers
that in the human foetus, if  a limb be amputated spontaneously
in utero, at an early period, there is an attempt at the production
of a new limb by germination.  In some of the remarkable cases
of spontaneous amputation of limbs in utero, first investigated
by Dr.  Montgomery  and Professor Simpson, the amputated
limb is found in the uterus, and from the stump small or  rudi-
mentary fingers or toes are seen to be growing, which  remain
visible in after life.
  One of the  most remarkable phenomena in the  history of
generation is that first investigated by Bonnet, Reaumur, Steen-
strup, and others,  and  to which great significance has been given
by Professor Owen, under the name of Parthogenesis, or Tirgin
Procreation.  In many forms of animal life—as, for instance, in
the Salpae amongst mollusca, the  Distomata  amongst entozoa,
and the Aphides amongst insects—it is found that the parent
animal gives birth to an embryo different to itself; that this em-
bryo lives as an independent animal, but gives birth, without
sexual intercourse, to another, and to a successive series,  until at
length a progeny is formed bearing the likeness of the  original
parent.
  In the Distoma, the  embryos have at first the form of ciliated
monads,  and these are  metamorphosed  into  Gregariniform
worms.  In the interior of each of the latter,  numbers  of Cer-
cariform, or  tailed animalcules, are developed, which in turn be-
come true Distomata.  In the winged Aphis, the ova are  depos-
ited by the parent insect,  and in due time produce larval, wind-
less aphides.   Each  virgin aphis of this brood will produce
other similar broods without contact with the male.  This Lu-
cina sine concubitu has been observed to  go on to  the eleventh
generation,  the last generation being winged, and male and
female.   These have  intercourse, another fecundation  occurs,
and in the following summer the phenomena which have been
described  again occur. 
OVIPAROUS, GENERATION.
45
  The explanation of these cases is, that in the first instance the
coitus fertilizes the ovum, and part of the derivative germ cells
produced from the embryo cell, instead of being  consumed in
the development of the first generation of aphides, are kept as a
reserve.  In the second generation, these derivative germ cells
give origin to a new generation of derivative germinal cells, of
which a reserve remains as before, and so on until the spermatic
force of the germ cell is exhausted.  To illustrate this  matter,
let us look to the early development of the mammalian ovum.
The embryo cell divides into two, these two into four, the four
into eight, and it is not until the segmentation has affected the
whole mass of the germ and yelk that the formation of the new
individual begins.  But suppose each generation of germ cells
occurring in this fission or segmentation, to have the power of
going on to the production of new individuals, we should then
have the power observed in the virgin  aphides, where each gen-
eration of germ cells goes on to the production of a larval aphis
before a new fission or segmentation of the derivative germ cells
takes place.  We may see traces of this power of the sperma-
tic  element to fertilize or modify more than  one generation of
ova and germ cells in other animals than those in which perfect
parthogenesis occurs.   For instance, a single coitus of the cock
fertilizes, not only the eggs which are  mature in the ovary, but
those which are immature, so that eggs which reach maturity a
long time after coitus  are  found to be fertilized.  The  patho-
genetic influence may even be seen in the mammalia and in the
human female.   In the well-known case of the mare covered by
the Quagga, the foals produced afterwards, by intercourse with
her  own kind, still  bore the stripes  of the quagga.   In the
human^female, it is found,  that a woman  having  married and
borne children by her  husband,  becomes a widow, marries a
second time,  and bears children to her second  husband which
have the lineaments of her first husband.  The  same occurs in
the lower animals, and it is difficult to explain the matter in any
other way than by supposing  that one coitus must have  influ-
enced several generations of ova.   The relation of such pheno-
mena to parthogenesis is obvious.
  The  next step in the  process of reproduction  brings  us to
Oviparous Generation.  This form of generation is very early
met with in the animal series.  Ehrenberg discovered in many
of the Rotiferous animalcules  distinct male and female organs, 
46
METHODS OF IMPREGNATION.
and  generation by means of fecundated ova.  In some of the
more simple infusoria, ova appear to be formed in the  general
parenchyma of the body without any sexual operation, and to be
extruded in the form of a reticulated mass.  In the  lower part
of the zoological scale, oviparous generation  is mixed up with
fissiparous and gemmiparous generation, and there seems to be
hardly any difference between the production of free gemmules
to be developed  apart from the parent, and the formation and
elimination of  ova from the  infusoria, in whom distinct sex is
wanting.  It is in Insects, Fishes, Reptiles, and Birds, that ovi-
parous generation reaches its  full development.  In insects, the
ova,  which consist of a germinal vesicle, yelk, albuminous and
shelly coverings,  are very  small,  and the embryyo  is  early
extruded from  the shell in a larval state, but fitted to acquire its
own  nourishment, and passing through numerous metamorphoses
before it reaches the perfect condition.  All insects are dioecious,
or of distinct sex, and the impregnation of the ova occurs within
the body of the female.  In fishes the sexes are also distinct, and
in this class we get the first commencement of the ovarium as it
exists in the higher vertebrata  and mammalia.  In the lower
types of fishes  the ovarium  consists of a mere vascular  lamina,
in which the ova are formed  and thrown off into the abdominal
cavity, from which they escape  by orifices near the anal aper-
ture.  In the higher specimens of this class an oviduct is added
for the purpose of conveying  the ova from the  ovarium.  The
ova of fishes are generally impregnated out of the body, but in
some cases impregnation and development to  a certain extent
occur within the ovary, the male having a rudimentary intromit-
tent  organ, and the embryo  is  expelled in a living state.  In
reptiles  the oviduct is  a permanent condition; the  ova *are gen-
erally fecundated out of the body, in transitu, by the lower gen-
era ; but in the more  advanced  specimens of this class ova are
impregnated within the body of the female, and in some of them
the young are born alive.   In birds, the ova are  contained  in
ovaries,  and the egg reaches its highest state of development,
consisting of the germinal vesicle and a large yelk; an extensive
layer of albumen  or white  being also  added so as  to  support
the development of  the young, with  various membranes for the
protection of the egg,  and the maturation of the ovum.  Paren-
tal affection, of which there  are traces in insects and  fishes, is
present to a very great degree in the case of the bird. 
MARSUPIAL REPRODUCTION.
47
  In the mammalia we have, in all cases, viviparous generation,
though  some are termed  ovoviviparous, but the instances of
ovoviviparous generation in birds, amphibia, and fishes, in which
the eggs are hatched in the  body of the parents, are  very dif-
ferent from any  of the forms of generation  met with in the
mammalia.  In the monotrematous type there is a near approach
to the bird ; and as the phenomena of generation have not been
actually observed, it is only by analogical reasoning that Profes-
sor Owen  has arrived at the conclusion that the Ornithorhyn-
chus brings forth its young alive.  In  marsupial reproduction,
the impregnated ovum remains a short time  in the uterus, and
receives nourishment, but at a very early period of development
it is transferred from the uterus to the marsupium  or pouch,
where it  hangs by the nipple during the  rest  of  its foetal
development.   Neither in the monotremata nor the marsupiata
has any vascular connection between the parents and the ovum
been  observed.   The uterus enlarges;  and it is probably by a
secretion found within its cavity, and absorbed by the  yelk, that
the young embryo is developed.
   In the higher mammalia, a true vascular connection is formed
between the ovum and the mother by means of the chorion and
the mucous membrane of the uterus; and the embryo, after a
prolonged term of intra-uterine development, is expelled to pass
through another  protracted phase  of  maternal  nutrition  from
the mammae.  In mammalia, except  in the lowest types, we have
the separation  of the generative canal from the urinary and
intestinal organs.  The  generative organs reach their greatest
state of development in the human species, and  consist of parts
adapted to coitus, ovulation, menstruation, impregnation, utero-
gestation', parturition, and lactation—functions which are placed
in relation to the highest affection and parental love.   The vas-
cular intra-uterine  connection between the  mother and foetus
acquires  its  most perfect development in the placenta  of the
human  species, and it is mainly owing  to this intimate vascular
relation, the intricacy of the organs  of generation, the arrange-
ments of  the pelvis in accordance with the upright position, and
the  development of the  human intellect, as evidenced by the
comparatively large size of the brain and cranium of the human
foetus, that the pains and perils of childbirth, and the necessity
for the cultivation and practice of Obstetrics, are produced. 
LECTURE II.
           the external organs  of  generation.

  Gentlemen :—The Organs of Generation in the female are
generally divided into the external, or those chiefly concerned in
coitus, and the internal, or those employed in the  development
of the ovum.   To the former belong the mons veneris, the labia
majora  and  minora,  the clitoris,  the  hymen or carunculae
myrtiformes, the perinaeum, the vagina and  the mammae; the
latter includes the uterus and its ligaments, the Fallopian tubes,
and  the ovaria.  Both the internal and external  organs have
important relations to utero-gestation and parturition.
  The Mons Veneris  is a cushion-like  layer of adipose and cel-
lular tisssue, developed at the time of puberty, situated in front
of, and above, the pubes.  It is covered by a thick integument
studded with hair.   Its use is to guard the pubes from  mecha-
nical violence during intercourse, and to act like the hair of the
axilla in defending this part of the body from the effects of fric-
tion and perspiration.   In general, the  hair of the mons is short
and curled ; but, in sterile women, I have sometimes observed it
to be straight, and longer or shorter than usual—this condition
being indicative of a feeble development of the internal organs
of generation.
  The Iiabia Majora, or labia pudendi, are two folds extending
downwards on each side from the mons veneris to the perinaeum.
They are thick, and  lie in  contact, above; but  below they
become thinner, and are separated from each other.   Externally,
the labia majora are covered by skin, which has a smaller quan-
tity of hair upon it than the mons; but  internally,  they are
lined with the commencement  of  the genito-urinary mucous
membrane, and are  studded with numerous sebaceous follicles,
which secrete a fatty and odorous matter.  The union  of the
labia above constitutes the superior commissure; and that below,
   48 
external organs of generation.
49
the inferior commissure of the pudenda. Within the posterior com-
missure, a fold of mucous membrane stretches across between the
labia, which  has been called the  fourchette,  though the same
name is frequently applied to  the commissure itself at the com-
mencement of the perinaeum.  The fold, or frenulum referred
to, is almost  always lacerated in  first labors; but  before this
laceration has taken place, and particularly during  labor, a  dis-
tinct depression, or fossa, can  be felt  between the frenulum and
the edge of the perinaeum, termed the  fossa navicularis. (Fig. 9.)
   About an inch beneath the  anterior commissure and between
the labia majora, is found the Clitoris, which resembles a small
penis, and is, in fact, the analogue of  the penis of the male.   It
is composed  of two corpora cavernosa, which are  attached by
crura to the rami of the  ischium and pubes, and meet together
in the median line.  Each of these bodies is enveloped in a thin,
fibrous sheath.   The clitoris is imperforate, but at its point there
is a small spongy or cavernous mass, called the glans, and
covered by a fold of integument, or imperfect prepuce.  It  has
two muscles—the erectores clitoridis,  representing the erectores
penis, arising from the rami of the pubes  and ischium, as  low
down  as the  tuberosities, and inserted  into the crura clitoridis.
A  suspensory  ligament  connects  the  clitoris with the pubes.
It is supplied with blood by the internal  pudic artery, and pos-
sesses a dorsal  vein,  similar to the vena  dorsalis penis.  The
clitoris is capable of erection, and when in the erectile  state is
almost of cartilaginous hardness.   It  is the chief seat of sexual
sensibility, constituting,  according to  Dr. Meigs, " the organ of
touch to  the aphrodisiac sense."  In  hysterical  females, it is
sometimes subject to a constant erection, almost similar to that
observed  in  priapism in the male. During this condition, it is
difficult or impossible to pass urine—apoint first noticed, I believe,
by Dr. Silvester, of  Clapham.   These are, in fact, the cases
in which, in  hysterical subjects, the  catheter is often employed.
I have observed the clitoris to be subject to a peculiar mechani-
cal  displacement, or dislocation, in females who have been the
subjects of self-abuse.   It becomes  loose, probably from relax-
ation of the  suspensory ligament, and is raised higher over the
pubes than is natural.  When such women marry, they are often
deficient in the  sexual orgasm during coitus, in consequence of
the removal  of the clitoris from its proper position.  The clitoris
                                 4 
50
CLITORIS, NYMrHAE, VESTIBULE.
is larger, comparatively, and more prominent, in the infant than
the adult.  It is subject to hypertrophy, but the special sense is
not increased in such cases, in proportion  to the hypertrophic
growth.  The clitoris receives large branches from the internal
pudic nerves; and in some  of  the  lower animals,  Pacinian
bodies have been found in this organ.
  The Labia Minora,  or  nymphae,  are two folds of mucous
membrane extending from the prepuce of the clitoris, downwards
and  outwards, for about an inch and a  half or two  inches.
Externally, there is a  furrow betwixt these folds and the labia
majora, covered with the commencing mucous membrane, and
studded with numerous fat-glands ; and, internally, they form the
commencement of the vagina.   On their inner surface may be
seen the openings of  numerous mucous follicles, from  which
mucus is secreted for the lubrication of the  ostium vaginae.  The
separated nymphae  have been compared  to the  fissured male
urethra  from  arrest of  development in  hypospadia, and the
analogues of the bulb  and corpora spongiosa are found deeply
seated behind the nymphae.  These consist  of a plexus of veins
lying on each side of the clitoris, called the pars intermedia;
and of two leech-shaped masses of reticulated veins inclosed
in a fibrous sheath.   The bulbous masses were  known  to the
older anatomists, De Graaf and Santorini, but they have been
described anew by Mr. Guthrie, Kobelt, and others.  The bulbs
are situated below  the pars intermedia, and behind the middle
and lower portions of the nymphae.  They have received various
names, such as plexus retiformes, bulbi vestibuli, and crura cli-
toridis interna.  The objects both of the labia majora and minora
are, no doubt, to defend  the genital fissure, to afford an extensive
sexual surface, and to  facilitate the  expansion  and  dilatation
of the pudenda  during parturition.
   Below the clitoris and between the nymphae there is a grooved
space, about an  inch  long, pointed above and broader below,
termed the Vestibule.  In the centre, and at the lower portion
of the vestibule, is situated the Meatus Urinarius, consisting of
a raised and irregular rim of mucous  membrane, with an open-
ing in the middle.   The eminence is caused by a slight pucker-
ing of the mucous membrane by the contractile  fibres  which
keep the  meatus closed  under ordinary circumstances,  an
arrangement which admits of considerable distension during mic- 
METHODS  OF CATHETERISM.
51
turition, or in catheterism.   The meatus is generally so promi-
nent as to be readily felt by the experienced finger.   (Fig. 9.)
Fig. 9.
 1, Vena Dorsalis; 2, Glans Clitoridis ; 8, Crus Clitoridis; 4, Meatus Urinarius; 5, Bulbus Vestibuli
6, Vulvo-vaginal Gland ; 7, Sphincter Vaginae.

  Catheterism of the female bladder is one of the minor opera-
tions at which the  accoucheur ought to be expert, and  in  this
place a few remarks  may be made on the mode of finding the
urethra, and  passing  the  catheter.  We have to draw off the
urine in the unimpregnated state, during pregnancy and labor,
or  after delivery, and under other circumstances in which the
meatus and urethra may be  considerably displaced.  The situa-
tion of the meatus has already  been indicated, and the  length of
the urethra is about an inch and a quarter.  The meatus itself is
on a level with the summit of the pubic arch, the bladder being
in the natural condition above the pubes, and the  direction of
the urethra is backwards and upwards, or the same as the lower
part of the anterior wall of the vagina, in which it is embedded.
The urethra  may be  felt  rolling like a cord under the finger
between the vaginal wall and the symphysis pubis.
  There are two or three modes of finding the urethra in catheter-
ism, without  exposing the  patient—a matter which, of  course,
should always be avoided, if possible.   The woman  may be
placed on her back or on the  left side, and the attendant having
found the anterior commissure, with the index finger of his  left
hand, should pass the finger down lightly over the clitoris to the 
52
DIFFICULTIES OF CATHETERISM.
bottom of the vestibule, when he  may feel the  borders of the
raised meatus, and, with a cultivated sense of touch, the aper-
ture in  its centre  may be made out.   The catheter should be
passed over the point of the finger, which may be used both as
a director, and to steady the parts into the canal, when it gene-
rally passes readily into the bladder, the handle of the  instru-
ment being a  little depressed while it is passing.   It must be
remembered that the meatus is an aperture in a mucous surface,
and it may be searched for with the point of the  catheter, if the
canal is not readily found.  Occasionally, however, the meatus
is  in a  state of firm contraction, and must be  hit exactly in
order to  pass the catheter.  This  spasmodic contraction of the
meatus, and of the whole canal, is  met with in hysterical sub-
jects.  In another and better mode of performing the operation,
the accoucheur first finds the cord-like urethra in the upper wall
of the vagina,  and withdrawing it, feels  for the meatus with the
index finger of one hand, at the angle formed by the lower part
of the vagina and the vestibule, and  introduces the instrument
with the other.   In a third mode, the operator knowing the rela-
tion of the meatus to the pubic arch, and possessing tact and
experience, goes to it at once, the patient being on her left side,
with the knees raised.  In this way only one hand need be  used.
It scarcely need be said that the latter is  the most perfect
method of operating, and one which all should aim  at  being
able to perform.
  Various circumstances  alter  the anatomical relations of the
meatus and urethra.  The meatus may be so flaccid and relaxed
that it is found with  difficulty; or  after painful and lingering
labors, the external parts may become so  swollen  from inflam-
mation,  and the effects of pressure, as to render it no easy mat-
ter to find the urethra by the touch alone.   In prolapsus, occur-
ring during pregnancy, the direction of the meatus  becomes
altered so as to point towards the sacrum, or coccyx.  In retro-
version  the meatus in drawn upwards, and the direction of the
upper part of the  canal is turned backwards  and  downwards,
while in anteversion of the gravid uterus the urethra is dragged
upwards; but the  upper part of  the canal is turned more for-
wards than usual. In the unimpregnated state, the urethra is dis-
placed by ovarian tumors, fibrous  tumors of the  uterus, and by
the various alterations of position  to which the uterus is liable. 
VARIETIES IN  THE HYMEN.
53
Sometimes one of the mucous lacunae, close to the meatus, may
be so enlarged as to admit a small-sized catheter, and the oper-
tor may suppose he has reached the bladder, while the  instru-
ment is really in a cul-de-sac.  The length  of the urethra and
the possibility of this mistake should always therefore be borne
in mind.   An inexperienced hand may pass the instrument along
the upper floor of the vagina, but  the sides of the urethra,  or a
slight  clasping of the instrument by the canal, will generally
assure  the operator that he is in the right passage.
  The  instruments used are, a common number  8 or 10 male
catheter, with or without a stilette; a gum-elastic catheter very
similar to the male catheter, except that it is somewhat shorter,
and a flattened silver catheter.  The stop of the silver catheter
is perfect, and the urine can be drawn off by it without wetting
the patient;  but during labor, when this is  not of so  much  con-
sequence, a gum-elastic catheter is to be preferred, and if used
without a stilette, it is scarcely possible for any accident to occur.
It should be seen that the apertures of the catheter are free, and
the point of the instrument should be dipped in oil or glycerine.
The catheter should be held gently in the fingers, being  lightly
poised  rather than grasped, and no force should be used, as both
bladder and meatus have been perforated accidentally.  It should
be borne in mind that  in  case of difficulty it is far  better to
expose  the patient than to use force, or incur the risk of injury.
  Immediately below the  orifice of the meatus  is the Ostium
Vaginae, slightly oval in form, and of variable diameter, accord-
ing to  age, childbearing, etc.  In the Virgin this opening is partly
closed  by a membranous fold, constituting the Hymen, which is
commonly crescentic in form, the concave free  border being
turned upwards.  Sometimes the hymen is  deficient or wanting
altogether, either congenitally or  as the result  of accident, so
that  its absence  is no absolute proof of intercourse.   In other
cases it is circular in shape, or possesses several cribriform open-
ings, or it  may be thickened and  imperforate.   During inter-
course  this membrane is generally  ruptured; but cases occur in
which  it  is so strong and resisting, that surgical interference in
the shape of  a crucial incision is required.   In some women, on
the other hand, it is so distensible, that it readily yields, instead
of tearing, and remains  unbroken, even after perfect and habi-
tual intercourse.  This may account for  the circumstance men- 
54
ANATOMY OF THE VAGECTA.
tioned by  Parent Duchatelet, that in some  prostitutes  the
vagina resembles the virgin state.   Rupture of the hymen is by
no means necessary to  conception, as impregnation is known to
occur through the cribriform hymen, or when only a very small
aperture  exists.   Usually, after intercourse, the place of  the
hymen is occupied by several fleshy eminences,  termed  the
Carnneulac Myrtifornies, which some anatomists believe to be
formed by the cicatrization of the ruptured hymen, while others,
as M. Rigaud, believe  them to consist of reduplications  of the
mucous membrane, which exist before  the  loss of the hymen.
There is a considerable amount of contractile tissue in the situa-
tion of the  carunculae, and in some cases the irritation and spas-
modic  painful contraction at this point is  so great as to render
intercourse  difficult  or impossible long after marriage.
  Externally to the carunculae, on each side, and on the surface
of the nymphae, are two small  openings, admitting the point of
an Ancl's probe, which are the ducts of the Vulvo-Vaginal
Glands.   These glands, which were known to Bartholine  and
Duvernay,  and called after their names, have recently been des-
cribed with much accuracy and  minuteness  by M. Huguier.
They are seated on each side of the  vulva, outside and below
the bulbi vestibuli, and in shape and size have been compared
to apricot stones;  their ducts are about half an inch long.  The
vulvo-vaginal glands secrete a  clear albuminous mucus, of a pen-
etrating odor during intercourse, which  Huguier and Scanzoni
believe can be ejaculated by the involuntary contractions of the
neighboring muscles.   These  glands are  considered the  ana-
logues of Cowper's glands in the male.  M. Huguier points out
that they may be the seat of abscess, or of encysted tumor, from
obliteration of their  ducts.
 ' The Perinaeum is the space between the posterior commissure
and the margin of the anus.  To the  obstetrician the anatomy
of this part is  matter of great  interest; though it must be con-
fessed, that the anatomy of the male perinaeum has been culti-
vated somewhat to the neglect of that of the female.   In the
ordinary  state it is from an inch to an inch and a half in length
but during labor  it elongates to twice or  four times this size.
At the  fourchette, the perinaeum is comparatively thin,  but
towards  the anus it is of considerable  thickness.   It is com-
posed  chiefly of skin,  cellular tissue, muscular fibres, and the 
PERLNEAL  MUSCLES.
55
mucous membrane of the vagina.  There are certain peculiari-
ties in the arrangements of the muscles of the perinaeum which
deserve notice.  They are all inserted by at least one extremity
into tendinous structures and  fasciae.    This occurs with the
sphincter ani,  levatores  ani, coccygei,  transversales  perinaei,
erectores clitoridis, and sphincter vaginae.  The fibres of many
of these muscles are  indistinct as compared with other  muscles,
and  are mixed up with  a considerable quantity of elastic  dar-
toid tissue.  These circumstances greatly facilitate the dilatation
of the perinaeum  at  the time  of labor.   It  must be borne  in
mind that the perinaeum  has  a two-fold  function;  one  to dilate
during the passage of the child; the other to support the pelvic
viscera under other conditions.   When its structures are rigid
and undilatable, we  have the  danger of laceration; and when
its dilatability is excessive, the patient is liable to prolapsus and
other  displacements  of  the  uterus  and vagina.    A  similar
arrangement with regard to insertion holds good in the case of
the abdominal muscles, and  facilitates their  distension by the
gravid uterus during pregnancy. (Fig. 10.)

                            Fia. 10.
 1, Sphincter Ani; 2, Tendinous point of Perinasum; 3, Sphincter Vaginas; 4, Transversus Perinasi;
5, Hrector Clitoridis; 6, Aponeurosis: 7, Levator Ani; 8 Gluteus-maximus.

  TU Vagina extends between the internal and external parts
of gelation ;  but as it is concerned with the latter in coitus,
and bea-s no share in the development of the ovum, it may be
conveniei-tly described with the external organs.  This canal is 
56
SIZE OF VAGINA.
slightly curved, the concave surface being upwards and forwards,
and its direction is nearly that of the outlet, and lower portion
of the middle, of the pelvis.  The  anterior wall of the vagina is
about four inches long, the posterior being five or six inches in
length.   This is partly on account of the greater length of the
lower curve, and partly because of the way in which the uterus
is inserted into the vagina.  The axis of the uterus is nearly the
same as the axis of the inlet of the pelvis, so that the uterus  is
inserted, as it were, into the anterior wall  of the vagina, while
the posterior wall is prolonged behind the os uteri.  This canal
is longer in virgins than in women who have borne children, par-
ticularly multipara?.  It is also longer in the middle months  of
pregnancy than in the beginning, or towards the termination  of
gestation.  It is elongated in  some cases of fibrous or ovarian
tumor, when  the tumor is supported  above the  brim of the
pelvis, and  raises the  uterus with it.  The  diameter of the
vagina varies in different  parts of the  canal, being  smaller  at
the outlet than in the middle and upper portions.  In ordinary
cases, the sides of the vagina are in contact; and this acts as a
valvular arrangement for  preventing the  access  of air to the
uterus.   As regards structure, the vagina is composed of an ex-
ternal, middle, and mucous coat or tissue.  The  external layer
consists of cellular tissue, which connects it anteriorly with the
bladder and urethra; laterally with the levatores ani, and pos-
teriorly with the rectum and the peritoneum.  The connection
with the  peritoneum is  in the upper and posterior fourth of the
vagina,  where the peritoneal  cavity  dips down between the
vagina and the rectum.  The middle coat is dense and fibro-cel-
hilar, and is similar in  structure to the proper  uterine tissue,
with which it is continuous at the os and  cervix uteri.  It has
been  compared by Cruveilhier  and  other  anatomists  to  the
dartos.   During pregnancy, it partakes of  the  growth of the
uterine muscular tissue, though in a less degree.  The mucous
lining of the vagina has upon the mesial line of its anterior and
posterior surfaces two ridges, termed the columnae ru^aruro.
From these two columns folds of mucous membrane  project at
nearly right angles, the folds being most numerous at the lcvver
part of the passage.  The rugae of the vagina are most distinct
in virgins, less so in women accustomed to intercourse, aid they
nearly or altogether disappear in women who have bor*e child- 
          SECRETIONS  AND FUNCTIONS OF THE VAGINA.        57

ren.   The vagina also becomes smooth in virgins after the time
of childbearing has passed.    The objects of the  rugae  are  to
yield an extensive surface for sensation, and  to provide for the
distension of the canal during labor. Examined microscopically,
the vaginal mucous surface is found to  be studded with vascular
papillae, which have been  described and figured by Dr. Franz
Kilian, and which are probably the seat of the great sensibility
of the organ.  The whole surface is covered by a thick layer of
tessellated or squamous epithelium.  Writers on the subject gen-
erally describe the vagina as containing great numbers of*mu-
cous follicles, which are supposed  to secrete the  mucus which
lubricates the vagina at ordinary times,  and especially at the
time of parturition.  In my  own examinations, I failed to find
any large number of glands,  except at  the outlet of the vagina;
and with this exception, the  mucus of the vagina is, I believe,
produced by the epithelium,  and consists of plasma and epithe-
lial particles.   The secretion of the vagina, as pointed out  by
M. DonnC", and Dr. Whitehead, of Manchester, is distinctly acid.
The  acid  secretion is  believed to be serviceable in preserving
the fluidity of the menstrual secretion, and thus of facilitating
its escape from the vagina.   It has also an antiseptic effect, and
tends to prevent the decomposition of coagula.  It likewise con-
tributes, with the rugae of the vagina, to stimulate the penis dur-
ing coitus.  Besides the coats of the vagina already described,
it is surrounded, particularly near the outlet of the passage,
with a plexus  of veins, resembling erectile tissue ;  and it posses-
ses a muscle, the sphincter vaginae, arising from  the tendinous
point of the  perinaeum, inclosing the  bulbi vestibuli, and  in-
serted into the clitoris.  A fasciculus of the  muscle crosses the
vena dorsalis,  and aids in promoting the turgescence of the cli-
toris.  The arteries of the vagina are branches of  the internal
iliac, and the veins empty themselves into  the internal vein.  It
derives  its nerves from  the hypogastric  plexus, and from the
third and fourth sacral nerves.
  The vagina  resembles skin almost as much as  mucous  mem-
brane, and in cases of procidentia, where it is exposed, it be-
comes converted into  dermoid tissue.   The chief functions of the
vagina are as an organ of sensation and introception,  and as a
canal for the passage of the foetus and the catamenial secretion.
It undoubtedly possesses some contractile power, both voluntary 
5g
PHYSIOLOGY OF COITUS.
and reflex.   This is seen in the expulsion of coagula during men-
struation, and after parturition, and on the introduction of the
speculum.  The vagina also  contracts with considerable force
during the passage of the child, and it sometimes expels the pla-
centa after labor.
  It may be necessary to say a word respecting  the  physiology
of Coitus, as regards the female.  The sexual orgasm of the male
is well recognized.   We know that it begins with excitement of
the glans penis, and ends in spasmodic contraction of the vesi-
culae'seminales and ejaculatores muscles, this contraction being
attended by  the sensorial orgasm.   The female is considered
" passive," both by Professor Muller and Dr. Carpenter, during
coitus, but this is a great mistake.  The sexual " paroxysm " in
the female was fully recognized by John Hunter, and  is as  dis-
tinct as that of the male.  It begins in the clitoris, and ends in
an  orgasm or paroxysm of sensation.  Whether the  sensation
produces any spasmodic reflex action is a question.  Is the ejac-
ulation of the secretion of the vulvo-vaginal glands described by
M.  Huguier, the  analogue of emission in the male  ?  Whytt
and the older anatomists believed in the contractions of the  Fal-
lopian tubes during  intercourse.   Of the existence of the  sen-
sorial orgasm there can be no doubt, and its absence constitutes
impotence in the female.  It should be observed, however,  that
the orgasm is not  at all necessary to conception.   Women to
wdiom Heberden applied the term " frigida " conceive  as well as
those  who are perfect in this respect.  Impregnation consists in
the meeting of the spermatozoa and  the  ovule, and can never
take place at the moment of coitus.   The union of the  male
and female elements  of reproduction in the uterus or Fallopian
tubes is no more attended by sensation than the conjugation of
the OregarincB.
  An account of the external organs of generation would not
be complete without  a description of  the  Mammae from which
the infant derives its  nourishment for some time after birth.  The
mammary glands are placed upon the pectoralis major  muscle
on each side, extending from the third to the seventh rib.   This
situation, which is  in great measure peculiar to the human fe-
male—the mammae  being, in the vast  majority  of  animals
placed upon the abdomen—is  evidently adapted to the nursino-
of the infant while supported in the arms of its  mother.   Theso 
            1       ANATOMY OF THE BREAST.               59

glands are hemispherical in shape, the external aspect being con-
vex, the  posterior, flat or slightly concave.  The left breast is
generally the larger of the two, and is more  used in nursing.
Each gland is enveloped in a fibrous or  dartoid capsule, which
dips down between the various portions of the gland, and is sur-
rounded by a considerable quantity of adipose tissue.
  The  intimate structure  of each  gland consists of numerous
lobes, which are divisible into smaller and smaller lobuli, until
we  arrive at the ultimate follicles of which the substance of the
gland is composed.  The follicles and ducts are  covered with  a
layer of epithelium.  It is by the growth and multiplication of
the nuclei, and the bursting of the epithelial  cells, which have
been found  by Professor Goodsir to be  filled with milky fluid,
that the lacteal secretion is produced.   These follicles or vesi-
cles, having caecal  extremities,  empty  themselves into  small
tubes, which unite with  each other, and proceed in a tortuous
course towards the centre of the  gland, becoming larger  and
larger, and  terminating  in from ten to fifteen  galactophorous
tubes, which are collected  together, but without much inoscula-
tion, near the base of the nipple.   As they approach the nipple,
they dilate,  to form sinuses or ampullae, which act as reservoirs
for the milk.  Underneath the nipple  they contract  again, and
pass by separate ducts to the surface of the mamilla, where their
openings are  found in depressions of the mucous membrane.
The lactiferous tubes are  wanting in valves,  but are closed  at
their external apertures.
   The surface of the gland is covered by delicate integument,
and at its summit is placed the nipple, which  in the virgin, or in
women who have not borne children, is conoidal in shape, but in
nursing women assumes a flattened or cribriform appearance  at
its extremity.   The  site  of the nipple is on a level with the
fourth rib.  This,  the most vascular part of the  breast  contains
a certain quantity of erectile tissue, which makes the nipple tur-
gid, and  tends to dilate  the openings of the milk-ducts, under
irritation.  The turgescence is generally accompanied  by plea-
surable sensations, the surface of the  nipple  being covered by
numerous nervous papillae.  The  sensation of  "the draught,"
which is excited by emotional causes, the  suckling of the
child  or, as  a reflex action,  by the  ingestion of blood,  or
drink  into  the  stomach, and is felt in  the  nipple, and is fol- 
60
THE AREOLA.
lowed by a  rapid  secretion of milk.  The nipple contains  a
considerable  quantity of dartoid contractile  tissue,  which  is
probably concerned in the  closure  and dilatation of the milk
ducts.  The action of this tissue and the capsule covering the
gland contributes to the expulsion of the milk.  The base of the
nipple is surrounded by an areola of a pinkish hue in the vir-
gin, but in the pregnant woman pigment cells  are  deposited in
it, and the  areola becomes darker in color.  On the surface of
the areola are numerous small tubercles, or sebaceous glands,
which secrete a fatty matter, intended to defend the nipple dur-
ing lactation.   Sudoriferous glands are also  found  upon the
areola.
  The mammary glands receive their supply of blood from the
thoracic intercostal, internal mammary, and  epigastric arteries.
The veins are those accompanying these arteries.  Around the
nipple, the veins are arranged in a circular manner, the circulus
venosus of Haller.  During pregnancy, as Mr. Nunn has pointed
out, owing to the interference with the internal circulation by the
pressure of the gravid uterus, the circulation through the internal

                            Tig.  11.
            1, Galactophoroua ducts.  2, Lobuli of the Mammary Gland.

mammary and epigastric arteries, and the veins of the surface of
the abdomen and thorax, is very much increased—a mechanical 
LYMPHATICS OF THE BREAST.
61
condition which probably contributes to the development and sup-
ply of the gland during gestation. The nerves are chiefly branches
of the  intercostals.  The  lymphatics are very numerous,  and
maintain connections with the lymphatics of the axilla, anterior
and posterior mediastinal, and other  parts.  These lymphatics
are believed to absorb the watery portions  of the milk when
first secreted, and it is to these vessels that we address ourselves
when we endeavor to diminish the quantity of the milk by fric-
tions. 
LECTURE  III.
            THE INTERNAL ORGANS OF GENERATION.

   Gentlemen :—The Uterus is, in an obstetrical sense, by far
 the most important of all the organs of generation.  It is in this
 viscus that the ovum is received, retained, and nourished until
 the foetus becomes fitted for extra-uterine existence, and to the
 physiological action of this organ its expulsion  at the end of
 utero-gestation  is mainly  due.  The following  description will
 have reference chiefly to the unimpregnated uterus.
   In  shape  the Virgin  or  Nulliparous uterus is  pyriform.
 Dubois describes it as a cone compressed from before backwards,
 and compares it  to a flattened calabash, the base of  which is
 directed  upwards, and the orifice downwards.  The  uterus is
 placed in the middle of the upper part of the pelvis, its direc-
 tion being the same as that of the pelvic inlet.  It is situated
 above the vagina, and  below the  ilium, having the bladder in
 front, and  the  rectum behind  it.   Thus the  inferior part of
 uterus has a vaginal, and  the upper part a peritoneal  aspect.
 The lower part of the organ consists of the Os uteri, possessing
 an interior and posterior lip, and constituting the outlet of the
 uterus as regards the catamenial secretion and the products of
 impregnation; and its inlet, with respect to coitus, and the fer-
 tilization of the ovum. Above the os uteri is situated the Cervix,
 and the highest part of the uterus is called the Fundus, the
 upper and middle portion being termed the Body.  The cervix
 and body contain a canal and cavity, but the great bulk of the
organ consists of its walls, which are of  considerable thickness.
The external surface of the uterus is in part covered  by mucous
membrane, and in part by peritoneum, the rest of its superficies
being occupied  by attachments  to other  organs.  The uterus is
from two and a half to two and three quarters of an inch in length
its breadth being, from one Fallopian tube to another, about an
   C2 
VIRGIN CERVIX UTERI.
63
inch and a half, or an inch and three quarters.  At the cervix
the breadth of the uterus is about an inch.  From before back-
wards its greatest diameter is about an inch, and the greatest
thickness of its parietes, which is in the middle of  the body, is
about half an inch.  The anterior surface of the uterus is some-
what flattened, the posterior being convex.
  The os uteri is circular or somewhat oval  in form, its trans-
verse diameter being generally greater than the antero-posterior.
Of the two lips of which it is  composed the anterior is the  low-
est, so that it hides the posterior lip as well as the orifice.  The fis-
sure itself is, in the nulliparous uterus, not circular, but trans-
verse, the external angles of the rima being directed backwards,
like the mouth of a fish.  It  is from this peculiarity that it de-
rives its name of os tincoe.
  The canal of the cervix is fusiform in shape. There is a slight
constriction at the os uteri, and a more considerable narrowing of
the canal at the os uteri internum, or the point at which the canal of
the cervix enters the cavity of the body.  The cervical canal is flat-
tened from before backwards, and is about an inch and a half in
length.  It is lined by the mucous membrane, which is arranged
in a peculiar manner.   When the cavity of a  virgin cervix  uteri

                           Eig. 12.
 1, Cavity of the body; 2, Canal of cervix; 3, Opening of Fallopian tukes; 4, Penniform rugae :
5, Os uteri internum; 6, Fundus.

is laid open, the internal surface is generally found to contain four
columns of rugae, arranged more or less in a transverse direction.
The reduplications of the cervical mucous membrane may be 
64
ANATOMY of cervix uteri.
compared to an open book, and the names penniform rugae, pal-
mae  plicatae, and arbor  vitae internus  have been applied to
them.  These rugae are separated by four grooves or sulci, two
of which divide the anterior from the posterior walls ; the other
two, which are most marked, being upon the median line in the
anterior and posterior walls.   There are from ten to fifteen rugae
in each column.  These  rugae, and the spaces between them,
are everywhere covered by such multitudes of mucous  cysts or
follicles, that,  on a moderate computation under  a  power of
eighteen diameters, ten thousand mucous follicles are visible in
a well-devoloped nulliparous organ.   The cervix uteri may in
effect be considered as an open gland.  The rugae are evidently a
provision for the dilatation of the mucons membrane in the latter
months of pregnancy, and  during parturition.  They also  pro-
vide an extensive secretory surface.  The objects of the secre-
tion  are to keep the cervix uteri impermeable in the ordinary
state, to provide a fit medium for the ascent of the spermatozoa,
to furnish the plug which fills the cervix during pregnancy, and
to secrete the mucus which lubricates the os uteri and vagina
during labor.  The secretion  consists of  mucous corpuscles and
plasma, having a distinct alkaline reaction, while  the secretion
of the external portion of the os is decidedly acid.  The limits
of the acid and alkaline secretion-are determined by the presence
of squamous or cylindrical epithelium.
Fie, 13.
  The cavity of the body of the nulliparous uterus is triangular in
shape, the base of the triangle being above and the apex below,
At the two superior angles, the Fallopian tubes enter the uterus, 
MUCOUS  MEMBRANE OF THE UTERUS.
65
while at the inferior angle the canal of the cervix communicates
with the body of the organ.  The angles leading to the  Fallo-
pian tubes  are grooved;  and at the  middle of the triangular
space the anterior and posterior walls of the body of the  uterus
project internally.  The thinnest part of the walls of the  uterus
is  at the entrance of the Fallopian tubes : the thickest is  at the
middle part of the fundus, and the parietes of the body oppo-
site the middle of its triangular cavity.
  Perhaps the most remarkable structure  of the uterus is the
mucous membrane which lines the cavity of its body.  It is, in
the healthy condition, pale in color about a line in  depth, and
forms  a thin layer, one aspect of which is free,  the other  being
closely united to the proper tissue of the walls  of the uterus.  If
the surface of the unimpregnated womb be examined with  a

                           Fig. 14
 A, Uterus laid open; 1, Mucous membrane of uterus; 2, Substance of the uterine walls.
 B, A single gland from the mucous membrane of the uterus; 1, Caecal extremity"; 2, Mouth of
the gland.

lens, numerous points are visible, which are openings of the
glands of  the mucous membrane.   The openings  are  given by
Kolliker as one-thirtieth of a line in diameter.  These glands
are tubular, and slightly coiled upon themselves, closely resem- 
QG
PAPILLA OF THE OS-UTERI.
bling the glands of Lieberkuhn in the intestine.   Their general
arrangements, and that of the connective tissue around them, is
concentric, the open mouth of each gland being  upon the sur-
face of the mucous membrane,  and its caecal portion deeply
seated in the attached surface.  Sometimes the utricular glands
are double, or two glands may open upon the mucous surface by
the same outlet.  These glands are supposed by some to secrete
mucus. Dr. West, for instance, supports the view that in Jeucor-
rhcea much of the discharge is, in  certain cases, derived from
these glands.   Some believe they secrete  the  nfenstrual  fluid.
Others affirm that they elaborate the material out of which the deci-
dua reflexa is formed. The latter, which is the opinion of Professor
Goodsir, Dr. Sharpey, and Kolliker, is probably the correct one.
  The mucous surface of the uterus is covered by an epithelium.
In the cavity of the body this is  cylindrical and  ciliated.   The
cilia vibrate from below upwards, and probably assist the ascent of
the spermatozoa.   In the cervix, the cilia are not alwayTs pre-
sent, and at the margin of the os, at the lowest part of the canal
of the cervix, the cylindrical epithelium ceases, the whole of the
vaginal aspect of the os and cervix being  covered by squamous
epithelium,  similar to that of  the  vagina.   Underneath the
epithelium, club-shaped papillae or villi are everywhere found.
Each villus consists of one or two looped bloodvessels and  a cel-
lular envelope, the whole being covered by epithelium.  These
villi  are larger within the os uteri than upon its external surface,
but they are  less numerous in the upper  part of the cervical
canal,  and the  cavity of   the body.   At the  os uteri  these
papillae appear to possess special sensation of a sexual character.
It is  also probable that they play  a part as excitors of reflex and
peristaltic action.
  According to the recent researches of Kolliker, Kilian, Mr. Rai-
ney,  and others, the substance of the uterus is made up of connec-
tive tissue and a vast number of fusiform fibre cells, fibre o-erms,
or embryonic nucleated cells, having the power of development
into  non-striated involuntary muscular fibres.  The diameter of
these cells is about * oVoth of an inch, and  their length  is some-
what greater, so that they are slightly elongated in shape. In the
unimpregnated uterus, under ordinary circumstances,  the fibre
cells or germs remain quiescent, and are not the subject of any
increase in size.   On the  occurrence  of impregnation, the 
WEIGHT OF  UTERUS.
67
growth of a polypus in the uterus, or auy continual irritation of
Hie cavity or walls, the embryonic fibre cells commence a career
of growth and multiplication.  These fibre cells  are of great
importance, as it is entirely to their development that the gravid
uterus owes its contractile properties.  They may be compared
to the derivative germ cells by which lost parts are reproduced
in the lower animals, and  which, but  for the loss which calls
forth their development, would forever remain inactive. In the
case of the uterus, unless  impregnation or some other stimulus
be applied, these germ fibres remain through life in a rudimen-
tary state.   In the unimpregnated  condition, it is probable that
the germ fibres or fibre  cells are  in a more advanced state in
some uteri  than others, particularly in  multipara.  Cases are
met with in which the uterus expels coagula, or the dysmen-
orrhoeal membrane, by contractile efforts, even in the unimpreg-
nated condition.   It is probable that, by relaxation of the fibre
cells of the os and cervix, and contraction of those of  the body,
the os uteri may be  opened and  matters  expelled  from the
cavity of the virgin uterus.
   The difference between the virgin or Nulliparous uterus and
the Multiparous organ have been very strongly insisted upon by
M. Paul Dubois.   The term nulliparous  is evidently to be pre-
ferred to that of virgin uterus, as intercourse without impregna-
tion exerts no influence  upon the anatomical characters of the
or^an.   In the multiparous  uterus the anterior and posterior sur-
face of the  body is more rounded.   The fundus, instead of being
flat, is convex, so that there is  a considerable protuberance above
 a line drawn from tube to tube.   The  vaginal  portion of the
 neck is altered, being more conical and elongated.  The os uteri,
 instead of presenting a transverse fissure, is rounded or puckered
in shape.  The depression felt by the finger is more evident, and
the orifice is considerably larger.  These changes in the os uteri
 are most evident in women who have borne large families.  They
 are imitated to a  slight extent in  nulliparous women who  have
 been  subject  to  inflammatory conditions of  the   os  uteri,
 dysmenorrhea, polypus, or  any of the conditions  which excite
 the growth of the organ.  The uterus which  has been  fully
 developed by gestation never  returns, unless as a morbid condi-
 tion, to  the size  of  the nulliparous organ.   Meckel  gave the
 weight of the nulliparous organ at  seven or eight drachms, and 
68
6HAPE OF THE CAVITY OF THE UTERUS.
the multiparous at an ounce  and a half.   The diameters are all
increased in the multiparous organ.  The  interior of the uterus
also offers some remarkable differences in the two organs.  The
cavity of the  bodyT of the multiparous  womb is  considerably
enlarged.  The os  uteri internum is less distinct, and the canal
of the cervix is shorter, the penniform rugae being to some extent
obliterated.  The cavity of the body, instead of being distinctly
triangular, is oval in shape, the angles into which the Fallopian
tubes enter having entirely disappeared.   These changes are not
without practical importance.  Their consequence is obvious in
a medico-legal point of view.  A few years ago a lady of family

                           Fig. 15.
Section of the Nulliparous and Multiparous uterus.
and her maid were  burnt to death together in a hotel at the
West-end.   The bodies  were so mutilated as  to  render any
recognition  by external  signs impossible;  but  the  lady had
borne a numerous family, and the identity  of her body was
ascertained from the condition of the  uterus.   Again,  in the
return of the uterus to the unimpregnated state after parturi-
tion, the involution of the organ may be so excessive  as to pro-
duce  amenorrhcea and  sterility,  or which is more frequent, it
may be incomplete, and give rise  to monorrhagia.
  The uterus is supplied with blood by four arteries, the two
ovarian, or spermatic, and the two uterine.   The upper part of
organ is supplied by the ovarian, and the lower by the proper uter- 
       BLOOD  VESSELS AND LYMPHATICS OF  THE UTERUS.      69

ine vessels.  In the substance of the uterus they run a very tor-
tuous course, anastomosing  very frequently.   The veins corres-
pond to the arteries.  Their walls are very thin  in the uterus,

                           , Fig-. 16.
External view of the Nulliparous and Multiparous uterus.
and they possess no valves.  They communicate with the veins of
the bladder and vagina, and empty themselves into the iliac and
ovarian veins.  The lymphatics are numerous but of small size
before impregnation, and chiefly enter the lumbar glands.   The
uterus is principally supplied with nerves by the  hypogastric
and  sacral nerves, and by branches from the ovarian plexus;
but I propose to enter into the question of the nervous supply of
the uterus when I come to treat of the  increase of the various
tissues of the gravid  uterus, and of the  motor endowments of
the parturient organ.
  The Fallopian  Tubes  extend on each side from the upper
angles of the uterus towards the brim of the pelvis.  Each tube
is  from four  to  five  inches  in length.   The  first  direction  is
upwards and outwards; it then  passes  downwards, backwards,
and inwards.  The tubes can be felt  as a cord-like structure in
the broad ligament, the uterine half being thicker than the exter-
nal or ovarian half. They are pervious throughout, the  diameter
of the canal being smallest at  the uterine extremity.   At the
entrance to  the uterus it, however, readily admits a fine whale-
bone stilette.   At the distal extremity, or ostium  abdominale, 
70
FUNCTIONS OF THE FALLOPIAN TUBES.
each tube  terminates in the corpus fimbriatum—a fringe-like
structure, which may be compared to the tentacles of a polyp.
In the centre of the circular fringe is  seated the ovarian aper-
ture of the tube, considerably larger  in  size than the  ostium
uterinum.  One of the  fringes, or a separate ligamentous band,
generally connects the  Fallopian  tube with the ovary, but the
aperture and the general mass of the  corpus fimbriatum floats
loosely  in the neighborhood of the ovary.   The internal  sur-
face of the tubes is lined by the mucous membrane of the uterus.'
It is thrown into longitudinal folds, so  as to admit of dilatation,
and is covered by ciliated cylindrical epithelium, the movements
of the  cilia being from the ovarian towards the uterine extre-
mity.  The mucous membrane of  the tubes is thin, and devoid
of villi or glands.  The middle  coat of the Fallopian tubes is
continuous with the middle coat of the uterus,  the fibres being
more developed, and arranged as  an external and longitudinal,
and internal and circular layer, fitted for the vermicular or peris-
taltic movements which the tubes are  called  upon  to  perform.
These layers are intermixed with connective tissue, similar to
that found in the stroma of the ovary and the  middle walls of
the uterus.   The external  surface of the tubes consists of the
peritoneal folds, constituting the ligamenta lata.  (Fig. 17.)

                           Fig. 17.
[he uuirapregnated uterus, ovaria, and Fallopian tubes.  * Round Ligaments.
  As regards the function of the tubes, the ciliary currents and the
muscular contractions combine to convey the impregnated or un-
impregnated ovum from the ovarium to the uterine cavity.  The
tubes are really to be considered as the oviducts of the human eco-
nomy.   When they fail of their office in the impregnated condi-
tion , we have extra uterine gestation as the result. There is scarcely 
SITUATION OF THE  OVARIA.
71
anything more  mysterious in the range of physiology than the
grasping of the ovary by the fimbriated extremity of the tube
where  there  is an  impregnated ovum to  be conveyed  to the
uterine cavity.  At the time of impregnation there is not merely
a grasping of the ovary but the  tube must be  applied to pre-
cisely the spot upon the ovarium  from which the ovulum is about
to emerge.   How is this selection to be accounted for ?  It is
evidently one of those reflex actions in which excitor and reflex
stimuli are in such exact and exquisite relation as to stimulate the
perfect effects of volition.  Perhaps it is not more wonderful than
what occurs in  the case of the polyp.  When a particle of food is
placed on any part of the surface,  the filaments of the oral fringes
turn with precision to the foreign  matter, and grasp it for convey--
ance to the interior of the animal.  It appears either as though the
different parts of the ovary were in exact relation with the corpus
fimbriatum,  or that when the ovarian stimulus  has  excited the
fringes to contractions upon the ovarian surface, only that part of
the ovary is  firmly grasped which is in a state of irritation, such
as that which attends the maturation or escape of an ovulum.
During menstruatren, the Fallopian tubes have been found firmly-
grasping the  ovaria by Gendrin  and other  observers.  The
embrace of the ovaria is favored by the turgescence and rigidity
which  the  tubes assume  under excitement,  as  observed by
Cruikshank, and which directs them towards the ovaria.
  The  Ovaria  are the analogues of the testes in  the male, and
constitute the dominant organs of the female generative system.
They are two flattened bodies, somewhat oval in form, or tend-
ing to  a crescentic shape.   Their length is considerably greater
than their breadth,  but the upper surface is slightly convex, and
the lower somewhat concave.  They are situated in the posterior
fold of the broad ligament, and behind the Fallopian tubes.  The
ovaria are about half an inch thick, three-quarters  of an inch
wide, and from an inch  to an inch and a half long.   They are
connected, as already mentioned, to the corpora fimbriata, and a
ligament attaches them  to the uterus, near the  insertion of the
Fallopian tube.  This  ligament,  the Ligamentum Ovarii, con-
nects the stroma, or parenchyma, of the ovarium with the pro-
per tissue of the uterus.  These  organs  are entirely covered by
peritoneum, except at the hilus, where the nerves  and  vessels
enter,  but are  directly  enveloped by a white fibrous tunic, the 
72
CONTENTS OF THE OVARIA.
tunica albuginea, analogous to the membrane of the same name
in the testis.  The tunica albuginea incloses the  proper struc-
ture or stroma, of  the  ovary, which is  reddish-white  in color,
and similar in constitution to the proper fibrous structure of the
uterus.  Scattered about in the stroma of the ovary, but parti-
cularly towards  the  external  surface,  numerous small vesicles
are found, varying  in size  from a pin's head to  a small  pea.
These are the Graafian vesicles, or follicles, as they should more
properly be called.   There are generally from ten to  twenty, or
more, in,  or  near, a state of maturity; but a far greater num-
ber of small  vesicles are visible by the  aid  of the microscope,
and are constantly passing on to maturity to replace those lost by
the periodical rupture of the most advanced follicles. The ovaria
must be considered as two follicular glands.  Each Graafian fol-
licle represents  the  ultimate tubule, or follicle, of a secreting
gland, from which it differs only in being closed, except  at  the
time when it discharges its contents.  This tendency to the for-
mation of closed vesicles, or follicles, extends to other parts of
the generative system.  It is met with in the Fallopian  tubes, in
the cavity of the body and cervix, at the os uteri, as in the case
of the Nabothean follicles,.and even in the vagina.  The minute
anatomy of the Graafian follicles will be given in a subsequent
lecture, in connection with the subjects of ovulation  and men-
struation.   The ovaria are supplied with blood by  the spermatic
and uterine arteries, which enter at the lower border, and after
numerous divisions, take a serpentine  course  in the stroma, and
are distributed to the tunica albuginea, the stroma, and the walls
of the Graafian follicles.   The veins follow the same course, arid
empty themselves into the uterine and internal spermatic veins.
The  lymphatics  are few in  number.   The   nerves  are fibres
derived from the renal and spermatic plexuses.
Fi&. is.
(Section of Human Ovary showing the formation of Graafian follicles. Twice the natural s'' 
                    UTERINE LIGAMENTS.                   73

  The lower part of the uterus is attached to the bladder and
rectum by folds of the peritoneum, which are sometimes called
the Anterior and Posterior Uterine Ligaments.  The peritoneum,
reflected upwards, covers the anterior and  posterior surfaces of
the uterus, inclosing the organ between two layers of this mem-
brane.   These layers meet together at the sides of the uterus,
and  pass off* to  the  lateral walls of the pelvic cavity, dividing
the pelvis transversely.  In this way, the peritoneum  forms the
principal part of the Broad Ligaments  of the uterus.   The
fibrous or muscular  structure of the uterus itself also extends
into  these ligaments.  They contain besides, the Fallopian tubes,
the ovaria, the Round Ligaments, with bloodvessels, nerves and
lymphatics.   The  round ligaments arise from the upper angles
of the uterus, in front of the Fallopian tubes.   From this origin,
each ligament passes to the inguinal ring, descends the inguinal
canal, turning round  the  epigastric artery, and its  fibres are
inserted into, or  united with, the structures  of the mons veneris.
The length of the round ligament is  from four to five inches.
The  external transverse fibres of the proper substance of the
uterus  are prolonged into the round  ligaments, of  which they
form a constituent part.   Some  fibres of  the internal oblique
muscle also.enter  the lower  part of the canal, and extending
upwards, contribute to the formation  of the ligament.    The
ovaria have  been shown to be connected with the uterus,  at the
point of insertion of the Fallopian tubes, by a fibro-cellular
cord or ligament, prolonged  from the proper substance of the
uterus.   Thus the fibroid embryonic muscular tissue of the
uterus is continued from below into the vagina, and above into
the ovaria, Fallopian tubes, and the broad and round ligaments.
This arrangement probably facilitates the great displacements of
the vagina, tubes, ligaments, and  ovaria, which  occur physiolo-
gically during the growth  of the gravid uterus.   The growth of
the muscular tissue in these several parts allows of their elonga-
tion without injury or rupture.
  [ The student will be enabled to get a better idea  of the rela-
tive position of the organs in the recent pelvis  of the virgin, as
represented  by Dr. Kolrausch.   The subject  was a young girl
of 21 years of age, who committed suicide while menstruating.
The specimen was prepared in such a way as  to enable Dr. Kol- 
74
RECENT PELVIS OF THE VIRGIN.
rausch to see it while lying in a bath of alcohol, covered with a
glass plate ; looking downward through a diopter, firmly  fixed
24 inches above the glass plate, he used a pen dipped in prin-
ter's ink,  softened with oil of turpentine, and drew every one
of the lines with the utmost exactness on the intervening plate
of glass—seeing them through the diopter;  so that they could
not, perhaps, be more correctly taken by a photograph.  The cop-
per-plate was copied from the drawing.
  To the right is the buttock, (1) covered with the bisected sacrum 
RECTO-VAGINAL SPACE.
75
(2), in front of which is the rectum (3), which has been  opened
by the incision.  In the left, behind the os pubis (4), is the blad-
der (5) with its urethra (6).  Between the bladder and the rectum
is  the  tube  of the vagina (7), surmounted by the uterus (8).
whose summit or fundus does not rise quite so high as the plane
of the superior strait.  The womb rests upon the upper end of
the vagina, which incloses its cervical or neck portion, and keeps
it up in its place by means of its connection with the bladder in
front and the rectum behind, and more than  all  by means of
two utero-sacral  ligaments, which tie  the  upper ends  of the
vagina and womb to a certain place about an inch and a half in
front of the apex of the  sacrum.  I may here say, that  as long
as the utero-sacral ligaments remain in a healthy state, preserv-
ing by their tone a due  length, the womb cannot fall down-
wards or prolapse, because the cervix, being inclosed within the
upper  end of the canal of  the  vagina, it  cannot move down
unless the upper end of the vagina moves down also.  Douglas's
cul-de-sac (9) is a deep pocket between the  gut and the womb,
sometimes increased by frequent coition, and especially observable
in  prostitutes, to double  or triple its natural length,  as here
represented.   It is into this place into  which  the  fundus uteri
falls when it is quite turned over backward or retroverted.  Let
the student,  therefore, comprehend  that the posterior wall of
Douglass cul-de-sac is  the rectum and sacrum ; its  anterior is
the womb and upper  posterior end of the vagina, and its right
and left  walls, the right  and left utero-sacral  ligaments.   I
wish  him to understand this on account  of its importance in
retroversio uteri and in prolapsus of the bowels ; but also from the
danger in passing the blade of a forceps  behind the os uteri
through this " recto vaginal space,"  into the cavity of the peri-
toneum, almost certainly  producing the  death of his  patient.
It  is  through  this  " space,"  that Dr.  Sims  has passed  a
catheter for the purpose of drawing off the fluids  effused and
creating irritation after operating for the radical cure of ovarian
dropsy.
   Most plates intended to represent the inner  female genetalia
in situ exhibit the  fundus uteri on a level with or  above the
plane of the strait.  Kolrausch's drawing is the most beautiful
 and correct that has yet been produced, and gives to all the inter-
 nal organs their absolute right place.] 
LECTURE  IY.
                         OVULATION.

  Gentlemen :—The mature Graafian follicle is about the size
of a small pea.   It is formed of two  layers—one internal and
fibro-cellular in structure ; the other external and vascular, con-
sisting of the condensed ovarian stroma.  The external surface
of the ripe vesicle is also covered by the indusium of the ovary.
It is the internal membrane which forms the proper ovisac.  The
ovisac is lined by a  granular layer of epithelium.   Altogether,
the envelope of the follicle may be  considered as a mucous
membrane, and the Graafian follicles constitute the mucous fol-
licles  of the  ovarian  glands.  Graafian follicles appear  in the
ovary at or soon after birth, being at first small, and distributed
throughout its  structure;  but  they  gradually increase in size,
and at puberty the largest follicles are found upon the surface of
the organ.  From this time to the  decline  of the catamenia a
succession of Graafian follicles ripen  and find their way to the
surface of the ovarium, when they rupture and discharge their
contents, chiefly at the catamenial periods.  Each follicle  con-
tains a clear  fluid, similar to the serum of the blood, in which
are granular particles  and  nuclei derived from the epithelial
lining.   When  De  Graaf, of Delft, in  Holland, described, in
1673, the follicles, which have since borne his name, they were
supposed to be  the actual ova of mammalia, though  anatomists
were at a loss to account for the small  size of the impregnated
ova occasionally found in the  uterus  and Fallopian tubes, as
compared with  the ovarian vesicles themselves.   But in 1827,
Von Baer, of St. Petersburg, discovered the true Ovule within
the Graafian vesicle,  and since that time the relations  of the
ovule to the  other contents of the  ovisac have  been carefully
examined by many distinguished anatomists.   I may here men-
tion that, in  speaking of the  unimpregnated  state, it will be
   76 
             ANATOMY OF THE  GRAAFIAN FOLLICLE.           77

more precise to use the word Ovule, or Ovulum, reserving the term
Ovum for the ovule after the occurrence of fecundation.  It may
also be observed that a close analogy exists between the ova of
all animals, so that observations made upon one class of animals
have a general application, and the history of the human ovule
has been made out partly by the study of the ovule in the human
female, and  partly  by the light thrown on  the  subject  by
researches in comparative  anatomy.  At first, and while the
Graafian follicle is imbedded in the  ovary, the ovule is found in
the centre of the vesicle.   At this time the semi-transparent and
albuminous matter and granules contained in  the follicle have
the following arrangement.  The  granules are  accumulated in
the form of a layer on the internal surface of the  ovisac, so as in a
great degree to resemble an epithelial lining.  This layer has been
termed the Membrana  Granulosa.  Immediately surrounding
the ovule, another granular layer is found, which has been called
the  Tunica  Granulosa.   Passing between these  two layers
are  certain granular bands constituting the Retinacula which
retain the ovum  in  its place.   When the follicles  mature and
approach the ovarian surface,  the ovules also rise towards the
free surface of the follicles, as Dr. Martin Barry believed by the
contractions of the bands of  the retinacula  on the superficial
aspect of the vesicle ;  while  the membrana granulosa and tunica
granulosa now become fused  together near  the surface of the
                            Fiq. 19.
Section of two Graafian Follicles enlarged about eight diameters, p. Peritoneal covering; s t,
 Ovarian Stoma; o v, the two Layers of the Ovisac; m ff, Membrana Granulosa, or epithelial
 lining of the Ovisac.  Around the ovum this membrane is seen forming the Proligerous Disc.

ovisac.  The ovule thus becomes imbedded in  an aggregation of
granules, which is named the Cumulus Proligerus, or prolig-
erous disc.  If the  Graafian follicle were spread out, we might 
78
VESICLE OF PURKINGE.
consider the ovule as lying upon the surface of a mucous mem-
brane, and  enveloped in  an accumulation of granular or epi-
thelial matter.
  Passing to the description of the ovule itself, it is found to
measure about 2^„th of an inch in diameter, and to consist of
an external membrane,Zona Pellucida, or vitellary membrane,
a vitellus or yolk, and a cell, which is termed the Germinal
Vesicle or germ cell.  As regards size and position, the germi-
nal vesicle tears much the same  relation  to  the ovule  as  the
ovule does to the Graafian follicle.  The yolk of the mammifer-
ous ovule is very small, as compared with the yolk of birds and
amphibia.  In the mammalia, the yolk consists of elementary
granules, all or nearly all of which are exhausted in the early
germinal processes of the ovum  after impregnation  has  taken
place ;  while in the ovipara the yolk is composed of  two kinds
of material, the one  consisting of granular particles,  similar to
those of the mammalian ovule, and termed the Germ  Yolk;  the
other, and larger portion,  of fat globules,  intended for  the
nutrition of the  ovum during incubation  or early development,
and termed, in contradistinction to the former, the Food Yolk.
  The germinal vesicle was first discovered in  the ovule of the
bird by Purkinje, of Breslau, in 1825, and when the mammalian
   Fig. 20.     ovule  became known, the vesicle  of Purkinje
              was soon sought for, and found  by M.  Coste.   In
              man and mammalia, the germinal vesicle is about
              the one-sixtieth of a line in diameter.  Within
              the germinal vesicle  itself is contained another
              important element of the  reproductive process.
              In 1835, Rudolph Wagner, of Gottingen, and Mr.
              Wharton Jones, in this country, discovered con-
temporaneously,  a nucleus or collection of fine granules in  the
interior of the germinal vesicle, which has been called the Mac-
ula Germinativa, or  germinal spot.   In some animals  the
macula is nuclear in character, while in others the germinal spot
consists of a mass of small granules.  This addition to  our know-
ledge of the ovule  brought the germinal vesicle  within  the
category of ordinary nucleated cells.
  The macula germinativa is the nucleus or centre of  the  whole
of this wonderful organism, and it may be useful to  trace  the
anatomy of the nature of a mature Graafian follicle from within
 
GLANDULAR STRUCTURE OF THE OVARY.
79
outwards.   Surrounding the germinal spot, we have the germi-
nal vesicle.  On the outside of the o-erminal vesicle there is the
yolk, inclosed in  the  vitellary membrane.   These structures,
taken collectively,  constitute the ovule.   The ovule itself is con-
tained in the Graafian follicle,  but it does not remain in its cen-
tre, this being occupied  by the liquor folliculi.   The  ovule  is
seated in a cumulus, or mamelon of granular epithelial  matter,
constituting the proligerous disc, and forming part of the lining
membrane of the follicle.  On the  outside  of this membrane
there are the fibro-cellular and vascular layers of  the  follicle;
and lastly, upon its free surface, the  indusium, or ovarian por-
tion  of the peritoneum.
   When the Graafian follicle is ready to shed the ovule, it pro-
trudes slightly above the surface of the  ovary, and
the rupture of the  follicle is apparently caused by
an increase of the  liquor folliculi, or fluid secreted
by the epithelial lining of the ovisac.  The gradual
distension  of  the follicle  causes a thinning  of its
fibrous and vascular walls, and of the indusium, un-
til at length it bursts.  The ovulum has at this time
approached the apex of the projecting part of the
follicle, and is discharged with  the liquor folliculi,  surrounded by
the granular matter constituting the proligerous disc. If the Fal-
lopian tube is applied to the ovary, the ovulum at once passes into
the oviduct.  At this step  of the process, we may recognize  the
glandular structure and function of the ovary.  When the peri-
toneum and membranes of the ovisac are perforated, and thesug-
                           Fig. 22.
Fig. 21.
Germinal Vesicle
and Macula Ger-
  minativa.
Ruptured Graafian follicle, with the escape of the Ovule.
escent embrace of the ovarium by the Fallopian tube occurs, the
channel from the uterus to the ovary is quite as unbroken as that 
80
MENSTRUATION AND OVIPOSITION.
from the bladder to the kidney. The ovisac is now the caecal ex-
tremity of a glandular follicle, and the tube is its excretory duct.
  At this  point the question occurs as to  the  mode in which
the ovule  is  formed  in  the Graafian  follicle.  The  earliest
condition in which the follicles are seen in the embryo is in the
shape of a spherical mass of cells, containing the germinal vesi-
cle in its centre.  From the external cellular mass is developed
the membranes of  the follicles,  its epithelial lining, and  the
vitellary membrane.  It is a question whether the germinal vesi-
cle is formed or  secreted by the cells forming the follicle, or
whether  its nucleus exists  at the time the spherical arrangement
of the cells takes  place, the follicle being developed around the
germinal vesicle and its nucleus.  Some believe, with Huschke,
that the ova are formed of acini, detached from the substance of
the stroma of the ovary;  others hold,  with Dr. Martin Barry,
that they are formed from the nuclei found in great numbers in
the ovarian parenchyma.   The latter seems most in accordance
with the  facts know respecting the origin of the ovary.   Accord-
ing to this  view, the germinal vesicles and their nuclei exist
from the earliest formation ofilthe ovary, and the follicle is devel-
oped for  the purpose of maturing and sustaining the ovule, and
finally of extruding  it from the ovarium when  it has become
fitted for impregnation.
              The  comprehension of  the  mode in which  the
  Fig 2"?
            ovule escapes periodically from the Graafian follicle,
            was  arrived  at quite as slowly, and occupied  as
            many observers as  the anatomy of the ovule Itself.
            Harvey drew a comparison between menstruation
            and  the  oviposition  of birds.  In  1672, Kerkrin-
tiieFova£ of°a  &ius  advanced the idea  that ova, at that time sup-
newiy-bom child,  posed to be identical with the follicles of De Graaf
MembranUerelof   were thrown off at the time of menstruation.   The
Foincie; 2, Epi-  first  positive  observation of the rupture of a Graa-
tbelium, or Mem-  £     p iv i   j  •        ,     •
brana Granulosa;  nan  toilicle,  during  menstruation, appears to have
minTvUlTs,  b!en made by Sir Everard Home-   Cruikshank, in
vneiiary  Mem-  1797, described the case of a woman who had died
brane.         during menstruation, and in  whom the  external
membranes  of the ovary were ruptured at one point.   lie sup-
posed that from this opening an ovum had escaped into the Fal-
lopian  tube.  But these were isolated cases.  The first body of
 
OVA DISCHARGED AT MENSTRUATION.
81
facts bearing upon the matter was supplied by Dr. Robert Lee,
whose first dissection was made in 1831.  Dr. Power had, ten
years previously, published his hypothesis respecting the period-
ical escape of the ovule, at the  catamenial periods.  But, as we
have seen, the discovery of the ovule, by Baer, was made in 1827.
This discovery,  which was not recognized by  Dr. Lee, soon ren-
dered the rupture of the Graafian follicle an intelligible fact,
and  the  theory of Ovulation in the human female, and in  the
mammalia, has been  completed by the researches of  Pouchet,
Negrier, Martin, Barry, Gendrin, Raciborski, Coste, Bischoff, and
others.
  It may now, then, be considered  as an established fact in
physiology, that during menstruation, or the rut or heat of ani-
mals, Graafian  follicles are ruptured,  and  ova discharged.  In
the human female, it is believed that in ordinary cases  the ovule
escapes towards or shortly  after, the termination of  the men-
strual flow, through  the pore or fissure found in the peritoneal
surface of the ovary.  Sometimes an  ovule escapes frem each
ovary, or more than one ovule may escape from the  ovary of
either side.   The observations of Dr.  Ritchie and others have
shown that ova, probably of immature formation, may escape
before the  time' of puberty, and occasionally Graafian follicles
are ruptured in the intervals between the catamenial periods. In
6ome cases, the excitement  of the  ovary during menstruation
may not be sufficient to cause the perforation of the follicle so
as to admit of  the escape of the ovule.  The ovule  has been
detected in the Fallopian tube in persons who have died during
or shortly  after menstruation, by Dr. Letheby  and  by Hyrtl.
The time occupied in the descent  of the ovule through the Fal-
lopian tube and uterus is  not known precisely, and can only be
inferred from the number of days after menstruation  at which
conception may take place.  It is evident that  several days must
elapse before  it escapes from the uterus.  In the case  of virgin
or infertile  ovulation, it is uncertain whether the  ovule becomes
decomposed or is discharged externally. Before the advent of
puberty,  the  surface of  the  ovary  is smooth, and the organ
comparatively full  and large ; but at each  menstruation, one or
more perforations occur, and  the organ becomes, in process of
time, scarred  with  numerous cicatrices ; so that, in   the aged
female, it is shrunk  and corrugated with the remains of the
                              6 
82       CAUSE OF THE  COLOR OF THE CORPUS LUTEUM.

numerous follicles which have been ruptured during  the whole
of the child-bearing epoch.
  Certain changes occur in the Graafian follicle, or  ovisac, at,
and subsequent to, the time of ovulation.  These changes are
more marked when impregnation has occurred, than in cases of
virgin  ovulation,  and result in  the  formation  of the Corpus
iLutcum.  At the time of the escape of the ovule, there is  a
greater afflux of blood than usual to the membranes of the ovisac,
a clot of blood is effused into its cavity, and, according to the
views of M. Pouchet, the epithelial lining, or membrana granu-
losa, undergoes a remarkable development.   This membrane be-
comes thickened by a cell-formation,  the hypertrophied cellular
layer being at first of a  reddish color, but afterwards becoming
yellow.   The yellow matter is arranged in the form of plicaB,
which diverge from the cavity towards the circumference of the
ovisac.  The  new formation is  gradually thrown into folds, or
corrugations,  by the contraction of the ovisac,  and becoming
thicker  as  the development of the corpus  luteum proceeds, its
internal surfaces at length  are brought into contact.  In this
way the stellate cicatrix found in the centre of  the true corpus
luteum  is  formed.  Before  this apposition  has occurred, the
fibrinous clot has been decolorized, or converted into fluid, and
in either case absorbed.  The substance of the corpus luteum is
soft, fleshy, and friable, and is permeated with numerous vessels
from the external surface of the ovisac, so that the true corpus
luteum  admits of  being  ejected from the vessels of the ovary.
It should be said, that although little  difference of opinion  exists
as to the appearances presented by the corpus  luteum, numer-
ous hypotheses have been  advanced  as to the mode in which
the yellow layer, constituting its chief bulk,  is formed.  The
latest evidence appears, however, to be in favor of its origin in
the membrana granulosa.  Dr. Lee contends that it is a deposit
external to the lining membrane, and Mr. Wharton Jones  joins
him in his  opinion.   Knox, Miller, and Dr. Dalton regard it as
a hypertrophy of the outer membrane, while Kolliker considers
it to depend partly upon enlargement of the epithelial lining,
and partly  upon that of the internal or fibro-cellular layer of the
ovisac.
  In size and shape the  true corpus luteum, that which follows
upon  impregnation, resembles a small bean, and projects from 
CHARACTER  OF THE  CORPUS LUTEUM.
83
the surface of the  ovary as a mamillary body, occupying from
one quarter to one half of the entire superficies of the organ.  It
is largest in the early weeks of pregnancy, and after the third
month it slowly decreases in  size until the time of parturition,
when it  rapidly retrogrades, and at length becomes a mere scar.
Its cavity is obliterated, at  a variable time, being found in some
Fid-24
     Section of the Ovary, showing the Graafian Vesicle at the third month of gestation.

cases after  labour.   It is at first filled with a clot, or  serum, or
the remains of the  liquor folliculi, and the aperture through
which the ovule has escaped sometimes remains pervious for a
considerable time after impregnation.
       Fig. 25.
a>          h           c
 Diagram of the formation of the Corpus Luteum in a Mammifer. a, The cavity of the follicle filled
\rith blood; b, c, The clot diminishing in size, while the epithelial lining becomes thickened and
convoluted; d, 6,f, Completion of the process.

   Upon  the escape  of  an ovule  from a Graafian follicle in the
virgin, the  changes  described  occur, but to  a less extent  than 
81         DALTON's VIEWS OF THE COKI'US  LUTEUM.

when impregnation has taken place,  and a  false  corpus  luteum
is formed.  The  membranous layer is less considerable,  and in-
stead of being of a yellow tint, is of  a dull-red color.  Accord-
ing to Dr. Dalton of New York, who has carefully investigated
this  subject, it reaches its greatest  development about three
weeks after ovulation, and from this time rapidly disappears,
leaving no vestige of its existence beyond a small scar.  In the
case of the virgin  corpus luteum, other Graafian follicles are
passing on to maturity, pari passu with its development, where-
as in the true corpus luteum the occurrence of gestation suspends
the maturation of ovules.  As a general  rule, the virgin corpus
luteum is much  smaller than the genuine  formation, but cases
occur in which the spurious equals  the  true corpus luteum in
size.  The differences  between the corpora lutea of the virgin
and of the impregnated female  show that in the  case of  the lat-
ter there is at  the time of ovulation  a  greatly increased vascu-
larity, and that during gestation the corpus  luteum shares in the
excitement incident to the gravid  uterus.  Other formations
besides the corpora lutea of the nulliparous female have  been
mistaken for the true corpora lutea.   Small  tubercular masses
are sometimes  found  having a certain  resemblance to these
bodies, and after the decline of the catamenia, the follicles which
have not reached maturity during the era of child-bearing,
collapse, and form cicatrices which have sometimes been thought
to resemble the genuine corpora lutea. 
LECTURE V.
                       MENSTRUATION.

  Gentlemen :—During  the  whole  of  the  child-bearing era,
women are the subjects of a sanguineous  discharge every month,
except during the times of pregnancy or lactation.  The advent
of this discharge is the chief external sign of the appearance of
puberty, and it  occurs in temperate  latitudes at about the age
of fifteen.  In former times, the most exaggerated notions were
entertained respecting the influence of climate  in determining
the early or late appearance of the catamenia.  It was supposed
that  towards  the arctic circle the  catamenia occurred only  in
mature womanhood, and were  then frequently represented by a
colorless  discharge, or  only appeared during the summer months,
while in  the torrid  zone, children of tender  age became wive3
and mothers.   These views have been corrected by modern re-
searches, and especially by the investigations of Mr. Roberton, of
Manchester.  The results of his inquiries, and those of  other
observers, show that the difference  between the  date of the first
appearance of the catamenia in the Hindoo female, in  whom the
influence of heat of climate is strongly marked, and the natives
of this country, is about two years; the average age at  the first
menstruation  being about thirteen  in Hindostan, and fifteen in
England.  In Labrador a table of the first  appearance of the
menses has been obtained by Mr. Roberton, and the mean age,
at the first menstruation, is nearly sixteen.   Probably this vari-
ation of three years between the Hindoo and  the Esquimaux
female is amongst the greatest that can  be obtained, as the
result of climatorial influence, in different parts of  the world.
A variation of three years in the time of the commencement of
a function occurring between the ages of thirteen and  sixteen,
and lasting about thirty years, is, however, a very considerable
one; and, while  correcting old errors, we must be careful not to
                                                       So 
86
CLIMATE INFLUENCING PUBERTY.
ignore the real effects of climate and temperature in hastening
or retarding puberty.  Dr. Tilt has made a very extended in-
quiry into this subject, and the  results  of his tables  show that
there is an average difference of nearly  three years between the
date of the first menstruation in hot and cold climates.  Perhaps
if any criticism could be ventured upon respecting the valuable
work of Mr. Roberton, and those writers who have adopted his
views, it would be, that they have somewhat tended to make the
influence of climate upon the functions of reproduction seem less
than they undoubtedly are.
  It is found that other agencies, besides those of climate, affect
the  age  at which menstruation  commences.  The  catamenia
appear earlier  in the children of the rich than of the poor.  The
influence of a large manufacturing town like Manchester hastens
the appearance of puberty.  M. Brierre de Boismont ascertained
that menstruation begins  earlier in Paris than in the smaller
towns of France, and in these again at an earlier age than in the
wholly rural districts.  Raciborski  believes that race has an in-
fluence upon puberty, apart from climate—as, for instance, that
the English child, reared in India, menstruates at the time she
would have menstruated in this country; but if a Hindoo child
be brought to  England, she will menstruate as early as though
she had remained in Hindostan.  It is  also believed that Jew-
ish females menstruate earlier in cold latitudes than the ordinary
population.  Probably climate,  hygiene, temperament, and race
all exert  an influence in promoting or retarding puberty, but
within a narrower range  than was formerly supposed.  Cases
are met with occasionally of children menstruating, and having
sexual feeling  at a very early age ; but these must be considered
as irregularities, having but little bearing on the function as
ordinarily performed.
  The decline of menstruation, termed the change of life, or
catamenial climacteric, generally occurs between the ages of
forty-five or fifty, consequently  the catamenial era  spreads over
from thirty to thirty-five years.  The time of the decline varies
in different  individuals; sometimes it occurs as early as thirty-
five, or even before  that age;  at others it lasts up to sixty or
even beyond.  Putting thirty years as  the time during which a
healthy female should have the menstrual periods, and suppos-
ing  them to occur every month, their  number would be three 
MENTAL  EFFECT  OF MENSTRUATION.
S7
hundred and ninety ;  30 x 13=390.  But in married and child-
bearing women, much of this time is occupied in gestation  and
lactation.  During pregnancy, as the rule, the catamenia are
absent,  the cases  in  which  a regular  sanguineous discharge
occurs during the whole of pregnancy being exceedingly rare.
A discharge of blood for one or two periods after the occurrence
of impregnation is more common.   The great majority of women
do not  menstruate during lactation, but  menstruation  during
suckling is by no means so unusual as  the occurrence  of this
function in pregnancy.  Many women habitually menstruate as
regularly during lactation as at other times.  It has been re-
marked  by many  observers,  that  the intellect of women does
not reach maturity until after the final cessation of the cata-
menia;  and it has been instanced as a sign of the superiority of
the human race, that only a limited portion  of the life of a
female should be devoted to child-bearing.
   It is necessary to possess exact ideas respecting  the times of
the occurrence of a periodical function like  that of menstruation.
The catamenia, or menses, as the names imply, are said to return
once a month  in ordinary cases.  Some authorities speak of
solar,  others of lunar months, as the period  observed by the cat-
amenia.  Strictly speaking, the Solar month—that is, the time
occupied in the passing of the sun through one of  the signs of
the zodiac—is nearly thirty  days  and a half.   The  Lunar
month,  or  the time between one new moon and  another,  is
twenty-nine days and a half.  The Calendar month varies from
twenty-eight  to thirty-one da}rs.   The catamenial  month is dif-
ferent from any of  these, and consists of the common month of
four weeks, or twenty-eight  days,  dating from the  commence-
ment of one period to the commencement of another.  This is the
ordinary periodicity observed by the catamenial  function, or
that which obtains in the great majority of women.   Many
females become unwell on the  same day of the week for a long
time, without any irregularity.  In women who menstruate two
or three  days only, the interval between the cessation  of one
period and the beginning of another, is longer, and in those
who are many days unwell, shorter;  but the length or  brevity
of the discharge does  not usually affect  the time of its  return.
In some  women, the monthly periodicity is so continuous  and
exact, that the times between successive pregnancies, if reduced 
88              FREQUENCY OF MENSTRUATION.

to days, are found to be multiples  of twenty-eight.  Cases are
not uncommon, however, in which the  catamenia return regu-
larly at longer or shorter intervals than twenty-eight days, some
women being unwell every six weeks, and others  every two or
three weeks, but there is generally a tendency to observe some
multiple  of a week.  In some habits, a  leucorrhceal discharge
constantly occurs, and lasts for three or four days at  the fort-
nightly interval between the regular periods.  Although there
is a very general tendency to  regularity in the performance of
this function, it is very common to  find occasional variations to
the extent of a few days.
  Each " Period," as it  is now common with educated women
to call the monthly discharge, lasts usually in healthy women
four or five days.  Five days  may be  taken as  the  ordinary
duration  of the catamenial flow;  but every woman has her con-
stitutional peculiarity in this respect, some menstruating two or
three days only,  others always  remaining unwell a  week or
more, such variations in women  of different temperament and
constitution being quite within the limits of health.  The cata-
menial fluid consists chiefly of the  blood, modified to some ex-
tent by the. ordinary secretions,  and matters derived from the
uterus  and vagina.  This is the result both of microscopical and
chemical examination.  The menstrual fluid has been examined
with the microscope by MM. Donne, Pouchet, Dr. Ilassal, and
others.  It has been found to  consist of blood globules  and the
fluid parts of the blood, with mucus from the glands of the cer-
vix, cylinder epithelium, and  granular  matter from the cavity
of the uterus, and scaly epithelium from the vagina.   Dr. White-
head has pointed out that the  menstrual fluid as it escapes from
the os  uteri is alkaline, but that it  becomes acid when mixed
with the acid vaginal secretion, and this acidity, as  formerly
mentioned, tends to prevent its  coagulation and decomposition
in passing through the vagina.  The menstrual fluid  has been
examined chemically by MM. Denis, Franz, Simon, Bouchar-
dat, Rindskopf, and Dr. Letheby, and shown to consist chiefly
of  the  elements  of blood and  mucus.   An estimate  of the
amount of the discharge has been made  by Dr. Meigs, who rates
it at from four to six ounces at each period ; but this can only
be approximative in the case of a loss which, like the  number
of  days  through  which it continues, varies in different indi- 
          CHARACTER OF THE MENSTRUAL DISCHARGE.         89

viduals.  It was  long supposed that menstrual differed  from
ordinary blood in the absence of fibrine in the former.   It  is
now, however, understood that the cause of the non-coagulability
of the catamenial fluid, and the  apparent deficiency of fibrine,
depend on the acid secretions of the vagina.
  [The importance of this physiological distinction in the  char-
acter of the menstrual secretion, was recently recognized in a
legal aspect.  During the recent coroner's inquest on the  occa-
sion of the Burdell murder, certain articles of male apparel were
found  to be bloody, thereby implicating certain individuals to
whom they appertained.   A scientific examination showed con-
clusively that they were stained  not with the  blood of the mur-
dered  man, but with the menstrual non-coagulable blood,  filled
with  epithelial scales, etc., of some one of the females of the
house.]
  When contraction  of the os uteri exists, and the menstrual
blood does not escape readily, it coagulates in utero, and is ex-
pelled with pain in the form of clots ; or, if the fluid is in quan-
tity sufficient to neutralize the effects  of the vaginal mucus, it
coagulates  after its escape  externally.   I use  the terms  " dis-
charge" "loss" or flow," in preference to  that of  secretion,
because the catamenia are essentially different from the products
of any secretory process.
  The Influence of  Menstruation,  and the allied process of
ovulation, upon the female economy is very great.  The beauty
of form incident to womanhood ; the marked characteristics of
the female sex ;  and the development of the affections, are  in-
timately connected  with, and  dependent upon, the  healthy ap-
pearance and performance of these periodical functions.  The
periods are commonly preceded by Irypogastric and lumbar un-
easiness  or pain, tumidity of the breasts, a  dark  appearance
round the eyes, and a peculiar smell, especially adverted to  by
M. Pouchet, and which has been termed the vaccine odor. There
is also in many women  a tendency to relaxation of the bowels
for a day or two before the discharge appears. Women are  gene-
rally  more hysterical and  irritable at this  than  other  times.
These  symptoms are all  relieved by the healthy catamenial flow ;
personal loveliness is improved, and a new stimulus is imparted
to all the organs of the body.
  The condition of the whole uterus is modified at the catame- 
90
PHYSICAL EFFECTS OF MENSTRUATION.
nial periods.   The determination of blood to the organ renders
it larger and  darker in color than it is at other times.   It is
firmer to the  touch, and lower in the vagina  than usual.   The
Fallopian tubes partake of the turgescence, and  have been  ob-
served almost black from engorgement.   In ordinary cases,  the
canal  of the cervix and the os uteri are somewhat dilated at, and
for a few days subsequent  to the menstrual date.  This renders
it easier to introduce the  uterine  sound just after  the period
than at any other time. In other cases there is a sphincteric con-
traction of the os uteri, similar to tenesmus,  which  constitutes
one of the forms of dysmenorrhcea.   For a short time after the
flow there is a marked increase of sexual feeling, and many wo-
men in whom the aphrodisiac tendencies are  moderate,  state
that they have little or no feeling at other times.  The intention
of this increased sexual sensibility, at the time when the ovule is
ready for impregnation, and the  uterus  to receive the products
of fecundation, is sufficiently evident. It is at this time also, in
those  whose feelings are intense, and unbridled by  the higher
qualities of the mind, that aberrations in regard to sex, and ten-
dencies to nyphomaniacal excitement, occur.  It is indeed  diffi-
cult to say in many cases of this kind, how much should be at-
tributed to disease, and how much to moral delinquency.
  The Cause  of Menstruation must be referred to the ovaria.
These are the prerogative  and ruling organs, a point insisted
upon  with great force and justice in the writings of MM. Pou-
chet and Chereau in France, and Dr. Tilt  in  this country.   It
is found that  in women with a proper development of  the ova-
ria, breasts, and external organs of generation, and in whom the
sexual feeling is strong, but in whom  the  uterus is congenitally
deficient, a monthly nidus occurs, consisting of pain in the back,
and other symptoms which  indicate that ovulation occurs  regu-
larly, although no sanguineous discharge takes place.  In  these
distressing cases there is occasionally a show from the vulva  or
an attack of epistaxis, or bleeding from some  other  part, at  the
periods of ovarian excitement, but nothing like the menstrual
flow.  On the other hand, in cases where the  ovaria have  been
extirpated, menstruation is effectually  arrested, although  the
uterus remains perfect.  This happened in a case in which Mr.
Pott removed the ovaries in an operation on a patient at St. Bar-
tholomew's Hospital. Dr. Frederick Bird has also informed me 
         COMPARATIVE PHYSIOLOGY OF MENSTRUATION.       91

that in a case in which he removed both ovaria, in  double  ova-
rian disease, and where the patient recovered, permanent ame-
norrhcea was the result.  We may look, then, to the ovaria for
the exciting cause of menstruation, and this function is evidently
subsidiary to that of ovulation.
  Symptoms in some degree analogous to those of menstruation
occur in the lower animals at the dates of ovulation.   A com-
parison has been made between the menstruation and the deter-
mination of blood to the comb of the domestic hen, the genitals
of the pigeon, and birds of the parrot  tribe.   In many of the
lower mammalia, discharges from the genitalia take place at the
time of the rut or heat, during or immediately  after the occur-
rence of ovulation.   In some of the quadrumana,  sanguineous
discharges have been observed; and it  is believed  that  in the
monkeys the oestrum  has a monthly periodicity.  Dr. Hille, a
Dutch physician of Surinam, possessed a female monkey, which
was the subject of a sanguineous discharge, lasting three or four
days,  every month.  In others, as the Macacus libidinosus, the
callosities near the anus, and the whole  of the parts below the
tail, become periodically of an intensely vivid red color, and
present an appearance, to use the words of M. Coste, of an im-
mense phymosis.   The  phenomena of  oestruation  are more
marked in wild  than in  domesticated animals, and in those
which only cestruate once a year, the date of oestruation  occurs
at such a time as  to admit of the  completion of gestation  and
parturition in the spring season. Little is known of the gesta-
tion  of the  quadrumana; but in  the lower  mammalia, the
changes which occur in the lining membrane  of the  uterus
could not well be the same as those belonging to the human fe-
male, because in the lower  animals  that which answers  to the
decidua of  the human female is  a permanent organ.
  Divers opinions have been held respecting the exact Source
of tne Menstrual Flow.  It has been referred to   the ovaria,
the Fallopian tubes, the cavity of the body of the uterus, the os
and cervix uteri, and the vagina.  Yery recently, M. Ch. Judee
has published the result of three autopsies of women who  died
near the menstrual period, in which he  states that  the  mucous
surface of  the os was abraded, and he considers this a proof that
the menstrual blood comes from the lips of the os uteri.   I have
no doubt these were  really cases  of abrasion,  or ulceration, of 
92
SOURCE OF THE MENSTRUAL FLOW.
the os uteri, and in such cases there is at the menstrual period a
discharge of blood from the diseased surface, as well as from the
interior of the uterus.   In such cases the os uteri becomes, for
a time, a menstrual ulcer, and the secretion of pus is converted
into a discharge of blood.  All the  exact  evidence we possess
points, however, to the cavity of the body  of the uterus as the
true  seat of menstruation, and  source  of  the  discharge.  The
catamenia may often be seen escaping from the os  uteri, in ex-
aminations with  the  speculum.  In cases of procidentia  the
whole  process  may be watched,  and in these cases the  fluid
always comes from within the uterus.  In cases of inversion, we
have a still more positive proof, as the blood may be seen  exu-
ding from the surface  of the inverted  organ.   The  commence-
ment of the flow at each period takes place very gradually.   In
examining patients, I have sometimes seen  the first trace of the
sanguineous discharge at the os uteri, but it has been twelve
hours or more before it has appeared externally.   The quautity
of discharge being at first small, it passes down the vagina very
slowly.  Probably the period ceases in the same  gradual man-
ner, atid has disappeared from the os uteri  some time before the
discharge is lost at the ostium vaginae.
  Within  the last two  years I have had opportunities of  examin-
ing three uteri taken from women who had  died during the  cata-
menial flow. In each of them I found the mucous membrane of the
body of the uterus either in. a state of dissolution or entirely want-
ing.   In one case, that of a woman previously in good health, who
died suddenly from a fit of apoplexy while menstruating, and
whose uterus was kindly sent to me by Mr. Filliter, of the Maryle-
bone Infirmary, the mucous membrane was altogether gone.  At
the upper part of the cervix uteri the break in the mucous mem-
brane  was very apparent.   In  the  cervical  canal the mucous
membrane was perfect; but at the os uteri internum, it ceased
as abruptly as though it had been  dissected away with a  knife
above this point.   Blood was oozing at numerous points  from
broken vessels in  the sub-mucous tissue.  I had the assistance of
Dr.  Handfield Jones  in examining this uterus with the micro-
scope, and we could find no traces of the  epithelium or of the
utricular glands.  The surface of  the cavity of the  body of the
uterus was exactly similar to that  which may be seen after abor-
tions,  in which the decidua, or in  other  words  the developed 
               APPEARANCES OF UTERINE TISSUES.            06

mucous membrane, has been discharged.   The sub-mucous sur-
face was a pulpy mass, in which epithelium, the ends of vessels,

                           Fiat 2S.
 Uterus of a woman who died from apoplexy during the catamenial flow. The whole of the mucous
membrane of the body of the uterus is wanting.

broken  tubes,  blood globules,  and  mucous  corpuscles  were
all that could be distinguished.  I compared this uterus with
that of a woman who had died after  an abortion at the third
month, and the appearances  in  the two  cases were precisely
similar.
  [March 11th, 1857.  I saw the  nulliparous uterus of a young
murdered woman, death occurring from loss of blood, exhibited
by Dr. Finnell to the New York Pathological Society.  This and
every organ, was blanched in the extreme.  One ovary exhibited
the corpus  luteum  of a menstruation some four  weeks ante-
riorly, containing a clot not yet entirely changed in color.  The
other ovary showed  the Graafian follicle  almost  ready to burst,
the peritoneum over it thin and highly injected.   The os uteri
was in a perfectly natural condition and with no flow from it or
exudation  from its  lips.   On laying  open the uterus,  the
mucous membrane of the body was found highly injected and
covered with a glairy, bloody effusion.   The cavity of the neck,
however, contained not a drop of fluid and did not seem to be 
94         POST-MORTEM  EVIDENCES OF MENSTRUATION.

in the least injected.  It showed, in short, the uterus  prepared
for menstruation, which had not however occurred.]
  The State of the uterine mucous membrane during men-
struation has occupied many observers. It has generally been
described as thicker and more swollen during the catamenia than
at other times.  It should be mentioned, however, that descrip-
tions of the uterus a few days before or after the menstrual flow
can have little bearing upon this subject, and it is a rare occur-
rence to get the uterus of a woman who has died in the middle
of healthy  menstruation.  No  safe conclusions can be drawn
from the  cases  in  which women suffering from  severe  dis-
ease have a sanguineous  discharge from the uterus  at the time
of death.  Professor Simpson, in 1846, in  his paper on the ex-
pulsion of the entire mucous membrane in certain cases of dys-
menorrhcea, drew a comparison between ordinary menstruation
and the process of digestion, in which the epithelial layer is shed
and removed  after every meal.   M. Pouchet has supposed that
a decidual membrane is formed during each catamenial period,
and  discharged in the shape  of an albuminous plug ten or
twelve days after the cessation of the flow. . Kolliker states that
the  mucous membrane becomes thickened during menstruation,
the  blood escaping from the ruptured superficial capillaries and
that the epithelium of the cavity of the body is in great part
thrown off; but he considers it as abnormal if the whole or part
of the  entire mucous membrane should be detached.  Muller
compares the change in the  mucous  membrane of the uterus
during menstruation to moulting, attended, perhaps, by the for-
mation of a new epithelium.  A case recorded  by Dr. Janser
has been often quoted. It was that of a girl murdered  four days
after menstruation.  He describes the  mucous membrane as
somewhat thickened, and easily lifted from  the surface by the
handle of the scalpel.  It was composed of the utricular glands,
arranged perpendicularly, side by side, and covered  by cylinder
epithelium.   This observer concludes that during  menstruation
the mucous membrane of the uterus presents the same charac-
ters as  in the early part of gestation.  Such cases,  however,
really prove nothing with respect to the condition of the mucous
membrane  during the actual presence of  menstruation.  In an
organ like the uterus, the most important changes may occur in
the space of four or five days.
* 
PECULIAR VIEWS OF MENSTRUATION.
95
  It appears to me to be in accordance with  what I have
observed in uteri examined during the menstrual period, the
facts  connected with   membranous dysmenorrhoea, and  the
detachment of the decidua in abortion and parturition, to sup-
pose that the mucous membrane is in great part or entirely
broken up, and its debris discharged during each  menstruation.
The blood is probably exuded during  the breaking up of the
mucous structure, and the duration of  the menstrual  period
represents the time occupied  in this periodical decadence and
renewal of the mucous membrane of the body of  the uterus.
  In  cases of Membranous Dysmenorrhea we have proof
of the exfoliation of the mucous membrane in an entire form, or
in detached pieces.  This  may occur  every month for  many
years, a new mucous membrane being developed after each men-
struation.  After abortions and after parturition we know that the
old mucous  membrane is  thrown off, and a  new one formed.
According to the view I have stated, a new mucous  mem-
brane is formed every month as part of the process of pre-
paration for the reception of a fecundated ovum ; not that  the
aptitude for the reception and implantation of the ovum  is lim-
ited to the newly-formed mucous membrane, though it is pro-
bably greater at this time than at others.  The  mucous mem-
brane may become  the seat  of  the changes consequent upon
impregnation just  before  a  menstrual  period,  and in cases
where menstruation is suspended.  According to my  view, the
mucous  membrane of  the  uterus  becomes  excrementitious
every month, and is discharged from  the  cavity of the uterus
in a state of disintegration, and the uterus forms a new mucous
coat, by  a process  similiar to the reproduction of lost parts.
  Such a doctrine may at first sight  appear startling,  but we
have  always had a  similiar condition,  during the menstrual
period, under our eyes, in cases of vicarious menstruation.  In
these cases, an ulcer upon  any part of the surface of  the body
may skin over, or assume healthy granulations, during the inter-
vals of menstruation, but on  the  occurrence of the period, the
newly formed skin gives way, or the healthy granulations slough,
and blood exudes from the surface for several days; after which
the ulcer heals, or puts on a  healthy aspect, until the approach
of the next catamenial period.  I have at the present time  a
patient with a  menstrual ulcer upon the dorsum of the tongue, 
96
VICARIOUS MENSTRUATION.
in whom the sore heals partially or entirely between the periods,
but at the catamenial dates the surface gives  way, the sore
becoming deepened, and exuding blood, while the catamenia are
flowing.   We have  only  to consider similiar phenomena  as
occurring to the mucous  membrane of the body of the uterus,
and we have a reasonable  explanation of the mode in which this
peculiar function is performed.
  [ It may be well to state distinctly that these views are far
from being generally accepted by the scientific, and the student
should read them cumgratio sails.   A forthcoming work by  an
American of great distinction, who I am not at liberty to men-
tion, will probably throw some new light upon this questio vcx-
ata as well as upon that of foetal circulation.] 
                      LECTURE VI.

   CONCEPTION, AND THE EARLY DEVELOPMENT OF THE OVUM.

  In  a  former lecture we traced the anatomy of the Ovule up
to the point of emission from the ovarium, considering it chiefly
with reference to ovulation and  menstruation in the unimpreg-
nated state.   It now becomes necessary to study it in relation to
the act of fecundation, and the early changes which occur in the
impregnated condition.  As the ovule approaches maturity, and
makes its  exit from the Graafian follicle, a  remarkable change
occurs in the  germinal vesicle.   It is believed by almost all
observers, either to disappear or  to become entirely transformed.
Dr. Martin Barry asserts that it  does not disappear, but returns
again to the centre  of the  ovule, where it becomes changed by
a process of cell-development, and ends in  producing two cells
in the centre of the yelk, from which  cells the embryo is after-
wards developed.  It  appears from the latter researches of  Mr.
Newport, that there is a partial return of the germinal vesicle
towards the centre of the yelk, and that considering the germinal
vesicle as a parent cell, its nuclear particles, which form the ger-
minal spot, are developed into secondary cells;  these again into
cells of tertiary formation,  and so on, until the germinal vesicle
has been transformed into a mass of  cells, which leads to the
rupture and diffluence of the parent cell, or germinal vesicle.
From some  one of these cells it is believed that a larger cell,
the future Embryo-cell occupying the site of the macula germina-
tiva,  and constituting the  true  Germinal  Point of the  future
being, is developed.   It is, however, as yet uncertain whether
the embryo-cell, or vesicle,  which replaces the germinal vesicle,
is formed just before or just after, the act of fecundation.
  It is necessary in this  place to glance briefly  at the male
element of impregnation.   The part of the seminal fluid actually
                            H                         97 
98
MALE  ELEMENTS FOR FECUNDATION.
required for conception is the Spermatozoa.  For a long time
the spermatozoa were  thought to be  distinct  animalcules, but
they are now  known to be particles, sui  generis,  developed
within the seminal cells found in  the secretion  of the  testis
before it leaves the gland.   While they remain within the cells,
these filaments  are arranged in bundles, but in the passage of
the fluid from the gland through the efferent apparatus, the cells
rupture and set free the spermatozoa.  Each spermatozoon con-
sists of an oval and flattened body, and a filamentous portion, or
tail.  The width of the body is about goVo Part of an  inch, and
the length of the  entire particle is from T^ to  g^o °f an inch.
Kolliker believes the  spermatozoa to be  allied to ciliated cells,
and they move in the fluid semen  or  traverse the mucous
membrane of the genital passages, by a succession of smart lash-
ing movements.   It has been proved by direct experiments, such
as filtering the  semen, and using the spermatozoa, and the pure
liquor seminis, the impregnation of the ova of  amphibia, that it
is the spermatic particles and not the liquor seminis which are
the real agents of fecundation.
  Thus, then, on the part of the female, we have the ovule pro-
duced in the  ovarium, the essential part of which is the germi-
nal vesicle or germ cell.  On the part of the male, we have the
spermatic fluid, the essential part of which is the seminal vesicle,
or sperm cell, produced in the testis.   The bundle of spermatic
particles, or spermatozoa, formed in the germ cell, correspond
                            Fig. 27.
 a,o, Sperm cells, containing nuclei, each nucleus having within it a spermatic filament,  o, A
nucleus with nucleoli,  d, Nucleus, with spermatic filament,  e, A cell, with a bundle of sper-
matic filaments, f, g, h, Spermatic filaments.

with the nuclear  particles forming the macula germinativa, or
germinal spot, of the germ cell.  The spermatozoa may be con- 
»
                 PHYSIOLOGY OF FECUNDATION.               99

sidered, in fact, as the nuclear  particles of the germ cell.  The
bursting of the sperm cell and formation of the spermatozoa,
on the one hand, and  the development of the nuclear particles
of the germ cell into the cellular mass which occupies the place
of the germinal vesicle after its rupture, is the highest point of
development to which the  male and female elements can reach,
if fecundation does not occur.  It will be observed that several
generations of cells have followed  upon the germinal vesicle and
its nucleus, before the ovule has been rendered ripe for impreg-
nation ; and the spermatozoa are  also the secondary or tertiary
products of the cells found in the secretion of the testis.
  We now approach the act of Fecundation or Impregna-
tion, and recent researches  have  gone far to solve this, one of
the most mysterious processes in the arcana  of Nature.  In the
fecundation of the vegetable ovum, it has long been known that
the moving spermatic particles of  the pollen cell penetrate the
ovum, and unite with the contents of the ge-rm cell.   Prevost
and Dumas believed that the spermatozoa penetrated the ovum
bodily,  and  became  metamorphosed into parts of the future
embryo.  In 1843, Dr. Martin Barry published, in the " Philo-
sophical Transactions," an account of the actual  penetration of
the ovum  of the  rabbit by  the  spermatozoa, and  he demon-
strated the fact to the satisfaction of Dr. Sharpey, Mr.  Owen,
and Mr. Grainger.   He  believed that the  spermatozoa pene-
trated the yolk, and there became divided into many parts.  The
following figure from Dr. Barry's  paper  represents the sperma-
tozoa  after they have entered the ovum :
 An ovum of the rabbit, taken from the Fallopian tube, twenty-four hours after leaving the ovary.
1. Zona pellucida. 2. The germ, consisting of two large cells.  Several smaller cells, and numer-
uos spermatozoa, are visible. 
*
100             PHYSIOLOGY OF IMPREGNATION.

  This view of Dr. Martin Barry was combated by many obser-
vers, particularly by Bischoff.  Mr. Newport, in his first investi-
gations into the impregnation of the ovule of the frog, published
in 1851, did not agree with Dr. Barry.   He believed  that the
moving spermatozoa  approached the ovule, became applied to
the surface, and disappeared in that situation by a  process of
diffluence  or  disintegration.   He  subsequently modified  this
opinion, and became convinced that the spermatic particles are
imbedded in the walls of the ovule and perforate the  vitellary
membrane in large numbers.  Keber discovered  that  in the
fresh-water muscle the spermatozoa pass into the interior of the
ovum by  a canal  or opening in the walls of the ovum.  The
researches of Keber have  been verified by  Dr. Martin Barry
and Dr. Webb, of  Lowestoft, and  confirmed by Meissner  and
others.  Miiller has described a funnel-shaped, canal in the ova
of every species of Holothuria, having probably the same func-
tion.  Lastly, Dr. Nelson has investigated the  reproduction of
the Ascaris Mystax, an entozoon found in the intestine of the cat,
and demonstrated the penetration of the ovule by the spermatic
particles in the clearest manner.  These observations of  Dr. Nel-
son have  also the  high authority  of Dr. Allen Thompson in
their favor.   It may be  considered, then, as proved that the
spermatozoa penetrate the ovum, and come into positive  con-
tact with the contents of the germ cell.   Impregnation does not,
however, depend on  the penetration of the ovule by one sper-
matozoon, but  by considerable numbers of spermatozoa.  Mr.
Newport found that the greater the number of spermatozoa in
apposition  with an  ovule the more certain  its  fecundation
became.  Dr. Nelson observed that in the ascaris mystax a suffi-
cient  number penetrated the chorion and vitellary membrane,
to form a ring  around the germinal vesicle.  It is not by the
influence of particle upon particle, but of mass upon mass, that
the phenomena of impregnation are accomplished. After the pen-
etration of the  ovule, the spermatozoa  lose their motor  power,
become disintegrated or dissolved, and disappear ; not, however,
until  they have communicated to the ovum,  that wonderful
force which leads to the formation of a future being,  but without
which the ovule dies like any other simple animal cell.
  The ovule having thus been converted into the Ovum  by the
process of fecundation, we have now to  speak of  the earliest 
GERM-MASS.
101
phenomena observed in the development of the new  organiza-
tion.  The first change which is known to occur is the cleavage
or segmentation of the  yelk.   The embryo cell first elongates,
then becomes violin-shaped, and afterwards separates into two
cells by spontaneous fission—an observation first made by Swam-
merdam.   With  this division  of  the embryo cell the yelk
divides into two masses, and the two cells are now in the cen-
tres of the two portions of  the yelk.  By a similar process, the
two cells divide into four, and these again into eight, and so on,
the yelk combining with the individual cells, until the process
of segmentation is completed, and  the product of the embryo
cell and the yelk form together a homogeneous mass of cells,
termed from its endowments the Germ-mass, and which, from
the appearance it presents, has been called by some authors the
mulberry mass.   In the formation of the germ-mass, the cells
have evidently multiplied by the assimilation and conversion of
the yelk.   This germ-mass is the plastic material out of which
the whole organization of the foetus is gradually evolved.
                           Fie, 29.
 A Ovum, with the first embryo cell. B, Division of embryo cell, and cleavage of the yelk round
it.  C, Second division, and segmentation.  D, Farther division.  E, Germ-mass or Blastoderm
forming.

  Professor Owen is of  opinion that not all these germinal cells
are consumed in the formation of the individual fabric, but that, in
the mammalia, for instance, a certain portion is reserved,  and that
this reserve becomes the ovarium or testis of the future animal.
In the amphibia, and still lower in the scale, the remnants of the
germinal  cells not  only go  to  form the sexual organs, but are 
102     MICROSCOPICAL  ANATOMY OF THE  EARLY OVUM.

located in different parts of the body, and become the agents in
the reproduction of lost limbs or organs.  This philosophical view
of Mr. Owen is combated by Dr. Allen  Thompson, one of the
ablest embryologists  in this country, on  the ground that at an
early period of development no difference can be seen between
the blastema  or commencing structure  of the ovaria or testes
and any other organ.   Still the opinion  of Mr. Owen upon  this
point cannot but carry great weight.  It is probable that the
blastema  of all organs contain, in the  first instance, germinal
cells, which are gradually exhausted in the development of the
tissues, but which in  the ovaria and  testes are reserved  for the
evolution of new individuals.  If we believed, with Mr. Owen,
that in each female a part of the residual germ-mass goes to the
formation of the  ovaria,  and the evolution of germs in a new
generation, wre might infer that  the  human race is still in its
infancy.   The changes in these germ-cells, occurring but once in
every generation, if multiplied by the generations of men which
have lived upon the earth, are infinitely  less in number than the
changes which occur in  particular  cells in the lifetime of an
individual.  The  epithelial cells of the  digestive tube may be
cited as an example, in which new progenies of cells are produced
and destroyed after every ingestion of food.
   After the formation of  the germ-mass  by the process  of  seg-
mentation, those cells which are nearest  the surface, and imme-
diately under the zona pellucida or vitellary membrane, become
aggregated together at one part  of  the  ovum, so as  to  form a
layer, which constitutes  the  blastoderm, or Germinal Mem-
brane.   This membrane, in the first instance, divides into  two
layers—the external or Serous Layer, and the internal or Mucous
Layer, for a knowledge of which we are indebted to Pander, of
Wurzburg.  Subsequently, other  cells of the germ-mass collect
between the serous and mucous  layers,  and arrange themselves
into a third  layer, which is termed the Vascular Layer.  The
serous layer gives origin  to the vertebral column, the brain and
spinal  marrow, the extremities, and the general skeleton.  In
the  mucous  layer arise  the  mucous structures and the  glands;
while in the vascular layer, the heart and vascular system origi-
nate.  In forming a proper idea of these  layers, the student must
bear in mind that they are not flat layers, but are three spheri-
cal membranes contained within the external  membrane of  the 
ZONA PELLUCIDA.
103
ovum—that is, the vitellary membrane, or zona pellucida.   On
one aspect of the sphere, these membranes become thickened by
the accumulation of cells, and in this thickened  portion of the
membrane the rudiments  of the foetus are formed.  Attention
must now be given to this thickened part of the  several layers,
and the student should consider himself  as looking at a circnm-
3cribed portion of their spherical surfaces.  The dense area re-
ferred  to constitutes the Area Germinativa, which is first round,
then oval, and subsequently pyriform in shape.  In the centre of
the area germinativa, the cells of the serous and mucous layers
become fewer in number, so as  to  render them  comparatively
transparent, thus forming  a space called the  Area  Pellucida.
Around this pellucid space  a boundary is formed by an accumu-
lation of cells in the vascular layer, and this circle  is called the
Area Vasculosa.  In the centre  of the area pellucida, and in the
"Ptts. 30.
 Diagram of Area Germinativa. In the centre, the Primitive Trace. Immediately surrounding it
is the Area Pellucida, bounded by the dark Area Vasculosa.

serous lamina, the first sign of the foetus appears in the form of
a transparent groove.   This groove, which  is  the  Primitive
Trace, is surrounded by two elevated ridges, called the Laminae
Dorsales.   The primitive trace may be said to represent the
future cerebro-spinal nervous  centres, the dorsal  laminae, the
cranium, and vertebral column.  The ridges or elevations of the
serous layer, constituting the laminEB  dorsales, approach each
other, as the process of development goes on, and unite above, in
this way closing over the  groove already described.  Thus the
vertebral canal is formed by the fusion of  two processes  of the 
104
DEVELOPMENT OF THE OVUM.
serous layer at their apices.  This  method  of forming separate
cavities,  from the  layers  out of which the foetus  originates,
deserves  attention, as it is repeated again and again as the devel-
opment of the ovum proceeds.
                           Fia. 31.




                       1     || j  ---M


         1, Area Pellucida, 2, Lamina dorsales. 8, Primitive trace or groove,
Pig* 32.
  1, 2, 8, Commencement of Cerebrum, Cerebellum, and Spinal marrow.  4, Commencement of
Vertebral column.
   While the upper portions of the  dorsal laminae are thus clos-
ing over to form the vertebral canal, the under portions,-which
•constitute the Laminae Ventales  of Baer, elongate to form  the
ribs and abdominal walls, and they have the  same tendency to
meet and unite  in the medial line.   In  this way the  abdominal
and thoracic cavities are formed,  and the mesial raphe indicates
in after life the  place  of union.   Thus the vertebral and cranial
cavities, and the cavities of the thorax, abdomen and  pelvis, all
lined with serous membranes, are inclosures separated off from
the general cavity of the primordial serous  layer of the  ovum.
The limbs with  the joints and their  fibro-serous linings are  also
derived from the same membrane, and possibly their sympathies
in disease with  the larger fibro-serous membrane, as in articular
rheumatism and pericarditis, may be referred to their common
origin.  It is easy to understand, that  if the closing in  of the 
CAUSE OF VARIOUS MONSTROSITIES.
105
spinal canal by the laminae  dorsales should be incomplete, we
have spina bifida or hernia cerebri as the result; or that, if the
lower laminae do not  meet  in the median line, we have cleft
palate, hare-lip, deficiency in the walls of the thorax and abdo-
men, and other malformations depending on insufficient develop-
ment at this early period.  At this epoch of development it is,
that various monstrosities, arising out of the  union of twin foe-
tuses, occur.   If two impregnated ova join anteriorly, before the
closing in of the abdominal and thoracic cavities, or posteriorly
before the arching in of the vertebral and cranial canals, we may
have an abdominal or spinal canal common to both. It is upon this
principle, applied to the serous, vascular, and mucous layers, that
all the varieties of double monster are to be explained.  In the
case of the African twin, recently exhibited in this country, the
junction was at the sacral bones, and the ova must have united
together at the sacrum, before the arching in of the sacral por-
tion  of the vertebral canals, so that the posterior aspects of the
two  sacral  bones became fused together, the vertebral  columns
being separated on every other point.
  In the vascular layer, and in that part of it which has been
referred to as the area vasculosa, surrounding the area pellucida,
the first blood channels are formed, by the unions of files of cells,
and the obliteration of the cell-walls  at the points of union; the
first  blood  discs  being formed, according  to  Dr. Carpenter,
from the nuclei of the  cells which have united to form  the ves-
sels.  These  vessels increase and  enlarge, and are destined at
first to carry to the embryo the nutriment absorbed from the yelk
and  from the chorion, the formation of which will hereafter be
adverted to.  The heart is  formed in the same manner as the
first bloodvessels, from cells,  and retains for some time its cellu-
lar  character.  The vessels are, however, first formed, and the
flow of the earliest blood globules is not from, but towards, the
Punctum Saliens, or commencing heart.  From  this beginning
the circulating apparatus is gradually developed, passing through
the phases which are permanent in fishes and amphibia, to reach
at the time of birth, the mammalian type.
  Early in the formation of the embryo, the Amnion, the envel-
ope belonging essentially to the ovum, begins to appear.   It is
formed in the following manner :  Beyond the two extremities
of the ovum,  and on the outside of the area pellucida, the serous 
106
WHAT IS MAN ?
lamina projects in the form of two hollow processes, which gradu-
ally arch over the whole of the  foetus, so  that the dorsal aspect
of the embryo is entirely covered by two layers of the series
lamina.  These processes meet in the centre, and unite together.
At first the processes are, at their origin, separated to a consid-
erable extant on the ventral  surface  of the embryo, but they
gradually approach each other at the umbilicus, and ultimately
surround the elements forming the umbilical cord.  Of the two
layers of which the amnion is formed, one surrounds the embryo,
and constitutes its proper envelope ; the other becomes adherent
to the external  or maternal membranes.  The cavity of the
amnion becomes  filled with a  watery secretion^ and the embryo
is thus suspended in a fluid  medium, which affords many advan-
tages during the progress of utero-gestation. From the time when
the amnion is first formed to the date of parturition, this mem-
brane and the bulk of the fluid it contains continues to increase.
The outward pressure of the amniotic fluid seems to be the chief
agent in promoting the extension of the external membranes of
the ovum.  It is  worthyr of remark that the secretion of a large
quantity  of fluid by  a serous  membrane,  which  secretion  is
closely allied to the dropsies of the serous  cavities, should in the
ovum be a purely physiological  process.  Sometimes the amni-
otic fluid is in excess, when we have what is termed dropsy of
the amnion.   It will not be  forgotten that the amnion, like the
serous lining of the vertebral and cranial cavities, and the serous
membranes of the chest and abdomen, are developed from the
serous layer of the early ovum,  and these membranes, like the
amnion, have in the foetal state  a tendency to  excessive secre-
tion, leading to congenital hydrocephalus and ascites.  We may
perhaps find an explanation of the sympathies between the skin
and the serous membranes, as in the production of peritonitis or
pleuritis,  by the influence of cold upon the  skin, in their com-
mon  origin  from  the serous or cutaneous layer of the ovum.
The amnion  is a reflexion from that part of  the layer which
forms the skin, and at birth  the skin and amnion are continuous
at the umbilicus, the amnion  being reflected on the umbilical
cord so as  to  form its external  covering.  The subject of the
evolution of the perfect individual from a triple membranous sac
would admit of an extensive development in human physiology
and pathology.  Man in his greatest pride does but consist of 
FORMATION  OF THE UMBILICAL VESICLE.
107
the involutions and devolutions of these membranes.  Upon the
vital energy possessed by these layers depends his health, his ten-
dencies to the diseases  of the systems evolved from them, and
the duration of his existence.
                  Fig. 33.               Fia. 34.
  Fig. 33.—Diagram of early Ovum. 1, Serous lamina.  2, The yelk. 8, Embryo.
  Fig. 84.—Diagram showing the commencement of the Amnion.  1, Chorion.  2, Yelk sac. The
folds of serous membrane are rising at two extremities of the embryo, to form the amnion.

  The mucous layer has been described as the most internal of
the membranous layers within the vitellary membrane.  It  is
therefore in immediate contact with the  central portion of the
yelk,  or  that part of the mulberry mass not used up in the for-
mation of the three primary layers themselves.  The first com-
mencement of the mucous canals is made by a  constriction of
the mucous layer on the under surface of the commencing foetus.
The constriction is formed by two processes of the mucous layer,
which  gradually  approach  each  other.    This  constriction
increases, until  the smaller mucous cavity,  from  which the
mucous  membranes and  glands are developed by a  process of
reduplication, is nearly cut  of from the larger mucous cavity,
containing the remains of the germ-cells.   This larger cavity it
is which constitutes the Umbilical Vesicle, and the point of
division between the two cavities is subsequently the umbilicus.
It is from the umbilical vesicle that the embryo at this  early
period derives the greater part of its nutriment.  At this  time,
the umbilical vesicle is continuous with the  abdominal  mucous
cavity, by  means of the vitelline duct  at  the  umbilicus, the
material of the yelk is  conveyed to  the embryo, not only by the
duct,  but by means of  vessels developed in the part of the muc-
ous layer composing the walls of the umbilical vesicle, and which
vessels  are  called  the vasa-omphalo-meseraica.  The omphalo- 
108
OFFICE OF THE ALLANTOIS.
meseraic vessels  consist of an artery and vein, which  extend
from the umbilical vesicle to the superior mesenteric artery and
vein, in which they terminate.  This state of things continues
until the whole material of the yelk process has been  converted
to the uses of the embryo, when the umbilical vesicle, with the
omphalo-mesenteric vessels, shrinks up, and  their remains con-
stitute the Vesicula Alba,  the white spot frequently seen, with
great distinctness, in the abortion of early ova.
Fig. 35.
 1, The Chorion.  2, Yelk mass and commencing Umbilical Vesicle.  3, Embryo.  4, 5, 6, Folds of
serous layer forming Amnion. 7, Commencement of Allantois.

  The Allantois is another temporary structure which, with its
mode of origin, it is necessary to  describe.  It is formed at the
lower and anterior part of the embryo, not apparently from any
reduplication of either of the primary layers, but from a mass
of cells,  in the same  way  as the heart  and  bloodvesels are
formed.  The cellular cavity is at first elongated in  shape, but
by the usual process of constriction it becomes divided into two,
a larger and a smaller portion, communicating with each other,
and of which the smaller is  the urinary bladder.  The uraclms,
the cord leading  from the bladder to  the umbilicus, is the
remains of the  duct which originally connected  the bladder and
the allantois.  The allantois is partly intended as an excrementi-
tious organ, receiving the earliest secretion of the kidneys, but
chiefly, in the mammiferous ovum, as a means  of conveying a loop
of the bloodvessels of the embryo to the maternal surface of the
ovum, and thus providing the permanent foetal provision for nutri-
tion and excrementation.  This will be  again adverted to when
describing the maternal portions of the membranes of the ovum. 
                     LECTURE  VII.

    THE  DECIDUA, CHORION, PLACENTA, AND UMBILICAL CORD.

  Gentlemen :—While the changes which have been described
in the previous Lecture as the results of fecundation,  are  pro-
ceeding in the embryo, other phenomena, equally necessary to the
development of the ovum, are occurring in the uterus.  The for-
mation of the Amnion on the part of the embryo has been already
referred to, and there remain for consideration two other mem-
branes, the Decidua and the Cliorion, both of which are formed
on the side of the mother; and the Placenta, which is  devel-
oped from the bloodvessels of the foetus, and  from certain  por-
tions of the chorion, and  decidua.   The clearest information
respecting these structures will probably be  conveyed  by an
account of the mode in which they are developed.
  On the occurrence of impregnation, a remarkable  stimulus is
imparted to  the uterus, before the ovum has entered this organ,
and certain changes are produced which fit it for the reception
and retention of  the embryo.  The  Membrana Decidua, so
called from its destruction at the time of parturition, is entirely
the production of the uterus, and has been the subject of many
discussions since  the  time of its first  accurate description by
William Hunter.   In the early part of pregnancy, the decidua
consists of two principal portions, the Decidua Vera, lining the
cavity of the uterus, and the Decidua Reflexa, which  immedi-
ately surrounds the embryo. At this time, owing to the small size
of the ovum, as compared with  the cavity of the  uterus, these
two portions are in contact only at  the point  where the ovum
rest upon the uterus, this being generally at the upper part of
cavity of the fundus, near the opening of one of the Fallopian
tubes.  Up to a comparatively recent period, the opinion which
chiefly prevailed respecting the  formation of  the decidua was,
that, immediately after fecundation, the uterus developed upon
                                                      109 
110
VIEWS RESPECTING THE DECIDUA.
its internal surface a membranous sac, constituting4he decidua
vera, and that the ovum, descending the Fallopian tube, entered
the uterus by pushing before it  a  reflexion of this new  mem-
brane.   It was supposed  that the fold originating in this way,
enveloped  the embryo, and  constituted the decidua  reflexa.
The ovum  thus appeared to become involved in a duplicate
membrane, which has often been compared to the double  envel-
ope of the heart formed  by the reflexion of the pericardium.
Dr. Sharpey was first to call into question the common  belief
respecting  the nature  and  formation of the decidua, and his
investigations led him  to the conclusion that the decidua vera
was not a membrane formed upon the-uterine mucous surface,
but that it consisted of  the actual  mucous  membrane  of the
uterus  itself, altered by  a process of development, under the
stimulus of impregnation.  Dr. Sharpey was followed  by E.
II. Weber and others, whose researches have all tended to con-
firm this view; and we now possess a large body  of  facts, which
appear  satisfactorily to explain the origin of the decidua vera
and reflexa, and  the relation of the decidua to the chorion and
to the formation of the  placenta.
   The earliest changes which occur in the cavity of the uterus,
after the impregnation of the ovule, consist of a swelling  of the
tubular glands of the mucous membrane, and of the capillary
vessels distributed in the interspaces  between these glands.  In
the uterus  examined a  short time after the occurrence of fecun-
dation, the glands are distinctly visible to the naked eye.  Their
length at this time is from  one  and a  half to two Paris lines.
The tubes beccme lined with epithelium of a whitish color, and
a  profuse  secretion of celloid  particles  and albuminous mat-
ter takes place from the surface of the mucous membrane in the
inter-follicular spaces.
   This cellular secretion is so profuse that it not only forms  a
layer upon the surface, but a  considerable quantity is  poured
into the cavity of the  uterus.  The enlargement of the tubular
glands already referred to, and of the capillaries of the intergland-
ular spaces, together with the plastic secretion poured out upon
them—in other words, the altered mucous membrane  of the
uterus—constitute the decidua vera.   With respect  to the mode
in which  the decidua reflexa  is  formed, the latest views are
those of Professor Goodsir and  M; Coste.  Mr.  Goodsir, in his 
GOODSIR's  VIEWS OF THE DECIDUA.
Ill
paper " On the Structure of the Human Placenta," published in
1845, explained the  formation of the decidua in the following
Fro. 36.               Fl&. 37.
 Fig. 30. Section of the lining membrane of the uterus at the beginning of pregnancy, twice the
natural size.  1, opening of the glands on the surface of the cavity; 2, The utricular glands.
 Fig. 87. A portion of glandular structure twice magnified. 1,1, Orifices of the glands; 4, Cae-
cal extremities of glands; 5, Tubular portion of glands.

manner.  He considered  the celloid matter  secreted  from the
uterine follicles and the inter-follicular spaces, to belong to what
he terms the third order of secretions—that is, the cells have the
power of  accomplishing  further  changes, and of  developing
other cells from their  nuclei, after they have  left the mucous
membrane which  originally produced them.   The small ovum,
on  entering  the uterus,  becomes, according to  Mr. Goodsir,
imbedded  in  the  cellular matter of the  cavity of the uterus,
which combines with its outer envelope, the chorion, hereafter
to be  described, and ultimately forms the decidua reflexa.  The
decidua vera, then—in the opinion of Mr. Goodsir—consists of
the uterine  mucous  membrane,  altered in  the   manner de-
scribed ; while the decidua reflexa is a membranous, or plastic,
structure formed out of the cellular secretion derived from the
mucous surface, or  decidua  vera.  According to the views of 
112
COSTE'S VIEWS OF THE  DECIDUA.
M. Coste,  published two  years later, the decidua  vera and
decidua reflexa, are both produced by the metamorphosis of the
mucous membrane of the uterus itself.  He believes that the
ovum, on entering the uterus, is embedded  in the soft and tur-
gid mucous membrane, which becomes specially increased in
thickness at the  point  which receives the ovum, and rising
around it like the florid granulations of an issue around a pea
ultimately meets, and is  united,  so as entirely to surround the
ovum.  The view of M. Coste was founded upon the  dissection
of  two uteri  at the twentieth and  twenty-fifth days  after
fecundation.  The difference betwen the  opinions of M.  Coste
and Mr. Goodsir is that the one considers  the decidua reflexa
to be  formed directly from  the  decidua vera, while  the  other
believes it to be produced from a plastic layer exuded upon the
surface of the decidua vera.

              Fio. 38.                     Fig. 39.
           Fig. 85. First stage of the formation of decidua reflexa.
           Fig. 39. More advanced stage of decidua reflexa.

  When first formed, the decidua reflexa appears to  differ from
the decidua vera in being composed chiefly of cells, while the
decidua vera is  characterized by the presence  of the  tubular
glands of the uterus.  The portion of the cavity of the uterus—
or, rather,  of the cavity of the decidua—not occupied by the
ovum, contains a fluid secretion, exuded  from the hypertrophied
mucous membrane, or decidua vera, of an albuminous character
which, in the early part of gestation, ministers  to  the  nourish-
 
              LEE  AND OTHERS ON THE DECIDUA.           113

ment of the ovum.  This is the hydroperione of Breschet.   Dr.
Robert Lee believes that blood passes through minute openings
in the decidua reflexa from the placental cells and the cells of
the chorion, to be taken back into the maternal vascular system,
through openings on the internal surface  of the decidua vera,
without being followed by the escape of blood.   The  internal
surface of the decidua vera is smooth, but  the external  surface.
or that in contact with the fibrous structure of the  uterus, has
been examined and  described by Dr. Montgomery, who found it
to consist of a number of cup-like elevations, or little bags, con-
taining a whitish fluid, and which present  open mouths on the
side of the  uterus.  Dr. Montgomery  terms these processes
uterine cotyledons.  They are best seen at the second or third
months, and disappear with advancing pregnancy.  Possibly
these appearances may be the utricular glands of more recent
observers. In cases of double uterus, in which only one is impreg-
nated, a decidual membrane is sometimes  found  in  the empty
cavity, and it is  occasionally, though not always, found in the
uterus in cases of extra-uterine gestation.  Considerable differ-
ence of  opinion obtains as to whether the decidua lines the Fal-
lopian  tubes or not, but the weight of authority is  against its
doing so.  The decidua vera increases with the development of
the uterus, but after the adhesion of the ovum to the site of the
future placenta,  its  chief development is at this part, and the De-
cidua Serotina, as the  portion of the  decidua vera entering
into the formation of  the  placenta is called, becomes the  most
important part of the decidual membranes.  The rest of the de-
cidua vera becomes a comparatively thin layer lining the whole
surface  of the uterus,  except at the cervix uteri, and the angles
at which the Fallopian tubes enter the cavity of the fundus. In
the early months, the space between the decidua vera and  deci-
dua reflexa forms a cavity which has been already referred to,
and which is called  the decidual cavity.  As  the uterus  is, up to
a late period of pregnancy, considerably larger than  the  con-
tained ovum, the cavity between the decidual membranes  con-
tinues to  exist  beyond the  middle of gestation.  In  cases of
doubtful pregnancy, or where pregnancy has not been suspected,
the uterine sound has  been passed into the uterus nearly to the
fundus without inducing labor or causing haemorrhage.   The in-
strument, of course, passed through  the mucous plug of the os
                                8 
114
FORMATION OF THE CHORION.
uteri into the decidual cavity without producing any laceration.
I know of a case in which the walls of the uterus and abdomen
were so thin that the limbs of the child could be felt with great dis-
tinctness, and extra-uterine  pregnancy  was suspected.    One
ground for this diagnosis was, that the sound had been repeatedly
passed into the uterus without causing mischief.  Of course, it
would be very wrong, in any case in which pregnancy w,as sus-
pected, to pass an instrument into the decidual  cavity, as  there
would be great risk of detaching the placenta.  The  external
surface of the decidua reflexa and the internal surface of the de-
cidua vera  become at  length so  smooth that  they have been
compared to serous membranes.   In the latter months, the ovum
entirely fills the uterus, so that the whole aspect of the decidual
surfaces is brought into contact,  and it is often difficult to divide
the two, in  the attempt to induce premature labor by separating
the membranes from  the cervix uteri.  At the  time of parturi-
tion, the amnion, chorion, and decidua reflexa are expelled with
the placenta, but the decidua vera is subsequently broken down,
and  escapes, in the form of detritus,  with the  lochial dis-
charge.
  The other envelope which the foetus derives from the mother
is the Chorion, which  is  internal to the  decidua and is formed
before the ovum enters the  uterus.  When  the ovule escapes
from the ovisac, it is surrounded by part of the  granular mat-
ter forming the proligerous disc.   After  fecundation, and as the
ovum is passing down the Fallopian tubes, it acquires, according
to Valentin, Mr. Wharton Jones, and other observers, an albu-
minous  layer, which becomes adherent to  the vitellary mem-
brane, or the outer covering proper to the ovule.  The album-
inous layer thus formed, which is the  commencement  of the
chorion, is considered by many authorities to be the analogue of
the white of the egg, which is  formed  round  the  yelk  in  the
egg of the  bird, during its passage through the oviduct.  It is
uncertain whether  the chorion is formed, in whole, or in part, be-
fore or after the act  of fecundation.   It is probable  however
that  in the  case  of ova which never become impregnated,
the vitellary  membrane  becomes  coated with   a  layer of
albumen.  The chorion is also found in cases  of extra-uterine
gestation, when the ovum becomes attached to  the  intestines or
the ovarium.  Mr.  Goodsir is of opinion that the decidua reflexa 
THE VILLI OF THE CHORION.
115
also contributes, with the chorion, to form the counterpart of the
white of the egg.  In the first instance, the albuminous chorion
is  itself a  supply of nutritive material  for the ovum ; but  it
soon becomes  converted  into an absorbent  organ, and obtains
nutriment from the decidua and  the decidual cavity.  When
first formed the external surface of the chorion is smooth ;  but
in the earliest  state, at which this membrane has been seen in
the uterus, it has been found covered with* villi, which present
a shaggy appearance, and are devoted  to the absorption  and
assimilation of material for the support of the embryo.  Each
chorionic villus is bulbous in shape, and consists of an external
membrane, including within it a number of cells, which are the
principal agents in effecting absorption.  At first these villi  pre-
sent no blood-vessels, but draw nutriment from the elements with
which they are in contact by endosmosis, like the spongioles of
a jrtant.  Afterwards, when the allantois, with the umbilical
artery and vein has approached  the chorion, the villi contain
vessels which  become largely concerned  in the nutrition  and
growth  of the  foetus.  In the second month the villi of the  cho-
rion  are of considerable size, and their cellular cavities commu-
nicate freely  with  each  other over the whole  surface of the
chorion.  After the end of the second  month, they diminish  in
size except at  the site of  the placenta, the diminution proceed-
ing from below upwards, until the whole of the unattached sur-
face of the decidua reflexa and chorion  become smooth.   By
the end of the fourth month, the villi of the chorion on the side
opposite to the placenta  have quite disappeared.  Dr.  Robert
Lee  believes that before the fifth month the cells of the chorion
contain blood, which is poured into them from the cavernous
structure of the placenta.  The villi of the chorion do not be-
come developed into the villi  of the placenta, hereafter to be
described, but form the most internal portion of these villi.
   With respect to the formation of the Placenta, it will be re-
membered, that in the preceding lecture we had described the
Allantois arising from the  caudal  extremity of the foetus, and
conveying the bloodvessels,  constituting the future  umbilical
vein  and arteries, towards the surface of the  ovum.  At the
same time that this occurs, the decidua vera and  d*ecidua re-
flexa are acquiring considerable thickness at the point towards
which the allantpis is  bearing the vessels, and a correspond- 
116
CURLING ARTERIES OF TUE UTERUS.
ing development  of  the villi  of  the chorion occurs in the
same situation.  From these elements the future placenta is de-
veloped.  In obedience to the wonderful formative force which
presides over all the operations  of the embryo, the  thickening
of the decidua vera, and chorion, occurs upon the  same  aspect
of the ovum, and towards this locality  the allantois also directs
itself, conveying thither the umbilical vessels.   This occurs with
almost unerring regularity, and in the fully formed placenta the
umbilical  cord is generally implanted in or near the middle  of
the placentary mass.   Sometimes, however, the umbilical ves-
sels are inserted towards the edge of the placenta, and rare in-
stances are met with, in which the allantois  projects the vessels
towards the wrong part of the chorion, when the ovum perishes
from a dislocation, so to speak, between the umbilical, chorionic,
and decidual portions  of the  placenta.  It is to  Mr. Goodsir
that we  are indebted for the latest and best account of the •ar-
rangement of the chorion, decidua, and maternal and foetal ves-
sels in the placenta, and in describing them I shall  chiefly fol-
low that able  anatomist.
  If the uterine arteries and veins are  examined in  the  gravid
uterus  while in connection with the  placenta, it  is  found that
the uterine arteries pass from the walls of the uterus, into and
through the thickened decidua serotina.  While passing through
the decidual layer, the arteries make a serpentine twist, and
hence are  called the  curling arteries of the uterus.  They con-
vey the maternal  blood into large cellular  chambers,  which,
as described by William Hunter, communicate with each other
throughout  the whole of the  middle portion  of  the placenta.
The  blood is  returned from  this, which Dr.  Robert Lee has
called the cavernous  structure of the placenta, by the uterine
veins, which,  as they  enter the uterine  walls, are dilated into
sinuses  of  considerable size.    These  vascular cells, situated
between the uterine arteries  and veins, form  in the aggregate,
an extensive placental  cavity, or cavernous arrangement.  Such
is the entire circuit of  the maternal portion of the blood in the
placenta.   The arteries, cellular chambers, veins, and sinuses are
lined throughout with  a membrane continuous  with the lining
membrane of the vascular system of the mother.  The large
placental  cells which  have  been spoken  of  as receiving  the
arterial blood from the uterus, and returning it  by the veins, 
FORMATION  OF THE PLACENTA.
117
may be said to stand in the place of the capillaries  in other
parts of the body.  The  placenta itself is nourished by special
capillary vassels, which enter it from the uterus.   In immediate
contact with the uterine  surface, cellular  bands are found cross-
ing  the sinuses, and threads of a  similar  character cross the
cells or cavities of the placenta, and are attached to the placen-
tal villi,  hereafter to  be described.  These bands and threads,
which  consist of files of  cells, similar with the cells exuded from
the surface of the decidua  at  the  commencement of gestation,
will have to be reverted  to presently.  The whole of the placen-
tal vascular apparatus, on the side of the mother, may be said to
be developed in the  hypertrophied  and metamorphosed mucous
membrane, or decidua; and, in fact, the vascular apparatus and
decidua form together, the whole of the maternal portion of the
placenta.
  The  fcetal half of the  placenta is found  to  consist  of  tufts
arranged in an arborescent  form; of villi, which are attached
to the  branches of the tufts; and  of  the ramifications of the
umbilical arteries and veins. The vessels of the  tufts consist of
a branch of the umbilical artery, and of a radicle of the umbili-
cal vein.  The foetal blood enters by the arterial channel, pass-
ing out by the veins; but between each branch of the artery and
vein there runs, not  an ordinary capillary, but a capillary vessel
of large diameter, capable of carrying five or six blood globules
abreast of each other.   These  peculiar vessels  enter the villi,
sometimes dividing  and uniting again in the  substance of the
villi;  at other times, one  vessel passes into a single villus, or
into two or three villi, and returns  to the vein without dividing.
These  large capillaries  present, in their course, dilatations and
contractions similar  with those  found in an intestine.  The fcetal
blood,  coming  to the placenta by  the umbilical arteries, which
carry the venous blood of  the foetus, passes  through the inter-
mediate vessels which have been  described, and is returned by
the umbilical veins, after having  undergone, in the placental
tufts and villi, the changes necessary to fit it for the support of
the foetus;  but there is no  co-mingling of the two streams of
foetal and maternal blood.   The two sets of vessels are entirely
separate, as  was first demonstrated by William and John Hunter.
As the uterine arteries and veins have developed  themselves in
the decidua, so the umbilical arteries and  veins have ramified in 
118       RESUME OF THE  ANATOMY OF THE PLACENTA.

the chorion and its villi, by a process similar with the formation
of the first bloodvessels in the area vasculosa.
  Thus, to resume briefly, the placenta is formed by the fusion of
the chorion and decidua at the site of the attachment of the ovum
to the uterus. The villi of the chorion, capped with a layer derived
from  the decidua, form the villi of the  placenta.  On the side
of the mother,  the vessels  of the placenta consist of arteries and
veins, with  a series of  cavernous  cells  between  them.  These
cells in  the aggregate,  form what has been termed  the pla-
cental  sac or*cavity.  On the side of the foetus, the vessels con-
sist of  branches of the  umbilical  arteries  and  vein, with the
large  capillary vessels of the villi of the placenta between the
two.  The maternal  portion of the placenta is  formed by the
decidua serotina, or developed mucous membrane of the uterus,
the arteries and veins which enter the decidua from the uterus,
the cavernous structure of  the placenta,  the blood circulating in
these vessels, and the external layer of microscopic cells cover-
ing the  placental villi.  The  foetal  portion of  the placenta is
formed of the chorion and its villi, the latter  forming the inter-
nal portion of  the placental  villi, and  of ramifications of the
umbilical arteries and veins.   In the process of the formation of
the placenta, the chorion and  decidua first  become applied to
each other.   On the maternal  side, at the site of the placenta,
the uterine vascular system is developed in  the way which has
been pointed out.   On .the foetal side, the allantois projects the
vessels which afterwards become the umbilical arteries and veins

                          Fia. 40.
 1, Substance of the uterus; 2, Cavity of a sinus ; 3, 8, Vital tufts dipping into sinuses • 4 Deci-
dual lining of the uterus ; 5, Curling artery of the uterus.                    '  *
to the chorion ; and in the chorion a vascular system  becomes
developed  in connection  with  the umbilical "vessels  which 
ANATOMY OF PLACENTAL VILLI.
119
together constitute the fcetal portion of the vessels of  the pla-
centa.
  To understand the intimate connection with, and yet perfect
separation from, the maternal and fcetal circulations in  the pla-
centa, and the mode in which the foetus is nourished after the
formation  of the  placenta, it will be  necessary to describe a
separate tuft of placental villi, or a single villus itself, the tuft
being made up of  an assemblage of villi.
  Each villus consists of its bloodvessel, a double-series of cells,
and its envelopes.   The  capillary is the central portion  of the
villus.  Immediately around the vessel of the villus  a  layer of
cells,  derived  from  the chorion,  is  found.   These cells are
bounded by a fine  membrane, which, in the early development
of the embryo, constituted the external membrane of the villi of
the  chorion, but which, at a later  period,  forms the  internal
membrane  of the  placental villi.   This part  of the placenta
villi—that is the  internal layer of  cells, and  the  internal
membrane—is,  in  fact, the remains of the  original villi  of the
chorion.
                             Fig. 41.
 1, Decidua serotina; 2, A venous sinus passing obliquely through it; 8, A curling artery passing
through the decidua from the uterus ; 4, Lining membrane of maternal vascular system; 5, Tuft of
foetal portion of placenta; 6, and 7, Connection of tufts with  each other and with the decidua
serotina.

  On the outside of this inner membrane  a cavity, or interspace,
is met with, and, surroundiug the space,  there is a second layer
of cells.   The  bands  and threads found  traversing the venous
sinuses and the cavernous  structure of the placenta, have already
been mentioned.  Mr. Goodsir ascertained that these bands or
threads are composed chiefly of cells,  and are  connected with 
120           THE VTLLT, PULMONARY CAPILLARIES.

the external cellular  layer of the placental villi.  He describes
them as being, together with the  external layer of cells belong-
ing to the villi, the remains of the most internal portion of the
decidua;  and  the external layer  of  cells  represents,  in his
opinion, the remains of the secreting mucous membrane of the
uterus, as it existed before the descent of the ovum through the
Fallopian tube.   Still  more externally, each tuft of villi, or
every single villus,  is  covered by the membrane  lining the
cavernous structure of  the placenta,  and  which  has been de-
scribed as continuous with the lining membrane of the vascular
system of the mother.   Each  tuft or villus projects into  some
part of the extended vascular  cavity which exists between the
uterine arteries and  veins;  and  Dr. John Reid  found that in
some instances  small tufts of villi  entered the uterine sinuses,
and could be drawn out from them without laceration.
Fi&. 42.
 1, External membrane of placental villus ; 2, External cells of villus ; 8 8, Germinal centres of
external layers of cells; 4, Space between the maternal and foetal portions of villus; 5, Internal
membrane villus, or external membrane of chorion; 6, The internal cells of the villus, the cells of
of the chorion ; 7, Loop of umbilical vessels.

  Thus, each villus is composed of a bloodvessel, a layer of cells,
and  a fine membrane, derived from the chorion ;  of a  second
layer of  cells,  and  a second  membrane,  derived  from  the
decidua;  with a small cavity between the two; the whole of
these structures  being inclosed  in the blood  membrane of the
mother.   Thus formed, the villi lie in, and are  bathed by, the
maternal blood passing from the curling  arteries of the uterus to
the uterine sinuses, through  the  great  placental cells.    Con-
sidering the placenta with reference  to its lung function, the
stream  of maternal blood represents the atmospheric air, and
the vessels of the villi take the place of  the pulmonary capilla-
ries.  The blood is presented  to  the villi in the maternal chan-
nels in a perfectly arterial form, since there are no capillaries on 
           THE PLACENTA, THE LUNG OF THE  FC2TUS.         121

the maternal side of the placenta, except those of the small
nutrient vessels of the placenta itself; and the changes usually
occurring in the passage of blood from the left to the right side
of the heart are here effected by the capillaries of the villi and
tufts, or the foetal portions of the placenta.  It may be said that
the fcetal portion of  the  placenta is an apparatus for projecting
a set of foetal capillary vessels into a portion of the maternal cir-
culation, which contains no capillaries, and where the capillaries
of the villi become interposed between the maternal arteries and
veins, in  such  a manner as, without  any actual vascular  con-
tinuity, to convert to the uses of the foetus those changes which,
in the systemic capillaries, are made subservient to the nutrition
and renewal of the tissues of the  different  parts of the body.
The capillaries of the foetus become, in effect, in the placenta, a
portion of the capillary system of the mother.   In another sense,
the fine blood  membrane covering the villi, and the vessels of
the villi, represent the lining membrane of the air vesicles and
the pulmonary capillaries, and, by the processes of endosmosis
and exosmosis,  oxygen passes into, and carbonic acid and  other
excrementitious matters escape  from, the  fcetal  circulation.
Though the placenta is commonly spoken of as the  lung of the
foetus, the changes effected in it, as far as the oxygenation of the
blood is concerned, is more closely allied with the action of the
gills.of the fish, the blood of the mother representing the water
passing through the branchiae, but being more highly oxygen-
ated.
   The pulmonic or  bronchial function is  not the only one per-
formed by the  placenta in foetal nutrition and  excretion.   The
layers of cells derived  from the decidua and chorion, and the
vessels of the villi, are also  analogous in function with the cells
and lacteals of the villi of the intestinal tube.  The external or
maternal  layer of cells is believed to grow continually by the
assimilation of material from the blood of the mother.  As these
cells  arrive at maturity, they burst, and  their contents, which
are of a milky appearance, are passed into  the  space  between
the two layers  of cells, new generations of cells being formed to
succeed them, from  the germinal spots found in the villi.   Thus
the ruptured cells are replaced  by others, and, in microscopical
examinations  of the villi,  cells of different sizes, from  mere
nuclei up to fully-formed cells, are constantly found.  The chy- 
122
SHAPE OF  PLACENTA.
mous fluid, thus  elaborated by  the first layer of  cells,  and
passed into the space between the  two layers of cells, is next
                            Fia. 43.
 Section of fully-formed placenta, with part of the uterus,  o, Umbilical cord; 6, &, Section of
uterus ; c, c, c, Branches of the umbilical vessels ; d, d, Curling arteries of the uterus.

assimilated  to a further and  higher degree,  by the  internal
and fcetal, or chorionic layer of cells, as in the former case,
by  the growth and rupture  of  the cells, and the chylous
material  produced is  absorbed  and  carried  into  the  fcetal
circulation by the  vessels of  the villi.   The placenta may be
said,  therefore,  to  perform in  the  foetus the functions of the
lungs and the intestinal  canal.  In some of the lower animals,
the connection between the  parent and the ovum is  much less
complicated  than  has here been  described.   In the bitch,  for
instance,  Dr. Sharpey found  that the  glands of  the mucous
membranes enlarged, and that into their cup-like cavities, pro-
cesses  of  the  chorion, or large single villi, were received and
became adherent during gestation.
  The human Placenta is, at the full term, round or slightly
oval in shape, its  average diameter being  from six to  eight
inches,  and  its circumference from eighteen  to  twenty-four
inches ; in thickness it varies from one inch to two inches accord-
ing as it may be full or  empty of blood.  The internal surface of 
SIZES OF THE  PLACENTA.
123
the placenta is smooth, and  covered by a layer of the  amnion
and cliorion.   Through  these membranes the  branches of the
umbilical arteries and vein are  seen ramifying and dividing in
every direction towards  the circumference of the placenta before
they disturb the substance of the organ.   The umbilical cord is
generally inserted into,  or near, the middle of this  aspect of the
placenta, but sometimes it  is attached near the edge,  forming
what  is called battledoor  placenta.  The external placentary
surface, that, namely, in contact with the uterus, is covered with
a thick layer of decidua, the decidua serotina.   This surface is
divided irregularly into a number of lobes,  between which pro-
cesses of the decidua slip down.   When the  placenta is expelled
after labor, the divisions between these lobes are sometimes dis-
tinctly seen, owing to the laceration of the decidua which occurs
on the separation and expulsion of the placenta from the uterus;
but when gently peeled  from the uterine surface, it is covered by
an unbroken layer of the decidua serotina, marked by the open-
ings of the decidual arteries and  veins.  The  openings of the
arteries are circular, some of them being as large as a goose-
quill ; while the openings of the veins are oval, and of consider-
ably larger size.  At the end of the second month  of pregnancy
the placenta occupies about one-half of the entire  surface of the
ovum.  As  gestation advances, the placenta increases in size,
particularly in thickness, but the increase  is  not in the  same
ratio  with that of the  uterus or the other  parts  of the ovum.
At the time of labor it extends  over about one-fourth of the
entire cavity of the uterus.   It must be  said, however,  that the
placenta varies  very much in size.  As  the rule,  children with
whom there is a large placenta are strong and well nourished,
while the contrary obtains in the case of thin and small placentae.
Large placentae increase the  risk  and  danger of haemorrhage
after  parturition, which rarely occurs when  the placenta is con-
siderably below the average size.   It is doubtful if the  placenta
possesses  nerves or lymphatics.   Its nervous  matter, if any, is
probably diffused throughout its  structure, as in the case of the
lower classes of animal life, in which nervous functions are per-
formed without the existence of any special nervous system.
   The placenta, at the full period, frequently bears upon its sur-
face and structure evidence of  its caducous character.   This has
been  made known more especially by the original researches of
Dr. Robert  Barnes, followed by those of Dr. Druitt.   The cir- 
124
PLACENTAE OF TWINS.
cumference of the placenta is often marked by a rim of yellow-
ish material, consisting partly of fibrine and partly of fatty mat-
ter, and indicating the diminution  of the area of the placenta in
the latter months by a process of fatty degeneration.  The uterine
surface of the organ is frequently rough and gritty to the touch,
from the deposit of earthy matter, chiefly carbonate and phos-
phate of lime.  Patches of a lighter colour than  the  rest of the
placenta are often seen upon its surface:  these spots consisting
of fatty matter, and single villi and vessels in the interior, give
unmistakable evidence of commencing degeneration.
  In the  case of plural births, it generally happens that each
child  possesses its own involucra,  and  a separate placenta.
Sometimes the placentae are attached  to different parts of the
uterus, but most  frequently the twin placentae are side by side,
the one apparently fused into the other to some extent, but with-
out any vascular inosculation between them. In  rare cases there
is but one placenta, or the umbilical vessels of the twin or trip-
let children anastomose before their distribution to the placentae ;
and cases have been met with in which there has been but one
cord at the placental surface, and one placenta, the cord dividing
to pass to the separate children.
  The Umbilical Cord, or Funis, furnishes the  channels of
communication  between the placenta and  the  foetus.   At the
end  of gestation, the cord varies very  much  in length.  In
some cases it does not exceed six or seven inches, while in others
it has been known to measure five or even six feet.  It contains
the two umbilical arteries and the umbilical vein.  The  vein  is
much larger in diameter than  the  two arteries together, but the
arteries are much longer than the vein.   No doubt the blood
impelled by the fcetal heart, moves faster in the arteries  than  in
the veins, so that the  same quantity of blood  passes through
both.  The vein in the umbilical cord and in its ramifications in
the placenta is without valves, and conveys the purified blood
and nutritive material from  the  placenta  to the  foetus.  The
arteries convey the impure blood  of the foetus to the placenta.
In these particulars the umbilical arteries and veins resemble the
pulmonary  arteries and veins  of the adult.  Both  arteries and
vein are arranged in the cord  in  a  spiral manner, the arteries
being much more twisted than the  vein, and coiling  round  it.
The direction of the spiral turns made by the vessels  is almost
constantly  from  left to right.  Sometimes a single or double 
ANATOMY OF THE FUNIS.
125
knot is tied upon the cord, at others it is twisted once or twice
round the neck, or it is coiled round the body and extremities,
so as almost to resemble the Laocoon.  The foetal pulse is read-
ily felt in the cord when the child is alive  and before the funis
has been separated.   It  occasionally happens that only  one
artery is met with instead of two, and cases have been observed
in which the cord has contained two veins.' The arteries do
not communicate except by a branch near the surface of the pla-
centa.   Usually, the vessels  divide on entering the placenta, but
sometimes division commences before they reach that organ, a
circumstance which commonly diminishes the strength of the
cord.
   The bulk of the funis is  made up of gelatinous matter inclosed
in cells which do not communicate freely with each other.   The
contents of these cells surround the vessels, and  are means of
defence against pressure.  The quantity of gelatinous  material
varies much in different embryc-s, and to this  is chiefly due the
thickness or thinness of the cord.  The funis is also covered by
a layer of chorion, and externally by a layer derived from the
amnion.   It is doubtful whether the cord contains lymphatics or
nerves, or, at all events, if the nervous  matter assumes a separ-
ate form.  In this place a word may be  said about the transmis-
sion of impressions from the mother to the foetus.  The absence
of nerves in the placenta and funis would be no disproof of a
communication between  the  nervous system  of  the foetus and
the mother.  When the ovum consists of the blastodermic  vesi-
cle, and before the beginnings of the  nervous system have  been
evolved in  the course of development, it manifests properties
which afterwards belong to the nervous  system.   In the unicell-
ular animalcula, the same  functions are performed which  in
higher animals, where the nervous system has assumed a separ-
ate type, are executed by the nerves.   In these peculiar organ-
isms, the nervous system, though not collected  into tubes,  or
surrounded by neurilemma, pervades the whole animal.   This
may be  the  case  with the umbilical cord and the placenta, or
future research may demonstrate the existence of nerves in  these
temporary structures.
   No explanation has  been  given of the spiral arrangement  of
the vessels of the umbilical cord.  When the cord is first formed,
the vessels take a straight direction from the foetus to  the  deci-
dua, and the arteries and  vein are not close together.   After  a 
126
CONVOLUTIONS OF THE FUNIS.
time they become coiled round each other, and the cord dimin-
ishes in size, but increases in length.  This increase is greater in
the early and middle months of pregnancy than subsequent!}7-, so
that at the middle of gestation the relative length of the cord is
greater than it is at the time of parturition.  The same remark
may be made respecting  the  quantity of the liquor amnii.
When the cord is long, and  the amount of liquor amnii  consid-
erable, it is easy to  conceive that the foetus may, by  it own
movements, or the changing positions of the mother, pass through
a loop in the cord, and thus form a knot.  In the same way the
passing of the cord round the neck or body has been explained.
It appears to me  that this  explanation may be extended to the
curious  spiral arrangement of the vessels, and of the whole cord.
The cord is originally straight, and can only have been twisted
by the movements of the foetus, the placenta being a fixed point.
It would seem that the foetus, when it moves, always tends to
move in a certain direction, and that the number of spiral turns

                           Fig. 44.
 The umbilical cord and external surface of the placenta. The amnion and chorion raised from
one portion of the placenta.

in the cord must represent the number of times which the foetus
has slowly rotated in the uterus during the course of ^station.
In no other way can we  explain  the alteration of  the vessels
from the straight to the spiral form.   I shall have to revert to
this subject when  treating  of the movements of the foetus in
utero. 
LECTURE  VIII.
                    SIGNS OF PREGNANCY.

  Gentlemen :—The changes induced in the female economy
by pregnancy are very various and extended.   From the initial
steps in the act of reproduction to its final close, a great number
of phenomena occur in different and remote organs. The evi-
dences manifested in the generative system are, no doubt, the
most important;  but the vascular system  and its  contained
fluid, the different portions of the nervous system, the digestive
apparatus, the skin, and the glands and their secretions, all con-
tribute to  the  sum of those  organic and functional  conditions
which  we group  together as  the Signs of Pregnancy.  The
difficulties attending the diagnosis in particular  cases are mani-
fold.  We  are frequently asked for a positive  opinion at an
early period of gestation,  when the signs are not pronounced
with distinctness.   The symptoms vary  in different women, or
in  the  same women at different times.   Some of the more
obvious signs may be wanting altogether, or they may be simu-
lated by disease.   Difficulties often arise from the mental condi-
tion of the patient.   We have at one time to deal with women
extremely desirous  of having  children,  or, again, with women
who hold pregnancy in horror.   In another class of cases our
dictum is required when the most violent protestations of chas-
tity are  made.   Under  these various  circumstances,  women
magnify certain symptoms,  and suppress others, as far as possi-
ble, in accordance with their own wishes, or in order to deceive
the attendant.  We should, to use a legal phrase, " dismiss from
our minds," in any case of  doubtful pregnancy coming before
us, all  considerations except  those of a  physical character.
Gooch expressed this when  he said, with  more force than ele-
gance, that not " women's words, but their bellies " should be
believed in suspected cas,es. 
128       IMPORTANCE OF THE SIGNS OF PREGNANCY.

  It is of importance, not only that accoucheurs, but all medical
men, should pay attention to the signs of pregnancy;  otherwise
the practitioner may  be confounded by the  birth of a  child,
when no increase of the population  had been expected ; abor-
tion may be  produced  unwittingly by emmenagogues or examin-
ations ;  or, under  the false impression  that pregnancy  exists,
serious disease may remain for months untreated and unchecked.
In all cases which admit of doubt, the medical attendant will do
well to  suspend any positive judgment  until the  evidence one
way or the other becomes certain, and, in the meantime, to be
cautious in all that relates to the treatment and management of
the patient.
  The most convenient method of relating all that pertains to
the signs of pregnancy is to consider them very  nearly in the
order in which they arise, by which means a double advantage
will be  gained; the symptoms of commencing and advanced
utero-gestation will be grouped separately, and a method of ex-
amination will be fixed upon the mind.
  The first indications of pregnancy  are to be found in the
reproductive organs.  No sooner has a fruitful congress  taken
place than a change in the condition of the Uterus  occurs—from
a state  of comparative quiescence, in which, apart from men-
struation, the  decay and  repair common to all other tissues is
its only function, it emerges into energetic activity, constructs a
nidus for the  reception of the expected  ovum, and commences
those intimate changes which result in the transformation of a
fibroid mass into a muscle of immense energy.   The greater the
functional activity of an organ, the greater the amount of blood
which passes through it in any given time.  The uterus is no
exception to this general law, and hence, when an examination
is made per  vaginam but a few days after conception, the organ
is found hot, turgid, and almost erect, as if endowed with the
properties of erectile  tissue.  This state of the uterus is  by no
means persistent;  before any great length of  time it  gives way
to softness and increased bulk;  the uterine vessels increase in
size from day to day; small twigs of artery become  developed
into vessels of considerable calibre;  there are capillaries where
none apparently existed before; the cellular tissue of the oro-an
is in a manner unravelled by the dilated  and dilating vessels, as
well as by certain  histological changes, and the parenchyma is 
LOCAL SIGNS OF PREGNANCY.
129
moistened by interstitially-effused serum.  The body of the im-
pregnated uterus is, in all ordinary cases, slightly anteverted
during early pregnancy, and the  enlarged body of the organ
may be felt by the experienced finger in the anterior vaginal
cul de sac.  A soft  and cushiony state of the os uteri, with the
detection of the dense body of the uterus between the anterior
lip and the pubes, are amongst the earliest signs which lead us
to believe in pregnancy.   The unimpregnated  uterus may be
anteverted, but this condition is not attended by a soft  condition
of the os uteri.
  Examined with the speculum, the os and cervix  uteri are
somewhat increased in size, the tissues appear less dense than in
the impregnated state, and the white plug  of mucus is  dis-
tinctly visible in the lower parts of the cervical canal.  Owing
to the permanent condition of the plug during gestation, and the
increased acidity of the vaginal secretion, the mucous plug is
more firmly coagulated, and is of a more intensely white color
than usual.
  Suspension of the Catamenia  is commonly the first symp-
tom of pregnancy which arrests  the attention of an intelligent
female, wTho has exposed herself to the possibility of impregna-
tion, and is  perhaps the one in which women most firmly rely,
especially if any abdominal enlargement  coincides  with the
absent function.   Its  value  as  evidence  of  utero-gestation is
modified by the fact, that the suspension of the menses, although
tolerably constant, is liable to many aberrations, and is indica-
tive of other conditions than pregnancy.  Menstruation  may
continue through a part of, or the whole term of, utero-gestation.
Cases in which it has  appeared once  after  impregnation are re-
corded  by Johnson, Puzos,  Desormeaux, Dewees, Stein,  and
Gardien.   Burton,  Maunsell, Campbell, and others,  mention
cases in which it appeared three, four, and six times, and similar
instances  have fallen under  my own observation.  There  is a
case detailed in Hebernden's Commentaries, in which the func-
tion persisted during the whole term of pregnancy, and Deven-
ter, Hosack, and Haller, testified to  the occasional appearance of
the phenomena.   Deventer and  Baudelocque speak of females
in whom the catamenia appeared only during pregnancy, and a
still more remarkable abnormality has been witnessed in some
women, who have performed this function for the first time sub-
                              9 
130
PHYSICAL SIGNS OF PREGNANCY.
sequent to impregnation.  The necessity of preserving the out-
ward appearance  of virtue has  instigated women  to  feign
themselves " regular " by smearing their persons and staining
their linen periodically.   Belloc mentions such an instance, and
suggests that if the vulva is washed, and the discharge does not
reappear,  the case should be suspected.
  An exactly opposed series of cases to those we have been con-
sidering is constituted by instances in which the  catamenia are
suspended, and pregnancy does not exist.   Cold, shocks of any
kind, exhausting discharges, incipient phthisis, the worst forms
of ovarian disease, and several other  circumstances, frequently
suppress this function.  Women who are  nursing, as a general
rule, do  not menstruate, and, as the  catamenial  climacteric
approaches,  intermissions, even of  several months, are frequent.
There are cases again in which the history of the  menstrual
function is of  no use whatever in  determining the  question of
pregnancy.  Some women  prove pregnant before menstruation
has ever  occurred;  some after it  has apparently ceased alto-
gether ; and others at a  time when the function has been sus-
pended for several  periods by known causes, such as lactation.
The  best rule,  perhaps, for applying the catamenial test to cases
of suspected pregnancy, is that if  the suspension has persisted
for several months,  if, at  the same time, the health has not
suffered, and if the  person is  not  giving suck, the probability
that  she is pregnant has  reached the highest point  to which  it
can be brought by evidence from this source alone.
  Various derangements of  the Digestive Organs usher in
pregnancy.  The exact period at  which they occur  is various
and  uncertain.  In some  women nausea follows close upon the
heels of conception; in  others, no gastric sympathies appear
until two  or three months have elapsed; but from the second to
the fifth or sixth week is the general period at which they are
established.  They usually decline about the fourth month; but
their disappearance is liable to the same uncertainty  as their in-
vasion.    Nausea, vomiting, eructations, heartburn,  a peculiar
sense of sinking at the epigastrium, cravings for peculiar or par-
ticular articles of diet, and antipathies to other comestibles are
the ordinary manifestations of gastro-uterine irritation observed.
In general, the nausea, vomiting,  and sinking occur upon the
first rising, or  assuming the erect posture, and persist only for a 
PHYSICAL SIGNS OF  PREGNANCY.
131
short time.   The  comparative universality  of  this rule has
caused  these symptoms to be expressed by the term morning
sickness, a phrase which has become  almost vernacular.   It is
obvious that the causes of gastric derangement, similar with
those alluded to, must be numerous ; and hence, except as cor-
roborative proof, we can throw little light upon the diagnosis of
a case of  doubtful pregnancy by discovering that sickness has
occurred  in the morning, or that an affection has been shown
for chalk, slate pencil, or some previously abhorred article of
diet.  The value of this, as of several other signs of pregnancy,
rests  upon its  coincidence with  other recognized  signs.   The
synergic action between the stomach and the uterus, both as re-
gards secretion, sensation, and motor  action,  are amongst the
most remarkable  phenomena of reflex  nervous action.  In the
case of the gastric irritation  of pregnancy, it is worthy of re-
mark, that it is during  the early months that the affection is
most common and  constant.   It is probably caused  by the dis-
tension  and evolution of the  dense structure of the uterus after
impregnation, or by the pelvic irritation  caused  by the gravid
uterus before it  emerges from the brim, or  from  both  these
causes.
   Certain Glandular Sympathies  are excited during pregnancy,
of  which one of the  most remarkable results is Salivation.
This form of salivation  is, of course, quite distinct from mercu-
rial or other metallic affections of the  salivary glands, differing
in the absence of foetid breath, of sore gums, or the prostration
observed in such cases.   It is probable  that the watery vomitings
of pregnant women partly depend on increased pancreatic secre-
tion—a supposition which is favored  by  the analogy between
the structure  and  secretion of the pancreas  and the  salivary
glands  and the frequent excitation of the latter during  preg-
nancy.  It has been  said that the pancreas is a supplementary
salivary gland.  Cases illustrating utero-gestative salivation are
mentioned by Dewees, Van Swieten, Dr.  Blundell and others.
In a slighter degree, such cases are not uncommon.
  When pregnancy is but a few weeks advanced, the Mammae
begin to take on certain new actions, preparatory to their per-
fection as  secretors of a nutritive fluid.   The changes which take
place in the breasts at puberty may be called the primary evolu-
tion of the mammae.  This is parallel to, and synchronous with. 
132
DOUBTFUL SIGNS OF PREGNANCY.
that evolution of  the uterus and ovaries which produces the
capacity to conceive;  and the changes which take place in the
mammas after conception  constitute their secondary evolution,
and are parallel to, and synchronous with, those uterine changes
which  give  the capacity to nourish.  The first indications of
pregnancy given by the mammae, consist  of a certain sense of
fullness and weight, with shooting pains, these latter being some-
times confined to the gland itself, but at other times extending
to the mammilla, where they may be almost constant, producing
what is technically called  " mastodynia."  The afflux of blood
to the breast which now takes place, speedily replaces the mere
sense  of fullness by  actual increase of  volume;  the gland
becomes hard, knotty, and tender to the touch, and  large blue
veins may be seen meandering over its surface,  just below the
integument.   A  very  cursory  examination will  suffice to
distinguish this  condition  from the mere  increment in  bulk
attained by persons who are growing  corpulent.   A deposit of
fat does not give the same  knotty feel to the breasts ;  the vascu-
lar supply is not sensibly  altered, and a great volume may be
acquired without any of those  peculiar white, shining streaks
appearing on the surface of the integument which are the result
of distension by growth  of the gland.  The most probable
embarrassment is likely to occur in women who, having  pre-
viously borne children, and having reached the threshold of the
sexual  climacteric,  have their  menses temporarily suspended,
their breasts painful, and their stomachs irritable.  Almost any
uterine irritation will produce  enlargement of the breasts and
sympathetic pains.  Retention of the menses from an imperforate
hymen, fibrous tumours of the  uterus, and ulceration of the os
and cervix uteri, are  frequently concerned in these  mammary
changes ; and habitual and excessive  copulation  sometimes has
the same  effect.    These  possible  causes will,  however, be
remembered and sought for where any doubt exists.  The  most
characteristic changes are to be found in the nipples and the sur-
rounding areolae.   The nipples  become turgid and more promi-
nent,  and the discs around them assume a darker hue, more
marked in  persons of  a  dark  than  of  a light  complexion.
Ingleby observes that the  cuticle of the areola becomes scaly,
and that the general  surface of the breast presents  a mottled
appearance.  As pregnancy advances, especially if it be a first 
MILK, A SIGN OF PREGNANCY.
133
pregnancy, the  deposit of pigment in the areolae increases,
the areolae themselves become moister, and the follicles studding
their surface  are prominent, distended, and bedewed with tran-
suded fluid.   In women with dark hair and eyes the outer part
of the circle surrounding the mammilla presents an appearance
of small white patches, as if the color had been discharged by a
shower of rain.  Dr. Montgomery trusts more to the appearance
of the follicles, the moisture on the areolae, and the turgescence
of the parts, than to  the deposit of  pigment, which results
occasionally from uterine irritation, and not unfrequently is per-
sistent after the first pregnancy.  The mammillae are sometimes
so effectually compressed by tight corsets as never  to rise above
the level of the  mammary surface until  artificially drawn out.
About the sixth  or  seventh  month numerous white, silvery
streaks make their appearance on the surface of the breast; they
are exactly  similar to those found on the abdomen, and are
called linece albicantes.  They are  in reality the exposed floors
of furrows which naturally exist in the  skin, and they are
unfolded  in  consequence of  the distension of the subjacent
gland.  Once formed, they do  not entirely disappear,  and are
therefore of little value as a  sign of pregnancy, except in primi-
parous women.  In common with the altered nervous and vas-
cular condition of the  mammae, their secretive endowments are
called into play at a variable period, ranging from  the fourth or
fifth month to immediately  before labor.  It may be said, as a
general rule, that no  secretion of milk takes  place until eight-
and-forty hours  after labor;  and on the other hand, there are so
many irregularities regarding the secretion of milk, that neither
its absence nor presence can be rated at any considerable value,
as proof  or  disproof of  utero-gestation.   Suppression of the
milk in persons  who are nursing and liable to impregnation is a
more valuable sign of pregnancy than the converse condition.
Lastly, it must be remembered that recent abortion and lacta-
tion produce  the same conditions of the mammae  as obtain in
pregnancy.
  The Size and Form of the Afodoineu next arrest our atten-
tion in relation to pregnancy.  During the first two months, no
enlargement  is visible, or, if visible, can be trusted, as flatulent
distension and other evanescent conditions of the abdominal con-
tents produce variations in dimension beyond the possible limits 
134
BULK, A SIGN OF PREGNANCY.
of any size that may be attained at such an early period.  At
first, indeed, the belly becomes flatter, and the navel  is deeper,
as if dragged down by the increased weight of the uterus; there
is a French proverb, " en ventre plat, enfant il y a," and in this,
as in many other instances, popular belief coincides with  scien-
tific observation.  The traction at the navel is said to  be painful
occasionally, and the navel itself tender to the touch.  About
the third month abdominal enlargement becomes obvious in the
nude figure, and from this period steadily increases until nearly
the end of pregnancy.  By the fifth month the navel has become
shallower, and the uterus  may be distinguished  through the
abdominal walls ; at the sixth month, it is flattened out; and in
another month protrudes beyond  the level of the general sur-
face of the abdomen.   Numerous other circumstances give rise
to enlargement of the  abdomen.   Ovarian dropsy, ascites, cer-
tain  diseases  of the spleen  and liver,  flatus in  the  bowels,
accumulated   faeces, tumors of  the omentum,  and  unusual
deposition of fat in the omentum and abdominal walls, as well as
hydrometa, hydatids in  the  uterus,  physometra, fibroid and
other tumors of the uterus, and intra-uterine  polypi, all pro-
duce an increase in bulk, which  may to a certain extent simu-
late pregnancy.   It is necessary  to  observe, that  some  of
these  conditions may  co-exist with  pregnancy.  A little care
will, however, suffice  to distinguish  between the above-men-
tionedforms of enlarged abdomen andan abdomen distended by
the gravid uterus.   Such a mistake  as that quoted by Gooch
from Lowder's MS. lectures,  where a practitioner mistook preg-
nancy with distended bladder, for ovarian dropsy,  and thrust a
trocar through both sides of  the  bladder, and through the walls
of the uterus, into the child's head, would be unpardonable at
the present day.  The history of the  enlargement, its form, and
the evidence  procurable by means of auscultation, palpation,
and  percussion,  ought to preclude the possibility of any grave
error  in practice.   Inquiry  will almost always elicit  the fact,
that in ovarian dropsy the enlargement has at first been on one
side, and fluctuation is easily distinguished.  In ascites there is
a previous history of disease, and  the form of the  abdomen in
the recumbent posture, is widely different from the ovoid belly
of a pregnant woman; the contained fluid, in a case of ascites
from its obedience to the law of gravitation, produces a bulo-ino- 
SILVER STREAKS IN PREGNANCY.
135
between the crest of the  ilium  and the false  ribs, the anterior
and  middle aspect of  the  abdomen  being  its flattest part.
Enlargement of the liver and spleen increases from above down-
wards, and tympanitis is extremely easy of detection.  The only
real embarrassment arises from those cases in  which the  uterus
itself is distended, and then other symptoms must be referred to,
in order to determine  the question. The elastic nature of the
uterine tumor is simulated by no other abdominal enlargement,
and  is so far valuable as evidence of pregnancy; but fluctuar
tion may be obtained where  the liquor amnii is very superabun-
dant ; or an ovarian cyst may intervene between the  gravid
uterus and  the surface of the body, so that the absence of the
peculiar impression conveyed by palpation is not so negative  as
the converse is positive.  When a  blighted fcetus is retained  in
utero, no  further increase in size takes place; and this contin-
gency must not be forgotten  in forming an opinion as to the con-
dition of a woman who has had progressive abdominal enlarge-
ment, with other signs of pregnancy up to a certain date, fol-
lowed by recession of her uterine sympathies,  etc., and arrest of
increase in bulk.   Silvery streaks appear on the surface of the
abdomen when it  becomes much distended; once formed they
are permanent, but they do not by any means occur in all cases.
They are only of use  as  a sign  of pregnancy in first cases, or
where long  intervals have passed between  successive preg-
nancies.  Dr. Cormack has drawn attention to the dark line which
occurs during pregnancy in the  median line of the abdomen.
It is constant in the latter part of gestation, but being the result
of distension, it is present in the case of other abdominal tumors.
   Reference has already been made to the  condition  of the
uterus immediately after impregnation.  During the  first three
months of pregnancy the lower part of the  uterus feels soft and
almost oedematous; the  os, which had before been firm and
with well-defined lips, becomes of a more rounded form, and the
tip of the  finger can be  inserted between them.  In first preg-
nancies such  changes are  more  marked  than  in  multipara,
especially if the parts have beeu at all  ruptured during labor.
The  whole body of the uterus  sinks lower down in the pelvic
cavity, and the os  can be felt, not only lower down,  but some-
what displaced towards the hollow of  the  sacrum ; the fundus
of the organ is anteverted  to a corresponding extent, and it is 
136
CAUSE OF THE RISE OF THE UTERUS.
partly to this circumstance, as well as to the intimate sympathy
between the uterus and the other pelvic  organs,  that  the  fre-
quent micturition  and sense of weight in  the rectum, which
accompanies early gestation, is attributable.  Approaching men-
struation or the engorged condition of the womb, sometimes met
with in  menorrhagia,  simulate  these  earlier  changes  of preg-
nancy to some extent.  The body of the  uterus can be distin-
guished more readily in the anterior vaginal cul-de-sac  as preg-
nancy advances, and about the fourth  month  the  fundus  may
occasionally be felt  just  above the pubis.   With its  gradual
increase in bulk the  womb has  gradually risen to the pelvb.
Many authors state that the uterus rises suddenly out of the
basin of the pelvis into the general abdominal  cavity.  There is,1
however, no real proof that the uterus at  once emerges  from the
pelvis, and  there  are many  circumstances  which render  it
extremely improbable.  The idea of the  sudden  escape of the
uterus from the pelvis involves a notion of some great  and sud-
den  increase  in the contents of  the  cavity, or  the  sudden
removal of some impediment.  In cases  where there  is much
antero-posterior contraction   of  the  brim,  a  malformation
which  involves  less  contraction of the cavity than most other
distortions, permanent  incarceration  should result at or about
the fourth month, if the uterus really  remains entirely in the
true pelvis until that period; and cases of extreme contraction
of the  brim or pelvis  generally, should have a history of diffi-
culty at  the time of the supposed  emancipation of the womb.
No such  histories are on record.   The real state of the case
appears to be, that the uterus  rises slowly out of the pelvis,
partly because its increase in  bulk is  from above, the fundus
being the first part  developed, and the  cervix the last; partly
because it is in reality a wedge with the apex below; partly
because the bladder pushes the uterus  upwards every time it is
distended, directly, by means of the fluid contained  in it, and
indirectly, by elevating the vesical layer of the pelvic  fascia, to
which circumstances may be added the obliquity of the pelvis
and frequent  changes  of  position on  the part of the  mother.
About  the fifth month the uterus is found  to  have risen  half
way to the umbilicus.  It is now that the cervix uteri begins to
shorten its cavity, being taken up into the general uterine°cavity
by a process of development commencing at the junction of the 
          CHANGES OF  TOK CERVIX UTERI IN PREGNANCY.    137

cervix with the  body of the  organ, and terminating at the os
itself.  The finger may be inserted between the lips of the mouth
of the uterus with greater facility as each month passes, and the
follicular glands of the cervix may be felt just  within.  At the
same time the orifice of the womb moves upwards and back-
wards towards the sacral promontory, and by the time it has
reached its most posterior and superior  position, the cervix has
completely disappeared, the os uteri being a mere rim.  Exter-
nally, the uterus reaches as high as the  umbilicus at  the  sixth
month, half way between the umbilicus and the ensiform carti-
lage at the seventh, and as high as the  latter structure at the
eighth ; after the eighth month the increase in size is more obser-
vable in the way of increased tension, and indeed, shortly before
labor sets in, it would  appear ,as if an actual diminution in size
Fig. 46,
Os and cervix uteri at the third month of gestation.
Fia. 46.
Os and cervix at the sixth month.
took place.  The head, on presenting part of the child, may now
be felt through the os uteri. 
138   STOLz's VIEW OF THE CHANGES IN THE CERVIX UTERI.
Fig. 47.
Os and cervix uteri at the eighth month.
Fig-. 48.
Os and cervix at the full term.
  [Dr. Smith here gives the prevailing opinion which has been
thoughtlessly adopted by writers since  it was first  promulgated
by Smellie, of the manner  in which the cervix uteri  becomes
absorbed and merged in the ovoid form of the womb.  I prefer,
however, to accept the description given and demonstrated by
M. Stolz in 1826, which has received the sanction of the most
eminent modern physiologists  and pathologists.   According to
the description  of  M. Stolz,  which is  now fully  confirmed,
instead of this internal opening of the  neck expanding and the
superior part  spreading  out downwards during gestation, the
reverse takes place.   Early in pregnancy, the os and lower part
of the neck begin to soften.  This softening  gradually extends
upward, though less rapidly, in primiparae cases.   As the ram-
ollissement extends from the os upwards, the os and neck expand
in multiparas  cases,  though in primiparae  cases  the  cavity
of the neck expands without a corresponding patulence  of the
os, which gives the neck a spindle shape.  The cervix loses but
little,  if any of its length.   By the seventh month, the intra-va-
ginal  portion of the neck has undergone this change,  beino- soft-
ened,  and the os so dilated  in women who have been mothers
as to admit readily the first phalanx of the index  fino-er.  This 
FIRST MOTIONS OF THE  FOETUS.
139
ramollissement and expansion of the cervix progress upwards, so
that a few days before full time in its proper course, the circular
fibres, closing the internal opening of the neck, become softened,
and it dilates.  This is shown by the following figures, which we
place in antithesis to those of the author.]
  Quickening generally occurs when pregnancy is  advanced
about half way ; Denman gave the sixteenth week as the period
at which it most commonly occurs, and Dr. Fleetwood Churchill
gives nearly the same average; Dr. Ramsbotham places it be-
tween the sixteenth and eighteenth week; Puzos had  known  it
to occur at the end of two months, and it has not unfrequently
been postponed till the sixth, seventh, and eighth months ; it  is
in truth, very variable, Levret having recorded an  instance in
which it did not occur  at  all.  By some authors  it is believed
that quickening is the first sensation by the mother of  the move-
ments of the foetus;  others have supposed it  to be  a sudden
ascent of the uterus from the  cavity of the pelvis.  The nature
of the sensation will be differently described by different women.
The child of Elizabeth is said by St. Luke to have " leaped in
her womb," when  she  heard  the salutation of Mary; in  some
women it is described as a pulsation, and others speak of it as a
fluttering or an occasional shock, attended  by a sense of faint-
ness,  sickness, and sometimes a slight sanguineous discharge.
The physical cause of the  symptom is doubtless motion  of the
foetus, and the period at which it occurs is most  probably due
to the increased size and activity of  the child, which  permit  it
to come into occasional contact with the walls of the uterus,
through  the liquor  amnii.   Accidental  circumstances  may
perhaps give rise to the particular motions first perceived, and
it may occasionally happen, that these accidental  stimuli being
wanting, no perceptible  motion occurs.   The  value of the
symptom as a sign of pregnancy depends partly upon whether 
140
PERISTALTIC UTERINE MOVEMENTS.
the patient has experienced these sensations before, and partly
upon the amount of credence to be attached to her statements
and opinions.  The  motions of the foetus having been  once
established, they may continue to be felt at intervals of variable
duration by the mother or by another person.  Dr. Montgomery
thought he could determine the motions of  the foetus before the
mother was conscious of them;  it must, however, take  a very
prolonged examination to elicit any information at so early a
date, and even then some doubts may be entertained as to  whe-
ther the observation can be trusted.  At a later period, it be-
comes  very easy to perceive the movements of the living foetus.
As the points by which it comes into contact with the uterine
walls gradually multiply, more trifling  circumstances suffice to
set up  excito-motor actions; the mere pressure of the hand  upon
the abdomen will sometimes produce palpable kicks.  It is not
always easy to distinguish between the  movements of the foetus
and some other movements which occur in the pregnant woman.
The uterus and abdominal walls have  special actions of  their
own.   The uterus is subject to  peristaltic  contractions, which,
starting from  one end of the organ, traverse its whole  extent
like a wave.  They may be discriminated from  the foetal kicks
or plunges, by the travelling ridge which  they produce, and
which may be felt under the hand.  At other times, the uterus
contracts at certain portions.  These contractions shift from one
place to another, and convey the impression to the  mother that
the child's head is moving about.  It is the  peristaltic actions of
the uterus,  and not the movements of the foetus, which are pro-
duced when the hand is cold or dipped  in iced water.  The
abdominal  muscles  are subject to involuntary contractions,
arising from the irritation which the contact and pressure of the
uterus produces, but it is voluntary contraction of the abdominal
muscles which most  usually stimulates  the motions  of  the
child.
  In the year 1818, a great advance was made in the diagnos-
tics of pregnancy.  Mayor, of Geneva, published a memoir in
the Bibliotheque Universale, on the  detection of pregnancy by
the pulsations of the foetal heart.  This  discovery attracted  very
little attention  until four years afterwards, when  Kergaradec
published a systematic work on Auscultation as applied to preg-
nancy ; he added a knowledge of the so-called bruit placentaire 
CHANGES IN THE  UTERINE SOUFFLE.
141
to M. Mayor's discovery.  At  a  later period, Dr. Kennedy dis-
covered the funicular pulsations, and Naegele described what
may be called " sounds  of the  displacement  of the foetus."
Other sounds may be heard on applying the stethoscope to  the
abdomen of the pregnant woman ; they are the products of mus-
cular action.  The  value of these auscultatory phenomena is
very different, but there are no other  signs of pregnancy so
unequivocal, or upon which we may so safely rely.  The subject
of utero-foctal auscultation in this country has received its
chief development from the writings of Dr. Kennedy, and  the
translation of Naegele's work  on Auscultation by Dr. West.
  The uterine souffle, bruit placentaire, or placental murmur,
as it is called by different authors, is distinguishable before  any
of the other intra-uterine  sounds.  Great difference of opinion
has existed as to the earliest period at which it may be heard ;
a similar variety of opinions has prevailed as to the exact  seat
of the murmur.  Dr. Kennedy averred that he had  heard it at
the tenth  week, while Velpeau states that the mere fact  of its
having been discovered even  at the third month is  sufficient
proof that, whatever the sound observed may have been, it could
not have been produced by the utero-placental circulation.   It
may be said  as a  general rule, that until  the fourth or fifth
month, that is, until the uterus has risen out of the pelvic cavity,
the uterine souffle is inaudible; after that period it may gene-
rally be heard on  any one point of the region of the uterus
which is accessible  to the ear.   The situation of the sound  will
vary as pregnancy advances; in the earlier part of the second
moiety of utero-gestation, it is heard nearer the pubes, and it
gradually ascends from week to week.  It is seldom heard quite
at the fundus uteri or in the lumbar regions.  The character of
the sound is very different in different persons, and varies in the
same individual; sometimes it is a hoarse and sometimes  a  soft
blowing murmur, at others it is a cooing sound, and again, it is  sibi-
lant or musical. Now it is immediately beneath the ear, and again
it is distant.  It is synchronous with the radial pulse.  It is modified
by the pressure of  the stethoscope and may disappear and recur
again under the instrument.   On some days,  in the early  part
of its appearance, it is absent,  and on others it is present. What-
ever may be the exact physical cause of this sound, there can be
little doubt now that it is  produced in  the walls of the uterus, 
142
VALUE OF THE UTERINE SOUFFLE.
and not, as Hohl  supposed, in the  placenta, or  as  Kiwisch
believed, in the epigastric, and others, in the iliac arteries. It may
be well to state the foundations for this opinion ; the same sound
has been heard in cases of fibrous tumor and vascular  sarcoma
of the uterus, and in moles; it is often heard  over the whole
surface of the uterus, accessible  to the stethoscope; it persists
for a short time after delivery ; it has been heard in cases where
putrid foetuses have been born, and the placenta found with its
vessels full of thickened and coagulated blood.   These reasons
appear to be conclusive against the placental theory, and others
exist which eliminate the iliac arteries or aorta from the question.
If the sound were produced by pressure on  the  iliac arteries or
aorta, it should disappear when that pressure is removed by the
assumption of the prone posture, whereas it persists in every posi'-
tion ;  pressure should intensify the sound if this hypothesis were
correct; the contrary frequently obtains, and indeed the  murmur
not unfrequently disappears under pressure, even when it is made
on the  anterior aspect of the uterus, directly  towards the spine.
And finally, the metroscope of M. Nauche, applied to the cervix
uteri,  in the vagina, transmits the sound when abdominal exam-
ination has failed to distinguish it.  The sound is heard  most dis-
tinctly at the usual site of the attachment of the placenta, and
this circumstance appears to have misled Hohl and others ;  it
is, however, only in accordance with the fact that  the uterine
vessels are largest where the placenta is attached.  As  a sign
of pregnancy, the uterine souffle is extremely valuable ; it can
be  distinguished  from any possible arterial imitation by the
absence of impulse, or by changing the position of the  patient;
and a very simple  device will distinguish between it  and the
vesicular  murmur, if the latter should happen to be audible
lower than usual; for if the stethoscope be moved gradually up-
wards, any lung sound will of course become intensified, whereas
the uterine souffle would diminish.  The  uterine  souffle is no
proof of the life of the  foetus, nor can it be made use of to deter-
mine  the position of the child, or whether the uterus contains a
double foetus.
   Widely different  from the foregoing acoustic phenomena is
the double pulsation discovered  by Mayor.   The ticking of a
watch heard through a pillow has been aptly compared with the
rapid pulsations of  the fcetal heart, as heard through the uterus 
            IMITATIVE SOUND  OF THE F02TAL HEART.         143

and abdominal walls. There is a distinct rhythm in these sounds,
consisting, as in the perfectly developed individual, of two sounds
of unequal length, followed by a pause.  The number of pulsa-
tions  varies, according to M. Jecquemier, from 108 to 160 per
minute, but  130  will represent the average frequency  of the
embryonic pulse.   It, however,  subsides to a certain extent, dur-
ing the last month of pregnancy, a change which is continuous with
that well-known declension in the frequency of the pulse  which
advances pari passu  with increasing age. Dr. Hope gives 150 as
the foetal pulse at the fifth month, and 120 as that of the ninth
month.  The beating of the foetal heart may generally be
distinguished, for the first  time, during some part of the fifth
month.  At  first the sound is  very feeble and distant, but by
degrees it acquires strength, and the diminution of the  liquor
amnii, by allowing the foetus to come into contact with the uter-
ine walls, facilitates the conduction  of the sounds to the ear of
the observer.   Nothing can be more shifting and  variable than
the sounds of the fcetal heart—now they may be  heard  on one
side of the abdomen, and now on another; their  position even
changes during the same examination, and sometimes they sud-
denly cease,  or rather escape observation, for days together.  A
like  change  in their intensity occurs, but frequent observation
detects steady increase  in their force.  Occasionally,  they are
never heard  during the whole of pregnancy, and the absence of
these sounds is not conclusive of the death of the foetus, unless
they have undergone a gradual declension in intensity previous to
their cessation, and even then it is perhaps safer to look for cor-
roborative proof elsewhere  before coming to a decision.   They
are accelerated temporarily by the motions of the foetus.  The
area  over which the sounds of the foetal heart may be  distin-
guished  varies according to the force of the heart's action, the
amount of liquor amnii, and the position of the child.  There is
only  one possible circumstance which can  at all imitate the
sound of the foetal  heart,  and that is, when the sound of the
maternal heart, from emotional or other causes, are increased in
frequency and force, and conducted through the diaphragm and
liver  to  the  uterus; the same device which has been recom-
mended for  distinguishing between the vesicular murmur and
the uterine soufflet will establish the differential diagnosis in this
case. 
144
FUNIS DISTINGUISHED EXTERNALLY.
  Dr. E. Kennedy states, that, " in some cases, where  the  pari-
etes of the abdomen and uterus 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 have been discoverable, remarkably strong."   Dr.
Churchill and Naegele support Dr. Kennedy against  Ilaus and
Hohl, who deny the fact.  The observation, however, although it
reflects much credit  upon the acumen  of Dr. Kennedy, can
hardly be of practical use;  because, where the abdominal and
uterine walls are so thin as to permit us to feel the  pulsation of
the funis through them, the  other  auscultatory signs of preg-
nancy, and the evidence obtained  by palpation, must already
have set the question at  rest, and except under such circumstan-
ces it must  be  very difficult to discover  the  funicular soufflet.
The sounds of the displacement of the foetus  consist  of shocks,
sometimes quick, like  a light tap, and at other times  more like
a heavy plunge; and there are also friction-sounds, which are
evidently produced by the gliding  of the surface  of  the foetus
over the inner uterine surface.  Naegele avers that  these sounds
may be heard before quickening has taken place.
  Ballottement is a means of acquiring information as to the
circumstances of pregnancy, first made use of in France.   There
are two kinds of ballottement, the internal and the external; the
first of which is practised by one or two fingers introduced into
the vagina;  and the latter, by manipulations applied to the sur-
face of the abdomen.  " Ballotter" signifies " to toss a ball, as
at tennis ; and the manoeuvre in question  is a kind of tossing up
of the foetus in the waters of the amnios.  The method of
forming the internal ballottement is as follows:  The worn; 
                  METHOD OF BALLOTTEMENT.              145

placed in bed, with the trunk in a semi-recumbent position, so as
to make the axis of the uterus coincide with a line passing per-
pendicularly from  the fundus uteri to the ground, and to bring
the uterus as low down into the pelvis as possible.  The bladder
and rectum should have been previously emptied.  The first or
two first fingers of one  hand must now be introduced into the
vagina, and applied to that part of the cervix  uteri, or uterus,
which is situated between the  anterior lip of the os and the pubis.
[The experimenter must be careful not strike the os uteri, as the
sensation might be deadened by the length of the neck; and in
cases  of uterine displacement, where the body was bent  upon
the neck, percussion upon the neck by jerking the body upon the
neck might cause a serious error in the diagnosis.]  The other hand,
or the hand of an  assistant, should then exercise steady pressure
on the abdomen ; and a deep inspiration on the part of the patient
will finally bring the uterus into the most favorable position for
the experiment.  Immediate advantage  must  be  taken of the
temporary cessation of breathing to make a rapid jerking push
against the uterus with the tips of these fingers which are applied
to it in the vagina; if there is a foetus in the uterus, and if the
proper period of pregnancy has been selected, a hard  body will
be felt to recede from the fingers as if rising in  the intra-uterine
fluid, and in a second or  two it  will fall again on the tips of
the fingers.  This is the  internal ballottement.   The period
at which  it is applicable is  from the end of the fourth to the
end of the sixth  month, as  a  general rule ; but it must  vary
according  to circumstances, such as the  bulk of the foetus, the
quantity of the liquor amnii, and the width of the pelvis. When
once  discovered, it is a tolerably conclusive proof of pregnancy.
The  external ballottement  is  best performed  by placing the
woman on  her side, on the extreme edge of the bed, so  as to have
her abdomen projecting beyond it.   One hand  should then be
applied to  the undermost side of the belly, and another to the
opposite surface, in order to steady the  uterus.  If a foetus  is
present a similar  manoeuvre may now be practised,  as in the
internal operation  ; a sudden impulse from the lower hand pro-
pelling the foetus towards the upper part of the amniotic sac, from
whence it will gently descend again upon the same hand.   If the
foetus is very small, no sensation will  be imparted to  the  hand
by its descent; and if the liquor amnii be scanty and insufficient
                               10 
14G
DIFFICULTIES OF BALLOTTEMENT.
to float the child, the experiment  will entirely fail.   Regarded
as evidence of pregnancy, the external  is very inferior to the
internal ballottement.  It is not applicable in so early a stage of
pregnancy, a much larger bulk being necessarily obtained before
the uterus is brought into sufficiently extensive contact with the
abdominal parietes for such a delicate manipulation.  After the
six months of utero-gestation, the quantity of  liquor  amnii
becomes relatively decreased, and the foetus is not so well floated,
except in some few cases  in  which the fluid  is preternaturally
abundant.  A kind of spurious ballottement  may  be sometimes
found in cases of ovarian dropsy, where a pedunculated cyst floats
within a larger cyst.  The ballottement is no proof of the life of
the foetus.  It should be mentioned, that great length of the cer-
vix uteri, or a footling position of the foetus, will make the inter-
nal process difficult, and sometimes impossible.
   A substance called Kiestcin, which occurs in the urine, is one
of the minor signs of pregnancy.   So far back as 1486, Savon-
arola gave an account of a urinary deposit which was evidently
this material;  he compared it  to  carded wool, but did not pur-
sue its history beyond this point.   MM.  Nauche and  Eguisier,
in publishing their supposed original discovery of this matter,
made use of Savonarola's simile, speaking of it as a cotton-like
cloud, and  they gave a further  detail of the transformations it
goes through, which are  as  follows:  The cotton-like  cloud, in
the course of from two to six days,  becomes resolved into a num-
ber of minute opaque bodies, which rise to the surface, forming a
fat-like scum; this persists for three or four day^s; the urine then
becomes very turbid,  and  minute flocculi  detach  themselves
from the crust and  sink  to  the bottom of the vessel, until the
whole  pellicle disappears.  This crust never  becomes mouldy,
and never lasts more than three or four days.  The pellicle con-
tains  crystals  of triple phosphate, fat, and  a peculiar  nitroge-
nous body allied  to casein.  It is  supposed that  during preg-
nancy the mammae  secrete a certain quantity of abortive milk,
if the expression may be  allowed, which is again taken up into
the circulation, and excreted by the kidneys.   Analogous facts
exist regarding other secretions.  Casein has been  found in the
blood  by MM. Grullot  and Leblance  during lactation, and
thus an additional probability has been given to the truth of this
hypothesis.  When kiestein is present  in the urine  it persists 
               VARIOUS SIGNS OF PREGNANCY.             147

from the end of the first month to delivery.  A minute investi-
gation of the exact nature of the body, and the opinions of all
writers on the subject, is unnecessary; but the following consid-
erations will point out how far it is really valuable as affirmative
or negative of pregnancy.   It has been  found in the urine of
women not pregnant.  It is found, for instance, in the urine of
women  taking  cod-liver  oil; it is not always to be  found in
women who are with child.
  There  are  a  great  variety of miscellaneous evidences of
pregnancy, many of which are not constant  enough to be of
any great value, unless they have occurred  in former pregnan-
cies ;  such are the different intellectual and moral peculiarities
which affect  certain women.  The countenance  becomes much
altered  from the absorption  of fat, the  eyes, look somewhat
sunken, and  surrounded with  a dark  areola, the  alae  of the
nose are pinched, and the corner of the  mouth dragged down,
and the  mouth hence looks  larger.   The blood is said to be
buffy; but Dr.  Montgomery suggests that this may be, because
those women who have been  bled whilst pregnant, have been
so bled on account of some inflammatory disease; and he  alto-
gether denies that any indications of pregnancy can be  derived
from  the blood.  Dr. Garrod has stated  that the  proportion of
fibrin is not increased in the blood of  pregnant woman.  Lecat
mentions a woman, whose face became black in three successive
pregnancies, and Gardien  relates other instances.   Burns men-
tions discoloration of the skin as not infrequent, and some women
always  have some cutaneous eruption during utero-gestation ;
others have dark spots developed upon the face.
   [I  have had two  patients who had a marked change in the
color of the hair during each pregnancy; it becoming two or
three shades lighter so as to be very noticeable both by herself
and friends.  One of these ladies supposed herself a second  time
pregnant from this alteration coming on when suffering from  a
6evere ulceration of the cervix uteri, accompanid by hypertrophy
of the whole organ, gastric disturbance, pain in the mammae, and
all the usual symptoms of pregnancy except the suppression of
the  menses,  which were,  however, only diminished in quantity.
With returning health the natural color^was restored.]
   Intense pulsating occipital headache has been considered a
 sign  of pregnancy by Dr. Beccaria, and hence called Beccaria's 
148            OCCASIONAL  SIGNS OF PREGNANCY.
                 %
test.   Pruritus is with some women a very constant indication of
the commencement of pregnancy.
  Jacquemin and Kluge called attention to a violet color of the
vagina and inner surface of the vulva as an indication that the
uterus was tenanted.  Parent Duchatelet corroborates these state-
ments, and says the color is never absent in pregnancy.  Pres-
sure from any other cause, obstructing venous  return from the
parts, would have  the same effect; hepatic disease, or pelvic
tumours, or obstructed respiration, may be attended by a similar
discoloration.  Osiander attached some importance to  the vagi-
nal pulse, which may be felt somewhat increased in volume and
force as pregnancy advances.  The vaginal  artery, he  says, can
be felt pulsating more rapidly than the radial when  abortion is
threatening. 
LECTURE IX.
                  DISORDERS OF PREGNANCY.

   Gentlemen :—The special disorders of the pregnant state
chiefly arise from sympathetic irritation of other organs by the
uterus and its contents; from morbid conditions of the gravid
uterus itself; from the effects of mechanical pressure and  dis-
placement ; and from the influence  of these causes, combined
with the modifications of nutrition and excretion incidental to the
development of the foetus and the suspension of the catamenial
function, upon the maternal vascular and nervous systems.  In
the production of many of the affections of pregnancy, all these
causes more or less occur ; and some of the prominent disorders
are but the signs of pregnancy in an exaggerated form.  Too
much attention cannot be given by the student and practitioner
to the diseases of the pregnant state, and to the prudent manage-
ment of pregnancy.  It is during gestation that the foundations
are laid for some of the most  dangerous affections of labor and
the puerperal state.  Pregnancy is the time for prophylactic mea-
sures, having reference to the safety of the mother and child in
parturition.  Conjunctures frequently occur, in which no amount
of care and skill at the time of labor can make up for apparently
trivial neglects during the course of gestation.  This is the espe-
cial period when difficulties may be foreseen, aud prevented or
avoided.   Nothing will contribute more to the reduction of the
dangers and mortality of obstetric practice than a careful atten-
tion to the disorders of pregnancy.
  Of the  disorders  depending upon  sympathetic  irritation,
excessive  Nausea  and  Vomiting are  amongst  the  most
troublesome to which the pregnant woman is liable.  Sometimes
the affection is bearable, the stomach returning certain kinds of
food, or being irritable only at particular times of the  day, espe-
cially in the morning.  In  other cases, it continues to  such an
                                                       140 
150
the vomiting of tregnancy.
extent that constant nausea distresses the patient, and vomiting
invariably  follows upon every  attempt to take nourishment,
whether in the liquid or solid form.  The epigastrium becomes
tender, and  there is  general fever, with great  prostration and
debility as in idiopathic gastritis.   An almost  poisonous  influ-
ence seems to be exerted by the  gravid uterus in some constitu-
tions.  Such a state of things may go on for weeks  or  even
months, and it is difficult to account for the continuance of life
in some of these cases, except upon the  supposition that a  small
quantity of food remains in the stomach after each vomiting.  It
occasionally  happens  that  other  circumstances besides the
uterine irritation  increase the tendency to vomiting: women,
for instance, who have  undertaken voyages during pregnancy,
have  died  from the combined effects  of sea-sickness  and the
vomiting of pregnancy.  A  friend of my own lost a sister from
this kind of vomiting, during a voyage to Australia.   I  have
known of two other similar instances, and such cases are not very
uncommon.   I have seen the gastric irritation much aggravated
by the concurrence of hooping-cough  during the gravid  state.
In the worst cases, women who are not relieved, or who do not
abort, perish slowly from starvation, or they  die from  the rup-
ture of a bloodvessel,  convulsions, or  exhaustion, after violent
and continued fits of vomiting.   The matters vomited from the
stomach consist of the food and drink swallowed, an acid, glairy,
or watery mucus, secreted by the stomach and pancreas, and,
when the sickness is excessive, of bile  which has  ascended into
the stomach by an anti-peristaltic action, or of blood from rup-
ture of vessels during paroxysms of vomiting.
  The first thing to be attended  to, as  regards  treatment in the
vomiting of pregnancy, is to  attempt to get the secretions,  parti-
cularly those of the stomach  and  bowels, in  as healthy a  state as
possible.  One of the most old-fashioned and serviceable reme-
dies  is the infusion of calumbo  with soda,  The calumbo and
soda, with from three to five drop doses of  the  dilute  hydrocy-
anic acid, three times a day, is a very useful combination.  A
grateful and sedative tonic  is  also  made by giving  citric acid
with the calumbo and soda, so as to form an effervescing draught.
Cases are met with in which vomiting affords  great relief, by
getting rid of  vicious gastric secretions, and contributing  to re-
store the stomach to a healthy state;  such patients  should be 
REMEDIES for pregnant vomiting.
151
puked occasionally with warm wrater, camomile  tea, or  a mus-
tard emetic.  In some patients, the stomach retains food after
taking moderate doses of opium  and  morphia, and  perhaps the
solution of the bimeconate of morphia is one of the best forms in
which an opiate can be given.   Salicine, in doses of three to
five grains,  three  times a day, is a valuable medicine, which
was first mentioned to me by a medical practitioner.  It allays
sickness, and promotes appetite and digestion.  Kreasote, in one
or two drop doses, made in pills, with crumbs of bread, is well
known as an efficient remedy in this affection.  Professor Simp-
son strongly recommends the salts of cerium, particularly the
nitrate of cerium,  in doses of one to two grains  in  water.  Dr.
Simpson has also used the vapor  of laudanum as an inhalation
with good effect.
   [Chloroform, ten drops in mucilage  or syrup taken every two
or three  hours, or by inhalation,  is sometimes effectual in
arresting it; also Hydrocyanic, acid in some form.  The infusion
of the bark of the wild cherry frequently gives speedy relief.
Water  without  syrup,  impregnated  with carbonic acid  gas,
known as plain soda water, taken by the  wine-glass full, cham-
pagne and brisk bottled cider are very grateful and not unfre-
quently entirely relieve this very distressing and often danger-
ous symptom.]
   Where there is tenderness of the epigastrium,  with fever, and
an active state of  the circulation, a few leeches  may be applied
to the pit of the stomach, or a small bleeding from the arm may
be practised with  good effect.  Counter-irritation, in the shape
of sinapisms, the turpentine stupe, or  blistering,  will sometimes
afford great relief.  In some cases, the stomach is soothed by
the application of  warm poultices sprinkled with laudanum, or
a pledget of  lint dipped in laudanum, the epigastrium having
first been stimulated by a mustard plaster.   The  recumbent pos-
ition,  and perfect quiet, is of great use in the worst of cases.  It
is sometimes necessary to treat not. only  the sickness, but also
the Marasmus which is the result of excessive vomiting.  A
daily  warm bath is a great comfort to such patients, and in cases
of excessive prostration, gelatinous matter  may be added to the
bath,  with a view to the endermic  absorption of nutriment.
Beef-tea injections, and the inunction of cod-liver oil, or sperm
or salad oil, are very useful.  I have seen a  patient suffering from 
Vy2
INDIGESTION AND HEARTBURN.
incessant vomiting, in a state of great anaemia, with  oedema of
the lower extremities from pure  debility, kept up in the latter
part of pregnancy, mainly, as I believe, by the daily inunction
of cod-liver oil over the  abdominal surface.  When all  other
means fail, and when the exhaustion of the patient cannot be
arrested, the  remedy is the emptying of the uterus,  and this
should never be delayed so long as to put the patient in a state
of imminent peril.  Nature herself often terminates  the distress
by spontaneous abortion.  It has  happened to me to have been
twice consulted within a recent period in cases in which the in-
duction of premature labor artificially was so long delayed, that
the patient died before abortion could be induced.   Paul Dubois
has stated that he met with twenty fatal cases in thirteen years.
It is a reproach to our art that such  cases should occur.   The
means of inducing abortion and premature  labor will be dis-
cussed hereafter.
   Anorexia,  Indigestion,  Heartburn,  Gastralgia, and Variable
Appetite, are caused in certain patients by the reflected irrita-
tion of the gravid uterus upon the stomach.   Some women never
feed so well as  when they are pregnant, but in general, the
appetite fails somewhat, and particular  articles of food are re-
garded  with aversion.  A  morbid desire for  salted  matters,
acids, or alkalies, is not uncommon.   Sometimes  there is  great
loathing of every kind of food, or there is an  extravagant desire
to eat particular things, amounting to pica.  These longings,
as they are termed, should be gratified as far  as they reasonably
can be.  The common tendency of the appetite in pregnancy is
to prefer fresh vegetables,  fruits, and  cooling  drinks, and  to
avoid stimuli of all  kinds.  In  this, the taste  of  pregnancy
accords very  well with its requirements.   When  the appetite is
unnatural, the state of the bowels should be carefully regulated,
and the patient kept as far as possible from taking things likely
to be  absolutely hurtful, as convulsions before and during labor
are sometimes caused by the habit of indulging in improper and
indigestible  kinds of food.  The remedies serviceable  in exces-
sive vomiting are also  useful  in  the  gastric disturbances  now
under consideration.   Soda and magnesia are the best antacids'
in heartburn.  In the neuralgic  state of the  stomach, which
occasionally obtains,  bismuth, hydrocyanic acid, kreasote or an
opiate plaster to the  epigastrium, are  useful.  Sometimes small 
VARIOUS DISORDERS OF PREGNANCY.
153
doses of acetic acid,  or the mineral  acids, will relieve  the
stomach in a re narkable manner; and when the neuralgia re-
curs at  a particular hour of the  day, it is generally relieved by
quinine.  In certain cases, uterine irritation  excites the bowels
to increased action, and tenesmus and diarrhoea are the results.
In such cases, astringents should be given  sparingly,  unless the
diarrhoea should  be so  considerable as to produce debility or
lead to the risk of abortion.  Care should,  in the first instance,
be taken to render the secretions as healthy as possible, and to
avoid articles of diet likely to irritate the bowels.  If necessary,
the purging should be  arrested by an opiate, with  compound
chalk mixture, bismuth, or gallic  acid.   When  the diarrhoea
depends, as it sometimes does, upon  faecal accumulation, or
vicious  secretions, a brisk purgative is  the best remedy.
  Facial Neuralgia from  uterine irritation is  a very common
affection of pregnancy.  It generally affects the dental nerves,
particularly those of the upper  jaw.   In many subjects,  acute
caries of the teeth occurs; and in some child-bearing women, a
tooth or two is lost in  each pregnancy.  In neuralgia of the
face, with  or  without disease of the  teeth,  a  generous diet  is
called for, with wine and porter.  Quinine and the lighter  pre-
parations of iron  are very useful in such cases.   Cold  and damp.
and residence  near a  river, or  the neighborhood of any large
body of water, should  be avoided as much as possible.  Teeth
ought only to be  extracted with caution during pregnancy under
such  circumstances.  The  local  application  of chloroform,
kreasote, camphorated spirit, nitric acid saturated with camphor,
and other  anodynes, scarification, or  the application of a leech
to the gum, are the best means of alleviating the pain.
   A painful state of the Mammae sometimes occurs during preg-
nancy,  but seldom requires anything  more than frictions, with
an anodyne liniment or  warm fomentations.   Occasionally,
however, acute Mammitis occurs from the irritation of preg-
nancy, requiring leeching and other active treatment.  One of
the most remarkable sympathetic disorders of pregnancy is the
occurrence of Goitre to a slight extent.  The treatment of  this
enlargement of the thyroid is not of much avail during gestation,
and the goitre generally disappears after parturition.   Allied  to
this affection is the excessive Salivation which occasionally  hap-
pens in pregnant women, leading to no serious results, and gen- 
154
DROPSIES  OF  PREGNANCY.
erally requiring no further treatment than the use of an astrin-
gent wash to the mouth.
  We shall have presently to cousider  the  cedematous states of
the lower extremities,  depending upon pressure  and debility ;
but there is another  form of dropsy incidental to pregnancy,
affecting not only the limbs, but the cellular tissue of the body
generally : this is the (Edema Gravidarum of the older  authors.
No other cause than pressure on the vessels was, I believe, known
for such a state of things until Dr. Lever  pointed out its connec-
tion with albuminuria.   Other observers have added to this
valuable advance in pathology, and it is now a well recognized
fact that pregnant women, especially' primipara,  are often  the
subjects of Albuminuria, resulting in local and general dropsy,
and involving, unless  relieved, very grave  dangers at the time
of parturition.  Albuminuria was first pointed out by Dr. Lever
and Professor Simpson in 1843, in connection with puerperal con-
vulsions, but since that date more attention has been paid to this
condition at the time  of labor than  during its  early stages in
pregnancy.   This is a misfortune, inasmuch as little can  be done
in such cases at the time of parturition, while if detected early,
the disorder can be relieved  in the  great majority of cases.  It
has been said that this  disorder cannot be arrested during preg-
nancy ; but I have never met with a case that resisted treatment,
unless it had been neglected until towards the close of gestation.
The cause of albuminuria of pregnancy has been considered to
be the  pressure of the gravid uterus.  It has been found  that
ligatures applied to the  renal veins will produce  albuminaria
artificially.   Its prevalence in  first pregnancies, when the abdo-
minal walls are  more  tense than in multipara; in twin cases;
and in  subjects affected with dropsy of the amnion;  and its
rapid  disappearance after labor, in  most cases, seem to favor
this view.  Probably pressure on the kidneys  is one cause of
albuminuria; but I have seen it occur in  primiparous  women of
relaxed habits as early as the fourth  or fifth month, where  the
abdominal walls were flaccid, and no apparent pressure or ten-
sion existed.  The disease appears to me in such cases to depend
upon sympathetic irritation of the kidneys by the gravid uterus,
similar with  the irritation of the salivary glands, .the mammae,
thyroid,  etc., and not upon mere pressure.   It certainly has not
the same tendency to occur  in ovarian  dropsy,  or in large 
EFFECTS OF ALBUMINURIA.
155
fibrous tumors of the uterus, in which the pressure may be quite
as great, and  sometimes as rapidly induced,  as in pregnancy.
According to the researches of M. Blot and Professor Litzmann,
albuminuria is not a very uncommom  affection  in pregnancy.
M. Blot found it in about twenty per cent, of the women he exam-
ined, and Dr.  Litzmann in a somewhat larger proportion.   It is
found, as already stated, more frequently inprimiparathan in mul-
tipara.  Probably when the albumen is in small quantity no spe-
cial symptoms  result. When the amount of albumen is excessive,
and the disorder has proceeded without check, we have the legs
enormously swollen, and the vulva and vagina become so tumid
as to render an examination very difficult.   There is puffin ess
of  the face and hands, oedema of the  abdominal  walls, and
almost every part of the body pits  deeply upon pressure.  The
patient complains of headache, and sometimes dimness  of  sight
and amaurosis.  Lumbar pain is frequently  present, and there
is general pyrexia.   The urine is small in quantity, and nearly
solidifies upon the application of heat and nitric acid.  It is gen-
erally  of high specific gravity, loaded  with phosphates, fre-
quently alkaline- in character,  and containing  epithelium or
fibrinous casts of the tubuli uriniferi.  Besides the loss of albu-
men, urea is  retained in the blood, and appears to  have been
detected in this fluid  as such by Dr. Lever.  Other observers
have failed to find urea.   According to the view of  Frerichs
and Litzmann, urea becomes  converted into ammonia, which has
been found in the  blood and in the secretions of the  skin and
lungs of albuminurious patients.  As the poisoning of the cir-
culation  by urea and  the loss of the albuminous portion of the
blood proceeds, an intense degree of anaemia is  induced.  It is
of  great importance to relieve such a state of things before the
corning on of  labor, as albuminuria predisposes powerfully to
convulsions and phrenitis, and according to  my  experience, to
dangerous haemorrhage during and  after  labor.   The treatment
consists in  small bleedings where there  is distinct lumbar pain
and general and febrile excitement, or cupping upon the loins,
or counter-irritation by sinapism, in the same  situation.   Warm
baths and  vapor baths are  often  very  useful in restoring the
function of the skin, removing the effused  fluid, and disposing
the kidneys to act.  I have also found the use  of diuretics, as the
acetate of  potash, oil of juniper, and infusion of broom,  most 
156
TREATMENT OF ALBUMINURIA.
 useful.   Frerichs  and Litzmann have given benzoic  and citric
 acids, with a view to remove  the ammonia from the blood, and
 it is said with good  effect.  When there are no signs of renal
 inflammation  or congestion, and the quantity of albumen has
 diminished, and that of the urine increased, a generous diet and
 the administration of iron and  tonics should be resorted  to, in
 order to repair, as  far as possible, the weak condition of the
 blood which has been  produced.  The detection and  treatment
 of albuminuria in pregnancy is one of the  points of progress
 deserving the special notice of all engaged in the practice of
 midwifery.   I have no doubt  the rate of  obstetric mortality
 may  be sensibly diminished by attention to this subject.  The
 urine should  invariably be tested for albumen in all cases of
 oedema  of the extremities.
  I am  not aware that the  matter has  been observed by obste-
 tric authors, but in  some pregnant women the urine, without
 being albuminous, contains habitually a large quantity of triple
phosphates, is of high specific gravity, and has an alkaline
reaction during  the greater  part of pregnancy.  The nervous
and vascular erethism attendant upon, or produced by, the state
of pregnancy, is followed by the same results as other and more
marked  causes of exhaustion.  I have known this Phosphatic
Diathesis to exist in  cases in which fatty degeneration of the
placenta has  occurred in successive pregnancies.  In one lady
who had given birth  to eight dead children at or near the full
time, this state of the urine was very marked.  The death of the
children occurred  before the  end of  gestation  from  placen-
tal disease, and was caused by the separation of the placenta
before the occurrence of uterine action ; or  its attachment was
so slight that it was separated by the first contractions of the
uterus ;  or the children were born in such a weak condition that
they died soon after birth, leaving the foetus to die of asphyxia.
The treatment in  such cases should be that employed in the
phosphatic diathesis  occurring under  other circumstances than
pregnancy—namely,  the mineral acids, opiates, rest, and a nutri-
tious regimen.   Such patients also require, either during or after
the completion of pregnancy, preparations of  steel, as a marked
degree of anaemia is produced by the  persistence of the dis-
order.
  Some  gravid women experience great distress durino- preo-- 
HEADACHE OF PREGNANCY.
157
nancy from the sympathetic irritation of the Heart, palpitation
occurring upon the slightest exertion or emotional disturbance ;
in others, the respiration is  similarly affected, and attacks of
dyspnoea, approaching to asthma,  harass  the  patient.  These
affections are aggravated as pregnancy proceeds; and the effects of
mechanical pressure upon the heart and lungs by the ascent of
the diaphragm, and  upon the great vessels in  the  abdomen,
become added to those of sympathetic irritation.  In such cases
an opium or belladona plaster over the heart, and use of anti-
spasmodics, such as sulphuric or chloric ether,  valerian,  musk,
and similar  remedies, are useful.   Every means  should also be
taken to diminish, as far  as possible, the effects  of mechanical
pressure.  Cough is very troublesome in  some cases.  At the
commencement of pregnancy, the cough  may be spasmodic,
and caused by sympathetic irritation of the throat and glottis ;
and, in the later months, by the upward pressure  of the gravid
uterus upon the diaphragm and lungs, a condition often accom-
panied  by  pleurodynia.   In the  former  case,  the  cough  is
soothed by opiates and a good diet; in the latter, nothing can be
done  beyond obviating the effects of pressure as much as pos-
sible, by attention to the bowels, and the position of the patient.
Such patients, for instance, require to  sleep with their heads
raised, and very great comfort is  often obtained by the use of
small air-pillows, which  can  be shifted about with ease by the
patient.
   Cephalalgia and Cerebral Irritation are  sometimes  produced
by the  irritation  of  the gravid uterus.    They  are,  however,
more frequently  the  secondary result of some  other disorder
incident to pregnancy.  Thus, headache occurs as a symptom of
albuminuria,  constipation, anaemia, indigestion,  etc.   When it
is caused directly by the condition of  the uterus, it should be
relieved by cooling applications, as ice  or a spirit lotion, to the
head, and a few leeches to the temples, small blisters behind the
ears, aperients, etc.  When headache is only a symptom of some
other condition arising out of pregnancy, the treatment must be
modified  according to the particular  disorder upon  which it
depends—as, for instance, a purgative in constipation ; quinine
or iron in anaemia ; albuminuria, the treatment adapted for the
relief of  this  condition, and so forth.   Severe headache  is  a
6ymptom which  should always attract the attention of the 
15S            VARICOSE VEINS  OF PREGNANCY.
accoucheur, since we know that it  may be the possible forerun-
ner of puerperal convulsions or mania.  It occasionally happens
that actual  mania has been  caused by the irritation  of preg-
nancy, and apoplexy,  epilepsy, and chorea  have  been  met
with.  In these  severe complications,  the only efficient treat-
ment consists in the artificial evacuation of the contents of the
uterus.
  Having  referred to  the principal forms of disorders depen-
dent upon sympathetic nervous irritation, we come to the consi-
deration of  those  caused  chiefly by the pressure of the gravid
uterus.  Amongst the  most obvious results of pressure are the
impediments to  the circulation in the  lower extremities.   The
weight upon the external iliac veins, particularly in the upright
position, very commonly causes a varicose state of the  veins of
the legs.   This condition is most aggravated towards the end of
pregnancy, and  in women who have  borne  large families, or
who have  been  obliged to exert themselves  during gestation,
the varicose veins sometimes inflame  at  particular points, or
throughout  a considerable extent,  and the walls of the veins
may become thin and  burst, giving rise to dangerous haemor-
rhage.  In other  cases, varicose ulcers are formed by  the inflam-
mation and suppuration of a patch of  varicose veins.  Certain
inconveniences also arise as the result of pressure  on the inter-
nal iliac veins.   In the latter months of pregnancy, the disten-
sion of the  internal iliac  veins is caused by the pressure of the
gravid uterus upon the common iliacs ;  mit in  the  early months
the pressure is exerted directly upon the internal iliac vessels by
the expanding uterus before it has yet emerged from  the pelvis.
In  this way, haemorrhoids, congestion, and  varicosity of the
vagina, and a varicose state of the  vulva, are  caused.  In the
latter condition,  effusion of blood may take place from the veins
into the cellular tissue, constituting  thrombus, which sometimes
attains a  considerable  size,  and proves an  impediment at the
time of labor.  Haemorrhoidal discharges  are not uncommon in
the early months of pregnancy from this  cause,  and,  in some
habits, blood is  lost  from the haemorrhoidal vessels for the first
monthly period or two after  the commencement of pregnancy.
Similar disordered conditions of  the  pelvic veins  may after-
wards be caused  by pressure upon  the common iliac.  Proba-
bly the effects of pressure  have some influence in causing a pie- 
CEDEMA OF LIMBS.
159
  thoric state of the uterus itself ; but as the uterine veins empty
  themselves partly into  the internal  iliac, and partly into  the
  inferior  cava and renal veins, the early gravid uterus is to a
  considerable extent defended against the consequences of pres-
  sure.
    In the management of these conditions, as in all the disorders
  of pregnancy,  it must  be  remembered that  except in the  last
  resort, the  cause of disorder  cannot be  removed, and that we
  can  only deal in palliative measures.  The varicose state of  the
  veins of  the  lower  extremities may be relieved  by rest in the
  recumbent position, and by wearing a roller, or an elastic stocking.
  In the event of a varicose vein bursting, the patient ought to be
  laid down, and placed, with her legs raised above  the level of
  the head, until the bleeding has ceased, and pressure should be
  applied  to the  ruptured vein.   The distension of the haemor-
  rhoidal and  vaginal  veins  may  be relieved by rest,  and  the
  avoidance of constipation ; and if the  veins of  the  vulva  are
  varicosed, by the pressure  of an elastic bandage applied to the
  part.
    The pressure of the gravid uterus upon the lymphatics in the
  pelvis sometimes gives  rise to simple (Edema of the lower
  extremities, in  cases where no  disturbance is  caused by venous
  pressure.  At others there is oedematous enlargement of the
  feet and  ankles,  combined  with  a varicose state of the veins.
  The oedema is aggravated by standing or walking, and becomes
  worse every evening, particularly as pregnancy advances.  It is
  generally relieved  by  rest in the horizontal  position, or, if
  painful,  by an opiate embrocation.  It disappears very soon after
  the  occurrence of  parturition.  Cramp  in  the  leg is a very
♦ troublesome affection to some pregnant women, and in subjects
  in whom it  occurs during gestation the disorder occasionally
  amounts to intense and continued agony during labor, affecting
  the  muscles of the abdomen as well as those of the lower extre-
  mities.    It depends  partly on the  pressure  upon the lumbo-
  sacral nerves in the  pelvis, and partly  on the  irritation of  the
  gravid uterus, or constipated bowel, reflected upon the nerves
  of the lower extremities, apart from mere pressure.  The  ten-
  dency to cramp is increased by unusual exercise, long standing
  in the upright  position, or by the omission of accustomed exer-
  cise.  The treatment consists  in friction  and  extension of the 
160
INCONTINENCE OF URINE.
limbs during the paroxysm, and the  avoidance, as far  as possi-
ble, of the causes of this  painful aftection—that is, the bowels
should be kept regular, and rest and exercise should be attended
to in due moderation.   Constipation is prone to  occur in preg-
nancy,  partly  because of the mechanical pressure exerted on
the rectum, and  partly because the  state of the  gravid uterus
acts as  a contra-stimulant to the intestinal canal.   Sulphur,
bitartrate of potash, manna, or the lenitive electuary, should be
given  in cases  of  constipation, when the bowels are  readily
moved.   In  more obstinate  cases, castor  oil, or the compound
rhubarb  pill,  or an injection of  soap-and-water,  are useful.
There is a very  common  prejudice  in favor of aloes, and  this
medicine is well  suited to cases in which the derivative influ-
ence of the gravid uterus has reduced the rectum to a state of
torpor.   Its effects, however, should be kept  within .certain lim-
its, otherwise it is apt to excite the uterus.  Magnesia should be
avoided  as a purgative during pregnancy, and it should not be
used to any great extent as a means of relieving heartburn, on
account of its tendency to accumulate in the rectum.  Serious
complications may occur at the time of labor, or  subsequently,
from neglect of the bowels, or from habitual constipation during
the pregnant state.   This  is  particularly  the case with women
who have required opiates during pregnancy, in whom accumu-
lations of faecal  matter  in the colon are very  apt to occur.
There may be a daily partial  action of the bowels in such cases,
but  the  bowels may become so loaded notwithstanding, as to
complicate, favor, and tend to the production of fever or convul-
sions after parturition.
  Strangury and incontinence of urine  are  often met with in
pregnancy; in the early months, from irritation of the  bladder,
the  irritation being  partly  caused  by  pressure, and  partly
reflected from  the  gravid uterus; and  in the latter months,
chiefly as the result of pressure.  Little  can  be  done in such
cases beyond enjoining rest, giving an opiate—particularly when
the affection occurs in the early months—and taking  care  that
the urinary secretion is kept  in as healthy a state as possible.
The distension of the diaphragm and abdominal muscles by the
gravid uterus is occasionally the source of severe pain  in these
muscles.   This muscular pain may be felt especially in the  dia-
phragm,  in the situation  of its insertion into the ribs  in  the 
HERNIA INTO THE LABIA.
161
course of the rectus, or in the bellies of the oblique muscles. It
is relieved by an occasional warm bath, the use of frictions with
olive oil to the abdominal surface, an anodyne embrocation, and
especially by wearing  a  suitable bandage, so as to support the
strained muscles.   I have sometimes  seen  these pains,  after
bleeding and leeching had been tried in vain, relieved at  once
by the use of a well adjusted bandage.  Occasionally the  skin
is the seat of great uneasiness from the distension of the abdomen
becoming cracked, and oozing out a watery secretion. The best
relief for this state is the use of oleaginous frictions, an  occa-
sional warm bath, and the  support of the abdominal bandage.
   [Hernia  sometimes accompanies pregnancy, the intestine
coming down by the side of the vagina and filling the labium so
as to greatly enlarge it.  It is rarely a very serious complication,
but it is sometimes a cause of much anxiety to the patient. Occa-
sion  should be taken  to  restore it  by making  gentle pressure
while the woman lies upon her back.  If kept up for a few days
or weeks it will rarely reappear.  It is generally the result of a
strain in lifting.]
11 
LECTURE  X.
                  DISORDERS  OF PREGNANCY.

  Gentlemen :—In the  last lecture, reference was made  to the
disorders of pregnancy depending  upon sympathetic Irritation
and Mechanical Pressure; and we  now come to  the  considera-
tion of displacements of the Gravid Uterus, and their effects.
  Conception may, and does occur  in women suffering from Pro-
lapsus or Procidentia, as in cases where the uterus is occasionally
reposited, or returns of itself when the patient is in the recum-
bent position.   Under such circumstances,  there may be pro-
lapsus or procidentia of the pregnant uterus in the early months.
Harvey mentions a case of this kind.   Unless abortion should
happen  while the uterus hangs externally, no other evils but the
discomfort of such a state of things and the risk of abortion are
usually  experienced.   After  a while,  the  uterus  no longer
descends, the ovum acting as a very efficient intra-uterine pes-
sary.  All that is required in the way  of treatment is the return
of the uterus within the vagina by gentle pressure, and the con-
tinuance in the recumbent position for a time.   Occasionally,
however, where  the uterus has formed  adhesions, abortion is
caused,  or inflammation and pelvic abscess is the result.
  In women who have borne  many children, or who  are  of
relaxed  habits, or  in whom large  umbilical hernia  exists, the
uterus in the latter months of pregnancy hangs over  the  pubes
constituting Anteversion of the gravid uterus. Occasionally, in
these cases, considerable  disturbance of the bladder is expe-
rienced  in consequence of the dragging  and pressure exerted
upon the neck of the organ.  When the anteversion is consider-
able, the bladder is drawn  upwards to a  considerable extent;
the unwieldy condition of the patient interferes very much with
progression ; and the loss of the proper axis  of the uterus, and
the impeded action of the abdominal  muscles, become impedi-
 162 
THE UTERUS  DISPLACED.
163
ments to parturition.  In the first  month or two of pregnancy,
the natural position of the uterus is, as  already mentioned, a
slight anteversion of the organ, as compared with the axis pre-
served in the ungravid state, and the body of the organ can be
felt in front of the os uteri, and  between the os and the pubes.
This generally produces no other inconvenience save that  of
pressure on the  bladder;  but  when  the  anteversion is very
marked, as when a womb already anteverted becomes impreg-
nated, or when large accumulations in the rectum  takes place,
the vesical irritation and disturbance becomes more distressing.
In the early months, the patient should be a good deal on her
back, and the rectum should be  emptied daily by an  enema or
some mild aperient.  The treatment of anteversion  in the latter
months consists of rest in the supine position, and the use  of a
proper bandage.
  By far the most formidable displacement to which the gravid
uterus is liable is Retroversion—an affection noticed by Daven-
ter and some of the early obstetricians, but first observed dis-
tinctly by Gregoire, and fully described by William Hunter and
Denman.   This  affection  occurs  in its most  decided form at
about the third  or fourth month, when the uterus is entirely
within the pelvis, and when it is  of such  large  size that any
alteration from the natural position occasions  great inconveni-
ence  to the neighboring organs.  It is usually described as
arising from excessive distension of the bladder, through neglect,
reserve,  or restraint on the part of the patient.   It  is believed
that the full bladder, rising in the  abdomen, drags the  neck of
the  uterus  upwards, while  the bulk of the  distended  organ
presses the fundus uteri backwards.  The  displaced uterus, by
the pressure  it exerts  upon  the neck of the  bladder, in turn
increases the distension of this viscus, and the retroverted uterus
at length becomes fixed across  the pelvis, the fundus lying in
the hollow of the sacrum, and the os being- tilted  against the
pubes, so as, in the worst cases, to render the evacuation of the
rectum difficult, and the bladder impossible.  This  explanation
of the matter, which has been implicitly followed by almost all
writers on midwifery, was current, it should be  observed, long
before the subject of retroversion of the unimpregnated uterus
came to be understood.   My own observation  inclines me to
give a different view of  the mode in which retroversion of the 
 164        RETROVERSION FROM DISTENDED BLADDER.

 gravid uterus may occur—a view illustrated  by a case which
 recently fell under my care.  A lady in whom the symptoms of
 retroversion of the uterus had existed for some years before her
 marriage, became pregnant, and the inconveniences from which
 she had suffered immediately became aggravated. I examined her
 when she had been pregnant  about ten weeks, and found the
 uterus completely retroverted.  The fundus was almost pressing
 upon the perinaeum, and the os uteri could be felt high up  in
 front, behind the  pubes.  At this- period there was no sensible
 pressure on the bladder; the organ could be readily emptied,
 and the urine was retained the ordinary time.  It was upon the
 rectum that the pressure  was chiefly felt.  The uterus did not
 lie horizontally in the pelvis in the usual way described, but the
 organ was bent upon itself at the cervix, just as a retort is bent
 at its neck.  As the case went on, and the uterus occupied the
 greater part of the pelvis, pressure on the bladder became pain-
 ful, and I have little doubt the worst symptoms  of retroversion
 would have occurred,  had not care been taken to keep the blad-
 der and rectum comparatively empty. The leverage of increased
 growth, aided by attention to the bladder and rectum,  gradually
 raised the fundus  uteri, and as the organ emerged from the pel-
 vis  it assumed the proper position.  Without question, retrover-
 sion of the gravid uterus may be caused by an  over-distended
 bladder, but I suspect that many cases of retroversion occur in
 the way I have  described—from impregnation  of the uterus
 already retroverted. At first, no great inconvenience is felt, but
 there comes a time when  the os uteri presses on the bladder and
 prevents its evacuation.  Then ensue the symptoms of retrover-
 sion, and  that which  has occurred slowly is looked upon  as  a
 sudden displacement.   I have seen  other cases in which preg-
 nancy  happened  in patients  suffering from  retroversion,  and
 sometimes retroversion has occurred in  successive pregnancies
 in the same subject.   It is believed  that a pelvis above or below
 the  average size, or narrower at the brim than at the outlet, may
 predispose to this  affection.
  The  symptoms  of retroversion, when the uterus is of such
 dimensions as to exert mechanical pressure upon the antero-pos-
 terior walls of the pelvis, are, in the  first instance,  partial or
 complete retention of the urine, pain in the pelvic region and a
sense of pressure on  the rectum, giving  rise to the constant 
            TREATMENT OF UTERINE DISPLACEMENT.         165

 desire for defecation, even when the bowels are empty.   Should
 these  symptoms pass unrelieved, the bladder  becomes enor-
 mously distended, and it is sometimes ruptured mechanically, or
 its coats inflame and ulcerate, allowing the urine to escape into
 the peritoneal cavity, and the patient sinks or dies of peritonitis.
 If the uterus cannot be replaced, and the water is occasionally
 and with difficulty drawn off, the bladder gradually enlarges
 and elongates, and its mucous membrane diseased : muco-pnru-
 lent, ammoniacal, and bloody urine is passed, and the  kidneys
 may become diseased by the effects of the backward pressure of
 the urine.   The structures between the bladder and the uterus
 may become inflamed, and the patient be destroyed by irritative
 fever.   In some cases all these mischiefs are averted or modified
 by the occurrence of spontaneous abortion.  In others  the dis-
 placement continues to the fifth or sixth month, without destroy-
 ing the patient, and it has been known to go on to the full term
 without causing a fatal result.
   As regards treatment, the first thing to be done is to  obviate
 as far  as possible the  effects of pressure, by catheterizing  the
 bladder and emptying the bowels by aperients or enemata.  In
 some cases,  these means, and  directing the patient to empty the
 bladder frequently, and the bowels daily, are so efficient that no
 further inconvenience is felt, and the uterus rises into  the abdo-
 men  as  pregnancy advances.  When the  pressure cannot be
 relieved by  these means, an attempt should be made to raise the
 fundus uteri mechanically. This should be done by introducing
 the fore-finger of one  hand into the vagina, and  the fore-finger
 of the other into the rectum, when the  os should be drawn down
 with one finger on the  uterine  sound, and the  fundus  elevated
 with the other.   The most convenient position for the  patient
 during these manipulations is on her knees in bed, with her
 head  lowered.   M. Gariel has proposed that one of his vul-
 canized india-rubber  pessaries  should be introduced  into the
rectum, or into  the vagina, and that  the fundus  uteri  should
be raised in inflating the pessary.  I  do not know   if this
plan has been tried in practice, but it would probably be effec-
tive in a case admitting of the mechanical re-adjustment of the
uterus.  When  the uterus was firmly wedged in, it might, how-
ever, unless great caution were observed, lacerate the soft parts.
If the symptoms are so serious as to threaten  the safety of the 
166 INSTRUMENT FOR REPLACING RETROVERSION OF THE  UTERUS.
mother, and the reduction of the retroversion cannot be affected,
the uterus should, if possible, be emptied of its contents, by pass-
ing the uterine sound or a  curved bougie into its cavity, and
either rupturing the membranes, or detaching the ovum.  We
have seen that Nature itself sometimes gets rid of the difficulty
by abortion.   If the uterus  cannot be  emptied in this way, it
should be  punctured from  the vagina or the rectum.   These
operations have been successfully performed, but they should of
course, only be resorted to in dangerous cases, and when there
is no time for the induction  of abortion.

                          Fia. 49.
  The action of M. Gariel's instrument for replacing the retro-
verted  uterus, is shown in Figs. 49 and  50.   The instrument
itself consists of a  dilatable air pessary terminating in  a tube,
and an air reservoir, with small taps affixed to each.  After  im-
mersion in warm water, the collapsed pessary is passed  into the
rectum, behind the uterus, by  means of a probe.  The air reser-
voir is then fitted to the tube of the pessary, the taps are  opened,
and by the pressure of the hand, the air contained in the reser-
voir is transferred to the pessary, so as to lift  the  uterus out of 
RELIEF OF RETROVERSION.
167
the hollow of the sacrum. This instrument is made by Mr. Hux-
ley, of Old  Cavendish street.
                           Fig. 50.
  Dr. Henry Bond, of Philadelphia, has invented an instrument
for the relief of retroversion, which Dr. Meigs states was  suc-
cessful in a difficult case which had resisted other means. The
following is the description of this instrument, as given by Dr.
Meigs (see Fig. 51):
  " The instrument consists of two arcs of circles  of different
radii; the inner  one  is terminated by a small oval  piece of
ivory; the outer terminates in a small ivory ball.  The exterior
arc is formed at its lower extremity into a plate-piece, in which
is a mortise;  to the end of the plate-piece is attached  an ivory
handle, by which it may be conveniently held.   The inner or
smaller piece is attached to a sliding piece, also mortised,  and
overlapping by its edges the mortised  plate-piece, and secured
by a clamp or pinch  traversing the mortises, and  fastened or
loosened  by turning the thumb-piece.  If the  thumb-piece be
unscrewed, the clamp may be turned lengthwise, and the  arcs
are  then easily separated.  In order to use the instrument, the
arcs should first be separated, and the ivory ball on the largest
arc  introduced into the rectum, while the oval one on the smaller 
168
DISORDERS  OF  PREGNANCY.
arc should be  introduced  into  the  vagina.   By sliding the
smaller arc upwards, the two balls can be placed opposite to
each other;  or the vaginal arc can be set a quarter of an inch,
a half inch, or an inch lower down than the one that is  in the
rectum.  Upon being adjusted and firmly secured  by turning
the thumb-piece, it is manifest that the two balls cannot be
separated from each other, and that if they be moved upwards,
parallel with the curve of the sacrum to the height of the pro-
montorium, they must carry the retroverted uterus before them,
and thus  serve very effectually and  easily to reposit  the  dislo-
cated organ."
  The disorders of pregnancy depending upon the uterus and
vagina are, Uterine Plethora, Hysteralgia, a painful condition
of the Round Ligaments, Pruritus, Sanguineous Discharges, and
Leucorrhcea.
  Uterine Plethora in the early part of pregnancy, as the joint
result of pressure and the determination of blood to the  uterus
in the processes of nutrition, may  exist to such  an extent  as to
cause bearing-down, heat and pain in the back, and  a sense of
pelvic fullness, with inability to walk—symptoms which, if not
relieved, are pretty sure to produce abortion.   On examination
per vaginam, the canal is  found hot and  dry ; the uterus is 
RHEUMATISM OF PREGNANCY.
169
swollen, low down in the vagina, and  rigid and  painful to the
touch.   This condition should be treated by the avoidance of
intercourse, absolute rest, aperients of the gentlest kind, or mild
enemata, the  application of leeches  to  the perinaeum, or the
inside  of the  thighs,  cooling saline  medicines,  and  a light,
unstimulating  diet.  When the uterine pain is considerable, an
opiate, or hyoscyamus with  camphor, should be given, or  an
opiate suppository should be introduced into the  rectum.
  Occasionally in the middle and  latter months of gestation,
the uterus itself becomes the seat of severe pain.  If the organ
be pressed upon with the hand it is found to be painful, and the
movements of the child and the contractions of the uterus itself
are accompanied by much  suffering.   This  kind of pain is
accompanied by fever, a coated tongue and high colored urine.
It is generally considered to be of a  rheumatic  character, and
admits of relief by a  light diet, saline aperients, warm  baths,
Dover's powder,  anoydyne embrocations, and liquor potassae,
with or without colchicum, according  as the rheumatic element
may appear to prevail.  Some women feel this pain very dis-
tinctly in the direction of one  or  both round  ligaments, and I
have certainly seen several instances in which rheumatism has
appeared to seize  upon these ligaments during pregnancy—a cir-
cumstance very well explained by their fibrous structure.  The
treatment would be the same as in rheumatism of the uterus. In
both cases every  care should be taken to  relieve the organ from
all strain or pressure as far as possible by rest and recumbency.
  Pruritus is often met with in pregnancy, and in some women it
is so constant as to be a source of much annoyance. It commonly
depends on follicular irritation of vthe vulva, which, if unchecked,
passes  on to aphthous  ulceration.  Sometimes the vulva is quite
free from irritation, and the itching is referred  to the surface of
the os  uteri itself.  In  either situation, the pruritus is frequently
accompanied by  sexual  excitement.  In pruritus of the vulva
the secretion from  the  surface is highly acid.  The affection
may sometimes be relieved by washing the part with common
yellow soap on account of the alkali it contains.  Dilute hydro-
cyanic acid, Battley's  solution, and carbonate of soda, make  an
excellent wash, in the  proportion of  one drachm of each of the
two former to  two drachms of the latter, in six ounces of water.
Of  this wash,  the patient should be  directed  not to use  more 
170      ABRASIONS OF THE  OS UTERI IN PREGNANCY.

than a tablespoonful at a time.  A lotion of borax is often very
useful.  Occasionally,  when  alkaline applications fail, relief is
obtained from an acidulated wash.  Sometimes a lotion of tar-water
is very soothing in this  affection.  If the disorder resists these
measures, painting the vulva, with a solution of the nitrate  of
silver, in  the proportions  of  ten  grains to an  ounce of water,
every day or every other  day, or with the  tincture of iodine
mixed with an equal quantity of  water, is an excellent remedy.
In pruritic irritation of the os uteri, the solution of borax, or of
the nitrate of silver, should be used as an injection ; tepid or cold
bathing, a cooling diet and occasional aperients are necessary in
such cases. It sometimes happens that the pruritus has a periodic
character, coming on or becoming aggravated at particular times
of the day.   In these cases I have seen great benefit from the
administration of quinine.
  Leucorrhoea is a very  common affection of pregnancy.  The
glands of  the canal of the cervix share in the increased develop-
ment of the uterus, and  the secretion  which  forms the thick
plug of mucous closing the cervix uteri is frequently in such
excess as to cause a constant  discharge.  The secretion is thick
and perfectly white in color, as it escapes from the os uteri.  It
is composed entirely of plasma and mucous particles, but in pas-
sing through the vagina it becomes mixed with the scaly epithe-
lium  of  the vaginal surface.   In  some  cases, the epithelial
covering of the os  uteri is abraded to a  considerable extent,
when muco-purulent or purulent matter  is secreted from  the
abraded  surface, and is discharged  from the  vagina with  the
mucous of the cervix. Sometimes this abrasion exists before the
occurrence of pregnancy, and is only aggravated by the afflux
of blood and increased action natural to the gravid  uterus.  At
other times,  it originates during pregnancy itself.  This subject
of the abrasion of the os uteri  in pregnancy has been investigated
in France by MM. Boys  de  Loury and Costilhes,  and by Dr.
Henry Bennet and Dr. Whitehead in this country.  The symp-
toms  consist  of purulent or  muco-purulent vaginal discharge
pain and weight in the lumbar and hypogastric regions all of
which are increased  by walking  or sustained exertion of any
kind. Examined by the speculum,  the os uteri is seen denuded of
epithelium to a greater or  less extent, and secreting puriform
matter 
MENSTRUATION  OF PREGNANCY.
171
  I have ascertained that it is in these cases  that the supposed
menstruation of  pregnancy sometimes  occurs.   Occasionally
large quantities of blood are lost from  the abraded surface at
each catamenial  date.   If  allowed to pass without treatment,
besides the debility induced by the constant puriform discharge,
and the occasional  loss of blood, there is some danger of abor-
tion, or of painful and laborious labor at the full term.  In cases
of simple mucous leucorrhoea, little is required beyond the use
of an astringent injection.  [I have given from 3 to 5 grains 
172
sums' LEVATOR PERINEI.
of the Potasii Ferrocyanuretum dissolved in water three times a
day, with much benefit.]
  In the severer forms of disorder, the treatment should consist
of rest, keeping the bowels in a lax  state, the use  of injections
of tannin, alum, the  sulphate of zinc, or diacetate of lead, and
the occasional local  application of the solid nitrate of silver.
The application of the nitrate should never be  severe, and the
employment of the more powerful escharotics should be avoided,
lest they should cause abortion.  As an astringent, the dilute
sulphuric acid, with the  compound  infusion of roses, or  the
dilute muriatic acid, may be given.   By  these  means, severe
cases of this kind are  often  cured.   It must be  confessed that
abortion may, and does sometimes occur, from the treatment; and
if the use of the nitrate of silver or astringent injections should
cause much pain, they ought immediately to be disused.
  [In the position which  the os uteri frequently takes in  the
early stages of pregnancy it is not unfrequently a matter of no
little difficulty to bring the os and cervix into view with any of
the ordinary specula.  The instrument invented by our distin-
quished countryman, Dr. J. Marion Sims—for the purpose of ex-
posing the whole of the vaginal walls, as well as the os uteri, will
be found in the hypertrophied uterus of pregnancy  with the os
thrown back into the hollow of the sacrum, to be of great avail. It
might perhaps be  properly called  a levator  perinei, for  the
patient placing herself in the position  delineated in  the cut an-
nexed, as nearly as possible  lying upon her breast and stomach,
the left  arm thrown  behind and  the chest  rotated forward?,
bringing the sternum quite in contact with the table or bed, the
feet drawn up, one extremity of the instrument is to  be inserted
into the vulva, and by the other the perineum is to  be forcibly
lifted up, allowing the pressure of the atmosphere to dilate the
vagina, thus giving a full view of the entire vaginal cavity; after
a little experience with this instrument, the practitioner will
rarely be induced  to  use the ordinary cone-shaped or even the
many valved instruments.]
  The source of the blood in menstruation, or menorrhagia, dur-
ing pregnancy, has often been the subject of discussion.  Before
the modern views respecting the formation of the decidua, it was
difficult  or impossible to  account for the  occurrence of a dis-
charge having a menstrual  character from  the  gravid uterus. 
SOURCE OF MENSTRUAL BLOOD IN PREGNANCY.
173
How  could  a  sanguineous flow issue from the cavity of the
uterus when the whole of the internal surface of the organ was
occupied by the decidua ?   Obstetricians were driven to suppose
that the discharge must in such cases be poured out from the
cervix, the os uteri, or the vagina.   In accordance with the
modern ideas respecting the development of the mucous mem-
brane of the uterus into the decidua vera, Dr. Matthews Duncan
has suggested that the menstrual discharge may be secreted
from the decidual lining of the gravid uterus in the early months,
before the  decidua reflexa comes to be in apposition with the 
174
AN.EMIA OF PREGNANCY.
 decidua vera in  its whole  extent.  According  to  the  view 1
 have advanced respecting the loss and renovation of the mucous
 membrane at the menstrual periods, it is not difficult to conceive
 that in the first  part  of pregnancy the lower  portion of the
 decidua vera may become broken  down and  thrown off with a
 sanguineous  discharge.  Probably, in cases of threatened abor-
 tion, in which there is  a colored discharge for several days or a
 more considerable period, without the loss of the ovum, the lower
 portion of the decidua  vera is destroyed and formed  anew.   In
 several cases which  have  occurred to me, of menstruation during
 pregnancy, I have,  however, found  them, on examining  with
 the speculum, to be cases of abrasion of the os uteri.  In the in-
 tervals  between the periods the abrasions have secreted pus;
 but, under the influence of the vascular congestion which occurs
 at the menstrual dates throughout part or the whole of preg-
 nancy, they exude blood after the manner of a menstrual ulcer.
 I met in the course of last year with two cases of  this kind.
 One case I saw with Dr. Sibson and Mr.  Johnson, of Kilburn,
 and in  this the periodical hemorrhage was very violent, but it
 ceased as the abraded  surface  became healed;  the other case,
 in which a molar pregnancy went on for several months with
 regular menstruation, the os uteri being abraded, I saw with
 Mr. Napper, of Cranley, Surrey.
  Pregnant women are  occasionally affected with  symptoms
 similar to those met with in  cases of amenorrhcea.  In  certain
 constitutions, even while the physiological processes of gestation
 and lactation are going on, the absence of the  stimulus of the
 catamenial function is  felt,  and general pallor,  oedema of the
 lower extremities, and  other signs of chlorotic anaemia, are the
 results.   I have seen many well-marked cases of this kind.  The
 subject has  been slightly adverted to by M. Chailly, and more
 positively by M. Cazeaux.  The same thing may happen, to some
 extent, during lactation ; and it is my opinion that in many cases
 of anaemia from undue suckling, the milder preparations of iron,
 as the ammonio-citrate, are called for, and should be given with
 a view to remedy the condition  of  anaemia.  It is necessary  to
 bear this tendency of the  pregnant woman to  anaemia in mind,
 as it forms a  part of many of the other disorders of gestation.
This state of anaemia is  increased by the vomiting of pregnancy,
and by several other disorders of the gravid state. In ordinary 
          DISEASES,  HOW INFLUENCED BY PREGNANCY.        175

cases, the last thing wre should do would be to give any prepar-
ation of iron, from the fear of inducing abortion; but when the
anaemia is marked, the administration of steel tends to the pre-
vention of the premature expulsion of the ovum.
  The influence of pregnancy upon  other diseases is an interest-
ing subject.  It is well known  that blood drawn from healthy
women during pregnancy generally shows the buffy coat, and it
is found that all  inflammatory diseases have a tendency to a
more  acute  course  than usual, and  require a more prompt and
active treatment  than under any other circumstances.  This is
particularly the case in inflammatory disease of the chest.  Cer-
tain diseases are more dangerous during pregnancy than at other
times.  Small-pox and Scarlatina (also Cholera and Dysenteries)
are very fatal, especially the former, from the almost inevitable
occurrence  of abortion, and the unfavorable condition  under
which the patient  is thus placed.   Syphilis is not  especially
modified by pregnancy; but there is the twofold risk of abortion
—from syphilis itself, and from  the  anti-syphilitic treatment re-
quired.   There is this peculiarity in the relations of  syphilis to
pregnancy, that it offers, I believe, an instance in which second-
ary syphilis may be transmitted from one constitution to another
without  the  intervention of a primary sore—that is  to say,  the
germ cell receives from the sperm cell  of a man laboring under
secondary syphilis a dose of the poison, which is, in the first in-
stance,  developed in the  ovum, and  imparted  to the mother
through the  medium of the placenta.  Some patients suffering
from  spasmodic asthma are entirely free from the disorder dur-
ing pregnancy.   All affections of the  heart are aggravated by
the pregnant state.  The progress  of phthisis is often remark-
ably stayed by gestation;  but, after labor, the disease generally
goes  on at  an accelerated  pace, and  it is  not  uncommon  for
women in consumption to die within  a few days after parturi-
tion.   [See  on this point the Fiske Prize Fund Essay for  1856,
by Ed Warren, M.D. (published by request  of  the  R. I. Med.
Soc.)  in the Am. Journal of the Med. Science for July, 1857.]
Cancer,  when affecting the  uterus, acquires  a  considerable
impulse from the afflux of blood to  the organ, and the develop-
ment of the os and cervix uteri, in the latter months of gestation.
Epilepsy is, in some cases, entirely arrested by pregnancy, and
no  puerperal convulsions  occur at the time of delivery;  in 
176
DISEASES AS AFFECTED  BY GESTATION.
others, the character of the  fits is not altered by pregnancy, or
they become more violent and frequent, and there is a marked
increase  in  their number at  the time  of parturition.   These
points  I  made  out  by a pretty extensive investigation  a few
years since,  the results of which were published in The Lancet.
The influence of gestation upon mollifies osseum is very marked.
This disease, which we shall have to refer to when  treating of
pelvic deformities, commonly increases with every pregnancy. 
LECTURE XI.
                     CAUSES OF  ABORTION.

   Gentlemen :—In the last  two lectures, certain special disor-
ders of pregnancy have been considered.   We now  come to
treat the particular malady to which the gravid woman is liable
—namely, the premature loss of the Ovum.  It will be seen that
many of the other disorders of the pregnant state  tend to this
catastrophe, and require to be  borne in mind in connection with
it.  Abortion consists in the separation and  expulsion of the
immature ovum from the uterus.  The real adhesion  between
the ovum and the mother is at the points of connection  between
the chorion  and decidua.  At first, this  connection is slight.
William Hunter stated that in the earlier part of gestation, the
chorion and decidua may, by delicate manipulation, be separated
from each other without laceration.  Afterwards,  the intimate
connection between the chorion and decidua, and the fusion of
the two parts, and of the fcetal and maternal vessels in  the pla
centa, renders the separation more difficult, and the risk: of abor-
tion is consequently diminished.
   The  older accoucheurs  paid much attention  to the real or
supposed  loss of the  ovum  very shortly after impregnation.
Married women who passed  over a monthly period by a  few
days, and then menstruated profusely, were  believed  to  have
lost the ovum.  This was called an Effluxion, if it occurred before
the tenth day, " because," as Smellie observes, " the  embryo
and secundines are not then formed, and nothing but the liquid
conception, or genitura, is discharged."  In all probability, such
cases are not'uncommon, and  the ovum is unobserved, not  from
its liquid condition, but because  it is so little  above the size of
the unimpregnated ovum as not to be visible in the discharges.
An ovum of  fourteen days has been described  by Velpeau, and
its size did not exceed the following diagram.  In the expulsion
                               12                     m 
17S
FREQUENCY OF ABORTION.
of an ovum of an earlier date  than  this, the symptoms hardly
differ from those of profuse menstruation.
  For practical purposes, Abortion may be defined as the prema-
        ture expulsion of the ovum at any time after the ovum
        becomes visible, and before the twenty-eighth week of
        pregnancy.  Up to the latter date, the foetus is not
        viable, but after the sixth  month, it may with care be
        reared.  There are certain differences requiring notice in
abortions occurring before and after the end of the second month,
dependent on  the different size of the uterus, and  the altered
development  of  the  vascular connection between  the uterus
and  the ovum, before and after the  formation of the placenta.
The  discharge  of the  ovum between the end of the second month
and  the twenty-eighth week, has, in consequence, been termed
Miscarriage ; but bearing in mind the peculiarities mentioned, it
will  be convenient in practice to consider all expulsions of the
ovum, previous to the time at which the foetus becomes viable,
under the head of Abortion.
  This termination of  pregnancy is exceedingly frequent.  Of
two  thousand pregnant women who applied to the Manchester
Lying-in Hospital, Dr. Whitehead ascertained that the collective
number of their abortions had amounted to one thousand two
hundred and twenty-two.  Many of these were yToung women in
their first  pregnancies, or women who had not completed  the
child-bearing epoch.    As regards the individual  results,  Dr.
Whitehead found that of these two thousand women, thirty-seven
out of every one hundred mothers had aborted before they had
reached the age of thirty years.   The proportion of women who
have lived in wedlock  until the menstrual decline, to whom
abortion occurred, approached ninety per cent.  There are, in
fact,  few women who  have passed through the child-bearing
epoch, and actually borne children, who have not aborted once
or oftener.  This is probably one of the subjects open to  the
greatest improvement in obstetric practice.   Considering that at
the last census the married female population of England and
Wales, between the ages of fifteen and fifty-five, amounted to
2,563,894,  the loss of  fcetal life must be enormous.  The date at
which the  majority of abortions occur, is from the second to the
fourth month of pregnancy.  Taking the particular pregnancies
in which abortion is most  likely to happen, there seems to be
 
                    CAUSES OF ABORTION.                 179

greater danger of the accident in the first pregnancy, particularly
among the upper classes, and in those later pregnancies which
occur before the cessation of the menses.
  We have seen, while  considering the  signs and disorders of
pregnancy, that the uterus is in reflex relation with many impor-
tant organs.  These  organs react upon the uterus, and prov,e in
many cases the predisposing or active causes of abortion.   In my
work  on " Parturition," I stated that I had seen abortion caused
by irritation of the  Mammary nerves, as when abortions occur
during lactation from the irritation of constant suckling.  That
it is not mere weakness or exhaustion in some of these  cases is
proved by the fact that the mammary secretion may cease upon
the occurrence of impregnation, but that a plentiful supply of
milk returns after the occurrence of abortion.  The contraction
of the uterus after delivery from the irritation of the mammas is
well known.  When I first suggested this cause of abortion in
some  cases, the idea  was roughly  criticised, but it has been
adopted in the recent work of Dr. Gunning S. Bedford,  of New
York, and Professor Scanzoni has founded upon it a method of
inducing premature labor by irritation of the mammae.
  Irritation of  the Gastric nerves will sometimes produce abor-
tion.  It is astonishing-what an amount of nausea and vomiting
the uterus will bear without being excited to expel its contents,
and there is a belief, generally well founded, that sickness, pre-
vents the occurrence of abortion from rigidity of fibre or imper-
fect uterine devolution.  But  cases do occur in which abortion
is apparently brought on, as a reflex pathological phenomenon,
produced through the medium of gastric irritation.   Irritation
of the Trifacial nerves may also produce abortion. This happens
sometimes from the irritation of cutting the wisdom teeth, the
extraction of a  decayed tooth,  or the irritation of constant odon-
talgia.  Vesical or Renal irritation, as from  the presence  of  a
stone  in the bladder, or irritation of the kidneys in albuminuria,
is sometimes the cause of abortion.  Ovarian irritation has a like
effect, as shown by  the tendency to abortion at  the  catamenial
dates, particularly in  women who  have been the subjects  of
dysmenorrhoea.  The production of abortion by the irritation of
the Rectal nerves is a well recognized occurrence. It may  hap-
pen from haemorrhoidal inflammation, the irritation of ascarides,
the action of  violent purgatives, diarrhoea, or dysentery, or the 
180               COLPEURYSIS IN  ABORTION.

opposite  condition of excessive constipation.  The  mechanical
efforts of vomiting, coughing, sneezing, or straining of any kind,
will occasionally cause abortion in  delicate subjects.
  Irritation of the Uterus and  Vagina may excite  abor-
tion.  Plugging the vagina is sometimes practised  as a  means
of inducing abortion  artificially.
  [This  is  effected  by colpeurysis.  The  instrument used to
effect this  purpose is a simple bag of vulcanized india-rubber,
which is  to be introduced into the vagina and then dilated with
air, warm or  cold water, as may be  deemed expedient.   After
being more or less fully expanded  (and it may be advisable at
first to but gradually inflate  it, and  increase as the pressure is
less and less inconvenient) the aperture is closed by a stop cock,
and the bag allowed to remain in the vagina.  In Figs. 49 and 50,
this instrument may be seen, it is there applied in  the  same
manner, but for the purpose of overcoming a retroversion of the
uterus, and is there introduced into the rectum.  The meaning
of the Greek words from which the name of this  instrument is
derived, is  vagina-dilator, and expresses the idea of  the effect it
produces, dilating the vagina and even pulling open the os uteri,
and by its forcible presence, exciting by sympathy, action of the
uterus.
  The colpeurynter makes a superior tampon, and as the bag
may be filled with cold water and frequently changed by merely
opening the stop-cock, emptying it and refilling, the advantage
of this instrument may be perceived in cases of placenta-praevia
and uterine haemorrhage when tamponing is sometimes judged
expedient.]
  In abortion excited by violent horse or carriage exercise, the
accident depends upon the irritation of the uterus, and espe-
cially the os and cervix uteri, by the head  of the child, during
the succussion which occurs.  Coitus, plugging the os uteri, dis-
ease of the os and cervix, procidentia, anteversion, and retrover-
sion, the implantation of the placenta over the os uteri, cancer,
fibrous tumors of the uterus,  mechanical  injuries and metritis,
may all cause abortion.  In abortion depending upon the disease
or death of the. ovum, it  is  the  irritation  of the uterus  by its
abnormal contents, which  directly excites  the  act of abortion.
In  the  case of abortion from the irritation of  the uterus  by the
state  of the  rectum, stomach, mammae,  etc., the action  of the 
OXYTOXICS FOR ABORTION.
181
uterus is, in the first instance, purely excito-motor and  reflex.
When, however, the reflex action of the uterus is established, the
peristaltic action of the organ combines with the reflex uterine
action.   In the case of abortion from local uterine irritation, or
from  the irritation of the uterus by a dead  or  diseased ovum,
the reflex and peristaltic actions of the uterus are induced simul-
taneously.
  We may consider  abortion  from reflex action, as being in
some  points of view comparable with spasmodic asthma, or any
other excito-motor disease.  From  certain irritating causes, an
excitable condition of the excito-motor arcs concerned in partu-
rition is induced.   This state of excitability  once produced,
slight causes, which in  healthy subjects would  produce no  dis-
turbance whatever, are sufficient to produce morbid or spasmodic
parturition.    This excitability is not suddenly reached.  It  re-
quires that the nervous arcs, whether mammary, rectal, of other,
should be irritated for  a considerable time,  when  an excitable,
charged, or polar state of the uterine nervous system is produced.
The  period preceding  a case of reflex abortion may be likened
to the time preceding an epilectic attack.
  Certain agents have the power of exciting the uterus  to  con-
tract, and are hence called Oxytoxics.   The oxytoxic effects of
the ergot of  rye, cannabis Indica, savin, borax, galvanism,  and
the inhalation of carbonic acid, or its retention in the  blood in
asphyxia, are very generally believed in.  Abortion has been
often caused by the ergot of rye. [?]  During accidental or inten-
tional poisoning by carbonic acid, the ovum  has been found to
be expelled.  In the  celebrated razzia in Algeria, conducted  by
the present Marshal Pelissier, in which a number of Arab women
were  suffocated in the caverns of Dahra, many of those pregnant
were  found to have  aborted.  The same thing occurred  in a
similar exploit by the celebrated  Chevalier  Bayard.  In other
forms of death from  asphyxia, as in drowning, sudden abortion
has been known to occur.  Many of the poisons, when taken by
pregnant women in fatal doses, have caused, in the first instance,
the loss of the ovum.  Certain pathological states excite contrac-
tion of the uterus, and are frequently  the  cause  of abortion.
Loss  of  blood;  exhaustion, from  whatever  cause arising;  the
syphilitic poison ; mercurialization ; zymotic diseases, as small-
pox, scarlatina, and fever ; chorea; visceral inflammation ; albu- 
182
SEVERE INJURIES WITHOUT ABORTION.
minuria;  and according to Lugol, the strumous diathesis, may
excite the uterus  to  the premature  expulsion  of  its contents.
Emotion is another important cause of abortion.   It may be pro-
duced by  the emotions of fear, anger, grief, or any other violent
mental disturbance.  Under the influence of terror and pain,
martyred  women have aborted at the stake.   Of these oxytoxic
agencies, some affect the nervous centres, and are in this respect
to be distinguished from the ex-centric or reflex  causes of abor-
tion.  The ergot of rye, for instance,  passes into the blood, and
affects the spinal centre, being specially directed to the  lower
portion of the spinal marrow, and to that part of it in relation
with the uterus.  In the case of emotion, the influence is distinct
from other causes of abortion, in being dynamic or psychical.
Others, amongst the  causes of abortion  now enumerated, prob-
ably affect the nutrition and life of the ovum, and in this way
lead to abortion.
  The amount  of disturbance to which some  women may be
exposed without inducing abortion is extraordinary.  Mauriceau
relates the case of a woman, in the seventh month of pregnancy,
who fell from the  window of a house, and, besides extensive
bruises, broke one of the bones of the fore-arm and dislocated the
wrist, without aborting.  Dr. Henry Davies once told me of the
case of a  woman, who, throwing some  water from a window,
lost her balance,  and  fell  into the street,  breaking both her
thighs, but recovered without abortion.  Dr. Marshall Hall ren-
dered a frog tetanic by strychnia at  the time the  oviduct was
full of ova, and the ova were not expelled during  the tetanoid
symptoms, but some  days afterwards,  when the  spasms had
nearly disappeared.  Dupuytren relates the case of a woman
who had become the subject of traumatic tetanus during preg-
nancy, but who, nevertheless, recovered and went her full time.
Other women abort upon  the slightest  occasion.   A  habit of
abortion appears to be acquired in some cases, and abortions are
repeated many times  in succession, without  our being able  to
detect any very obvious cause.  I have known  a woman  abort
ten times  in fi>e years;  and another who  in eight  years had
fourteen  abortions,  and  gave  birth  to one still-born  child..
Madame Boivin mentions that she had ascertained by dissection
that, in women who abort regularly,  the uterus has sometimes
contracted adhesions to other  organs.  I have several  times 
       WHY FISSURES OF THE CERVIX PRODUCE ABORTION.     183

known abortions to occur in women who had been the subjects
of sloughing and  cicatrization  of  the vagina,  after previous
labors, or who had been affected with  pelvic cellulitis and pel-
vic abscess.  In some women it appears  as  if the uterus could
not be developed beyond a certain point.   But these points do
not acconnt for all the cases of habitual abortion.
  [The reason  why the uterus  appears incapable of being de-
veloped beyond a certain point  seems to me to be owing to fis-
sure of the os and cervix uteri. If we accept the view of Stolz
relative to the symptom of the  neck, vide page 138, and recog-
nize that the cnange in the os uteri  commences at the external
os, and not at the internal os, the explanation is easy.
  [Mr. Whitehead, in his  able work on Abortion and Sterility,
recognizes this cause of abortion,  but without  giving  its  ra-
tionale. He states " that it is found to exist in twenty to twenty-
four out  of every hundred cases of  abortion not  resulting from
accidental causes.  It is always accompanied by a  degree of
inflammatory induration, which extends more or less deeply on
each side of the fissure; this is  readily detected by the touch,
the circumference of the  orifice being uneven  and  lobulated.
Sometimes only one fissure  exists;  this generally occupies one
of the commissures, or it may divide one of  the  labia into two
portions, and in this case  the hardness may not  extend beyond
the boundaries of the ulcerated chink."  These fissures may
sometimes amount to actual rents, entirely dividing the os uteri,
several cases of which I  have spoken of in my work on the
Causes and Curative Treatment of Sterility.  I borrow from it
a  representation  of  an instrument made for the purpose  of
exposing the interior cavity of the os  uteri, by means of which
the fissure may be observed  throughout its whole extent.   Dr.
Henry Bennett,  in a recent article,  recognizes this cause of
frequent abortions.  This  point is farther enlarged upon  on a
subsequent page (205).] 
184
ABORTION A DECIDED EXFOLIATION.
  There is  one other  cause of abortion on the maternal side,
which I believe to be of very great importance.   In treating of
menstruation, and the formation  of the decidua, we have seen
that the  mucous membrane of the uterus is concerned  in the
menstrual discharge, and that  the decidua consists of the altered
mucous membrane itself.   Now, if this doctrine of the formation
of the decidua be correct,—and there is hardly any matter with-
in the limits of modern research, upon the subject of generation,
which seems better established;  if this be true, I say,  we must
push the matter into the domain of pathology.  Dr. Simpson has
done this in a very able  manner  in  relation  to membranous
dysmenorrhoea.  Denman  and  others  saw that the mass dis-
charged in  these  cases resembled  the  decidua, and made the
comparison between the two substances.  But Dr. Simpson, after
the true nature of the decidua had  been made out, was able to
carry the comparison further, and he has proved that the mem-
brane discharged in membranous dysmenorrhoea is, like the de-
cidua, the mucous membrane  of the uterus itself hypertrophied,
and  exfoliated  or thrown off at a catamenial  period.   Many
years ago I drew a comparison between menstruation and abor-
tion and parturition.   As regards the decidua, there is no great
difference between an abortion a few weeks after conception and
membranous dysmenorrhoea, except that in abortion the decidua
is loaded with the fruit of the womb, and may be discharged
more or less in a state  of disintegration.   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.
I believe that in many cases  of abortion, as in  menstruation of
healthy and morbid type, the disintegration  and exfoliation of
the 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 we  must consider the show in cases of abortion, and the
continuous sanguineous discharge, as similar to the discharge in
menstruation.   In many cases it happens that abortion  is threat-
ened, and there is a colored discharge  for many days without
the loss or  injury of the ovum.  In these cases the discharge
probably takes place from the surface of the decidual mucous
membrane,  as suggested by Dr. Matthews Duncan, in reference
to menstruation during pregnancy.   Abortion does  not take
place in such cases, probably  because the disintegration of the 
         DISEASE OF THE FG3TUS A CAUSE OF ABORTION.       185

decidua does not occur at the part at which the ovum or the pla-
centa is implanted upon it, or not to a sufficient extent to injure
it.  In abortion in the latter periods of pregnancy, the compari-
son between the loss of the ovum and menstruation holds good ;
only at this  time  the  decidua serotina has become by far the
most important part of the uterine mucous surface.  In all  cases
of abortion, this menstrual condition of the developed mucous
membrane  of  pregnancy plays an important part,  and is the
chief cause of the sanguineous  discharge; but in many cases it
is probably the actual cause of abortion.   The tendency of  abor-
tion to occur at the catamenial dates has long been a matter of
observation.   In  abortions occurring at  the menstrual dates of
pregnancy, the periodical influence of the ovaria, as well as of
the uterine mucous membrane,  must be considered.
   We have now considered the principal causes of abortion re-
ferable to the  mother: others remain, in which  disordered con-
ditions of the  chorion and decidua, or of the maternal and foetal
portions of the placenta, are  concerned.  There is also another
class of causes, in which the  foetus  and its diseased conditions
tend to the production of abortion.
   A new cause of abortion,  of great importance, affecting the
maternal and fcetal structures of the ovum, has been  made out
within the  last few years, chiefly by the  original researches of
Dr. Robert (Barnes: I allude to  Fatty Degeneration of the
chorion and placenta.   Kilian had noticed  a solitary  case,
but the  first systematic  account  of the disease we owe to Dr.
Barnes, who was assisted in  his microscopical  investigation of
the subject by Dr. Hassall.  This form  of degeneration  may
affect the secundines at any  time between the early  weeks of
pregnancy and the termination of gestation.   Fatty  degenera-
tion may exist in  the placenta as a post-mortem change—that
is, it may occur in utero after  the death of the foetus.  It may
happen also as the result of the transformation  of effused fibrin
in inflammatory disease of the placenta, or of a clot of blood in
haemorrhagic  effusion.  Lastly, it may consist of the  metamor-
phosis of portions of  the  maternal and  foetal structures of the
placenta during the life of the foetus.  The latter  pathological
phenomenon is that which is  of the chief  importance in relation
to abortion.
   In a placenta affected with  fatty degeneration, the lobes of 
186       DISEASE OF PLACENTA A  CAUSE OF ABORTION.

the placenta are altered in appearance, some of them being of a
yellow, fatty color, brittle, and exsanguine; the rest presenting
their  ordinary characters.   Examined more minutely, the tufts
are found to be glistening, hard, and tallowy, and not  expand-
ing when placed under water, as is the case  with the villi of
healthy placentae.  Under the microscope, the villi  are seen to
be studded with spherules and droplets of fatty matter and  oil.
The fatty material is found principally in the cells  of  the villi,
and in  the  coats of the  blood-vessels of the  villi.  When  the
fatty degeneration of the vessels exists to any extent, the vessels
do not  carry red globules.   The  villi  and the vascular loops
affected  with  degeneration  are  knobbed  and  misshapen  in
appearance.   Dr. Barnes believes the degeneration, or retrogres-
sive  metamorphosis,  to  commence  mostly  in  the villi and
decidual cells of the  placenta.   He has pointed  out that  this
state of things must materially interfere with the nutritive and
circulatory functions of the placenta, and  that if it proceed to
                             Fig. 53.
       Cells of the decidua as they appear in the healthy placenta.  420 diameters.

any great extent, it must inevitably destroy the foetus by cutting
off the connection between the maternal and fcetal circulations. 
         PLACENTAL APOPLEXY A CAUSE  OF  ABORTION.       187

Dr. Barnes  supposes  that, from the friable, non-resilient condi-
tion of the degenerated lobes of the placenta, partial separations
must occar, leading to haemorrhage and  abortion.  He suggests
also that partially degenerated  blood-vessels  may burst,  and
sometimes  lead to intra-placental  haemorrhage, or  placental
apoplexy.  Sometimes the dead  ovum is at once expelled; at

                           Fig. 54.
          Cells of the decidua in a state of fatty degeneration. 420 diameters.

other times the chorion or  placenta  remains in connection with
the uterus, and undergoes a further metamorphosis, so as to con-
sist very largely of fatty matter, before it is expelled.   In  all
probability, many of those  cases in which pregnancy repeatedly
goes on in the  same woman to the full time, and the foetus is
found to have died shortly  before the time of birth, the cause of
death will be found to be fatty degeneration.
  The metamorphosis of portions of the placenta explains many
of the descriptions of the placenta in  a morbid state found in
obstetric authors before the subject of  degeneration was under-
stood.   Dr. Druitt has contended, that in the  normal  placenta,
at the full time, the signs of commencing fatty degeneration  are
present, and this is no doubt true; but, under healthy conditions
the fatty  metamorphosis cannot be  extensive,  otherwise  the 
188              SYPHILIS A  CAUSE OF ABORTION.

health of the foetus could not be  preserved.   Dr. Druitt points
out, that in the placenta, as a caducous organ, the signs  of deca-

                            Fia. 55.
 1, Vessel with its investing chorion: 2, The same deprived of its chorion; 3, Chorion detached,
showing its cellular function. 420 diameters.

dence  begin to  be present  at the  time of its maturity.  As
regards the cause or origin of the fatty degeneration of the pla-
centa,  chorion, or decidua,  Dr. Barnes refers it  chiefly to  an
imperfect germinal or fermative force on the side of the  ovum.
He is also of opinion  that, dependent as the ovum is upon the
vascular system of the mother for support,  any imperfection in
the nutriment supplied to it must  contribute to the diseased
state of the placenta.   It is only upon  this hypothesis  that we
can hope to control this malady, by rendering the  system of the
mother  as  healthy as possible  during gestation.   The  later
researches of Dr Barnes  lead him to  believe  that constitutional
syphilis, maternal or  paternal  in origin, is a frequent cause of
fatty placenta. 
PLACENTITIS  A CAUSE OF ABORTION.
189
  The placenta is subject to  congestion and  inflammation and
their results, and these affections are not nnfrequently the  causes

                           Fie. 56.
 1 and 2, Branches partially deprived of chorion, and showing much fatty matter; 8, Blood-ves-
sel entirely deprived of its chorion, and in a state of degeneration.  420 diameters.

of abortion.   Congestion  of the placenta leads to what is
termed apoplectic effusion.  Blood may be poured out either on
the fcetal or external surface  of  the placenta; it may escape
into the parenchyma of the organ ; or it may be poured out on
the maternal surface.  The  loss of blood may lead to the death
of  the foetus, and in this  way  produce abortion,  or  it may
excite  the separation of the  ovum, and contraction of the uterus.
In other cases., the  blood effused coagulates, its fluid portions
are removed, and a fibrinous mass remains without  doing any
great injury.  In inflammation of the  placenta, or placentitis,
effusion of lymph may occur, or the disease may pass on to hepa-
tization, suppuration, or  gangrene.   Sometimes, when  the in-
flammation  affects the internal surface of the placenta, adhesions
form between the placenta and the external surface of the ovum. 
190      PLACENTAL CONGESTION A CAUSE OF ABORTION.

In this way, the placenta has been found adherent to the fore-
head or body of the foetus.  This disease has been investigated
by  Brachet and Wilde,  and one  of the  earliest  and  most
elaborate memoirs of  Professor Simpson was chiefly devoted to
this subject.  Its symptoms are  obscure, consisting  of pain in
the uterus, near the site of the placenta, pains in the back and
thighs, and general fever.   In cases where I have suspected pla-
centitis, I have examined with the stethoscope, but have not
found any modification of the uterine sounds.  The causes of
placentitis are not very obvious, beyond mechanical injuries, and
the great afflux of blood to the organ, which occurs  during
pregnancy.   Congestion and  its  results are probably common
causes of abortion, though it is by no means certain that  in all
cases  of  abortion, in which effused  blood  is found in the  pla-
centa, or the membranes, the  effusion  has  been the  cause of
abortion.   In many cases, the effusion occurs, without  doubt,

                            Fig.  57.
 An apoplectic ovum; blood being effused in masses under the foetal surface of the membranes.

during the progress of  abortion from other causes.  The  treat-
ment of placentitis and placental congestion consists in  local or
general blood-letting, according to the amount of pain and the 
            SYPHILITIC OVUM A CAUSE OF ABORTION.         191

constitution of the patient,  counter-irritation  over  the uterus,
and other means for equalizing the circulation.  Dr. Simpson is
of opinion, that many of the cases  of repeated  abortion in the
same person depend upon  placental  congestion.   The  placenta
is liable to other diseases, which  have a tendency to  repetition,
such as calcareous degeneration,  tubercular deposits, and  atro-
phy or hypertrophy.   In the case of a syphilitic ovum leading
to abortion, the placenta is very commonly diseased.
  When from any cause the foetus dies, the  circulation in the
foetal portion of the placenta is suspended ; this in turn affects
the circulation on the  maternal  side; the ovum  becomes  a
foreign body, and  abortion generally takes place.  Sometimes,
however,  the  placenta is  still nourished  imperfectly, and the
dead ovum is retained in utero  for a variable time. The foetus is
liable to many diseases which may tend to the death of the ovum,
such as inflammation  of its serous membranes, dropsies of the
serous cavities, or the amnion, disease of the liver or kidneys,
tubercular diseases, diseases of  the umbilical  cord, knots  upon
the cord, twisting  of the  cord tightly round  the neck of the
child, and various other affections which are sufficient to destroy
its vitality.  I have seen a case, in which the head was nearly
amputated by the twisting of the cord round the neck.  Proba-
bly a diseased ovum excites the uterus to expulsive contractions
in many cases, before actual death of the ovum has occurred.
                           Fig. 53.
Ovum showing morbid enlargement of the umbilical cord 
LECTURE  XII.
                  TREATMENT OF  ABORTION.

  Gentlemen :—The first Symptoms of Abortion are a  san-
guineous discharge, and the occurrence of lumbar, hypogastric
and  coxal pain.  The  pains which  precede abortion  are very
much like those which precede  or  accompany a catamenial
period.   Some women abort, however, without having suffered
much, if any pain.  It frequently  happens that a distinct rigor,
or frequent shiverings, usher in abortion.  There is sometimes
diarrhoea, and still oftener, an irritable condition of  the bladder.
Coldness of the breast and abdomen is sometimes complained of,
and there is  often a cessation  of sickness, where  this  has been
troublesome.  On being called to  a case of supposed abortion,
an examination should always be proposed, and made, if possi-
ble.  It may happen that  in cases of supposed abortion there
may be  no pregnancy at all.   Great care should be  taken, on
introducing the finger, not to give pain or use any violence, lest
the tendency to expulsion should be increased.  In threatened
abortion, the os and cervix uteri will  generally be found open
to some extent, and the body of the uterus may be felt in front
of the os, lower in the pelvis than natural, and hard, as if firmly
contracted.  When abortion is actively proceeding, the ovum, or
part of the ovum,  may sometimes be felt high up in the cervical
canal, or it may be partly  extruded from the os uteri.
  The first consideration, in a case in which the symptoms of
threatened abortion have occurred, is whether or not the ovum can
be preserved.  With this end in view, all irritations of a reflex
kind should be avoided or  removed, as much as possible.   Gen-
eral, local, or vascular excitement  should be treated by a sooth-
ing regimen and diet.   It is rare that cases are met with requir-
ing general  blood-letting; but leeching is  sometimes useful in
cases of uterine plethora, particularly  when the symptoms occur
  192 
PREVENTION  OF ABORTION.
193
 at what would, in the  absence of  pregnancy, have been a cata-
 menial date.  The leeches should be applied to the inside of the
 thighs, or the perinaeum.   When nervous excitement predomin-
 ates, a full opiate is of great service.   Opiates, in full doses, are
 also especially  called  for when  there  is intermittent uterine
 pain, or the continued  pain of  the back and lower part of the
 body similar to painful menstruation.  Dr. Fleetwood Churchill
 has given the cannabis Indica  with  good effect as an anodyne,
 and with a view to its  restraining sanguineous discharge.   In
 the earliest  abortions,  astringents are very valuable, the loss of
 blood in such cases very  much resembling  monorrhagia.   The
 acetate of lead, in combination with opium, the mineral acids,
 the oxide of silver, alum, gallic acid, are the best remedies of
 this kind.   If the discharge is profuse,  iced drinks  should be
 given.  Otherwise, the beverages  of the patient should be cool,
 without being absolutely cold, in order to avoid uterine contrac-
 tion.   In the treatment of abortion,  it must always be borne in
 mind, that in diet and medicine any agents which excite con-
 traction of the uterus  may arrest  haemorrhage for the moment,
 but with  danger of exciting further separation  of the ovum.
 We must be  careful,  therefore, not  to excite any  powerful
 uterine action.   The local application of cold to the vulva, and
 the introduction of sponge, or  pieces of lint dipped in water,
 into the vagina, are very useful, within certain limits ; but it must
 be remembered that excessive cold excites uterine contractions,
 and so, also, does the sponge or linen plug, if it  should be large
 enough to irritate the vagina mechanically.   Perhaps the most
 important  of all  the  means at our disposal  for the  relief of
 abortion is rest in the horizontal position.   The  patient should
 be kept in bed in a cool apartment, lightly covered with clothes,
 as long as any  colored discharge  continues, and for some days
 afterwards she should be kept upon a couch, and not allowed to
 assume the upright position or to Walk.  When the uterus is in
 the irritable  and congested condition which accompanies abor-
 tion,  the  standing posture, or  considerable movement of any
kind, greatly adds to the  probabilities of abortion.   The mind
of the patient should be kept as quiet as possible, and all  excit-
ing or  alarming intelligence withheld from her.  The bowels
should be kept open, if necessary, with  the mildest laxatives.
I prefer the senna confection, with a little  bitartrate of potash,
                            13 
194
PERIODIC CHARACTER OF ABORTION.
as an aperient.   Castor oil, as I believe, irritates the uterus and
mammae, and should  not be given.   When the threatening of
abortion has occurred at a  catamenial  date, every  precaution
should be taken, as the next monthly period comes round, in the
way of avoiding irritation, and  preserving quiet  of body and
mind.   Every pregnant  woman  should be told to take note of
the catamenial dates throughout pregnancy, and observe greater
care than usual at  these times, particularly if she  has been the
subject of abortion.  The attempts to prevent abortion should
be  carried out perseveringly, as it  sometimes happens that
women suffer from the symptoms of abortion  for a considerable
time, slight sanguineous discharges lasting for weeks, and yet,
with continual care, they go on to the full term.   It sometimes
happens that the bleeding is very profuse, and  the  os uteri so
closed  that the finger could not possibly be introduced into the
uterus.  All the more powerful astringents may have been tried
in vain.  In such cases the vagina must be plugged firmly with
lint or sponge.  This arrests  the bleeding almost invariably, and
tends to the promote coagulation at the mouths of bleeding ves-
sels.  If, however, it  is  necessary to continue the  plugging for
any length of time, the uterus becomes excited by the mechani-
cal irritation, and  throws off its contents.  Sometimes the loss
of blood is so  great  as  to  require the free administration of
brand}', ammonia,  and   other  stimulants.    As abortions fre-
quently spread over  a considerable time, every care should be
taken to support the  strength of the  patient.  In abortions at
the fourth  or fifth  month, the haemorrhage may be so profuse
and  sudden as to  be alarming from the first.  This is particu-
larly  the  case in abortions  occurring about the  time of the
cessation of the catamenia.   In such  cases, if the  haemorrhage
cannot at once be arrested by astringents, cold and the tampon,
the membranes  should be ruptured with a  view to stop the
haemorrhage, and to excite expulsive action of the uterus.
  When an abortion is threatened, the accoucheur should order
all the discharges to be saved for his examination.   Every clot
and every portion of solid matter should be carefully inspected.
Otherwise it may happen that the patient or her nurse shall tell
you she has aborted when she has not done so, coagula havin^
been mistaken for the ovum.   Or it may occur that the ovum
having passed unnoticed, and slight or profuse haemorrhage con- 
TREATMENT OF ABORTION.               195
tinuing, as it sometimes does, for a considerable time, the accou-
cheur is puzzled by expecting an abortion long after it has been
accomplished.   In connection with  these  points, it must be
borne in mind that cases occur in which the  ovum appears to be
dissolved, and slowly discharged with sanguineous matters, just
as the decidua is discharged  in the lochia after parturition.   A
delicate ovum of a few weeks may disappear within  the uterus,
as occurs in certain cases of molar  gestation, and the mem-
branes may be broken down and discharged as detritus.   Either
of these three cases may prove  very embarrassing  to the practi-
tioner.  Whatever care may be observed, cases will occasionally
occur in which women who have passed two or three menstrual
periods, and exhibited the signs of  early pregnancy,  will be
seized with the symptoms of abortion, and suffer from a sanguin-
eous discharge for a  considerable time, without passing any
detectible portions of an ovum.  After this the patients may men-
struate regularly, and it becomes exceedingly difficult, or impos-
sible, to decide  whether they have  aborted or suffered from a
temporary suppression only.                      ^
  The  indications which should make us abandon all  hope  or
intention of saving the ovum are, sudtlen losses of blood to such
an extent  as to imperil the life of the mother, or such a continu-
ous drain  as seriously to endanger her health ;  it being also cer-
tain, or nearly so, that  in such  cases  the ovum is diseased  or
already dead.  If, on examination, we can feel the ovum at the
os uteri, or in the cervix uteri within reach of the finger, we
may be certain that its expulsion is only a question of time. As
a rule, there is little hope of saving the ovum after the  rupture
of the  membranes and the discharge of the liquor amnii.  I
have, however, seen at least one case in which gestation went on
to the full term after the discharge of the liquor amnii at the
fifth month.  Foetid  discharges, particularly in early abortions,
are a pretty sure sign of  the death of  the ovum.
  When  all  expectation  of saving  the  ovum has been aban-
doned, means  must be  taken to  obtain  its removal from the
uterus.  If the bag of the  early ovum can be felt with  the fin-
ger in the cervix uteri, it can generally, by careful manipulation,
be separated from  the uterus, and got away by the  finger alone.
Sometimes it is necessary to introduce  the hand  into the  vagina,
in order to get the finger into the uterus ; and if the haemor- 
196
INSTRUMENTAL ASSISTANCE IN  ABORTION.
rhage is alarming, the  case urgent, and the os  uteri sufficiently
dilated to admit the finger, there need be no hesitation in adopt-
in o- this measure.   I have never seen any ill effects arise from
such an introduction of  the hand and finger.   When the os
uteri is undilated, and the haemorrhage is great,  Dr. Simpson
recommends the  introduction  of  one of his sponge  pessaries,
with a  view to the mechanical dilatation of the os and cervix.
The only precaution necessary in such cases, as in all instances
in which sponge is used in the vagina, is not to  allow the sponge
to remain long enough  to become foetid.  The  ergot of rye and
the cannabis Indica may be given for their oxytoxic effects in
cases where it is  thought  unadvisable to remove  the ovum, or
portions of the ovum, mechanically.  Galvanism has  been sug-
gested  by Dr. Robert Barnes, and from what I  have seen of its
action in cases of  intra-uterine  polypi, I have no doubt it would
contribute to expel an ovum in a difficult case of abortion.  We
may turn  the  reflex connection between the  rectum and the
uterus to great account in the treatment of abortion when there
is no hope of saving the ovum.  A drastic cathartic enema will
often complete the expulsion of an ovum in the most rapid man-
ner.  Yarious  instruments  have been proposed and recom-
mended for the mechanical extraction of a partially-detached
ovum.   There  is, however, no  instrument equal to one or two
fingers when they can be introduced.   The last  invention of this
kind is an instrument proposed by Dr. Fleetwood  Churchill, on
the principle of the familar apparatus for getting a  cork from
the inside of a bottle.  In France, a  small forceps,  somewhat
resembling the lithotomy forceps, is used for the same purpose.
Dewees invented  a wire crochet for the extraction  of  the ovum.
   [A far better instrument is  the polypus forceps with rache*
handle, invented by Mr. Luer of Paris.  By its broad edges a
large portion of the ovum or placenta is seized, which is firmly 
REMOVAL OF EMBRYO.
197
held by the grooved edge, and  is not easily tearing away, as is
the  case  with  other  instruments  apparently more  conve-
nient.]
  It must be said, however, that, with all  instrumental devices
for the  removal of  the  embryo, there is danger of injuring the
uterus, and with the hand in the vagina, a case can hardly occur
in which the embryo, membranes, or portions of the latter, when
retained, cannot be  detached and brought away by the finger.
Time and patience  are  sometimes necessary for this manipula-
tion, but I have never known it to fail.
  [Any one who has had much experience has discovered the
difficulties which  not  unfrequently occur in  the attempt  to
remove the whole or the remaining detached head of an embryo.
When the  finger is  introduced into the cavity of the uterus, the
further  attempt to pass it around  the embryo, will, not unfre-
quently, push away the  uterus, so that almost insensibly the fin-
ger is out of the organ,  the hand upon the abdomen not suffic-
ing to hold the uterus down into the cavity of the pelvis. Then
the diameter of the head is greater than the diameter of the
undilated and rigid  os.
  To  obviate these difficulties I have invented the instrument
represented on p. 198.   The end A is moved by  a screw B in the
handle.   Being introduced straight, by the  side of the finger into
the cavity of the uterus,  the screw is turned by an assistant or by
the unemployed hand of  the operator.   This bends the end A,
till it is almost perpendicular to  the  staff, and is then to be
directed externally and  catching upon the internal os the uterus
may be  held firmly down while the finger can be moved freely
in the cavity.  When the ovum, embryo, detached head, or pla-
centa, is surrounded by the finger, the end A, can be so turned
as to  oppose  the finger,  catching what  may be between them,
retaining the neck  of the embryo (or polypus)  in the notch a /
crushing the head ; or assisting in the traction necessary for deli-
very.
  Advantage has been taken of  the mobility of  this instrument
to attach to it several other instruments which  may be seen in
the cut, so that by  unscrewing the spatula a, Simpson's sound
X, probe pointed bistoury W, scarificator, portecaustique Y, and
instruments may be  easily  substituted as desired.]
  I have seen cases  where  it was  necessary to give chloroform 
198               CHLOROFORM IN  ABORTION.

before introducing the hand.   In a case I saw with Mr. Ballard,
„ limiilitniiniTm
of a retained placenta in an abortion at the fifth or sixth
no other means would have enabled us to extract the rer 
CONDITION OF THE OVUM IN ABORTION.
199
the ovum.  The ofdinary modes of procuring its removal had
been tried in vain.   The patient was in such a  state of frenzied
excitement that any introduction of the hand would have been
impossible  while she  remained conscious.  The cord had bro-
ken  and the  placenta  had been retained thirty-six hours, and
there was no choice but that of leaving the placenta or giving
chloroform.  There was no difficulty in introducing the hand,
but the placenta had to be peeled from the surface of the uterus.
The dangers of  retained placenta are well known, and  in a case
of difficulty I should  not hesitate  to  advise the use of chloro-
form in  similar  cases.
  The condition in which the ovum is  expelled varies greatly in
different cases.   The most favorable way in which an early
abortion can occur is, where the detachment of the entire ovum
takes place before  the act of expulsion occurs.  The perfect
ovum is then expelled at once, and  the uterus  contracts without
much haemorrhage.  In other cases  the membranes are ruptured,
and the small foetus comes out alone or enveloped in the amnion,
or the membranes may be discharged piecemeal, leaving the
ovum to escape afterwards.  As a  general rule,-the membranes
remain  after  the expulsion of the foetus ;  and the  earlier the
abortion, the longer the membranes or placenta have  a  tendency
to remain.  This is probably owing to  the extended adhesion of
the ovum to the internal superfices of  the uterus, and the feeble
power of the uterus to contract on  its  contents.  Sometimes the
membranes of an early ovum will remain for weeks, but in such
circumstances there is not the same tendency to decomposition
and its dangers, as there is in the case of placenta  at the full
term.
  The mechanism of abortion varies considerably, according
to the time between conception and the term of naturallabor at
which the accident happens.  No doubt the abortion may occur
in cases where conception has taken place just before  a period,
when the motor act of expulsion would probably be limited to
the  Fallopian tubes, the ovum being carried out of the uterus
with the menstrual  discharge.   In  cases occurring in  the early
months, the canal of the cervix and  the os uteri have to be
dilated before the ovum can pass, and this process of dilatation
occupies a  considerable time, and  frequently  causes much suf-
fering.  When  the dilatation has occurred, the  ovum is expelled 
200
DANGERS OF ABORTION.
by the contractions of the  imperfectly-developed uterus.   The
contractions of the uterus  occur periodically,  and are accom-
panied by periodical  pains, as  in labor at the full term.   The
nearer the time at which the abortion takes place is to the time
of labor, the more closely do the pains and the motor action and
mechanism resemble those of natural parturition.  In abortions
occurring after the formation of the placenta,  the tendency, as
regards the expulsion of the ovum, is to imitate labor at the full
term.  The cervix uteri  is slowly dilated, the  membranes rup-
tured, and the foetus expelled,  to be  followed, at a longer or
shorter interval, by the membranes and placenta.   In the early
months,  the difficulty occurs, not in the passage of the  foetus
through the pelvis, but in the dilatation of the undeveloped cer-
vical  canal.   As  gestation advances, and  the  cervix  uteri
becomes developed, the difficulty of  passing through the cervix
becomes diminished, while that of passing the pelvis is increased.
When  the ovum is small,  the  contractions  of the uterus are
chiefly or solely concerned in its  expulsion ; but when it is large
enough to distend  the vagina,  the  abdominal  and respiratory
efforts are called into play.
  Usually, an  abortion is  not attended  by  any great danger.
Women recover rapidly from the loss of an ovum, and there is
a remarkable  aptitude for conception  afterwards.  They  do,
however,  sometimes perish  from loss of  blood, convulsions, or
rupture of the uterus.  They are also liable to the dangerous
and fatal affections which attend the puerperal  state.   Tetanus,
resembling the traumatic disease in  character, has been known
to occur after miscarriage, and  in rare cases blood has passed
through the Fallopian tubes into the  peritoneum, causing  death
by peritonitis.  Abortion occurring  from small pox and scarla-
tina is especially dangerous to the mother.  When women  abort
frequently, great damage is done to  the general health ; a pro-
found anaemia  is caused;  and patients may die of secondary dis-
eases arising out of the debility induced by the recurrent mis-
carriages.  When the whole of the ovum has been expelled, it
is rare  to meet with any profuse  post-partum haemorrhage.   The
uterus  is at once so diminished in size  as to prevent the risk of
bleeding.   It happens, however,  that occasionally small portions
of the membranes are left in utero and are a source of irritation and
bleeding for weeks after the loss  of the ovum.   When the entire 
                 TREATMENT  AFTER ABORTION.               201

ovum is extruded, or brought away completely in detached por-
tions, the woman is at once in  a state of ease.  A  discharge,
generally similar  to  the lochia, continues for some days.  As
regards rest and  other management, a patient, after a severe
abortion, should be cared for in the same way as a woman who
has been delivered at the full term—that is, she should be kept
in bed  and ordered  a light, unstimulating  diet, until she  has
regained  her strength.  The breasts are' sometimes  stiff  and
painful, but rarely give much trouble after an abortion.
  We must take cognizance of diseased states of the placenta in
the treatment and prevention of  abortion.   When the foetus is
threatened with death because the placenta cannot perform its
nutritive and respiratory functions, we may, through the mother,
act upon  the placenta, and  assist  it in  the performance of its
factions.  Dr. Power prescribed the inhalation of air containing
an increased quantity of oxygen, or the use of medicines contain-
ing a large proportion of ox}'gen in a loose state of combination,
as nitric acid, in cases where the  child has been lost repeatedly
in the latter months of pregnancy.  Dr. Simpson states that he
has found chlorate of potash  useful in cases where the fcetal  res-
piration is imperfect.  Every care should be taken in such cases
to keep the blood of the mother in a healthy state.   It is  evi-
dent that  the sanitary  condition of  the foetus must mainly
depend on the condition of  the  arterial blood of  the  mother,
this being the medium in which the embryo respires.  It  has
been recommended that, in cases of repeated  peritonitis or cere-
bral disease in the foetuses of the same mother, mercurialization
and other means should be employed with the view of reaching
the ovum through the maternal  circulation ;  but, in the present
state of our knowledge, our means of diagnosis in diseases of the
foetus are too obscure to render therapeutics of much value.  In
syphilis affecting  the mother, or when the father is syphilitic,
there can  be  no question  of  the  propriety  of mild  mer-
curialization as a means of warding off the dangers of abortion,
regard being had to the feet, that the careless use of mercury may
itself be the cause of abortion.  In the  prevention of abortion
from fatty generation of the placenta, the strength of the mother
should be supported in every  way. The chlorate of potash,  nitric
acid, mild preparations of iron, and, above all, fresh air, should
be recommended.  The treatment of fatty placenta should be
the same as fatty heart, or fatty degeneration of any other organ. 
202
PREVENTION OF ABORTION.
  The  prevention of abortion is an important  subject.   The
whole of the treatment of the disorders of pregnancy has a direct.
bearing upon  this subject.  In  women who abort from habit,
when the nervous system is chiefly concerned in  the production
of the accident, all emotional disturbance and reflex sources of
irritation should be avoided as  far as possible.  The  pregnant
woman  should not suckle, or be subjected to any mammary
irritation.    Mr. Lloyd  has related a  case in  which a small
tumor having  been removed  from the  breast of  a  pregnant
woman, she  aborted,  and died of  metritis.   Irritation of
the dental nerves should be  guarded  against.    The rectum
should be  remembered, not merely as a neighbor to the uterus,
but as possessing  an  excitor surface in reflex relation with the
uterus.  Ovario-uterineand vaginal irritation should be soothed,
and excitement avoided, particularly at the catamenial dates.
It is a useful point in the Periodoscope I constructed some years
ago, and some thousands of which have been used by the pro-
fession,  that it points out, at a glance, the  catamenial dates of
any pregnancy.  The late Dr. Griffin, of Limerick, recommend-
ed large doses of quinine  in  the case of women who  abort
repeatedly at the same date of pregnancy.  [I would especially
caution practitioners in this country from prescribing quinine to
pregnant  women  generally, and particularly where there is
much uterine  susceptibility.   In my experience  quinine will
more  surely produce abortion  than ergot, which does not seem
to have  the power to excite uterine action in a womb in a healthy
state, but acts  as a stimulus when there is a diseased condition,
or with  unusual susceptibility, as where labor pains have  com-
menced.]  Mr. White, of  Manchester, recommended cold or
tepid bathing,  with success, as a preventive of abortion.  Some
accoucheurs advise a daily enema of cold water, in women of
weak, irritable habit.   When the tendency to  abort is  very
strong, nothing is so likely to prolong gestation to the full  term
as absolute  rest in the horizontal position.   When  all  other
means fail, an  attempt should  be made tp eradicate the abortive
diathesis by a  year's  marital separation, and a tonic treatment in
the meantime.
  [Except in rare instances, the  haemorrhage before full time is
always preceding the delivery, while that at full  time  is  poste-
rior to  it.   Haemorrhage  not  unfrequently occurs at the next
menstrual period following conception.   The woman,  especially 
PERCEPTIBLE CAUSE OF ABORTION.
203
she who has never borne children, after half suspecting from
various signs that she was pregnant, at  her usual period is not
only u regular," but profusely so, with more than  usual  pain,
and with numerous clots which  have not previously character-
ized  her periodic secretion.   A careful examination of  these
clots  would discover imbedded in  them a rudimentary foetus.
The long formed habit of nature, conjoined perhaps to too vigor-
ous exercise, too stimulant food, or even mental emotions, caused
the secretion to be continued  as usual, and the ovum to be ex-
pelled.
  These cases are generally considered to be  simple monorrha-
gia, and are treated accordingly.  They rarely, if ever, result in
farther difficulty.
  At a somewhat later period in gestation, when the  ovum is
from two to five or six months, abortion is very frequent, when
the haemorrhage is alarming.   These occur from various causes,
and never  without a cause which  should be discovered by the
physician, and the difficulty obviated afterward.   This I wish
most especially to have noted, that wherever there is a miscar-
riage, THERE IS ALWAYS  PRESENT SOME ACTUAL PERCEPTD3LE AND
often tangible cause.  In many  cases  this  is  easily known.
Some  injury, sudden fright,  the effort of vomiting,  has  been
sufficient to destroy  the  integrity of the ovum, and  as a dead
substance,  as a foreign body, it has  been expelled.  This may
occur as the effect of mercury, quinine, or other medicines, or the
action of the uterus sympathetically stimulated by cathartics.
Great fatigue may be the existing cause of the expulsive uterine
action.  But there are many abortions  which have been con-
sidered to be without cause. Females have aborted without any
particular reason, every few months during many years, and the
physician,  in his ignorance of any  cause, has  stated that it was
from the force of habit;  that there was a tendency, from habit,
of the uterus to  throw off its contents upon  the least irritation
or excitement,  when  the ovum  arrived  at a certain  maturity.
Females have been made to believe, what the  physician himself,
once equally credulous, believed, that there was a " tendency to
abort;" and have been made to lie in bed for weeks and months,
made  sick by  want of air and  exercise, to prevent a senseless
organ, devoid even of the nerves of sensation, from  yielding to
the temptation  or tendency to abort. 
204         EVIDENCE OF THE  SPECULUM IN  ABORTION.
   Thanks to  the added wisdom of the  nineteenth  century, we
now  know  better than this.   The  new lights of science have
added ocular evidence to the vain  theories invented to conceal
our ignorance,
   At  the given  period,  or  thereabout, the  woman with  the
uterus having these bad habits, perceives that the usual vaginal
secretion is  slightly tinged with red, which by degrees  deepens
in color, till a decided  haemorrhage,  accompanied  by pains in
back, thighs, etc., with involuntary expulsive efforts, is  the re-
sult ; and sooner or later the foetus is expelled.  If one examine
the uterus, as  far as may be done by means of  the speculum,
either before these symptoms commence, or after the abortion is
completed, he  will find that there is local disease of the os uteri,
which is the fons et origo of all the trouble ; that there is uterine
congestion,  ulceration, or lesion of the epithelium, and  enlarge-
ment of the mucous follicles, or fissure of the os.
   Uterine congestion, as a cause of abortion, not unfrequently
depends upon  high-feeding—not too much in  quantity,  but too
stimulating  in its  character upon  the circulation.  This is  noticed
in animals.   Lewis S. Hopkins, M. D., says :

  " In the August number of the Farmer, complaints are made of abortion in cows.
  " High feeding has a direct tendency to produce this; if  a cow has done so once,
meal should be kept from her a month or  two before the anticipated period of
abortion, or during the greater portion of the period of gestation.   Many a female
of the human species  has only avoided the same "mishap," by strict attention to
diet.
  " Too high feeding,  with no hard work, often produces an irritability not only of
the nervous, but of the circulating system, in its minutest subdivisions, as spread
over secreting surfaces.  There is a greater tendency to this in the female system
than in the male.   The mare fed on oats, and but little used, will often become ex-
cessively snappish, and intensely cross.   Withdraw her  oats, and she  loses this
irritability ; or give her hard work, and the effect will be the same.  If  in the cow
this irritability of the secreting surfaces, induced by continued high feeding, is fed
and fanned by meal and grain, a tendency to >nf'animation is produced in the ute-
rus, which, during gestation, is the most irritable point in the system.  Nature has
no other way to relieve herself of this danger to the life of the mother, when the
meal and grain continue to flow in, than to prevent inflammation of the womb, and
death, by evacuating the contents of  the uterus.   The  increasing irritability of
that organ, excites its  repeated contractions, as at the full  period ; and abortion re-
sults, and the mother is saved at the expense of the young.  If the youn"- is carried
to maturity, it survives, and the mother dies of inflammation of the womb."

   Ulceration or lesion of the epithelium and  the enlargement of
the mucous follicles, as  the  second cause of abortion, depends 
CAUSE OF OFT-REPEATED ABORTIONS.
205
somewhat upon the situation of the placenta.   If high up at the .
fundus of the uterus, unless the abortion be effected early, the
current of blood is remote from the  abraded surface, which is
either healed by this derivative or remains in statu quo. Should
the placenta be inserted lower down, the tendency  to bleed is
much greater and  abortion more probable.
  In the greater majority of cases of abortion at the completion
of a certain  period, there is fissnrc of the os uteri.
  If we take the description of the changes of the os uteri during
gestation, as formerly believed aud  as  still described in the
books, we shall not be so well  able to  account for the fact that a
fissure of the os produces abortion.  But we take that given and
demonstrated by M. Stolz, already stated on page 13S, proving
that the change in the os uteri commences at the external os,
and not at the internal os.
  Now we know that the vast majority of cases where fissure of
the os exists, not only does it commence at the inferior extremity
of the cervix uteri, but that in far the greater number it is con-
fined to that portion.
  With  this fact  before us, and the  knowledge that  this  same
portion of the  cervix, in the progress  of gestation, first  com-
mences to soften and contract, we may  easily see the heretofore
unaccountable  cause for numerous  abortions.  The  softening
renders the already irritated portion,  to the  vessels of  which  an
unusual activity has been imparted,  still more  vascular.  The
subsequent contraction  draws apart  the sides of the fissure, ex-
poses  the orifices of the various vessels, a  slight  haemorrhage
ensues, which  gradually increases, till  the life of the germ is
destroyed, or the  bleeding becomes  so profuse as to stimulate
the uterus  to  the expulsion of its contents, or to endanger the
life of the mother.   An abundance  of  such cases are given by
Gooch, Dewees,  and other writers,  styled by  them  " irritable
uterus," but in which  the pathological changes were most un-
doubtedly  such as  have been  here  described.   This is  not a
fanciful theory, for which we  seek for facts to substantiate, but,
on the contrary, it is one deduced from facts.  Numerous cases
have occurred  in  my own  practice, and in those of my friends,
 which I have been called to see in consultation.
   A few marked  cases  only  will I relate, in a very brief man-
 ner, as illustrative.  A lady, about thirty years of age, was con- 
206
FISSURES OF THE  OS  IN ABORTION.
•fined with her first child at full time, after a very severe labor
 of some days' duration.  I saw her two  years  after, when she
 stated that she had never  enjoyed a well day subsequently to
 this confinement.  That she had nursed her infant about a year,
 constantly troubled by pain and weakness in the back and loins,
 accompanied  by a more or less  profuse, leucorrhoea.  That lat-
 terly she  had been much  debilitated by repeated abortions,
 occurring from about the second or third month of pregnancy.
 They commenced by  slight bleedings,  increasing to a profuse
 haemorrhage, threatening her life.  Vaginal digital examination
 discovered a  marked  prolapsus of the uterus when erect, but
 which subsided when in the recumbent position : the cervix im-
 mensely hypertrophied and ragged.    A better investigation
 with the speculum disclosed the os, so immense as to be scarcely
 admitted between the  fully distended blades of a  four-bladed
 Ricord, divided into  three  irregular-sized lobes, the  edges of
 which were covered  with profuse, unhealthy granulations, the
 whole surface denuded  of  epithelium, and  the entire organ
 bathed in a profusion  of the muco-purulent  secretion  usually
 accompanying these lesions.  The pase was a plain one.  The os
 had been torn in those  places at the first labor, and these lacer-
 ations, never  healed, were  a constant source  of irritation, and,
 when  pregnant, the undoubted cause  of all the abortions, sub-
 sequently.
   I will  mention but  one more case further  to substantiate the
 view which I have taken of this form of abortion.   I lay more
 stress upon it, because these cases have been one of the oppro-
 bria of medicine; and  having,  as I think, given a  conclusive
 proof of the theoretical cause of these affections, I wish now, by
 some cases plainly showing  the facts, as sustaining  the  theory,
 and from  which  I have deduced  the theory, to convince all of
 the correctness of this view, and to lead to a reformation in the
 past and present palliative  and temporizing method of treat-
 ment.   In the vast majority of these cases of irritable uterus, in
 nine out of ten, where there exists this periodical  tendency to
 abortion, cure is not only possible, but if the treatment proper
 for the affection be employed, the cure is as  certain as may be
 predicted in any disease that exists.   If, however, the  eyes are
 to be closed and the ear shut to the facts which the advance of
 science has revealed,—if, supine in our  conservatism, we  join 
CASE OF ABORTION.
207
with  the blind old fogy-ism in  its empty denunciation of the
speculum uteri, and its  immense utility in these affections,—
dogs  in  the  manger, we  neither use  it ourselves, nor permit
others so to  do,—worse  than the most arrant quackery, which
always proposes something new, and  thereby sometimes igno-
rantly benefits, we are content with the ashes of the past, instead
of seeking for living fire in the present; if thus contented in our
partial acquirement, there is henceforth no advance in science,
and the  unnecessary sufferings of millions remain unmitigated,
unassuaged.
   But my object is  not to'attempt to convince those " who see-
ing see not, and hearing hear not, neither do they understand,"
but merely to state my own views, in all simplicity, and some
of the facts upon which they are  founded.
   A  most instructive  case, to which I refer in consideration
of  several  views  here   presented,  is the  last reported by
myself in the American  Medical Monthly for  October, 1854,
entitled  " Fifteen  Selected Cases of  Operative Midwifery."
After  two confinements  at full  time, the lady  experienced  a
slight jar in stepping from her carriage.  She was daily expect-
ing her third confinement.  Pains soon came on.  She was speed-
ily confined  with a dead child.  Two years subsequently she
aborted  at about the third month.     This commenced with  a
slight  discharge of  bloody mucus, which was supposed by her
medical  attendant, and myself, to arise from fissures of the os,
and the next day was appointed for making an examination, but
before that time arrived  she had aborted, and her life was in
great jeopardy.  When sufficiently recovered, some weeks after,
from  the excessive haemorrhage, to  which  reference will be
subsequently made, her  physician found, upon examination by
the speculum, not only the local congestion to be  expected after
so'recent a confinement, but induration, and  fissures apparently
of long standing, and quite sufficient to account for all the diffi-
culty she had experienced.
  I might quote scores of similar cases from experience in the
Northern Dispensary, in the class of Diseases of Females, and I
am entirely convinced in my opinion of the origin of the hitherto
unknown or unsuspected  causes  of numerous  abortions as pro-
ceeding from local disease  of the womb, and not to be described
under the name of " irritable uterus," or any  other vague and
unsatisfactory appellation. 
208
TREATMENT OF ABORTION.
  The treatment of these cases is of two characters, viz.: the im-
mediate haemorrhage;  and secondly, for the cure of the causes
of the haemorrhage.
  When called early to a case of threatened miscarriage, when
the haemorrhage  is slight, and the symptoms indicate its local
character, from ulceration or fissure of the os, a speculum exam-
ination should be immediately instituted, and the parts, if found
in this condition, cauterized by nitras argenti, thus  temporarily
arresting the haemorrhage, and  the uterine  plethora allayed by
general bleeding, and  the  excitement quieted by  an anodyne.
Should this treatment be effectual, the disease of the os should
be subsequently treated by local  applications, until  the  parts
are  restored to their normal condition.
  If, however, the haemorrhage was not the primary symptom,
or if the abortion was threatened in consequence of some fatigue,
great exertion, or excitement, where there may be a debilitated
condition of the uterus, which, in its relaxed state,  opens the os,
or in some way diminishes the circulation, and impairs its vital
functions, I  have found great benefit from the tonic effects pro-
duced by small doses of secale  cornutum.   The slight contrac-
tion consequent upon  its action, closing  the  bleeding orifices,
and frequently entirely arresting all further discharge and dif-
ficulty.   This point I have already fully stated with cases illus-
trative, in an article  entitled, An Essay on  Ergot, with New
 Views of its Therapeutic Action /  published in the New York
Journal of Medicine for September, 1853.
  The cause of abortion will probably be allowed  to be  some-
times from a debilitated condition of the  organ containing  the
foetus.   The relaxed state  opens the os, or in some way  dimin-
ishes the circulation and impairs its vital functions ; the judicious
administration of ergot improves  its  tone, invigorates it  and
prevents the threatening miscarriage.   Ergot is not a medicine
of the cumulative order, neither is it confined to single action.
In  small doses it does not produce the convulsive, evanescent
contractions which accompany labor,  but  a slow molecular
character, permanent  and prolonged.   If this local tonic is
too freely  administered, it passes  on still further and then
a too high stimulation produces, from an opposite cause, exactly
the same result that was threatened by the previous debility.
  The bleeding in the cases I have mentioned, will rarely, if
ever,  be so  great as to endanger  life.   If  however, in  a case 
               ABORTION,  OR PLACENTA PR.EVIA.     •       209

where  the origin  of  the  flow  is doubtful,  it amount to  any
considerable quantity, the result will be to dilate the os, so that
the finger may determine whether there be placenta praevia.  If
so, we  should temporize,  by resorting  to perfect rest, external
and internal applications of ice, alum internally,—a large piece
passed into  the  vagina, and placed near the os uteri. These
means  will sometimes arrest the flow, to be repeated again at
some future  time.  If, however, the patient be at the full time,
or the  miscarriage cannot be  prevented, the next duty is to
rupture the membranes, either  through  the presenting placenta
by a small puncture, or, what is preferable when the  placenta
but partially covers the os, through the  membranes at one side.
Ergot should then  be  given in sufficient quantities to keep up a
continued contraction of the  uterus, and to  thus  force the pre-
senting portion of the child firmly down  upon the  bleeding
surface, and thus to dam up the flowing stream.  In this man-
ner the head forms a natural  tampon.   If this be not successful,
manual interference  must be  had recourse  to, and  the hand
passed through or by the side of  the  placenta, and the child
turned and delivered as speedily as  may be.   In  some cases the
vaginal tampon may be found advantageous, but rarely in this
form of trouble, when the child be d terme ! and in  general it
will be found  but a temporizing method of doubtful utility.
   When, by any accident, we have a detached placenta, the case
is indeed a grave and startling one, calling for great decision and
promptness of action.  It resembles rupture  of  the  uterus, in
many  of its  symptoms, and is often extremely hard to diagnosti-
cate.   The fluttering  pulse, anxiety of countenance, restlessness,
retrocession of the presenting portion, exist, as in rupture.  In
general, however,  the pear shape of the uterus is retained.   For-
tunately, the duty of  the  accoucheur is alike in each case.   Im-
mediate delivery is imperative.  From the prostration from the
loss of blood,  there is no rigidity of the os to interfere with the
introduction of the hand, and the immediate  delivery by turning
may be  effected, if the head has  so far retreated as to prevent
the  delivery  by the forceps.   I have seen but a few cases of
this form of difficulty, and  speak,  therefore from a limited ex-
perience.  There seems, however, to be no  other feasible  man-
ner of operating when these appalling accidents occur.]
                                14 
LECTURE XIII.
                  DURATION OF PREGNANCY.

  Gentlemen :—The question of the Duration of Pregnancy,
involving, as it does, the Cause of the Coming-on of Labor, is one
of the most interesting amongst the yet  unsettled problems of
Obstetrics.   It is  impossible to rest satisfied with the pious say-
ing of Avicena, that, " at the appointed time labor comes on by
the command of God," and we are impelled to attempt the pen-
etration of a mystery, which has been the subject of  numberless
theories and speculations, but which has hitherto  baffled all
attempts at its satisfactory solution.  It  may be said that at the
present  time obstetricians and physiologists are pretty nearly
divided  between two opinions, as to  the time of the duration
of gestation and the circumstances which influence its termina-
tion.  According  to one view the uterus  is excited to expel its
contents by the maturity of the foetus and its membranes.  Upon
the second hypothesis, the gravid uterus,  like the unimpregnated
organ, is ruled by the  catamenial periodicity,  and labor comes
at what would have been a  catamenial period, had  the woman
remained unimpregnated.  Both these ideas, in a more or  less
perfect form, are of a very ancient date.  Harvey, for instance,
taught that parturition came on at the tenth menstrual period
after conception.   Harvey's master, Fabricius, and  still earlier
authorities, held that labor came  on in consequence of the  matu-
rity of the foetus.  In my work on " Parturition," I have adhered
to the former view, and attempted to show that the ovaria  are
the organs which excite the uterus to  the act of  parturition.
While doing this, I have dwelt upon the  maturity of the embryo
at the time of labor, and urged it as a manifest instance of the
harmony of Nature, that the foetus should be perfectly developed,
and the placenta and membranes showing signs of unfitness for
their  functions, when the ovaria  excite the uterus  to expel its
    210 
THE DURATION OF PREGNANCY.
211
contents.  I  shall,  however, on  the present  occasion state as
impartially  as  I  can the facts which support,  or tell against,
either theory.
  The first  thing which  merits  our attention in this inquiry is
the statistical tables constructed by those who have kept regis-
ters of large numbers of cases.   The late Dr.  Merriman made a
very careful investigation into the duration of pregnancy, which
has been quoted by almost all subsequent writers on the subject.
He reckoned from, but without including, the last day of the last
catamenial period, and he gives a table of 150  mature births cal-
culated in this  manner.  Of these—

                  5 were delivered in the 37th week.
                 16     "      "   38th  "
                 21     "      "   39th  "
                 46     "      "   40th "
                 28      "      "   41st  "
                 18      "      "   42d  "
                 11      "      "    43d  "

This  variation  is very considerable, and the  question suggests
itself—In the  case of the fifty-seven women who  carried the
ovum beyond the fortieth week from the last  menstruation, was
the gestation protracted beyond the usual time, or was it  that
conception occurred one, two, or three weeks after the last cata-
menial appearance ?  To these questions we shall have to revert
hereafter.   Dr. Murphy has given a table of 182 cases, in which
the results were somewhat different from those  obtained by Dr.
Merriman.   In Dr. Murphy's cases, the numbers delivered in
the 40th and 42nd week were equal, twenty-five in each week;
while in  the 41st  week, thirty-two labors occurred.  The late
Dr. James Reid, in an elaborate  essay on  the Duration of
Human Pregnancy, begun  in 1850, and completed in The Lan-
cet in 1853, gives a table of the duration of  pregnancy in 500
cases calculating from the last day of menstruation.  Of these—

                 23 were delivered in the 37th week.
                 48      "       "    38th "
                  81      "       "    39th "
                 131      "       "    40th "
                 112      "       "    41st "
                 63      "      "    42d  "
                 28      "      "    43d  "
                   8      "      "    44th "
                   6      "      "    45th " 
212
DATE OF  CONCEPTION AFTER COITUS.
  These results prove, as in Dr. Merriman's table, that, calculat-
ing from the last day of the last catamenial period, considerable
variations in the duration of pregnancy occur.   Is there more
regularity in cases where the  duration of gestation, or the date
of the occurrence of labor, is calculated from the time of a single
coitus ?   Before entering upon this  topic, it must be  premised,
that in the case of the catamenia frequent mistakes are made by
the most careful women respecting the  time of  its  last appear-
ance.   Errors, intentional or unintentional, are still more likely
to occur in fixing the  time  of the coitus which  has resulted in
impregnation.  Many of these cases occur in unmarried women,,
in whom there is a very constant tendency to declare that the
fruitful  coitus has been a solitary one.  Dr. Reid, in the paper
referred to,  collects forty-three instances of conception  after
single coitus, all of them resting upon testimony as credible as
can be obtained in these cases.

            260 days after single coitus, delivery occurred in 1
            263        "       "        "        1
            264        "       "        "        2
            265        "       "        "        1
            266        "       "        "        2
            270        "       "        "        1
            271        "       "        "        2
            272        "       "        "        3
            273        "       "        "        1
            274        "       "        "        7
            275        "       "        "        2
            276        "       "        "        5
            278        "       "        "        l
            280        "      "         "         3
            283        "      "         »         2
            284        "      "         »         i
286
287
291
293
296
300
1
2
1
2
1
1

43
  Thus it will be seen from this table that the average duration
of gestation, reckoning from  a single coitus, is about  275 days.
But in this mode of calculating the term of gestation,  variations
quite as great as those wiiich occur in calculatinc from the cata-
menial  periods  are  met with.   Dr. Reid, who  wrote with  a 
TABLES OF COMPARATIVE GESTATION.
213
desire to show that the duration of pregnancy should be  calcu-
lated from the  time  of impregnation, rather than from the last
menstruation, was obliged to conclude as follows :  " If we allow
of a range from two to six days after menstruation  as  elapsing
probably before conception takes  place, it will then appear that
about the thirty-ninth week after  impregnation is more probably
the ordinary duration of pregnancy, and this will coincide with
the results of the table taken from cases of single coitus." This
means that we can calculate as well from  the  date of the last
catamenia, as from the date of conception, but that in one case we
must reckon thirty-nine, in the other forty weeks.  Upon which-
ever basis we make the calculation, it is proved that the duration of
gestation varies considerably, within  certain limits, and we must
look to other evidence than  that derivable  from such  tables,  to
show the real cause  of the  termination  of pregnancy, and the
occurrence  of parturition.   In animals, where the date of coitus
can be ascertained with greater  accuracy than in the human
female, the same variations  in the time  between impregnation
and parturition in  different  females  of the same species are
found to exist.   Thus the chief facts educed from these statisti-
cal data, are, that, in a large proportion of cases, gestation ter-
minates at a certain time, within the limits  of a few days, and
 that this time bears pretty  nearly the same relation to the cata-
 menial dates, as the dates of fruitful coition.   Dr. Reid's is the
 largest cases of conception from  single coitus  which has been
 made, and the result yields the 275th day as the average  time
 for the occurrence of labor.   In the calculations from the cata-
 menial dates, Dr. Reid's cases give the same result as those of
 Dr. Merriman, the average  time  of the  coming on  of labor
 being the 40th week from the termination of the catamenia.  If
 we  get two cases of pregnancy  in women in  whom the  cata-
 menia appeared at the  same  time, the  date  of parturition may
 vary within certain  limits.   The same variation  occurs  in the
 cases of two females to whom  impregnation  occurred  at the
 same time.  If we look to the results obtained from the observa-(
 tions made upon comparative  gestation, the same  variation
 of the  duration of pregnancy, as calculated from  the date  of
 intercourse, is found;  and in animals the utmost accuracy as
 regards dates can be procured.  Baron Tessier found that the
 average duration of pregnancy in 160  cows was nine months 
214    AGE OF PARENTS  INFLUENCING LENGTH OF PREGNANCY.

and ten days ; but of this number 68 went beyond the 280 days,
in 20 gestation lasted 300 days, and in  5 instances it was pro-
tracted to 305 days.  The late Earl Spencer had the duration of
gestation accurately noted in 764 cows.   Pregnancy lasted on the
average 285 days.  In 8 cases only was this period exceeded by
more than 12 days, and only one went 18 days beyond this time.
These results  differ somewhat from those of Tessier, but there
are no grounds for questioning the  accuracy of the observations
in either case.   Other observers have found the same variations
in the  gestation of the  cow.   Similar  variations  have been
observed in-the gestation of mares, and in elephants; and in the
smaller animals, where  gestation lasts a shorter  time, notable
variations in the time of coming on of parturition are found to
occur.   The last hypothesis respecting the variable duration of
pregnancy  is  that advanced  by Dr.  Clay,  of Manchester, who
argues from cases which have occurred in his own practice, and
the facts known  respecting the duration of gestation in animals,
that the younger the  parent the shorter is the term of gestation.
Dr. Clay believes that the ages of both parents  influence  the
duration of pregnancy ; but dwells particularly upon the influ-
ence of the mother.
   There is  a class  of cases not hitherto  noticed,  by which  the
•duration of pregnancy  from the time of coitus may be ascer-
tained with considerable certainty.  In 1851, Mr. Coleman, of
Surbiton, drew  my  attention to the  following circumstance:
Two ladies, patients of his, were married on the same day, and
both were delivered within ten hours of each other.  The mar-
riage took place on the 7th of May, 1850, and one was confined
on the afternoon of February 8th, 1851, and  the  other  at two
a.m., on the 9th, or 276 days from the date of marriage.   Both
had menstruated a few days before marriage.   I have collected
a  good  many  cases  of this kind, and they show that in  the
majority of those in whom labor occurs within the forty-first or
forty-second week from marriage, the  deliveries  occur  before,
rather than after, the 280th day from marriage.  It is usual for
marriages to take place shortly after a  catamenial period,  and
the inference is, that in these cases impregnation  must have
occurred within  a few days after marriage.  Such cases tend to
confirm the table of  Dr. Reid, in which the average duration of
labor was 275 days from the date of coitus.   They do not, how- 
            MALES THE RESULT OF LONG  GESTATION.        215

ever, bear distinctly upon the determining cause  of labor, and
probably no mere statistics will ever settle the question.  I now
proceed to state the arguments in favor  of the maturity of the
ovum as the exciting cause of parturition.
  Those who consider the maturity of  the foetus to be the
cause of labor, point to the periodicity observed  in the growth
or flowering of plants,  the  separation  of ripe fruit  from the
stalk, the leaf from  the stem,  the regularity with which the
young birds are hatched from the shell,  the regular appearance
and shedding of the teeth, and  similar  phenomena of growth
and development, as favoring the idea that the foetus  separates
from  the womb, and excites  the phenomena of parturition,  in
consequence of an inherent periodicity occurring as part of the
development of the embryo.  Dr. Carpenter refers to the pla-
centa as the organ upon which the contraction  of the  uterus
depends.  He draws an argument in favor of this  opinion from
the phenomena of superfcetation,  in which one child is  detached
from the uterus, a second remaining undetached, apparently  in
consequence  of the immaturity of the placenta.   Dr. Simpson
has advanced the opinion, that " the loosening or  decadence  of
membranes and placenta  from the interior of the uterus  consti-
tutes the determining cause of parturition ;  and that this loosen-
ing or decadence is itself the result of  the effete degeneration of
the structure of the  decidua towards the full term  of preg-
nancy."  In the observations of  Lord Spencer, it was found that
gestation with males  had a  tendency to  continue a  few days
longer than gestation with females.  There is a popular belief
that this occurs in the case of males in the human subject.   In
our fishing towns, where  the dates of the absence of the husband
are known, it is said that when gestation is  prolonged beyond
the usual term, a boy is expected, and that  this expectation is
generally fulfilled.   Lord Spencer also found that  cows in calf
by a particular bull had a tendency to go a few days longer than
those  impregnated  by other bulls in the herd.   Those  who
oppose the view that the catamenial dates rule the duration  of
pregnancy, ask why parturition should occur at the tenth rather
than at the eleventh or any other menstrual period ?   But this
may be replied to by other questions—why, for instance, should
the catamenial period, as  the rule, consist of twenty-eight days?
or why should puberty come on at a particular  age ?   The only
• 
216      REGULARITY IN MENSTRUATION AND GESTATION.

answer  is,  the  fact  that  these  particular  periodicities  do
occur.   In animals the  periodicities  of  oestruation  are little
known,  particularly in the wild state, but  it is asserted that  the
larger animals do not cestruate sufficiently often to render it pos-
ble that in their case the duration of gestation can be a multiple
of an cestrual period.
  There is one point which has already been adverted to in con-
nection  with menstruation,  and which is supposed  to militate
against  the  ovarian theory of the cause of labor.  As  the
rule, we have seen that the  menstrual periodicity recurs every
twenty-eight days ;  but in some women the period returns a day
or two earlier or later than this with considerable  regularity.
Others  are  regular every fortnight, or every three  weeks; or
the period returns only every five or six weeks.   What multiple
of the catamenial periodicity is observed in such  cases ?   I have
carefully noted all the cases I have met with of this  kind, and
I find that in such women  the duration of pregnancy is more
irregular than usual.  The future collection of such cases will be
very valuable in elucidating the true cause of labor, far more so
than cases in which the last date of menstruation and the occur-
rence of a single coitus are recorded.   It  is said by some who
oppose  the  ovarian theory, that if the ovarian  or  catamenial
periodicity ruled the coming on of labor, the date of  parturition
should always be exactly 280 days from the last menstruation.
This  is hardly a valid objection, inasmuch  as in the most regular
females, the  catamenia often appear a few days before, or a few
days after, the expected time, yet no one on this account refuses
to accept  the ordinary monthly periodicity as the rule amongst
women.   The irregularities in the duration of gestation are cer-
tainly not greater than the irregularities observed in menstruation.
  The argument in favor of the ovarian influence, as a determining
cause of labor and as regulating the duration of pregnancy,  has
now  to be stated.  It is allowed by all  observers,  that labor has a
tendency to occur, and does occur in a great proportion of cases, in
the fortieth week from the last menstruation ; and it is equally al-
lowed, that impregnation has the tendency to happen just after the
catamenial period.  It is also made out by the record of a consider-
able  number of cases, in which a single coitus occurred, that gesta-
tion lasts,  on  an average, about 275 days from the actual date of
impregnation.  These data make the average  duration of preg-
• 
             OVARIAN INFLUENCE IN GESTATION.           217

naucy approach 280 days from the last catamenial period, so that
the time between the last catamenial period and the occurrence of
parturition is on the average, very nearly a multiple of a single
catamenial period. This is a curious coincidence, even if it were
proved that the uterine function of parturition was quite inde-
pendent of the ovarian influence.
  But we know that the uterus  performs some of its most
important  functions under  the influence  and control  of  the
ovaries.  It is allowed, even by those who deny the influence 01
the ovaria upon parturition, that the catamenial function is ruled
by the ovaria, that the ovarian phenomena may  occur without
menstruation, but that menstruation never  occurs without the
influence of the ovaria.  It is admitted by almost, I think I may
say all, practical accoucheurs, that the influence of the ovaria are
felt during pregnancy, that women feel  uneasiness at the cata-
menial dates, and are more liable to abort at these times than at
others.  This is particularly the case with women who have suf-
fered from dysmenorrhoea previously to pregnancy.  In certain
cases of extra-uterine gestation, as, for instance, in abdominal
pregnancy, the development of the foetus has frequently gone on
to the usual limit of  pregnancy, when violent pains, as of labor,
and contractions of the  enlarged uterus, have come on.  Dr.
Ramsbotham observes on this point:  " It is a curious circum-
stance in the history of these cases, that if the child should live
till the term of gestation is completed, as soon as that time has
expired, the uterus takes on itself expulsive action, which is  at-
tended with pain similar to the throes of labor ; and, during these
pains, the deciduous membrane is expelled from the cavity with
more or  less sanguineous  discharge."  Cases have been not
unfrequently met with in which the ovum has been blighted in
the middle  part  of pregnancy, and in which  the decidua and
chorion have been diseased ;  but the mother has carried the dis-
eased ovum for a considerable time, or to the natural  limit of
gestation,  when  the molar  or  degenerated  ovum has  been
expelled.   There is another class of cases in which  twin gesta-
tion is proceeding; but one  ovum  dies, yet the uterus  is not
excited to contract, but the dead and living ovum go on to the
full term.  In cases of superfcetation, when one living child has
been born and birth has been given to the second some time sub-
sequently to that of the first, I have found  that  there is  a ten- 
218
CASES OF 6UPERFCSTATION.
dency to some multiple of the catamenial period in the inter-
val between the  birth of  the  two children.  Dr. Fleetwood
Churchill has given an account of the three most  remarkable
cases of superfcetation on record ; and I proceed to  an analysis
of these cases, quoting the words of Dr. Churchill:
  "In the 'Recueil de la Societe d'Emulation,' there is the case
of M. A. Bigaud, of Strasbourg, aged  thirty-seven,  who was
delivered of a living 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  months and a half after the first
delivery) she brought forth a second apparently mature and
healthy child."   The first  labor occurred on the last day  of
April, so that we have the thirty-one days of May, thirty days
of June,  thirty-one days  each of July and August, and seven-
teen days in September—in all, one hundred and forty days from
the first to the second birth,  or exactly five  catamenial periods,
5 x 28=140.  In a case related by Desgranges, of Lyons, to con-
tinue the account of Dr.  Churchill, " 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."  In this case we have eleven days in  January,
twenty-nine in February (it being leap-year), thirty-one in March,
thirty in  April, thirty-one in May, thirty in June, and six in
July, between the two births, in all one hundred and sixty-eight
days, or  precisely six catamenial periods,  6x28=168.  The
third case noted by Dr. Churchill is as follows, from the account
of the late Dr. Maton, in the fourth volume of the "Transactions
of the College of Physicians " :—" Mrs. T----,  an Italian lady,
but married to an Englishman, was delivered of a male child at
Palermo, November 12, 1S07.  On the 2nd of February, 1808,
not quite three  calendar mouths after the preceding accouch-
ment, 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."  If
we include  the  day on which the first child was  born, the time
between  the births amounts to eighty-three days, or within one
day of three periods of twenty-eight days.   In these cases it is
impossible not to recognize the close adherence  to the ovarian
periodicity, and it is difficult to imagine that this  could be a 
               EXPERIMENTS  UPON THE OVARIES.           219

mere coincidence.  All such facts militate against the supposi-
tion that the irritation of the uterus by the mature foetus and its
membranes induces  labor;  and  support the view that it  is
excited by extra-uterine and ovarian influence.  There is also
another class  of facts which tells against the hypothesis that
labor depends solely upon the maturity of the foetus and the pla-
centa and  membranes, and, as a consequence, in favor  of the
ovarian periodicity.   Instances are frequently met with in which
the  placenta  becomes  prematurely mature  and caducous,  or
affected with  degeneration, and the child dies in utero shortly
before birth.  It is well known that in certain women this hap-
pens many times in succession, the placenta becoming ripe, and.
positively unfit for  the performance of • its functions, without
exciting the uterus to expel its contents.   It is difficult or impos-
sible to account for such cases on the supposition that the mature
ovum excites the  uterus to the  efforts of  labor.  It  is not that
there is any special adhesion of  the placenta and membranes to
the uterus in these cases ; for if the foetus lives in  a feeble condi-
tion up to the time  of labor, it separates from the uterus with
the first pains, and causes the death of the child.  On the other
hand, labor comes on just as regularly in cases in which the pla-
centa has  adhered so firmly to the uterus, in consequence  of
inflammation, as to require mechanical detachment after labor.
   In 1850 I performed some experiments, with a view to  deter-
mine the possibility of exciting  the uterus  to  contraction  by
irritating the ovaria.  In these  experiments I had the valuable
aid of  the  late Mr.  Henry Smith, who  assisted Dr.  Marshall
Hall in his great course of experimental inquiry.  We found
that in the  gravid rabbits chloroformed, and with the abdomen
laid open, irritation of the ovaria by galvanism, a heated needle,
or pinching with the  forceps, excited distinct contractions of the
uterus and vagina.   In the rabbit at the middle period of gesta-
tion, after a few contractions of the parturient canal had been
excited artificially by irritation of the ovaria, the  intermittent
contractions of ordinary parturition went on until the foetuses
were expelled, artificial parturition being thus excited by ovarian
irritation.   Berthold experimented upon  animals during gesta-
tion by extirpating  the ovaria, and found that  this  operation
invariably led to abortion.  1 have heard that  Dr. Simpson a 
220    RESULT OF EXPERIMENTS ON  THE CAUSE OF LABOR.

few years ago  performed some  experiments with a different
result from those of Berthold, but  I believe  these experiments
have not been published.   In my  work already referred to, I
have shown that in  many of the  lower animals, ovulation and
oestruation are going on at the  time of parturition, and that
many of them admit the male, and conceive again on the same
day that the uterus has been emptied.
  I have thus advanced, and I trust impartially, the arguments
and facts for and against  the theory of the ovarian cause of
labor, which I believe I was the first to propound.  I have for
many years taught that the ovaria, acting at, or near the tenth
period from the time of the  ovulation which has ended  in im-
pregnation, excite in the uterus those changes which lead to the
expulsion of the ovum.  I have also compared the show which
accompanies parturition, and the lochial discharge which follows
it, to the menstrual discharge.  It has  appeared to me, that the
changes in the uterine portion of the membranes are similar to
the changes which occur in menstruation, and that  the contrac-
tions of the uterus resemble  those  more imperfect contractions
which occur  in  many women at  the catamenial periods, and
which we do not hesitate to refer  to the ovaria.  I believe there
are some facts which do not admit of explanation upon the sup-
position that the cause of labor depends on the maturity of the
ovum ; as, for instance, the occurrence of uterine contractions at
the end of gestation in cases of extra-uterine fcetation.  I believe,
on the contrary, that as to the facts which  appear  to militate
against the ovarian theory, most of them admit of explanation.
  In a practical  point of view, we  may consider that the aver-
age duration of pregnancy is about 280 days from the  date of
the last catamenia, or about 274  or 275 days from the  time of
coitus, when this can be ascertained.  As the  date of fruitful
intercourse can only be known in rare and exceptional cases, we
are compelled to date from the last catamenia,—the point which,
from time immemorial, has been  the foundation of the calcula-
tions  of women and  their attendants.   I constructed  the
periodoscope upon the data that  conception generally occurs
a few days after the completion of a catamenial period, and that
labor may be expected on some day of what would  have been
the tenth period, had pregnancy not intervened.  I have now 
PERIODOSCOPE.
221
for some years used this instrument in practice, and found the
results generally correct.   It is at the same time a mode of cal-
culation and a diagram of pregnancy.
   Those who calculate from the last  menstruation and those
who date from  conception, may equally use  the periodoscope.
The cases in which the date of fruitful coitus can be known are
rare, and for practical purposes the few days succeeding the last
menstruation may be  taken as the date of that event.   Five
days after the last menstrual date are marked in the following
diagram as the time within which conception generally takes
place:—
                            Fig. 59.
                       PARTURITION
Diagram of the Periodoscope. 
222             OBSTETRIC READY RECKONER.


  [The following table is much in use in the United States.:—

         TABLE FOR CALCULATING THE PERIOD OF UTERO-GESTATION.
NINE CALENDAR MONTHS.
From	To	Days.
Jan'y 1	Sept. 30	273
Feb'y 1	Oct. 31	273
March 1	Nov. 30	275
April 1	Dec. 31	275
May 1	Jan'y 31	276
June 1	Feb'y 28	273
July 1	March 31	274
August 1	April 30	273
Sept. 1	May 31	273
Oct. 1	June 30	273
Nov. 1	July 31	273
Dec. 1	August 31	274
  The  above  Obstetric " Ready  Reckoner"  consists  of two
columns, one of Calendar, the other of Lunar months, and may
be read as follows:—a Patient has ceased to menstruate on the
1st of July; her confinement may be expected at soonest about
31st of March, {the end of nine Calendar months) / or at latest,
on the 6th of April, {the end of ten Lunar months.)  Another
has ceased to menstruate on the 20th January; her confinement
may be expected on the 30th September, plus 20 days, {the end
of nine Calendar months) at soonest; or on the  7th October,
plus 20 days, {the end of ten Lunar months) at latest.]
TEN LUNAR MONTHS.	
To	Days.
Oct. 7	280
Nov. 7	280
Dec. 5	280
Jan'y 5	280
Feb'y 4	280
March 7	280
April 6 May 7 June 7	280 280 280
July 7 August 7 Sept. 6.	280 280 280
 
LECTURE  XIY.
              MOLAR  PREGNANCY—BLIGHTED OVA.

   Gentlemen :—Certain matters  are  occasionally  discharged
from the virgin or impregnated female,  which it becomes neces-
sary to distinguish from the  results of fecundation.  These con-
sist of masses of squamous epithelium from the vagina, fibrin-
ous collections from the cavity of the uterus, and the membran-
ous product expelled in some  cases of dysmenorrhoea.  There
can be no difficulty in deciding on the flakes or tubular pieces of
squamous epithelium, exfoliated from the vagina.  The fibrinous
masses expelled from  the uterus resemble an almond in size and
shape, being to some extent casts of the uterus ; they are smooth
externally, and possess  a very  imperfect central  cavity.   The
dysmenorrhoeal product consists of  the uterine mucous  mem-
brane, exfoliated in a more or less perfect form.  When entire,
it has the shape of the cavity of the body of the uterus, is rough
externally, and smooth within,  having  a distinct triangular
cavity, with two openings above, and one below,  at the sites of
the  Fallopian tubes and the  canal of the  cervix uteri.   There
are of course, no traces of funis, membrane, or foetus.  Examin-
ed microscopically, the squamous epithelial masses consist of
quantities of epithelial scales ; the  fibrinous masses are  com-
posed of filaments of fibroid material  arranged in bands, and
myriads of grandular   corpuscles,  similar  to exudation cor-
puscles ; in the true dysmenorrhoeal  membrane, the convoluted
utricular glands are found with their openings on  the smooth
internal lining of the cavity, and ccecal extremities of the glands
upon the rough or external surface.  The older writers included
polypi  and fibrous tumors  in the list of moles ; but  the above
constitute what are now considered False or Spurious Moles.
   The Genuine Moles, which are the result of impregnation,
are of various kinds, consisting of different forms of degenera-
                    '                                   228 
224
WHAT ARE MOLES ?
tion of the  membranes of the ovum.   We can readily distin-
guish the varieties of mole depending on the carneons or fleshy,
    hydatiginous, and the fatty and other degenerations of the
      •anes.  None of  these cases can occur without conception.
         great confusion prevailed  upon this subject.  Many
            ved that fleshy moles might occur in nuns and others
              ■> virgins, without  the  occurrence of intercourse.
1               Hat hydatids were  independent animals, and
that                was compatible with  the  purest chastity.
Denma.               sometimes originated in the uterus  as
independe.               id Sir Charles Clark was of opinion
that uteri'               .it  exist apart from pregnancy.  Cases
are recc              .1  uterine hydatids  have been retained
long be            .al period of gestation.   Madame Boivin,
Baude1           1, Desormeaux, and Velpeau,  are  quoted by
Dr. V      ;     as being in favor of the belief  that this form
of d'           jvum  may  be  retained for many months  or
eve-          .• the ordinary date  of labor.  I am not aware
tin"           t case of this  kind has been  observed.  The ten-
d'  .         modern research,  however, has been to demon-
p           e genuine mole  cannot occur except as the result of
           n, and as the  degeneration of a true ovum.  In some
          l  twin  conception, one foetus has disappeared under
         ice of hydatiginous degeneration, while the  other has
 ■ ■  ■   1 healthy up  to  the full  term.  It is related of the
       ed  Beclard, that  he was born  under  these  circum-

      en an  ovum is rendered unfit for continuing the develop-
ment  of the  embryo in  the early weeks of gestation, by the
effusion of blood between the membranes, or into the substance
of the cliorion, or by other  disease of the  membranes, it may
not be expelled at the time, but remain in utero, and undergo
the changes which constitute carneous  degeneration ; or  there
may be a partial separation of  the ovum from  the uterus, fol-
lowed by an  attempt to  repair the mischief by the reunion of
the separated portions.  The  fibrin of the effused blood becomes
pale and semi-organized, and a  perverted nutrition of the mem-
branes goes on. The diseased membranes increase in bulk but
become dense, and quite unfitted for the  development of the
foetus, which remains of the same bulk  as when the effusion or 
CARNEOUS  DEGENERATION OF THE  OVUM.
225
separation commenced, or it may become atrophied.  This may
continue for  three  or four months, until at length the degene-
rated ovum is expelled, consisting of the nest-like membranes
and a small embryo of two or three weeks' growth, or in some
cases the foetus may have disappeared, and traces only  of the
umbilical cord remain.  Such are  the main  points connected
with carneous degeneration  of  the  ovum.  It has often been
pointed out that such cases are of considerable importance in a
medico-legal point of view.   A husband, for instance, may have
believed his wife pregnant, and after his  absence from home for
several months she may abort on his return, of a foetus so min-
ute as  to give rise to a  suspicion of her fidelity,  unless  such a
matter  could be explained by the death, retention, and degene-
ration of the  ovum.

                           Fig.  60.
Blighted Ovum with Carneous Degeneration of the Membranes.
  The next form of embryonic degeneration to be considered, is
the hydatiginous variety.   The latest and best account of hyda-
tiginous degeneration of the ovum is that by Dr. Barnes, in
the British and Foreign Medico-Chirurgical Review, contained
in the volume for 1855.  In this article, the origin of the disease
from the perverted  growth of the villi of the shaggy chorion is
                              15 
226
WHAT ARE HYDATIDS ?
very  clearly traced.   When treating of the  cliorion and pla-
centa, we have  described  the clavate  villi of the chorion, and
the layers of cells  which they contain.   These villi increase by
a process of gemmation or  budding, very similar to the growth
of the roots of a tree.  From the sides of one villus, other villi,
by a process of cell-growth, sprout out, and from these, in turn
others arise.  Under  normal  plastic  influences, a  due  pro-
portion  is preserved  between  the  increase  of  the nutrient
and  depurative  powers of the chorion  and  decidua, and  the
requirements of  the enlarging  embryo.  But it  sometimes
happens  that this  growth  of  the villi is abnormal, and the
cells they contain increase in size, and become dropsical, consti-
tuting the hydatiginous degeneration of the ovum.  The hyda-
tids themselves, in the recent state, are full of transparent fluid,
and are either round, pyriform, or oblong in shape, the size of
the vesicles varying  greatly.   Some of them  are borne upon
pedicles, others are growing from the walls of larger hydatids.
Mr. Paget, following Mettenheimer, has pointed out that, on the
walls of the primary vesicles,  buds appear and develop into
separate  hydatids, just as  the buds protrude from the healthy
villi,  to  produce, by normal  growth,  new  villosities.   The
pedicles of those hydatids, which appear stalked, are formed of
the remains of the base of  the  villus at the expense of which
the hydatid has been formed.   As  a rule, the  activity of the
growth  and the increase of the villi are, Dr. Barnes observes,
greatest in  early pregnancy,  and it is at this time that the
hydatiginous degeneration is  most prone to occur.  Drs. Rams-
botham and Montgomery believe that small portions of placenta,
retained in utero after parturition at the full term, may become
the nucleus of  hydatiginous formations ; bnt  Dr. Barnes com-
bats this view, from the general history of hydatiginous forma-
tions, and the destruction of the  fcetal vessel of the  placenta,
which occurs at the time of birth.  This question is a very inter-
esting one, and must be considered as unsolved.   Ko doubt, the
tendencies to the formation  of hydatids diminish with advancing
pregnancy,  but  it  is not  clear  that  there  is  any difference
between a portion of placenta adherent to the uterus after labor
at the full term, and the whole placenta adhering to the uterus
after the death of the foetus, but without exciting the expulsion
of the ovum.  This form of degeneration frequently commences 
*
                    GROWTH OP HYDATIDS.                 227

at a very early date of gestation, and  the  destruction of the
embryo is much  more complete  than  in the fleshy variety of
mole.  Growth  is limited to  the  cliorion and the diseased villi,
so that all traces of the foetus  generally  disappear,  the  uterus
being filled  with a mass of hydatids, of  various sizes.
  The uterine hydatids were compared by  Gooch to currants,
and by Cruveilhier to a bunch of  grapes.   Dr. Barnes  quotes
the objections of Mettenheimer to the comparison of Cruveilhier,
and  gives  the  description  of Mettenheimer himself.   This
accurate observer considers  the chorion, which is itself a large
vesicle or bladder, as the  centre of the whole growth.   On the
walls of this great vesicle, a  new generation of cysts is formed,
and each of these cysts has the power of producing one or many
daughter cysts;  or, to use his precise words, "Berry grows out,
of berry,  and the  stalks do not unite berries with the principal
steins, but berries with berries, and, lastly, with a central mother

                          Fig. 61.
Portion of an hydatid Mass.
cyst."   This  arrangement of the vesicles is very well shown in
the above  engraving of a portion of a mass  of hydatids, from
a preparation of Mr.  North, in  St.  Mary's  Hospital.  In the 
228            FOETUS FLATTENED  BY PRESSUKE.

patient furnishing this preparation, enormous quantities of hyda-
tids were expelled at  the fifth month, the symptoms being alter-
nate haemorrhage and watery discharge.
  In the third form of degeneration, occurring at a later period
of gestation, the placenta may become  so diseased  as  to  be
unfitted to carry on the nutrition of the foetus, or the foetus may
die, or be destroyed by disease of the cord without in either case
inducing separation of the placenta from the uterus. The nutri-
tion of the placenta may go on more or less imperfectly, and the
foetus under  these circumstances,  becomes  shrunken and atten-
uated to  an extraordinary degree.   It sometimes occurs that this
is the case in twTin gestation.  Indeed, it  seems more  prone to
happen in twin than in other cases.  It may then occur that the
shrivelled foetus may  be  expelled  at some  period of pregnancy,
the uterus retaining the other to the  full  term, or the shrivelled
and the  living embryos  may be retained  together,  and  the
woman delivered of a full-grown foetus and one of  two or three
months at the full term.   Such cases are  often confounded with
cases of superfcetation.  I once attended a patient in a delivery
at full term, who, four months before, had aborted while return-

                         FiG. 62.
          Blighted Ovum, with Carneous Degeneration of the Membranes.

ing from the West Indies.   Dr. Simpson  has pointed out, that
when the dead foetus is  retained with a living twin, it becomes
flattened by pressure between the living ovum and the uterus of 
               SYMPTOMS  OF MOLAR PREGNANCY.           229

the mother.  Dr.  Barnes is of opinion that ill fatty degenera-
tion, of the placenta to such an extent as to destroy the embryo,
two or three weeks from the death of the foetus is the usual time
within which the uterus is excited to expel its contents;  but I
have  seen one  well-marked  cause of fatty  degeneration,  in
which the foetus died at  the  fourth or fifth month, but was not
expelled until the full term.   It is in the highest degree proba-
ble that in all cases of death  and  retention of the  ovum,  after
the formation of the  placenta, the retained  membranes become
the subject of fatty degeneration,  and that  this  also occurs
to  a  considerable  extent  in what are are  called fleshy moles.
  The symptoms of molar  pregnancy vary considerably in the
different forms of this disease.   In the carneous moles there is an
arrest of the breeding symptoms, and the patient remains out of
health.   The ovum,  from  the time of its  death, becomes  to  a
great extent a foreign body, and is a source of irritation to the
system generally.  No increase of size takes place, so that, at the
fourth or fifth month,  the  uterus may not be larger  than it
should be in the fifth or sixth week of normal  pregnancy.   The
complexion is muddy, and the breath foetid, with loss of appetite
and digestion.  Haemorrhage frequently occurs as the  degenera-
tion of the membranes proceeds, but not to any great extent, on
account of the  small size of the  uterus.  There is sometimes  a
constant sanious discharge, in which case the health suffers  more
than  usual.  But in  many of these cases, the symptoms, it must
be  confessed, are very obscure.  This is because the death of the
ovum occurs before the symptoms of pregnancy assume a positive
form, and  while the uterus is comparatively  undeveloped, so
that there is a considerable resemblance between  these  early
moles, and the mixed cases of amenorrhcea and  monorrhagia met
with in practice.
  In the hydatid mole, the symptoms are more strongly marked
than in the fleshy variety.   When the  ovum has taken on the
hydatiginous form of degeneration, the increase  is often  enor-
mously rapid, so that at the fifth or sixth month the  abdomen is
as large as it should be at the end of pregnancy, or even larger.
The shape of the uterus is frequently altered from the usual  pyri-
form  outline, its growth extending laterally on both sides;  or it
becomes irregular in  form.   With the marked increase  in  size,
there  is the absence of all foetal movements, and of the sounds of 
 2oO                SYMPTOMS OP HYDATIDS.

 the foetal heart, combined with a dense uterine tumour.   There
 is frequently also, after the three or four months of suspension
 of the catamenia which attends pregnancy, a copious discharge
 of water and blood, or of water slightly tinged with blood, resem-
 bling red currant juice.  This occurs at irregular intervals, and
 in variable quatities.  The watery discharge is accompanied by
 pains, and appears to be caused by the breaking  down of num-
 bers of the larger hydatids.  These symptoms  are sufficient, in
 most cases, to make the nature of the affection plain.  In a sus-
 pected case, the discharges  should be carefully examined, and, of
 course, the detection of a single hydatid, or of a portion of an
 hydatid, renders the  diagnosis certain.  Little  information is
 acquired by digital examination in  cases of hydatid mole, when
 the degenerated mass remains altogether within the uterus.  But
 the other cases in  which a discharge similar to that commonly
 met  with in hydatids occurs, are  cauliflower excrescence, and
 certain cases of polypus, in which the disease can readily be made
 out by examination.  The  loss  of health caused by hydatids is
 often of the gravest  character,  from the quantity of watery and
 sanguineous discharge.  Owing to the extensive  attachment of
 the hydatid  mass, its separation is sometimes attended  by flood-
 ing  equal  to that  met with  in placenta-prsevia.   Profound
 anaemia, failure of the heart's action, dropsical swellings, and
 even  paralysis, have  occurred in  the course of  this disease.
 Sometimes masses  of hydatids are discharged  from  time to
 time; but portions of the diseased structure being left behind,
 the growth goes on afresh, and  reduces the patient to the great-
 est extremity of weakness.  Two or  three wash-hand-basinfuls of
 hydatids have  been  expelled from the uterus  at once in some
 cases.
  The  moles occurring later in  pregnancy, or in which simple
shrinking of the foetus and degeneration of the  placenta occur,
 have their special symptoms,  and may, with care, be recognized
 by the attendant during their progress. As in the other form of
 mole, there is a recession of the ordinary signs  of pregnancv.
There is also an arrest of increase, and a positive diminution  of
size in the abdomen.   The auscultatory signs of the livino- foetus
are altogether wanting.  Either quickening does not occur, or
after having been felt, the movements of the child cease.  Peris-
 taltic actions of the uterus may  occur, but these  can readily bo 
REMOVAL OF HYDATIDS.
231
distinguished from the movements of the foetus.  Haemorrhage
generally  occurs  as  the  degeneration of the  placenta, and its
partial separation from the uterus, goes on.   The loss of blood
may be constant and slight; or it may occur  occasionally, and
to a considerable  extent.  This depends on the successive separa-
tion of portions of the placenta in consequence of disease, and
the irregular contractions of the  uterus.  In this form of a re-
tained ovum, as well as in the fleshy mole, there is frequently a
disagreeable discharge, and the health of the patient becomes
greatly deteriorated by the irritation of the dead mass, the loss
of blood, and the  poisoning of the circulation  by the absorption
of foetid material.
   The treatment of molar pregnancy consists in emptying
the uterus of its diseased  burden,  and in supporting the strength
of the patient, and warding off accidents while the mass remains
in the uterus.  In the carneous moles of small or moderate size
active treatment is very much impeded by uncertainty of diag-
nosis.  If in a case of suspected molar pregnancy the life of the
mother should be threatened, the  ovum should be detached by a
catheter or the uterine sound, without hesitation.  The ergot of
rye may be given, with a view to the arrest of bleeding and the
excitement of uterine contractions ; but in ordinary cases we are
obliged to wait, as in abortion, until the ovum presents at the
os uteri, or can be reached with the finger, before we attempt to
remove it.  If the diagnosis of this  form of  molar pregnancy
should become, as we may hope it will, more perfect and certain
than it now is, we might separate  the ovum by the sound, dilate
the os and cervix by sponge tents, or excite the uterus by gal-
vanism.  In the case of hydatid  degeneration the treatment is
more positive.  It is  usual  in  such  cases to give the ergot of
rye to induce uterine contraction. If the os uteri is dilatable.
we may introduce the hand, and  detach the hydatid mass.  Dr.
Gunning S. Bedford  relates the  case of a woman in extreme
danger from loss  of blood, in which he successfully broke down
the hydatids with a  female catheter.  The hydatids  are some-
times attached very firmly, and I once saw a  case in which the
uterus had been ruptured by the  violence of its contractions in
expelling an hydatid mole.   In the case of a retained ovum  with
degeneration of the placenta, the membranes should be ruptured, 
232        AFTER-TREATMENT OF MOLAR  PREGNANCY.

and the  expulsion of the diseased  ovum brought  on, as soon
as the mother's health suffers seriously, or the nature of the case
becomes  unmistakable.   The after-treatment of such cases is
much the same as after ordinary abortion ; but it  must be said
that the  health is more broken after molar pregnancy than by
the results of simple abortion. 
LECTURE   XV.
  SUPER-FCETATION--EXTRA UTERINE GESTATION--MISSED LABOR.

  Gentlemen:—The term Super-fcetation is applied to cases
in which  one gestation having  commenced, a second  super-
venes upon it during the continuation of the first.  We must,
before approaching this curious subject, separate certain cases
which simulate super-fcetation  to  a certain extent, but  are
altogether distinct  from it.   For instance, we referred in  the
last lecture to cases in which a woman may be delivered of a
blighted ovum,  and carry on a second foetus to the full term ; or
in which  a gravid woman may produce a full-grown foetus  and
a shrivelled ovum at the natural time of parturition.   Cases are
also met with, in which a patient is delivered of two children at
the same  time,  one of which is considerably more  developed
than  the  other.  Such cases are termed retarded  twins, and it
is 'doubtful whether in the  case  of twins,  conceived at  the
same time, the  retarded ovum may be  retained  in  the utero
beyond the natural term.  The  instances here severally referred
to, are altogether different in principle from cases of super-foeta-
tion, inasmuch as they depend not upon a variation in the time
of conception, but upon a difference in the time of  development
or expulsion, apart from any variation in the time of  fecun-
dation.
  There are several conditions under which super-foetation may
take place; and as the fecundation in twin cases  has an inter-
esting relation to this subject, I may mention the chief circum-
stances under which twin impregnation occurs.  It is probable
that in many cases of twin pregnancy the second ovum has been
fecundated by a coitus occurring subsequently to  the first im-
pregnation, and  such cases form the most simple  instances of
super-foetation.   But this is not always the case.  In rare instan-
ces, in twins, the placenta is found  to be single,  and I  would
                                                       283 
234         OVA IMPREGNATED AT DIFFERENT TIMES.

suggest that these  are  cases in which one ovule has contained
two yolks and two germinal vesicles, just as we  sometimes see in
birds, one egg with a double  yolk, producing two individuals.
In these cases the twin impregnation must occur at thesametime.
More frequently the placentae and membranes are double, but the
placentae are placed  side by side, and in these cases  two  separ-
ate ovules have probably descended from the same ovary, and
have been impregnated either at the  same or at different  times.
In some cases the placentae are attached to opposite sides  of the
fundus uteri, the inference being that the ova  have descended
from  the two ovaria, but they may have been impregnated by
a single coitus  or otherwise.   In all these cases5 impregnation
occurs within a  short space of time,  and the same preparation
of the uterus serves for  the  twin  fecundation.  We have the
positive proof that  twin  ova may  be impregnated at  differ-
ent times, in the history of cases  in which a white  woman is
delivered of a white  and of a black  child, or in which a  black
woman produces a black and  a mulatto, at one birth.  In the
slave  states of America, cases of the latter kind are so common,
as to  place  the  matter beyond doubt.  Numerous authorities,
including Buffon, Dewees, Dunglison, Beck, and others, testify
to the facts, that a white woman married to a white man, and
admitting a negro to her embraces after intercourse with her hus-
band, may  give birth to a white and a mulatto child at  the
same time, or that a negress receiving a white man under simi-
lar circumstances, may produce  a black and a mulatto infant.
In animals which produce many offspring at a birth, it is not at
all unfrequent for  the young to be the product of intercourse
with different males.  Dr. Henry,  in his excellent essay on
Super-fcetation,  quotes  a case which occurred in the Brazils
where the indigenous race is  copper-colored, but where  there
are negroes and whites, in which  a  Creole woman had  three
children at a birth, of three different colors, white, brown, and
black, with all the features of their respective races.
  Cases are on  record,  in  which women, the  subjects of  extra-
uterine gestation, have conceived  anew, and borne children,
while the extra-uterine foetus has remained  in the  abdomen.
M. diet, of Lyons, relates a  case  which had  fallen  under his
own observation, in which a woman died suddenly, and  upon
dissection, an extra-uterine foetus of  five months was found in 
SUPER-FG3T A TION.
235
the abdomen, while a foetus of three months occupied the uterus.
Cases of abdominal gestation, in which the foetus becomes enclosed
in a cyst, and  the woman bears other children, are less uncom-
mon than the  above.   Dr. Montgomery details the particulars
of an interesting case, in which, two years after an extra-uterine
gestation, a woman conceived,  and bore  three  children in suc-
cession,  while the  extra-uterine  foetus  remained  encysted.
Many  other writers have recorded similar cases.
  In another variety of super-foetation, the uterus preserves the
form met with in the lower  animals, being bi-cornual or bi-cor-
poreal, and a  conception occurs first in one side of the organ,
and after a time  in the other.  It has been  observed that in
cases of this kind, when one uterus has received an ovum, the
other cavity develops a deciduous membrane,  a circumstance
which  has been urged  by Dr. Lee and others against the pro-
bability of the occurrence of pregnancy in a double organ at two
different times.   Numerous apparently  unexceptionable cases
are, however, on  record.   The museum  of the University of
Modena  contains the  uterus of a woman who died of apoplexy
in 1847.  This woman  had borne many  children,  and on one
occasion she became  pregnant, and was  delivered on the 15th
of  February, 1817, of a child apparently at the full term.  The
abdomen diminished  on one side only, after her labor, and on
the 14th of March, she gave birth to a second mature child.
This case was regarded at  the time, by Professor Bignardi, as
one of super-foetation,  with double  uterus, and this diagnosis
was confirmed on a post-mortem examination, thirty years after-
wards, by Dr. Generali.  Of the authenticity of this case there
can be  no doubt.  It  may be urged that  it was only a  case of
retained and  retarded  twin; but  the probabilities are  against
such a supposition, and numerous  confirmatory cases have been
observed by Cassan, Voigtel, and Boivin, in wrhich a considerably
longer time occurred between the birth of the two children.  It
is worthy of remark,  that  in cases of double or divided uterus,
the two portions of the organ show signs of imperfection. Abor-
tions are very frequent in such cases, and delivery is difficult
from the imperfectation of the uterus.  The term double uterus
is not strictly correct, because  the organ is single, but divided
into two cornua.   In the early condition of the human embryo,
the uterus is always divided, and the so called double uterus 
230
DOUBLE UTERUS.
is merely the more or less perfect  persistence  of the embryo
type.  Occasionally the vagina is also doubled or  divided.
                             Fis. 63-
Uterus in which the cavity is divided by a septum, the vagina being single.

                    Fig. 64.
Bifid condition of the uterus and vagina.
  But in addition to these forms of super-fcetation, other cases
are on record, in which the uterus was proved to possess a sin-
gle cavity.   In one  related  by Professor Eisenmann, of Stras-
bourg, a woman was delivered of  a second child  140 days after
the birth of the first, both having been mature.  She subsequently
bore   many other  children,  and  after  her death the  uterus
proved to be single.  Unless we discredit this and  similar cases 
OPINIONS  OF  SUPEE-FGETATION.
237
recorded upon good authority, we must conclude that in  addi-
tion to the fecundation of two ova at short intervals by two male
parents, the occurrence of intra-uterine pregnancy after the com-
mencement of extra-uterine gestation, and conception in a second
uterus during the course of gestation  in a first, pure and simple
cases  occur, in which, while a single  uterus is occupied by one
ovum, a second fecundation takes place in the same cavity, some-
times within the limits of the third, fourth, or fifth months of gesta-
tion.   A little more than a year ago, I saw with Mr. Eardley of
Westbourne-terrace, the following  case:—A  young married
woman, pregnant for the first time, miscarried at the  end of the
fifth  month, and  some  hours afterwards a small clot was dis-
charged, inclosing  a perfectly fresh and healthy ovum of about
one month.  There were no signs of a double uterus in this case.
The patient had menstruated regularly during the time she had
been  pregnant, and was unwell three  weeks before she aborted.
She has since been delivered at the full term.
   Many obstetric  writers  have  combated the  occurrence of
genuine super-foetation  from  the difficulty of  explaining the
occurrence of a second pregnancy while the development of an
ovum is going on in utero, so that it may  be well to  say a few
words upon the subject.
   Dr. Fleetwood Churchill is of opinion that the  difficulties in
the way of receiving the theory of super-foetation are almost in-
surmountable.   He considers the  deciduous membrane to be a
shut  sac covering the orifices of the os uteri and Fallopian tubes,
and that the plug of tenacious mucus secreted by the cervical
canal, as  well as the mechanical  arrangement of the decidua,
apparently render it physically impossible, that the spermatozoa
and the ovule can come in contact.  Dr. Ramsbotham considers
it impossible to  suppose that a second impregnation can occur
while the uterus is occupied with another ovum, and that the
mucous plug of the cervix,  and the decidual lining of the uterus,
" would prevent  the possibility  of a fresh conception taking
place."   Many other obstetricians agree  with  these excellent
authorities.
   It can, however, be  shown that there is  no  positive physical
obstacle to the occurrence of super-fcetation in the mechanical
closure of the canal of the  cervix uteri, or the uterine apertures
of  the Fallopian  tubes  by mucus  and  decidua.   I  have, 
238
THEORIES OF SUPER-FCETATION.
I think, demonstrated, by numerous microscopical examinations,
that the mucous  plug of pregnancy is in no respect different,
except in quality, from  the  mucus found in the cervix in the
unimpregnated state, and through which the active spermatozoa
must make their way in ordinary fecundation.  I have  pointed
out that it is, in fact, similar to the secretion formed by  the pro-
state, as the medium for  containing the spermatic particles.  As
regards the difficulty presented by the decidua  at the  os uteri
internum  and the uterine  apertures of  the  Fallopian tubes,
William Hunter taught that the decidua was  perforated  at these
points—namely, the upper part of the cervix and the tubal ori-
fices, and no one has ever shown to the contrary. I have  seen
numerous preparations which prove that in early pregnancy the
decidua stops short at the upper part of the cervix, leaving an
opening into the canal of the cervix, and that the two apertures
of the  Fallopian tubes are distinctly pervious from the uterus.
In the  first three  months the ovum  consists  of  a bag which is
only attached to one portion of the parietes of the uterus, leav-
ing the cavity between the decidua vera and reflexa perfectly
free.   Professor  Simpson  and  Dr.  Matthews  Duncan have
pointed out  that in this  way the communication between the
vagina and the ovary may be free for a certain  time after the
commencement of gestation.   Thus, with the exception of the
mucous plug, there is no mechanical impediment between the
os uteri  and the  ovaria, and  we  have  seen that the  cervical
mucus  forms no insuperable obstacle  to the ascent of spermato-
zoa.  Super-foetation, then, cannot be denied from the presumed
impossibility  of its occurrence.  As  the  bag of the ovum in-
creases in size, so as to occupy the whole of the fundus uteri, the
mouths of the tubes are pressed upon  by the ovum, but  the cer-
vical, orifice remains open, with  the exception of  the  mucous
plug, until the end of gestation, except in placenta preevia.  The
infrequency of super-foetation probably depends more upon the
absence of perfect ovulation  during pregnancy, than upon any
positive mechanical impediment to the ascent of the spermato-
zoa, or the incapacity of the  decidua vera to receive a second
ovum.
  The  ovum may be impregnated,  or  become attached  and
developed, at any period between  the upper part of the cervix
uteri and the Graafian follicle, or it may fall into the abdominal 
EXTRA  UTERINE PREGNANCY.              239
cavity.   Whenever  the impregnated ovum does not enter the
cavity of the body  of the uterus, it is called Extra-Uterine
Gestation.   The several situations in which this grave error, so
to speak, of the generative functions may occur, constitute the
different forms of extra-uterine pregnancy.  These varieties are,
the  ovarian,  ovario-tubal,  tubal,  ventral, and  interstitial  or
parietal.  In  Ovarian gestation, the ovum is impregnated in,
and attached to, the Graafian follicle or the external surface of
the ovary.  In Ovario-tubal gestation, the ovum is attached both
to the ovarian and fimbriated extremity of the Fallopian tubes;
but it is probable that in the first instance the ovum adheres to
one  of  these  organs  only, and becomes attached to the other
during its development.  In tubal gestation, the ovum lodges in
the Fallopian tube.   In Ventral  pregnancy, the .ovum  appears
to miss the tube, and becomes attached to the peritoneal surface,
generally amongst the convolutions of  the  small intestines.
There is one  other form of misplaced  ovum, which  is usually
called a  variety of extra-uterine  gestation, although, strictly
speaking, it is not extra-uterine.   This, which has been made
out by Breschet, is  termed' Insterstitial or Parietal gestation.
The ovum lodges  near the point  at which the Fallopian tube
enters the uterus, and forms a  nidus in the walls of the uterus
itself.  The ovum in these cases becomes surrounded by a layer
of the muscular coat of the uterus, similar to the  layer which
surrounds the majority of fibrous tumors developed in the walls
of the uterus.   The ovum, in this form of gestation, is developed
in a kind of sub-cavity, formed in the upper part of the uterus,
or between the uterine layers  at  one of the Fallopian  angles.
We may compare  this form of gestation in some respects to pla-
centa praevia,  in which the attachment of the ovum takes place
at the os uteri internum.   One or two rare cases have been
observed, in which the ovum must  have been developed at the
very point of junction between the tube and uterus, where the
placenta has occupied the uterus, while the rest of the ovum  has
been contained in a cyst formed by the dilated Fallopian tube.
  The tubal is the most common form of extra-uterine gestation.
The  ovum becomes  enveloped in the  chorion,  a  decidua is
formed, as indeed is the case in all the varieties of extra-uterine
pregnancy, and a pouch is developed in the tube, the muscular
fibres of  the  tube being increased to  a  considerable  extent. 
 240        SYMPTOMS OF EXTRA-UTERINE PREGNANCY.

 There is, however, a briefer limit to this than to any of the other
 forms of extra-uterine gestation.  It is seldom prolonged beyond
 the second or third month, at which time, either from thinning,
 distension, or erosion, the cystic portion of the tube is rent, and
 the embryo escapes.  In very rare cases the tube continues to
 enlarge, and the embryo remains in its  cyst to  the  end of  the
 natural term of gestation, or  even beyond this.   If the ovum
 remains in the tube long enough, an attempt at the formation
 of the placenta is made, this organ being very thin and vascular,
 and it is at the part opposite  the  attachment of the placental
 tissue that the rupture of the tube usually takes  place.  Con-
 temporaneously  with the development of the embryo in the
 tube, a decidual membrane is  developed in the uterus in many
 cases, though this does not occur invariably:
  The symptoms of tubal pregnancy are in a great measure
 the symptoms of all the varieties of extra-uterine gestation.  The
 uterus is felt to be somewhat developed, but not to  the extent
 which obtains in intra-uterine  gestation.   It is high up in the
 pelvis, so as often to be  beyond the reach of the finger, though
 it  is  sometimes  lower  than natural.   Menstruation  generally
 ceases, but there is  an  occasional sanguineous discharge  from
the uterus in some cases, and there is sometimes an absence of
nausea  and  vomiting.  The  ordinary changes  occur  in  the
breasts.  The tumor of pregnancy is felt high up, and chiefly on
one side of the abdomen. Altogether the uneasiness experienced
in these cases in  every variety  of extra-utero gestation is greater
than in ordinary pregnancies, and  often gives  the patient the
idea of some unnatural  condition.  When  the tube  bursts,
the patient, generally without any premonition, is seized with
agonizing pain,  followed  by  ghastly pallor, fainting, hurried
breathing, and fatal  collapse.  Cases have, however, been met
 with, in which little pain has attended the rupture of the tube,
the symptoms being those of pure  collapse.  On dissection, the
ovum is found in the abdomen, with a rent in the tube, and a
large quantity of blood in the peritoneal cavity.  At the time of
the bursting of the tube, there  are  indications of uterine excite-
ment,  and an attempt  at detaching the  decidua where this
structure exists.  Death is evidently caused by the loss of blood
and by the shock incident to the effusion  into the peritoneum.
The treatment is unhappily almost nil.  Pressure and cold have 
CURIOUS CASE OF TUBAL  GESTATION.
241
been recommended.  Restoratives and opiates have been given
to allay pain and support the patient, but very rarely with any-
thing beyond the most transient good effects.  As, with a rare
exception or two, all these cases have proved fatal, if the diag-
nosis were perfect, it might afford a bare chance of safety, in
such a desperate conjuncture, to open the abdomen, and attempt
to arrest the flow of blood by deligation of the tube.

                           Fi& 65.
Case of tubal gestation.
  Some years since, Dr. Oldham wrote to ask my opinion upon
a curious circumstance which he had observed in a case of tubal
gestation.   It  was, that the corpus luteum was found  in  the
ovary opposite to the side on which the ovum was lodged.
Three explanations suggested themselves.   The unimpregnated
ovule might have been swept  by the cilia of the peritoneum
from the right ovary to the fimbriated extremity of the left tube.
This would be similar to that which occurs in the amphibia, in
which the ova always traverse the abdomen to  reach the ovi-
duct.   Or the left  tube may  have reached over to the right
ovary, and have taken up the ovule.   This was  the opinion to
which I believe Dr. Oldham and Mr.  Wharton Jones inclined.
According to the third explanation, it might be, that the ovule
had descended the right  tube,  entered the  uterus, and then
ascended through  part  of  the  left tube, by an antiperistaltic
action, or the ciliated currents, which move from below upwards.
My own opinion was in favor of the ovule having  entered  the
uterus by one tube and ascended by the other.  Such  cases are
very interesting in relation to  the causes of extra-uterine fceta-
tion.  Dr. Oldham has  now collected  three cases of this kind,
                              16 
242
CAUSES OF EXTRA-UTERINE GESTATION.
so that they cannot be very uncommon.  The  following wood-
cut is taken from a drawing of one of Dr. Oldham's cases.

                          Fig. 66.
 Tubal pregnancy, with the corpus luteum on the opposite side.  The decidua is in process of
detachment from the uterine cavity.

  As regards the causes of extra-uterine foetation, many hypo-
theses have been advanced.  It is believed that there is a greater
tendency to  this accident in the unmarried than in the married,
and some curious cases are on record, in which it has  happened
in women who were the subject of fright or terror at the time of
coitus.  In these cases emotion would seem  to be a  cause.  In
the ovarian and ovario-tubal varieties, it is suggested that inflam-
mation of the mucous lining of the follicles,  or of the  indusium,
or the extremities of the tubes, may have caused adhesions of
the ovum, and it has  been said that these  forms are prone to
occur in courtezans,  in  whom  ovario-tubal inflammation and
adhesion are common.  In tubal gestation, there may have been
large size of the ovum, feeble peristaltic action  of the tube, or
inflammation of the  tubal mucous membrane.  In vental  preg-
nancy, the cause would seem to be the faulty action of the tube
in grasping  the  ovary.   In the  interstitial cases  the ovum has
been supposed to lodge in some fold or depression upon the sur-
face  of the uterus.
  In ovarian pregnancy, the early symptoms are the same as
in the tubal variety, but the catastrophe  does not occur so early,
nor does death take place with the same rapidity.  The ovum is
in some cases attached to the interior of  the Graafian vesicle, the
placenta combining with the corpus luteum, or it is seated upon 
RESULTS OF EXTRA-UTERINE PREGNANCIES.        243
the internal surface of the ovary.  In the former cases, impreg-
nation occurs within the mucous follicle, and the ovule probably
never leaves its primary nidus.  There is, as in the tubal variety,
a thin placenta, and the decidua, chorion, and amnion are formed
within the  sac.  Sometimes death happens as suddenly as in
tubal gestation, from the shock and loss of blood  attending the
rupture of  the ovary ; in others, the  ovarium increases  in size,
and the foetus goes on to the full term, when it dies, and may be
retained for a considerable period.  When this happens, the case
follows the course  to be presently described, when treating of
the termination of ventral pregnancy.  In  this form of extra-
uterine pregnancy, a more or less perfect  decidua is formed in
the uterus, and there are constant and violent attacks of uterine
pain, accompanied by sanguineous discharges.  Of the occasional
occurrence of ovarian pregnancy there can be no doubt, though
it has been questioned,  chiefly upon  theoretical grounds,  by
Yelpeau and others.  I believe, however, that cases have been
ranked in this variety in which no pregnancy of an}r kind  existed.
Even in the celebrated essay of Dr. Campbell, cases are admitted
which are  open to doubt.   In the case of Louise Adelaide, for
instance, on a  post-mortem  examination,  a pouched tumor,
occupying  the situation of the left ovary, was found, containing
hair, teeth, bones, and greasy matter.   This may, however, have
been a case of ovarian disease without impregnation, in which
such structures are sometimes found.  The changes in the ovary
consequent upon the discharge of an ovule and the formation of
a spurious  corpus  luteum have also, before the function of ovu-
lation was  understood, been mistaken  for commencing  ovarian
gestation.  In the undoubted cases, the entire foetus has been
found  within the sac, or escaped from a perforation of the ova-
rian cyst.   The rupture  of the ovarian  cyst in  extra-uterine
cases is generally preceded by uneasiness and pain in the tumour,
and seems  to  be effected by an inflammatory process.  In the
interstitial  form of gestation, the development of the foetus usu-
ally goes on to the full term.
  In ovaria-tubal and ventral pregnancy, the ovum draws
its  nourishment more  easily than  in other  cases, and the
structures surrounding it yield, so that the tendency is to go on
to the full term of  pregnancy.  The auscultatory sounds are the
same as in  natural  pregnancy, but the limbs of the foetus are felt 
244       DISORGANIZATION OF EXTRA-UTERINE FCETUS.

with great distinctness; hardly more so, however, than in some
cases of intra-uterine gestation, where the parietes of the uterus
are of unusual thinness.   If the cyst containing the ovum bursts,
the symptoms  are similar to those which occur in ovarian or
tubal cases, but less severe.  The accident generally happens at
a  later period,  when  the pressure  of the surrounding organs
appears to restrain the haemorrhage.  When rupiure does  not
occur, the foetus has a tendency to perish at what would be  the
time of parturition; uterine contractions with the expulsion of
the decidua generally occur; there is a local discharge, and milk
is secreted.  The death of the foetus is sometimes attended by
violent movements and convulsions, of which the mother is sen-
sible.  These phenomena  are  probably the result of asphyxia,
induced by the unfitness  of the  placenta to continue its func-
tions.  In some cases the child has been considerably larger than
at the full term, and it has been supposed that it has lived one
or even two months beyond the usual time.  After the death of
the foetus, a  process of disorganization  slowly commences, the
bones separate, and the soft parts become converted into adipo-

                           Fig. 67.                   .
Case of abdominal pregnancy.
cerous material.   It may become smaller and smaller, the  cyst
contracting  upon it, and remain for a great number  of years 
             ART IN EXTRA-UTERINE PREGNANCIES.          245

without  causing any  considerable inconvenience.  More fre-
quently,  however,  it causes great irritation  and inflammation,
the residual mass attempting to make its way to the surface, or
to the rectum and bladder, to be discharged.   This process is
attended by suppuration, hectic, colliquative sweating and diar-
rhoea, great suffering,  and deterioration of the  general health,
which, spreading over a long period, very commonly destroys
the life of the patient.   Cases, however, occur in which perfect
recovery ensues.
  The treatment of such cases must be considered in relation to
the time  preceding and subsequent to the death of the foetus.
Dr. Campbell records nine cases of ventral pregnancy, in which
gastrotomy was  performed before the  death  of the foetus,  or
shortly afterwards, and all died, probably because  of the vascu-
lar connection of  the  placenta  with  the  abdominal  viscera
Nature appears to be more happy in  her mode of proceeding,
and when the remains  of the foetus point either upon the surface
of the abdomen, the vagina, bladder, or  rectum, Art may step in
and assist the process very efficiently.   When the fcetal abscess
has burst, the opening  may be enlarged to allow of the extrac-
tion of the extraneous matter, which consists of a mixture of
bones, fatty matter, and the remains of the  placenta, which is
generally converted into a soft purulent mass.   Of thirty cases
in which, according to Dr. Campbell, gastrotomy, or the dilata-
tion of the breach already effected by suppuration, was practised,
twenty-eight recovered.  During this process, which may occupy
months or even years,  the strength of the patient has to be sup-
ported, abscesses dealt  with, and inflammatory attacks treated as
they arise.  In the rare  cases in which, in  ventral pregnancy,
the cyst presents low down  in  the  pelvis, and the parts of the
child  such as the head, hands, or feet, can be felt through the
vagina, an incision  through the vaginal walls into the cyst is a
much more favorable  operation than simple gastrotomy.  Dr.
Campbell states  that  of nine cases in which  incision of the
vagina was performed,  in three both mothers and infants were
saved; in two the  mothers only recovered; in one the  child
alone  was preserved ; while in three, both mothers and children
perished.
  The present may  be  a proper time for mentioning a very curi-
ous and extraordinary obstetric and physiological phenomenon. 
246        EXTRAORDINARY OBSTETRIC PHENOMENON.

far more rare than either super-fcetation or extra-uterine gestation,
nd having  some relationship with both these  abnormal condi-
tions.  I allude to what has been called Missed  tabor, in which
the foetus being in utero, parturition from  some unascertained
cause does not come on at the usual time, but the foetus dies, and
remains included in the uterus without causing the  immediate
death of the  mother.  Dr. Oldham  exhibited the  uterus and
remains of  a foetus, from a most interesting  case of this kkid at
the first meeting of the Pathological Society in 1846.  In this
case the child was felt in utero, the fact having been ascertained
by Dr. Oldham himself, so that no error can be imagined: but
parturition  did not occur, nor any attempt at parturition.  The
child died,  and became disorganized,  portions of the foetus dis-
charging themselves or being removed through the os uteri for
the course of three months from the date of  the parturient nisus.
At the end of this time the woman died ; and on making a post-
mortem examination, Dr. Oldham found the remains  of  the
foetus, consisting of a moulded mass  of bones  and adipocerous
matter.  This  mass had apparently  worn through  the interior
wall of the uterus, apparently as an aneurism makes its  way
through the tissues with which  it is in contact,  and was  in
an imperfect cyst composed of the posterior wall of  the uterus
and the abdominal parietes.   There had been no sign of rupture
of the anterior wall of  the uterus at  any time.  The fundus of
the bladder was nearly eaten  through, so that if the woman had
lived, portions of the foetus would probably have escaped from
the urethra.   Dr.  Simpson states that similar  cases of  missed
labor are sometimes met with in  cows and  other animals, and
that, as in the above case, the bones of the foetus became moulded
into a compact mass, which may remain a long time in utero.
The following wood-cut represents the residual mass removed
from the cyst after death, by Dr.  Oldham, who  has  kindly
allowed me to have a drawing taken :—
  From the similarity of symptoms in this  case to  those cases
of abdominal extra-uterine   gestation  in  which  the foetus is
retained, becomes  encysted, and  is discharged by the  bladder
or rectum, it is quite possible  that cases of missed  labor have
been sometimes mistaken for ventral pregnancy.  The treatment
in cases of missed labor should evidently be  to excite the uterus
to contraction, if possible, by galvanism or  other means, when 
REMARKABLE PATHOLOGICAL SPECIMEN.
247
the time of labor has passed and the child has been  ascertained
to be dead, or to combine those means with attempts to break up

                          Fig. 63.
Contents of cyst in Dr. Oldham's Case of Missed Labor.
 the foetus and extract it through the os uteri.  When  this time
 has passed by, such cases resemble ventral  pregnancy, and  re-
 quire  similar treatment.   They are, however, perhaps the rar-
 est obstetric complication that can be met with.
   [Some years since I saw at the New York Pathological Society,
 a specimen brought from  Virginia, with the history that it was
 removed from a female  negro slave some seventy or  eighty
years of age, who some forty years previously supposing herself
pregnant went into the lying-in department, having all the signs
of immediate labor.  After several days of severe pains, they sub-
sided without anything  coming away—she  was  " good  for
nothing " for several months or years, but finally got about and
resumed her place in her master's kitchen.  The  tumor  in the
abdomen, perhaps somewhat diminished, still remained.   Some
thirty or forty years after, she died of dysentery ; the post-mortem 
248     0SSD7ICATI0N OF THE UTERUS AND ITS CONTENTS.

showed a bony tumor in the median line, apparently the uterus.
When this was sawed in two it was evident that it contained a
coiled  up foetus,  apparently perfect and entirely  ossified.  A
similar  case was  recorded  about the  same time as having oc-
curred  in a different locality.] 
LECTURE XVI.
                 THE GRAVID UTERUS.

  Gentlemen :—The  unimpregnated,  virgin,  or  nulliparous
uterus, is from two inches and a half to two inches and three-
quarters in length, its breadth being, from tube to tube, from an
inch and a half to an inch and three-quarters.  At the end  of
gestation, the uterus  is about thirteen  inches  long  by eight  or
nine in breadth; its greatest  antero-posterior diameter being
eight or nine inches.  Levret made some calculations, according
to which  the superficies of tbe virgin uterus may be taken
at sixteen inches, while at the time of the coming  on of labor,
its superficies may be  estimated at about  three hundred and
thirty-nine inches !   The  cavity of the unimpregnated virgin is
equivalent to about three fourths of a cubic inch ; while, when
fully developed, it exceeds four hundred cubic inches!   The
uterus in the virgin state, weighs about an ounce ; and that of a
woman, who has borne children about an ounce  and a half.
Immediately after labor, the uterus weighs about  twenty-four
ounces; but this weight is considerably exceeded  when it is
distended by the foetus, and its vessels  are full of blood.  These
facts show the wonderful  manner in which the  uterus increases
under the stimulus of impregnation—an increase having no phy-
siological parallel in  any other  organ in the  human body.  This
increase is divided between the mucous membrane or  decidua,
the lymphatics, the veins and arteries, the muscular structure,
and  the nerves of the organ.
  The measurement already given represents the general size of
the gravid uterus at the full term;  but the capacity of the
uterus varies much in individual  cases, chiefly from the greater
or smaller quantity of the liquor amnii, or the occurrence  of
twins.  In sorpe  cases, there  is only  a very small  quantity  of
liquor amnii; and in  others, there may be dropsy, and great dis-
                                                      249 
250
FORM OF THE GRAVID UTERUS.
tension of the amnion.   The shape of the uterus is  ovoid, but
its figure  somewhat shorter, and the smaller extremity is less
pointed than  in  the  egg.   The organ  is  more  developed
anteriorly than posteriorly ; and it is somewhat flattened behind.
It is moderately filled,  but not distended, by its contents.  Wil-
liam Hunter, whose descriptions of the gravid uterus are almost
as graphic as his beautiful plates, compares it to a bladder par-
tially filled with fluid, in consequence of which it yields to the
pressure of the surrounding parts, and is, to some extent, moulded
by them in shape.   The gravid uterus, when filled with its con-
tents, feels much thinner to  the  touch than  it actually is.  Its
parietes are from one-third to two thirds of an inch in thickness ;
but it exceeds this considerably at  the  site of the placenta.
Occasionall}r, in twins, the two lateral valves of  the  uterus are
developed in  such a way as to leave a division or cleft  between
them  ; and cases  are met with in which, with one  foetus, the
right  or left side  of the  organ is chiefly developed.  It some-
times occurs that a particular part of the uterus does  not per-
fectly take on the growth of normal pregnancy, so that  a ridge
or contracted portion remains in the interior of the organ. The
ligaments  of the uterus are  considerably altered by the  gravid
state. As the  organ  increases in size, it expands between the folds
of the broad ligaments, so that in their unfolded state  these liga-
ments form the peritoneal covering of the sides of the  uterus. As
a consequence, the broad ligaments and the ovaria, though they
ascend during pregnancy, are lower down  in their attachment to
the uterus, than in the  ungravid  state.  The Fallopian tubes and
the ovaria are close to the sides of  the uterus,  the  fimbriated
extremities pointing downwards, and  the  broad  ligaments are
shortened to the greatest possible extent. The ovarian ligaments
lie upon the sides of the uterus, and the round ligaments extend
almost perpendicularly downwards from  the fundus uteri to the
inguinal rings.
  The development of the decidual mucous membrane  has
already been described.  The lymphatics of  the  uterus and its
appendages, which were first described by Cruikshank, increase
from  the minute size, and almost invisible, .found in  the virgin
uterus, to  the size of a goose-quill, or even larger, in the princi-
pal trunks.  The lymphatic  vessels pervade  every part  of the
gravid uterus, but are especially abundant underneath  the peri- 
         UTERINE ARTERIES, LYMPHATICS  AND NERVES.       251

toneal covering.  They follow the course of the hypogastric and
spermatic bloodvessels, and reach the central lymphatic  trunks
by  entering  the glands  of  the sides of the vagina, and the
iliac,  sacral, and lumbar plexuses of  glands.  The  lympha-
tics  are,  no  doubt, largely  concerned  in the  processes  of
the nutrition  of the  uterine  tissues  during their  enormous
growth, and in that removal of effete material after labor, which,
in the course  of five or six weeks, reduces the uterus from a
pound and a half in  weight, to something less than two ounces.
The  uterine  arteries,  both the  hypogastrics and spermatics,
greatly  increase  in size, particularly the hypogastrics.   This
increase is greater at the part of the uterus to which the placenta
is attached.  The uterine  arteries, in ramifying in the structure
of the organ, have a tendency to anastomose to such an extent as
to form an arterial net-work;  and as they plunge  deeper into
the substance of the uterus, they take a convoluted  or spiral
course.   This  spiral arrangement especially occurs  before the
vessels enter the placenta, the spirals running parallel with the
decidua serotina,  and immediately beneath it, for  the  space 01
half an inch or more,  before  perforating the decidua  to pass
into the  placental mass.  The veins, which, in reverse, accom-
pany  the  hypogastric  and spermatic arteries, are still more
enlarged, and form plexuses especially in the  neighborhood  of
the placenta, and towards the  internal surface of the uterus, of a
larger extent  than  are found in any other veins of the body.
The uterine veins do not possess valves, and some of the largest
are of sufficient size to admit the point of the finger.   Altoge-
ther,  the mass of blood contained by the arteries  and veins of
the uterus, in  the  healthy gravid  organ, at full term, must be
very great, and forms a considerable portion of its entire bulk.
The serous or  peritoneal  covering  of  the uterus increases in
thickness and extent, and  but for  the increased strength  of the
serous coat, it is probable that lacerations of the peritoneum
would occur during the contractions of the uterus in labor.
  Formerly, everything was vague respecting the existence and
arrangement of the muscular fibres of the uterus. The pos
session,  even, of muscular fibres  by the human uterus was
argued because they could be seen in the lower  animals, and
because from the functions of  the uterus, they were necessarily
believed  to exist in this organ, rather than because  they could 
252
UTERINE MUSCULAR STRUCTURE.
be satisfactorily made out in dissections.   In the magnificent
plates of William Hunter, the  external  surface of the uterus
presents no definite muscular arrangement.   This  great anato-
mist could find nothing but" irregularity and confusion," except
upon the inner surface of the organ, where he observed the fas-
ciculi to have in some degree the regular arrangement observed
in other muscular structures.   His description of the internal
layer of muscular fibres is perfect even at the present day.  He
gives an account of the circular  fasciculi surrounding the body of
the uterus, and the two concentric circular planes of fibres which
surround the orifices of the Fallopian tubes, and gradually blend
with the circular fibres of the body of the organ. William Hun-
ter saw the analogy between these  concentric rings—the orbicu-
lares muscles, as he terms them, of the fundus uteri and Fallopian
tubes, and the circular muscles  found in the  two horns of the
uterus in animals  possessing the uterus bicornua.  His words
are, " The better to conceive this arrangement of the internal
muscular fibres, we may suppose each corner of the fundus uteri,
where the tube is inserted, to be stretched or drawn out, so  as
to make two horns, or a bifid uterus, as in the quadruped ; then,
if we understand the inner fibres to be circular in every part of
the uterus, we clearly understand how they will be circular in the
human uterus upon its body, and likewise circular and concentric
at each corner of the fundus."   Before this timeRuysch had de-
scribed the fundus of  the uterus as possessing a  single circular
muscle only.   Sir Charles Bell  carried our knowledge of  this
subject a step further, and described the muscular fibres diverg-
ing from the round ligaments to spread over  the whole of the
organ, and he considered these ligaments as in some respects the
tendons of the external  fibres  of the uterus.  His  conclusion
was, that the circular fibres  prevailed towards the fundus, and
that the longitudinal fibres were most apparent towards the os
and  cervix.
   According to the recent descriptions of Kolliker and other
minute anatomists, who have combined  the use of the scalpel
and the microscope in their investigations,  the gravid uterus
possesses three layers  of muscular fibres, all of them being of a
paler color than is found generally in other muscles.  These
three layers can be made out with tolerable distinctness, but not
so clearly as we can make out the circular and longitudinal layers 
MUSCULAR FIBRES  OF THE UTERUS.           253
of the Fallopian tube or intestine.  The internal stratum, or the
inner layer of William Hunter, is thin, and composed of delicate
circular  and transverse fibres, the circular fibres  being found
chiefly in the middle of the body of the uterus, around the Fal-
lopian tubes, and at the os uteri, in which latter position  they
form  an  imperfect sphincter.  The  middle layer is thick and
strong, consisting of flat bundles of fibres, running in different
directions, interlacing  with each other,  and  surrounding the
vessels of the uterus.  These bundles of fibres are more loosely
arranged than those of the internal layer, giving the middle por-
tion of the uterine parietes a spongy appearance.  This stratum
is strongest at the fundus of the uterus, where it seems to consist
of several layers.  The external layers consist of transverse and
longitudinal fibres forming a thin stratum, immediately beneath
and intimately connected with the  peritoneal covering of the
uterus.  The longitudinal  fibres are  arranged chiefly upon  the
anterior and posterior surfaces of the organ, and  extend from
the fundus to the lower  part of the cervix.  The transverse
fibres of this layer surround, or nearly so, the organ, and fibres
derived from it are continued, not only into the round ligaments
but into the broad and ovarian ligaments, so as, in effect, to con-
nect the fibrous structure of the uterus with the fibrous stroma
of the ovaria.
                       Fie. 69.
                 Internal layer of uterine muscular fibres.

  Sir Charles Bell pointed out a fact which has been confirmed
by subsequent observers—namely, that in all parts of the uterus 
254       MUSCULARITY  OF THE UTERUS DEMONSTRATED.

muscular fibres are found to surround  the  blood  vessels, and
that this is especially the case with the  open vessels  upon  the
Fie. 70.
Middle layer of uterine muscular fibres.
Fia. 71.
External layer of uterine muscular fibres.
surface from which the placenta has been detached.  William
Hunter had observed that at the site of the placental attachment
the inner layer of muscular fibres  lost its  regularity, and was
found to be interlacing amongst the bloodvessels.  The bearing
of this arrangement upon the  arrest of haemorrhage  after the
placenta has been detached is obvious.  Sir Charles Bell found
that when the muscular fibres were contracted the mouths of the
vessels were closed, and vice versa. 
                 FIBRK  CELLS OF THE UTERUS.              255

  As regards the intimate  structure of these  muscular laj^ers,
upon which the great increase in the mass of the uterus depends,
much has been  made out by  recent  inquirers, especially  by
Virchow, Franz Kilian, Ileschl,  and  by Mr. Rainey  in  this
country.  The mode of Involution and Devolution of  the
uterus during pregnancy and after parturition is now tolerably
well understood.  When describing the  unimpregnated uterus,
we  have seen that  the chief bulk of the organ is made up of
fusiform embryonic  cells,  possessing a central nucleus.    The
embryo  fibre cells are described  by Kolliker as about TJj-o °f
an inch in diameter, their length  being somewhat greater than
their diameter.   As  soon as fecundation and the deposition of
the ovum has occurred, these  fibre cells begin  to elongate by
growth at each extremity,  the  nucleus remaining in the middle
portion of the filament.  The  nucleus itself elongates, but the
great increase in length  is in the portion of the cell surrounding
the nucleus.  At the time of parturition, the fibre cells have so
increased, they  measure in length from  seven to eleven times
greater than in the embryonic  state.   Their width is  also
increased from two to five times.  There is not only an increase
in the fibre cells already existing in the  uterus at  the time of
conception,  but  new generations  of fibre cells are produced
during the course of gestation.  This new development of cells
takes place chiefly in the internal and middle muscular layers
though it also occurs in the outer layer.   The new formation is
especially active during the first half of  pregnancy.  After the
sixth month it  is believed to cease,  and from this  time  the
embryonic cells are all developed, so that at the time of  partu-
rition nothing but the colossal  fibre cells are  met  with.  It is
those fibre cells which collectively  give the uterus its enormous
contractile power at  the time of parturition.  The ligaments of
the uterus increase in size  chiefly from the development of the
muscular fibres which  they  contain.  This is particularly the
case with the  round ligaments, and Kolliker'supposes that the
enlargement may depend upon  the growth of the fibres derived
from the uterus, and also upon the increase of  the bundles from
the  internal  oblique,  which contribute to form  the  ligamenta
rotunda.  (Fig. 72.)
  After the occurrence of labor, these gigantic fibre cells are no
longer needed, and the  uterus has to return in a comparatively
short space of time from  a  weight of twenty-four ounces  to one 
256          FATTY DEGENERATION OF THE UTERUS.

ounce and a half.   The necessary involution of the uterus  is
effected  chiefly by the atrophy  and fatty degeneration of the

                           Fig. 72.
 1 and 2, Embryonic nucleated fibre cells of the unimpregnated uterus ; 8, 4, 5, Muscular fibre
cells of the gravid uterus in different stages of development.

colossal muscular fibres,  and the absorption and removal of the
fatty matter of the kidneys, the mammary glands, and the inter-
nal surface of the uterus  itself.   The whole uterus becomes soft:
it is  difficult  to  insulate individual fibre cells, from their exces-
sive friability, and they are found  to be studded with oily parti-
cles in their  interior.   The disintegrated muscular fibre of the
uterus, taken  into  the system by absorption, probably  contri-
butes to the  formation of the caseous matter of the  milk first
secreted, and fatty elements are found  in the urine at this time,
and  abundantly in the  lochial  discharge.  A brief, but very-
excellent account of the post-partum  changes occurring in the
uterus has been given by Dr. West, in the thirty-fourth volume
of the " Medico-Chirurgical Transactions."  During the involu-
 
NERVES OF THE UTERUS.
257
Fig. 73.
tion of the uterus  after labor, chiefly as we have seen, by the
fatty degeneration of the muscular fibres, a new series of nucle-
ated fibre cells, having the shape and size of the  fibre  cells of
the virgin, or nulliparous uterus, is formed.  Kolliker states that
three weeks ofter parturition  the embryonic  fibre cells again
appear, though a longer time than this expires before the com-
plete fatty  disintegration  and absorption or  discharge of the
developed fibres is  accomplished.   Probably  two or three
months have  elapsed before the involution of the uterus after
delivery is completed ; frequently the involution, as pointed out
by Dr. Simpson,  is  not  complete,  when menorrhagia is  the
result.  In  other cases the involution is excessive, the uterus
becomes smaller than before  the occurrence of impregnation,
leads to  amenorrhcea,  and subsequent  infertility.  Thus,  as
observed by Franz  Kilian  and Mr. Rainey, the highly develop-
ed muscular structure is removed, and a more lowly organized
structure formed in its  place for each labor, so that the gravid
uterus in each  successive  pregnancy  is to a great  extent, a new
organ.  Fig 73.
   The uterus receives its  supply of nerves from the
hypogastric, sacral, and spermatic nerves.   Below the
bifurcation of the aorta, we have the aortic plexus divi-
ding into the two hypogastric nerves.  The hypogas-
tric nerve on each side forms, in its descent to the cer-
vix  uteri, the hypogastric plexus. The hypogastric
plexus, when it reaches the cervix, terminates accord-
ing  to the dissections of Dr. Lee, in the hypogastric
ganglion.   Into the outer and lower portion  of the
hypogastric ganglion branches enter from the  third,
and sometimes from the second  and  fourth,  sacral
nerves.  From this ganglion nervous fibres are distri-
buted to the muscular structure and the internal sur-
face of the os, cervix, and the body of the uterus.  Dr.
Lee describes  sub-peritoneal  ganglia and plexuses
upon the external surface of the uterus, which maintain
connection with the hypogastric ganglion below, and
the spermatic ganglion and plexus above.  The nerves
of the virgin uterus  are arranged in a serpentine form,
and are always accompanied by a branch of an artery
and  vein.
                              n
  Muscular
fibre cells a
fortnight
after deli-
very,^ a
state of fatty
degenera-
tion. 
558     dr. lee's dissections  of the uterine nerves.

  We now approach the much-vexed question of whether the
nerves of  the uterus increase  during pregnancy or not, than
which nothing has more  agitated or perplexed the anatomical
and obstetric world in modern  times.  William Hunter, arguing
from analogy, suspected that the uterine nerves enlarged in the
same proportion as the bloodvessels.   John Hunter thought the
gravid uterus independent  of nervous agency, and capable of
motion " within itself," and he denied that the nerves were in
the slightest degree increased  during pregnancy.   Tiedemann
was the first  to publish figures of the nerves of the gravid
uterus, copied from actual dissections; but his two  plates, taken
from a woman who died six days after delivery, represent a very
sparing supply of nerves.   Since this time, it has been gener-
ally assumed that the  nerves  of the uterus are thicker at the
time of  parturition,  than in the unimpregnated state,  though
some anatomists, as Lobstein, Osiander, and Longet, have either
denied the existence of  uterine nerves, or have  limited  this
organ to a very scanty supply, both in the unimpregnated and
gravid states.  Dr. Lee, many  years ago, threw himself into the
investigation of this subject, and he has pursued it ever since
with characteristic ardor.   He  has made numerous dissections,
which  in his  own opinion, and in that of  a host of authorities
who have  examined his preparations,  prove to  demonstration
that the nerves of the uterus increase to a very  great extent
during pregnancy.   All analogy and reasoning are in favor of
the truth  and  fidelity of Dr.  Lee's dissections ;  and the most
recent investigations, by those aloof from  all personal feeling,
are chiefly  in  his favor.    Remak  states, as the  result of his
investigations, that the nerves enlarge during gestation.  Kilian
has made  numerous researches in the lower animals, which
prove that  the nervous fibres, in a medullated condition, can,
during pregnancy, be traced further into the substance of the
uterus than at other times ; while, in the unimpregnated uterus,
the nervous fibres  are found, even upon  the  surface of the
uterus,  in  an  embryonic,  non-medullated  state.   Kolliker
can see no impossibility in the multiplication of ganglion cells
and fibres,  and in the addition of newly-formed nerve fibres, as
branches to other nervous fibres, or that the nerves, by a multi-
plication of their ultimate divisions, may ramify over larger
spaces  during  pregnancy than at other times.  That the pre- 
     DR. 8N0W BECK'S  DISSECTION OF THE UTERINE NERVES.  259

existing nervous fibres increase in width and length, and may
be traced  further  into the interior of the uterus in the gravid
organ  than at other times, Kolliker entertains no doubt.  Dr.
Lee  believes that very  shortly after labor the uterine nerves
diminish in size,  and  return to the  condition which obtains  in
the unimpregnated state.
  Dr. Snow Beck has executed some dissections of the gravid
uterus, which appear to contradict those of Dr. Lee.   Dr. Snow
Beck believes  that  the nerves  of the uterus  are not by any
means so large or so numerous as they appear in Dr. Lee's dis-
sections.  He considers that the nervous  arrangement at the
neck of the uterus should be called the pelvic plexus, instead of
the  hypogastric ganglion; and that the  sacral nerves do not
enter into that portion of the cervical plexus which supplies the
uterus, but that they  are distributed  to the  vagina and other
parts.  Dr. Snow Beck further believes that there is no increase
in the size of the nerves during  pregnancy, but simply that the
nerves which, in the virgin uterus, have a sinuous arrangement,
become straitened during gestation.  There are, it must be said,
certain  anatomists, having great authority, who hold with Dr.
Snow Beck that  the  nervous  supply of the uterus is  very
restricted, having little relation, as regards size, with the import-
ance of the functions it is called upon to perform.  It should be
said, that Dr. Lee and Dr. Snow Beck have executed their dis-
sections upon a different  principle,  which may go somewhat
towards accounting  for the different results at which they have
arrived.    Dr.  Snow  Beck has, by very minute  dissections,
cleared the nerves of the neurilemma; while in most of his dis-
dissections, Dr. Lee  has preserved the neurilemma, as a consti-
tuent part of the nerves.   But  for this difference, the results of
the two dissections could  scarcely have been so antagonistic  as
they now are.   With every anxiety to form a correct opinion, I
think it must  be said, that during the last few years, the new
evidence which has been brought to bear upon this important
subject has been very greatly in Dr.  Lee's favor.
  According to the recent investigations of M. Robin, P. Hes-
chel and others, it is  the neurilemma of the nerves which chiefly
enlarges during pregnancy. Dr. Lee has contended for this, and
it is a point which  bears directly upon  the  dissection of the
nerves of the  gravid uterus by Dr. Snow Beck, in which the 
260
DR.  BECK VS.  DR.  LEE.
neurilemma was  as far  as possible removed.   [It is now con-
sidered that Dr. Beck has satisfactorily refuted the opinions set
forth by Dr. Lee.]
Fig. 75.
  The  left hypogastric and sacral nerves entering the  hypogastric ganglion, with the blood-
vessels, nerves, and ganglia of the Virgin Uterus, a portion of the neurilemma being removed, and
the size of the ganglia and nerves being thereby reduced below the natural size.—{From Dr. Lee.)
3710
5 
LECTURE  XVII.
          THE NERVI-MOTOR FUNCTIONS OF THE UTERUS.

  Gentlemen :—Uterine muscular and nerve fibre have been
considered in the last Lecture, and we come now to the study of
the motor  functions  performed by the gravid uterus.   The
developed organ is as  strictly a muscle as the  heart or dia-
phragm, and it is the chief agent by  which the expulsion of  the
foetus is effected.  It is of immense  importance  that the nature-
of uterine muscular action should be understood, since we are
obliged to take it into  account in all cases of natural labor, and
still more so in cases of preternatural parturition.   One class of
accidents  during labor, of which rupture  of the  uterus is in
the type,  arises  from  excessive uterine action; while  another
class of scarcely less importance, of  which haemorrhage may be
regarded as  an instance, depends upon deficient uterine action.
The older writers thought much of this subject, though the data
upon which they reasoned were slender and imperfect.   It is,
however,  remarkable, that considering the  interest of the sub-
ject, it has not been satisfactorily discussed in any  modern work
upon obstetrics.   The little that we  know upon the subject has
been almost entirely confined to works on physiology.  This has
arisen, in great part, from the idea that the  uterus was so unlike
the general muscular  system,  that it could not be reduced to
physiological rule.  But the muscular structure of the uterus,
and its dependence upon the nervous system, having been  made
out in recent times, it  becomes necessary to  study accurately the
nervi-motor endowments of the gravid organ, which is certainly
the largest, and as regards the perpetuation of the race, the most
important muscle in the human economy.
  The uterus is in relation with the  Cerebral, Spinal, and Gan-
glionic divisions of the nervous system, and possesses properties
derived from each of these sources of motor power.
                                                    2C1 
262          MIND, AS  IT AFFECTS UTERINE ACTION.

  In the first place, let us consider  the  relation of the Cere-
bral system to uterine motor action.
  The uterus is withdrawn from the direct influence of Volition.
The will has no  direct power  either to contract  or to dilate
this organ.   Labor may take  place when cerebral paralysis
exists, the will being entirely in abeyance, but the uterine move-
ments dependent  on reflex action and peristaltic action remain-
ing perfect.   But though not exerting any direct influence, vo-
lition may affect the  uterus indirectly.   In  certain cases of
uterine inertia, when the contractions of the uterus have entirely
ceased, voluntary efforts  are sometimes sufficient  to reproduce
uterine  contractions.   Efforts  at  expiration,  with  the  glottis
closed, cause the abdominal muscles  to  compress  the  uterus
mechanically, and this compression stimulates the  uterus in the
same  way as manual irritation of the organ.  What is called in
other organs consensual action,  may also probably  be excited in
the uterus,  to  some degree, by  volition.   Violent voluntary
action quickens the action of the  heart, and the voluntary con-
traction of the internal rectus muscle contracts the iris, though
both the heart and the iris are removed from the direct action ot
volition.  In a similar manner,  the uterus during parturition, is
probably affected during the intense  efforts at expiration and
bearing-down, which accompany the pains of labor.
  A very  powerful influence may be exerted upon  the uterus by
Emotion.  A  fright,  or any violent mental disturbance may
bring on labor prematurely, or produce abortion. During labor,
any sudden emotion of the mind may increase or arrest uterine
action.  The different  effects of hope or despair  on the com-
mencement, progress, and termination of labor have frequently
been  remarked.  Emotion  often plays the part of Tantalus to
the accoucheur.  His entrance into the lying-in room may arrest
the pains  of labor for a time, through the  influence of emotion,
but if he  should leave  the house, they as often   return with
increased vigor, and terminate the labor abruptly in his absence.
After delivery, the maternal emotion exerted by the sight of the
infant causes the uterus to contract in a  remarkable manner.
Emotional, like voluntary action, is psychical in its nature, and
originates  in the cerebrum; but it acts upon the uterus and
other parts through the spinal marrow,  this great organ of phy-
sical motion. This is evident fr,om the fact that emotional move- 
        UTERrNE ACTION BOTH REFLEX AND  PERISTALTIC.      263

ments may occur in  parts which are entirely paralyzed to cere-
bral voluntary motion.
  Let us now refer to the forms of uterine  action depending
upon the Spinal Marrow, a subject which did  not admit of com-
prehension, before the brilliant discovery of the spinal system by
Dr. Marshall Hall.
  The Reflex, Spinal, or Diastaltic action of the uterus is excited
in various modes; and it is upon this form of contraction, aided
by peristaltic action, and the extra-uterine  reflex actions excited
during the process, that natural parturition essentially depends.
Contraction of the uterus, of a reflex or diastaltic  kind, may be
excited by irritation of the mammae, as  in the act of  suckling
the infant;  by the impression of cold upon the vulva  or abdo-
minal surface; by irritation of the  rectum, as by a stimulating
enema; by gastric irritation, as in drinking a gulp  of cold water,
or swallowing a piece of  ice;  by  ovarian  excitement,  as in
occurrence of  abortion  from  the menstrual nidus ;  by irritation
of the vagina  or pressure on the perinaeum, and by irritation of
the os and cervix uteri.  These facts supply the proof  that the
uterus is endowed with reflex  action, and that the motor nerves
of the uterus  are in relation with the mammary, pubic, rectal,
pneumogastric, ovarian and vaginal nerves, and the nerves of
the  os  and cervix uteri,  as  incident excitor nerves.  There
can be  no doubt that in an organ thus subject to reflex action,
its own nerves are exciters, and  that in all contractions of the
uterus,  excited  by  irritation  of the internal  surface of the
uterus,  or of the os and cervix during the  passage of the foetus,
the  uterine actions  are both  reflex and peristaltic.   That the
internal surface of the uterus  possesses incident spinal nerves is
proved  by the occurrence of vomiting, etc., from uterine irrita-
tion.  There is, indeed, no instance of a mucous surface wanting
the power of exciting reflex action in other parts of the body.
It is a question if any pure spinal fibres reach or  proceed from
the  uterus, unmixed with  fibres from  the ganglionic.   This
admixture produces a curious effect upon the reflex contractions
of the organ.  If we irritate the conjunctiva with a feather, the
orbicularis muscle contracts instantly.  If  we tickle the fauces,
efforts at vomiting are immediately produced.   But in  the case
of the uterus, contraction  does not follow upon the irritation in
so sudden a manner.   I have  sometimes,  in  cases of alarming 
264
CHARACTER OF THE UTERINE ACTION.
haemorrhage, had my hand in the uterus for a considerable time,
and have carefully watched the influence of reflex stimuli upon
the uterus.  If, while the uterus remains flaccid, cold water is
sprinkled upon the face, the uterus does not contract at once,
but after an interval  of half a minute to a minute, or even lon-
ger, the organ  slowly begins to  contract,  reaches its acme by
degrees, and as slowly  relaxes.   The same thing happens if,
while the hand remains  in utero, cold or iced water be injected
into the cavity  of the organ.
  As a  motor  organ, the uterus stands alone in many respects.
Unlike the rectum and  bladder, it is  not directly influenced by
volition ; and unlike the heart, it is  extremely prone  to reflex
action.  It more nearly resembles the  oesophagus, which is unin-
fluenced by the will, but endowed with the  reflex motion and
peristaltic action.  It differs, however, from the oesophagus in the
number of excitor surfaces  with which the spinal system places
it in  relation.   There is no other  organ, not even the stomach,
which can be  excited by  so many  distinct organs, or which
acts as such an extensive excitor of motor action in other parts,
both in the impregnated and unimpregnated states, as the uterus.
  Besides the reflex action of the spinal marrow, and its system
of excitor and motor nerves, there is  the Direct action of the
spinal centre to be considered, though this form of spinal action
does not play the important part assigned to it by Serres,  Bra-
'chet,  and Segalas.   In what is  termed Direct or Centric spinal
action, the spinal centre with its motor nerves  are  concerned,
to the  exclusion of the incident or  excitor nerves.  Various
instances of Centric spinal action may be given.   Thus, ergo-
tine  passing into the blood, affects the  spinal centre,  and its
effects reach the uterus  by its  motor nerves.  Other oxytoxic
agents, such  strychnia,  carbonic  acid, savin, aloes, alcohol, the
biborate of soda, and probably ipecacuanha, act in a  similar
manner.  The state of the  circulation affects the spinal centre
in a very distinct manner.  It is well known that there is one
form  of puerperal  convulsion  depending  upon  haemorrhage,
where the  heart and great vessels have been  nearly emptied of
blood, and another caused by fullness of circulation.  The con-
vulsion probably depends  greatly upon the influence of defi-
ciency or excess of blood in the vessels of the  nervous centres.
Want or excess of blood, or materies morbi in the circulation, act, 
UTERINE ACTION AFTER DEATH.
265
then as direct stimuli to the spinal centre, and in this way the
state of the circulation affects the uterus during labor.  The
uterus acts with  increased  force  when the circulation is either
plethoric or anaemic; though in the latter case, exhaustion of its
nervous energy quickly ensues.
  We now come  to the consideration of Peristaltic action,
Ganglionic motor action.
  When any part of a muscular organ supplied in whole or in
part by the ganglionic system of nerves is irritated, the contrac-
tion which ensues generally spreads  in a vermicular manner to
a distance from the point of  irritation, and continues for some
time after the exciting cause is removed.   This is called Peris-
taltic motion or action.   The uterus is eminently endowed with
this peristaltic form of contraction.   When  one point of the
uterus is stimulated, through the  abdominal parietes, or by the
introduction of the hand into the uterus, the contraction excited
extends to the whole organ.  Harvey described this  peristaltic
action of the uterus in the  doe.  William Hunter saw it in the
cat and rabbit.  Muller observed it in the uterus of  the rat and
the oviduct of the turtle, and I have seen it in the uterus of the
guinea-pig and other animals.   The heart, oesophagus, and intes-
tine may be excited to contraction after death; and I have seen
the uterus and  vagina of the rabbit contract rhythmically,
when  irritated, for several  hours  after the cessation of respi-
ration. Many cases are on record in which women  have died
undelivered, but  the child has been expelled spontaneously after
death.  In one case a woman  dying during labor was placed in
a coffin, and  the foetus was found the next day perfectly expelled.
This post-mortem parturition must generally depend  upon peris-
taltic action, commencing after the occurrence of somatic death,
or upon the rigor mortis affecting the uterus.  It is well known
that the rigor mortis affects the other involuntary muscles, and
especially the heart, which is contracted by  this influence to
such an extent as to empty the ventricles, and even to stimulate
concentric hypertrophy.  Cases  are related in which the foetus
has apparently been  expelled some days after the death of the
mother by  gaseous distension of  the abdomen; but these  are
different from cases occurring shortly after  death, and  before
decomposition has set in.  In the living  subject, the peristaltic
action of the uterus is the basis of the other uterine actions.   In 
266    EXPERIMENTS ON TOE SOURCE OF UTERINE  ACTION.

natural labor it is combined with reflex uterine action, and with
various forms of extra-uterine action ; but, under  certain cir-
cumstances, it seems able to effect the expulsion of the  child
without other aid.   In paraplegia from disease of the lower part
of the spinal marrow, or in animals reduced to the same state
by experiment, the peristaltic action is the chief  power remain-
ing to the uterus.  In such cases, delivery has been effected in
an imperfect manner by the peristaltic action of the  uterus or
the application of galvanism to the organ.  It is not,  however,
known how much of the spinal marrow must be destroyed before
the reflex or diastaltic actions of the uterus cease.
  Certain experiments have been performed by various physio-
logists, with  a  view to determine the nature of uterine action.
M. Serres found that on dividing the spinal cord in gravid ani-
mals  before  the time of parturition, death ensued  at  variable
intervals,  but  abortion did not  necessarily  occur.   He  then
divided the cord in animals after the commencement of parturi-
tion, and the process was arrested. ' In  other experiments, he
excited abortion in  animals by irritating the spinal marrow in
the lumbar region.  M. Brachet divided the cord in  guinea-pigs
between the twelfth and thirteenth dorsal vertebrae,  after the
commencement of labor, and everything but feeble contractions
of the uterus were arrested, the animals  dying in a few  days
undelivered.  M. Segalas made  a section of the cord high up,
without influencing the uterus ;  but the  organ  was paralysed
when the division was practised low down.  Cases are detailed
by MM. Brachet and Ollivier, as occurring in the human subject,
in which, in  paralysis depending upon disease high up in the
spinal marrow,  uterine  action was not interfered with, but was
diminished or suspended altogether in cases of paraplegia, the
result of injury or disease, low down in the cord.  Dr. Simpson
has, I have understood, performed some experiments upon pigs
which go to negative the experiments  of MM.  Serres, Bra-
chet, and Segalas.  In Dr.  Simpson's  experiments, which have
not been published, I believe parturition occurred notwithstand-
ing the destruction of the lower portion  of the spinal marrow.
If Dr. Simpson's results are  as I have stated, they will not prove
the independence of the uterus of reflex  action, since from the
connections of the greater and lesser splanchnic nerves and the
thoracic, abdominal, and pelvic plexuses and ganglia, it is  quite 
CHARACTER OF A UTERINE CONTRACTION.
267
possible that the uterus may receive spinal fibres from the upper
part of the spinal marrow.
  The direction taken by the peristaltic action is of considerable
importance.   Professor Miiller, Michaelis,  and Wigand teach
that uterine contraction commences  at the  cervix, and travels
towards the fundus ; returning thence towards the os uteri. This
is thought by Michaelis to  prevent prolapsus of the umbilical
cord and the descent of the arms of the foetus before the head ;
the cord and the arm, when lying low in  the uterus being swept
upwards beyond the risk  of danger, at the commencement  of
every pain.  Wigand considers the direction of the contraction
to be proved by the phenomena attending a  labor-pain.  At first
the os uteri grows tense, the head or  presenting part  recedes
from the touch, and the bladder of membranes protrudes ; after
this the fundus uteri becomes hard, and the  presenting  part  of
the child begins to advance.   I  believe  this view of Wigand,
which has been particularly insisted upon by Dr. Rigby, to be a
very accurate  description of the direction in which the uterus
contracts during a labor-pain.
  If, as is most probable, the peristaltic action of the uterus does
take this course, it is not singular, for, according to the observa-
tions of Magendie, the contents of the stomach are, during diges-
tion, passed through  the  pylorus, by  a  peristaltic movement,
which begins  at the pylorus, proceeds to the cardia, and then
sweeps back again from left to right.   Miiller also describes the
contraction of the heart of the frog as commencing in the venous
trunks; then descending, in succession, to the auricles and ven-
tricles ; and then affecting the  bulbous aortae.  The  peristaltic
action commences at the auricle, travels  to  the  apex, and then
returns towards the base of the ventricle.   There seem good rea-
sons for the commencement of the peristaltic action at the cervix
in the human subject, in the necessity which exists for some pro-
vision against  prolapsus of the cord, and arm-presentations ; and
still more, from the great probability that, if contractions com-
menced at the fundus uteri, inversion of the organ would- be a
frequent accident.
  In addition  to  the  divers  forms of uterine  contraction, the
Dilatation of the os and cervix uteri remains to be  con-
sidered. The dilatation of the os uteri is, in  part, mechanical
or  passive,  depending on  the  contraction of the longitudinal 
2GS
DILATATION OF THE OS UTERI.
fibres of the uterus, which tend to pull the os uteri open, and on
the fluid pressure  of the liquor  amnii on the advancing head
of the foetus.  But, in addition to the mechanical distension, the
os uteri is in part  opened by an active mechanical dilatation.
The  presence of a power for dilatation  in the os uteri is not
more remarkable that its power of contraction after the comple-
tion  of labor.   We have seen that the os uteri contains numer-
ous fibres arranged in a circular  form.   But the muscular fibres
of the uterus, though of considerable length, do not at any point
surround the organ, either in the body or at the os or cervix.
This circular arrangement of  the fibres, without the existence
of single fibres sufficiently long to surround the os uteri, accounts
for its power of contraction and dilatation.  Before the  com-
mencement of labor in primipara, the os uteri is quite  closed;
while in parturition it is dilated to such  an extent as to permit
the passage of the child's head—a mass whose shortest diameter
is three  inches and  a  half,  making the  line  of  the circle
necessary for its passage, nearly eleven inches.   This is a dil-
atation far exceeding that required in the action of the recog-
nized sphincters, and we cannot but believe that  if complete
circular fibres existed at the os uteri, laceration would be inevi-
table.
  Some of the physiological proofs of the  possession of dilatile
and  contractile powers by the  os and cervix uteri may be enu-
merated, and these proofs are not less convincing than the most
certain anatomical evidence.   In the first place,  if the fibres of
the cervix contracted with the same force as the fibres of the rest
of the uterus, this organ could scarcely be emptied of its contents.
Doubtless the contractions  of the body and  fundus uteri are
strong, their bearing upon the cervix powerful, and the amniotic
bag  admirably  adapted for mechanical distension ; but it  must
be remembered that the short  fibres of the cervix act at a great
mechanical advantage, as compared with the fibres in any other
district of the uterus.   Let any one who supposes the body and
the fundus may forcibly overcome a contracted  state of the  os
and  cervix, consider that the united power of all the respiratory
muscles is insufficient to force  the small muscles  which close the
glottis.  The nature of the haemorrhage in placenta  praevia,  as
compared  with haemorrhage  from  the  fundus,  affords the
strongest argument in favor of a positive dilatation  of the  os 
OS UTERI, HOW DILATED.                269
uteri.  In  haemorrhage from the fundus, the  loss of  blood is
arrested during a pain, because the fundus is in a state of con-
traction ; in haemorrhage from  the os and  cervix, the flow is
increased at each return of the pains, because the cervix is in a
state of dilatation.  If the dilatation were merely a mechanical
distention,  the pressure which dilated  the os uteri would arrest
the haemorrhage at the same time.
  Owing to the mixed mechanical and muscular dilatation of the
os uteri, it generally opens slowly; cases,  however, occur,  in
which, after long-continued  rigidity, it dilates so suddenly,  that
even from  this fact alone it is  difficult to consider  it a mere
mechanical distension, the resiliency of the part affecting its sub-
sequent contraction.  But the strongest  physiological proof of
the existence of muscular power in the os and cervix uteri is
the forcible contraction which sometimes  occurs after full dila-
tation—as, for instance, in cases of encysted  placenta, in  which
the fingers can only be introduced with  the greatest  difficulty ;
and again,  in inversio uteri, where the speedy and powerful con-
traction of  the cervix is one of the elements of the accidents most
opposed to the re-position of the organs. 
LECTURE XVHI.
                THE  F03TUS  IN  UTERO.

  Gentlemen :—It was an antiquated  and fanciful notion, that
the foetus sat upright in utero, rubbing its  head against the
maternal stomach, so as to cause heartburn ; and it was supposed
that the larger quantity of hair in boys  caused a greater amount
of heartburn than occurred with female children.  Even as late
as the time of Sir Fielding Oulde, in the middle of the last cen-
tury, it was believed that the head of the foetus was uppermost
until the time of the coming  on of labor.  Although modern
                           Fig> 76.
Attitude of the mature fetus in utero.
researches have shown, that in the latter part of pregnancy, in the
great majority of cases, the head of the foetus is found over the
     270 
                 OVOID SHAPE OF THE UTERUS.            271

os uteri, obstetricians are not yet agreed as to the precise causes
which produce this result.   The mature foetus in utero and the
gravid uterus have commonly, since the time of William Hunter,
been described as two ovals, the one accurately adapted  to the
other.   Strictly speaking, the foetus and  uterus are pyriform
rather than oval; but the foetus  and uterus are  each composed
of two oval, rather than circular, figures.  In the  foetus, one oval
is formed by the head, and the other by the body and limbs of
the child.  These parts  correspond with  the two ovals, into
Fib. 17.
Outline of the ovoid uterus.
 which the developed cervix and developed  body of the uterus
 may be divided.   The lower oval of the foetus—that is to say, the
 head—is little compressible, while the upper and larger oval is
 greatly so, during the progress of labor; and thus, having in view
 their different degrees  of compressibility, the cranial  oval  may
 be  considered as the  larger and more permanent of the two.
 Bearing these circumstances in mind, it will, however, be conve-
nient to speak in general terms of the foetus and uterus as ovoid.
The lower end of the  foetal ovoid is  formed by the vertex, the
upper end by the nates.  The outline of one side of the oval is
formed by the occiput, the back of the neck, and the incurvated
spine;  the other, by the forehead and  the  mass of contracted
limbs gathered up together.   The chin  is close to the sternum, 
272
OVOID SHAPE OF THE F03TU8.
the arms are crossed upon the breast, and  the thighs  are  bent
upon the trunk, so that the knees approach  the elbows in front
                            Fia. 78.   •
Ovoid form of foetus at full term.
of the abdomen;  the legs are bent  upon the thighs and decus-
sate each  other, the feet approaching the  nates.  The position
of the extremities,  particularly of the upper limbs, varies, how-
ever in different cases.
                           fig, 79.
 
              POSITION OF THE F03TUS IN UTERO.           273

  We possess satisfactory proof that the child assumes the posi-
tion with the head presenting, in the latter months of gestation,
and that dead children do not assume this position with the same
frequency as the living.  The statistics of Dr. Collins extend to
upwards of  16,000 children.  In the living children, which ex-
ceeded 15,000, only 1 in 57 presented  preternaturally, or other-
wise than  the head ;  while of upwards of 500 children born in a
putrid state, 1  in 5 presented preternaturally.   Dubois found
that in births occurring before the sixth month, only 52 per cent.
were head presentations; of those born during the seventh month,
the head  presentations increased to 68 per cent.;  during  the
eight and ninth months, to 76, and at the full term,  to 96 per cent.
From an extended table made by Dr.  Simpson, from the  report
of La Chapelle, Boivin, Clarke, and Collins, amounting in  the
aggregate, to upwards of 48,000 cases, the proportion of cephalic
presentations amounted to 96 per cent.  Dubois obtained another
important result similar to that deducible from the tables of Dr.
Collins, by  comparing the  comparative frequency of  cephalic
presentations in dead and living children.   Of children born liv-
ing in the seventh month, the head presentations were in the pro-
portion of 82 per cent.; but  in dead  children born during  the
seventh month, the proportions were  reversed, no less than 55
per cent, being preternatural presentations.
  The chief causes to which the general presentation of the head
in living children at the full term has been referred in modern
times are Physical Gravitation, Instinctive and Voluntary move-
ments of the foetus, and Reflex foetal movements.
  No opinion respecting the cause of  cephalic presentation has
prevailed  so extensively as  that which referred it to Physical
Gravitation.  It was supposed that the weight of the head, as
compared with the rest of the body, contributed to its subsidence
in the waters of the amnion, and it was further believed that this
tendency was increased by the insertion of the umbilical cord in
such a  manner as to leave the upper part of the body heavier
than the lower, when  suspended from the umbilicus.   Dubois
found, however, that  in experiments in which the  foetus was sus-
pended  in a bath, or in a receptacle  having the shape  of  the
uterus, it was not the head, but the scapula or  the  back which
first touched the bottom.   This was the result in dead new-born
foetuses of various ages between the fourth and ninth month.
                             18 
274         CAUSE OF THE POSITION OF THE FOETUS.

Any argument drawn from the supposed suspension of the foetus
by the cord is evidently worthless.  The length of the cord is so
great as to render any suspension of the foetus by the cord in the
liquor amnii impossible.  Moreover, if the cord were short, it is
generally implanted not into the fundus, but into the side of the
uterus.   It is also found that  twisting of the cord round the
limbs or neck of the foetus exerts no influence upon the presen-
tation, which it should do, if suspension by the cord contributed
to the descent of the head.  The drift of all fact and argument
seemed, then, against gravitation as a cause of cephalic presenta-
tion in the foetus.
  Recently, however, Dr. Matthews Duncan has advanced some
interesting facts which claim for gravitation a considerable share
in determining the intra-uterine foetal attitudes.  Dr. Duncan has
pointed out that when the mother is in the upright  position the
foetus lies in utero, at an angle of thirty degrees with the horizon.
This plane of support is formed by the glabrous internal surface
of the anterior wall of the uterus, and the abdominal  parietes.
When the woman is lying on her back, the child is still upon an
inclined plane, having nearly a similar angle.  The plane is now,
however, formed by the vertebral column, the  abdominal viscera,
and the  posterior wall of the uterus.  It is only when the woman
lies upon either side, that the foetus assumes the horizontal posi-
tion.  The greater part of the twenty-four hours is  passed with
the foetus lying upon one of these planes.  In the upright posi-
tion, and when the woman is  in constant  motion, the influence
of gravitation, as far as it extends, must have  greater scope than
during the horizontal position.  The mechanical tendency of the
foetus is to slide down the plane, but this is resisted  to some ex-
tent by  the plane itself,  and by  the pelvis.   This resistance, thus
divided, forms the support of the foetus and of the gravid uterus.
The foetus must be considered not as subsiding simply in water,
but as sliding  down a plane in  an ovoid cavity surrounded by
fluid.  Under such circumstances, it is contended that the foetus
must have a tendency to obey the laws of  gravity, and, with the
restrictions mentioned, to slide down the plane.  The objection to
this is, that in women who preserve the horizontal position  dur-
ing the whole of the latter part of pregnancy, the head presents;
but cases of this kind are not sufficiently numerous to found a
positive argument upon them. 
THEORY  OF  FG3TAL  GRAVITATION.
275
   One argument used against foetal gravitation is, that the head
 does  not  present with the  same frequency in cases of hydro-
 cephalus, as in the case of the healthy foetus. Dr. Simpson dwells
 upon the  increased weight of the bones of the head and its con-
 tents, and shows, by a collection  of such cases by Dr. Keith, as
 many as 1 in 6 present preternaturally—the proportion in  ordi-
 nary  cases, it will be remembered, being only  1 in 57.   Dr.
 Duncan points out that it is the relative weight of the head in
 hydrocephalus, as compared with the density of the liquor amnii,
 which must be considered.  Though heavier in air, it is probably
 more buoyant in water, than  the normal foetal head.  To  this
 may be added that the  size of the foetal hydrocephalic head is
 frequently such  as to render its descent into the pelvis, and its
 presentation at the os uteri, impossible.
   But the strongest  evidence  against the theory of gravitation
 was that  derived from the greater frequency of preternatural
 presentations  in  dead, as compared with living  children.  It
 was argued that the dead child ought to obey the laws of gravity
 as readily and accurately  as the  living.   But it  seem to have
 been  forgotten that death may possibly alter the specific gravity
 of the foetus.  Dr. Duncan found, as the result of fourteen expe-
 riments, that when the healthy still-born foetus is placed in fluid
 of its own specific gravity, it floats obliquely with the head low-
 est, in a  position  corresponding  to that which it maintains in
 utero.  He further  observed, that  in cases  where the child
 has died in utero, before the time of birth, changes occur which
 make it float with its head highest, in a fluid of its own specific
 gravity.   This circumstance, he suggests,  may have some influ-
 ence in determining the frequency of malpresentations in the case
 of dead children; but he admits that a more extended course of
 experiments will be necessary  before full confidence  can be
 claimed for such results.  The ingenious observations and experi-
 ments of  Dr. Duncan, and the way in  which he  has met and
 controverted the objections to  the recognition  of foetal gravita-
 tion as a  cause  of position in utero,  must carry considerable
weight.   It is quite evident that gravitation cannot be omitted
from the several  influences which determine the natural presen-
tations of  the foetus.
  The latest exponent of the theory which refers the natural
presentation of the foetus to  Instinctive and Toluntary move- 
276         VIEWS RESPECTING THE FCETAL POSITION.

mcnts on the part of the foetus itself, is M.  Paul Dubois,
who wrote a very able es3ay upon this subject in 1832. Dubois,
excluding the  influence of gravitation, compared  the  power
which leads to  the assumption of the position of the foetus with
the head opposite to the os uteri, to the instinct which leads the
bird to build its nest. He  supposed that the foetus, moved by
an irresistible impulse, effects the  descent of the head, so as to
render it  the presenting part, by  a series of small volitions or
spontaneous determinations, occurring during the latter part of
pregnancy.  The chief argument in favor of the possession by
the foetus  of sensation, and  possibly of  volition, urged by  this
able obstetrician, is  drawn from the harmony which he believed
to exist between  the movements of the foetus  and the objects
which they were presumed to effect.   Had he written after the
reception of Dr. Marshall Hall's great discovery of the spinal or
physical  movements, as distinct from the cerebral or physical
motor actions of the animal economy, he would probably have
referred the motor powers of the foetus  to reflex action, instead
of to instinct or volition.   Dr. Simpson, coming after Dubois,
has taken reflex action as the clue to the fcetal movements, and
has shown that we  have no evidence whatever that the foetus
possesses any  manifestations which may not be attributed to
purely physical causes.
  Dr. Simpson, in a series  of elaborate and  original papers in
the London  and Edinburgh Monthly Journal  for 1849, main-
tains that the foetus  in utero is subject to a  constant succession
of Reflex Motor actions, which are the chief cause of cephalic
presentations.   Dr.  Simpson recognizes the ovoid outline  of the
uterus, and the ovoid shape of the foetus, as greatly tending to
maintain the foetus  in the uterus with the  smaller end of the
ovoid downwards;  but he  does  not consider that the relations
between the form of the foetus and the form of the uterus would
of themselves be sufficient to produce  the  position, with the
head over the os uteri.  He believes, on the contrary, that " the
regulating vital power   guiding it to the assumption of  that
normal position in  which  its figure corresponds as exactly as
possible to the figure of  the uterine cavity, consists of a succes-
sion of reflex or excito-motory movements of  an adaptive kind
on the part of the foetus, excited by impressions  made  on its
external  surface."   The  physical stimuli causing these  move- 
           Simpson's  views of the  fcetal position.        277

ments  are  referred to  temporary irritations of the cutaneous
surface of the foetus by  contact with the uterine walls, when the
foetus is thrown out of position by any movements or change of
position on the part of the mother, such as rising or lying down,
stooping, and other  motions of the body. Dr. Simpson points
out, that the soles of the feet, the knees and sides, parts which
in the  adult are marked excitors of reflex action, and which in
the young child yield  the sensation of  tickling, are precisely
the parts exposed to irritation in  the foetus.  Arguing from
these considerations respecting the cause of  the normal  presen-
tation  of the head, Dr. Simpson contends that the causes of
mal-presentation  are the occurrence of labor before the reflex
actions have established the natural position; the death of the
foetus—in other words, the loss of its adaptive reflex actions; the
causes altering the  shape of the foetus  or  uterus,  or physical
Fig. 80.
Position of twins in utero.
sources of displacement, such as by hydrocephalus, montrosities,
dropsy of  the  amnion, uterine  spasm, tumors of the  uterine
walls, placenta praevia, distortions of the  pelvis, and accidents
occurring to the mother.   Finally, Dr. Simpson indicates that
in the reflex movements of  the foetus lie  the  reasons of the
rarity of positions of the fcetal  head in the direct diameters of
the brim of the pelvis, and their great  frequency in the  oblique 
278            relative  frequency of positions.

diameters, particularly the  right  oblique diameter, and the
greater relative frequency of occipito-anterior to that of occipito-
posterior presentations.   In these papers, Dr. Simpson refers to
                             Fig. 81.
Adaptation of hydrocephalic fetus.
Fig, 82.
              Adaptations of foetus and uterus in breech presentation.

the influence of tone  as moulding the  form  and figure of the
foetus, but he takes no account of the uterine  movements in the
latter part of pregnancy, and repudiates gravitation as a cause of 
TONE IN THE FCETUS.
279
foetal position.  Dr. Simpson illustrates his views by a series of
admirable engravings, showing the outline of the uterus and the
foetus under different conditions.
  In my lecture  " On Parturition," published in  1848,  before
the appearance of Dr.  Simpson's papers,  while discussing the
abdominal movements of pregnancy, I endeavored to draw a dis-
tinction between  the movements of the foetus and those of the
uterus.  I pointed out  that many of the movements commonly
attributed to  the  foetus  really belonged  to the uterus.   I ad-
mitted that the foetus moved in ^obedience to reflex stimuli, but
I supposed these  reflex  movements  to be  faint and obscure,
because of the provisions which shield the foetus from reflex ex-
citation.   I believe I underrated the extent and influence of the
foetal movements; but after the best consideration I have  been
able to give the subject, I think  Dr. Simpson  has  attributed to
the reflex movements of the foetus results, in the production of
which other agencies play a very considerable part.
  The  ovoid shape of  the foetus, towards the end of gestation,
depends in part upon the  form of the uterus,  and in part upon
the muscular condition of the foetus itself.  As I pointed  out, in
1848, the foetus in utero, is,  when unexcited and at rest, under
the spinal influence of what Dr. Marshall Hall calls " Tone," or
the  continuous influence  of the vis nervosa; that  principle by
which the sphincters are kept closed in after life, and which
causes the contractions in limbs which are deprived of the in-
fluence of volition in cerebral paralysis.  Under this influence,
the stronger flexor muscles having more power than the exten-
sors, the body of  the child is slightly bent as  it is in the adult,
in the recumbent position when volition  is  at rest, as in sleep,
and the arms  and legs are contracted.  This contracted state  of
the arms and  legs, in the foetus, depends upon an active condi-
tion of rigidity; and we see that, after birth, it is often difficult
to straighten the  limbs—their natural position—until the influ-
ence of volition has gradually acquired power, being an approach
to that which obtains in utero.  In the lower animals, the limbs,
under  the same  influence, are straight instead of curved, the
fore-limbs especially being stretched out rigidly on each  side of
the head.   Tins  is  as necessary to healthy parturition  in the
lower animals, as the  contraction of  the limbs in the  human
foetus.   The principle of tone, then, in the  human foetus, tends 
280
EXPERIMENTS ON THE  FOETUS.
to preserve the ovoid shape of the foetus, and it also tends to
keep the child perfectly still and  motionless.   This continued
influence of tone tends to maintain the foetus in a passive state,
and under  the influence  and control of the containing  uterus.
It is quite as important in maintaining the position of the uterus
as the reflex actions are in restoring it, when this has been dis-
turbed by a change of position, etc.
  In 1850,  I performed some experiments with a view to deter-
mine the particular reflex movements manifested by the foetus
in utero under  irritation.   I  took a rabbit nearly ready  to
kindle, and having placed it under  chloroform, and fastened it
to a table, opened  the abdomen so as to expose the uterus.   I
now made an incision into the uterus opposite the situation of a
foetus, so as not to wound the amnion, or to interfere with the
placental attachment.  In this way the foetus was exposed in the
transparent amnion without  being  injured  in any way, the cir-
culation in the cord not being at all interfered with.  I found
that when any part of the foetus was irritated through the amnion,
the foetus  would  draw up  its  limbs, and shortly afterwards
returned to the  ordinary quiescent state.  The one movement
which constantly occurred, whether the ears, extremities, or tail
were pinched, was a movement of the head, as in  respiration.
The mouth was opened and  shut again once or  twice, in a way
somewhat similar to the movements of the mouth and head of a
kitten  while drowning.   No  liquor amnii  appeared to  be
swallowed, and no movements  of  deglutition were attempted.
I repeated the experiment several times with  the  same result.
The respiratory movement affected the whole of the upper part
of the body,  but no  inspiration or expiration occurred.  It
appeared  to  me  that  these imperfect  respiratory  movements
must occur with every movement of the foetus, and that move-
ments of respiration do not  occur, as is supposed, for the first
time, after  birth.  This would account for the curious  pheno-
mena of Vagitus, in which,  when air reaches the mouth of the
foetus, a cry is produced before the expulsion of the head of the
child.
  The supposed reflex foetal  movements of pregnancy have been
felt in cases of amyelitic foetuses, when the spinal marrow, and
as a consequence, all reflex movements, are absent.  I quoted
in my former Lectures a case of this kind from Lallemand, in 
        MOTION OF THE  FOETUS, REFLEX UTERINE ACTION.     281

which the spinal marrow was entirely wanting, but  in  which
the supposed foetal movements were present.  Since  that time
two cases have been supplied to  me, oiie by Mr. Hoadley Gabb,
of Hastings, and the other by Professor Zaviziano, of Corfu, in
which there was congenital absence of the brain and  spinal
marrow, but the intra-abdominal movements of pregnancy were
profuse in both cases.  I pointed out  that in the state in which
the foetus exists in utero, constant excitation and motion  would
exhaust the foetus.   Professor Simpson compares  the foetus in
utero  to a decapitated  frog, but the  frog in  this  condition is
speedily destroyed by excitation.  I mentioned that in the com-
mon experiment of placing the  hand in  cold water,  and then
applying it to the uterus, the resulting movements  must  neces-
sarily be reflex movements of the uterus,  excited by the irritation
of the excitor nerves of  the skin, which  we know happens very
readily after labor.   It is impossible  that the influence  of this
cold  hand  could  be transmitted  to the foetus through the
abdominal walls, the uterus, and the  liquor amnii.   The  same
explanation applies to the movements caused by taking food or
drink into the stomach,  or the sensation  of hunger.  The move-
ments excited by touching the feet, in footling cases, are feeble.
The motions produced by lightly irritating the feet of a sleeping
infant are inconsiderable,  and the soles  of the feet are well
known to be the most  excitable part of the cutaneous surface."
We may observe  after death evidence  that in some  cases the
foetus has  been quiet for some time before birth.  The legs of
the foetus may indent each other when they have lain  across, or
the mark of the hand is left on the  side of the head.   If the
movements of the foetus were so considerable as have  been sup-
posed, we should expect incessant movements during labor.
   No experiments can  imitate, even  to a tolerable  degree, the
conditions of the foetus in utero.   Suspending the mature dead
foetus  in a  similar fluid with the  liquor amnii, when  placed
within a vessel having the shape of  the gravid uterus, fails in
many of the essential conditions belonging to the living foetus in
utero.   In the early development of the embryo, the  limbs are
deficient in muscular power, and do not assume any definite form.
The nervous system has  hardly commenced its  control over the
as yet feeble muscles.  The quantity of liquor amnii is very
large  in proportion to the size of the  uterus, and the  uterus is 
282
CHANGE OF POSITION OF THE F02TUS.
circular rather than ovoid in shape.  We have to consider these
elements as slowly altering from  day to day in an  almost in-
itio. 83.
Foetus and uterus at fifth month.
appreciable manner, during  the  middle and latter months of
pregnancy, and while the foetus is  gradually taking up its ulti-
mate position. The limbs of the foetus enlarge, becoming subject
to the influence  of  the vis nervosa, and under  the  influence of
tone,  the arms  and legs, particularly  the  latter, become con-
tracted, so  as to form the foetal  ovoid.  During this  time, the
relative quantity of the liquor amnii diminishes, so that  at the
full term the liquor amnii scarcely does more than fill up the
interstices left between the foetus and the uterus. Synchronously
with these events,  the uterus itself, by the  development  of the
cervix,  changes from the circular to  the  pyriform  or  ovoid
shape.  With this  change of shape, the  uterus acquires more
power of muscular contraction, and becomes the subject of reflex
and peristaltic actions.   The  contractions of the  uterus  neces-
sarily exert a moulding or adaptive influence  upon the  foetus,
poised lightly as it is in the liquor amnii, and moved within the
limits of its prison  by the slightest impetus.  These causes are
probablyT  aided  by the  reflex movements  of  the  foetus  itself.
Under irritation, the  limbs of the foetus strike  out, but only to
return more closely to its ovoid shape,  and  to  accommodate it-
self as accurately and easily as  possible to the uterine cavity.
All these influences,  combined  with the effects of gravitation 
SPINAL PRINCIPLE PREDOMINANT.
283
and of the inclined planes upon which the foetus rests in the up-
right  and  recumbent positions  of  the mother,  arrange  and
preserve the foetus in the normal position with  the  head at the

                           FlGL 84
Form of uterus in deformed pelvis.
os uteri.   No  single power, however, gives its attitude or posi-
tion to the foetus, and it is difficult, amidst such a number of
adaptations, all contributing to the same end, to single out  the
most  important.  If we give  the predominance to any one of
them, I think the spinal principle of Tone must be considered as
the most influential, and it is to the absence  of this, more than
of any quality, that we must attribute the irregular presentation
of dead children. 
LECTURE  XIX.
   THE BONES, ARTICULATIONS,  AND LIGAMENTS OF THE FEMALE
                          PELVIS.

  Gentlemen,—The Pelvis consists of four bones, the two Ossa
Innominata, the Sacrum, and  the Coccyx.  In the female pelvis
the last lumbar vertebra also  requires to be considered in con-
nection with the above, as contributing to  form the framework
of the theatre in which the principal events of natural and mor-
bid parturition are performed.
  Up to the age  of puberty each Os  Innominatum consists of
three distinct bones, the Ilium, Ischium, and Pubis, which are
separated  from each other at the acetabulum  by cartilaginous
divisions (Fig. p. 285).   After this time the  bones become united
through the medium of a Y-shaped bony deposit.  Epiphyses are
also slowly formed upon the crest of the ilium,  the anterior and
inferior spine of the ilium,  the tuberosity of the  ischium, and the
pubis at the symphysis.  These additions increase  the size of the
bones which form the pelvis, and strengthen the principal points
for the attachment of muscles.  When the two innominate bones
are placed together, they form the anterior and lateral  portions
of the pelvis. x
  The obstetric points in the anatomy of the os  innominatum are
numerous and important, but these are of course chiefly confined
to the internal surface of the bone.  To the crista of the ilium
the  chief of the abdominal muscles concerned  in  labor, the
internal oblique, external oblique, and transversalis are attached.
Other muscles concerned in parturition are  attached, the pyrami-
dalis and the rectus abdominis to the  tuberosity  of the pubis; the
levator ani to the pelvic portion of the pubis ;  and the muscles
which contribute to form the perinaeum to the  tuberosity of the
    284 
OS INNOMINATUM.
285
ischium.  The iliac fossa, covered by the iliacus internus muscle,
contributes to the support of the lower segment of the gravid
uterus in the latter part of pregnancy, before the  head of the
foetus has descended into the pelvis.  A line  running from the
promontory of the sacrum  to  the  tuberosity of the  pubis, the
Division between the ischium, ilium, and pubis.
linea ilio-pectinea, forms the boundary  between  the  true  and
false pelvis, or between the cavities of the pelvis and abdomen.
This line also marks the greater part of the pelvic brim.  At the
 junction of  the ilium with the pubis, a prominence is  met with
upon the ilio-pectineal line, which is called the ilio-pectineal
eminence.
  The inferior and slightly  everted border of the descending
ramus of the pubis, forms, with its fellow of the  opposite side
the arch of  the pubis.  Between the body and  ramus of the
ischium and the ascending and horizontal portions of the pubis
an oval opening, the obturator foramen, is seen.   The smooth
inner surface of this ramus, and the smooth portion of the inter-
nal surface of the  ischium are the surfaces over which  the pre-
senting part of the foetal head glides in parturition, and which
give it its direction as it  emerges under  the pubic arch.  The
tuberosity of the ischium  and the spinous  process of  this por- 
286
SACRUM.
tion of the os innominatum contribute to form the outlet of the
pelvis.  Behind the spine of the ischium are seen the anterior
and superior spinous processes of the ilium, between which the
two sciatic foramina are formed.  The whole of the three bones
entering into the composition of the os innominatum contribute
to form about three-fourths of the pelvic brim.
  _ The internal surface of the Sacrum is of great obstetric sig-
nificance.   It forms the posterior part of the pelvic walls, being
articulated on either side with the  ossa  innominata.  Above, it
is united with the fifth lumbar vertebra, and  below with the
coccyx.  Its upper portion forms, with  the last lumbar vertebra
and the inter-articular cartilage, the promontory of the sacrum,
or sacro-vertebral angle, the  angle  being formed by the devia-
tions  of the  line of the lumbar vertebrae, and the line of the
upper part of the sacrum.  The anterior aspect of the sacrum is
smooth and concave from above downwards.  The depth of the
sacral curve is shown by two lines, one drawn from the promon-
tory to the point of the  sacrum, and the other  at right angles
from this line to  the middle of the third sacral vertebra.
Innominatum.
  From side to side, the pelvic surface is less concave, particu
larly at its extremities, where it is slightly convex.   It is marked
by four  transverse lines, indicating its original division into five 
COCCYX.
287
rudimentary vertebrae.  These  divisions  exist, the bones being
divided by cartilage and inter-vertebral  matter, until after the
age of puberty, when ossification begins between the lowest por-
tions, and  ascending upwards, the bones become one  osseous
mass about the age of thirty.   It presents on each side four inter-
vertebral foramina, for the passage of the anterior branches of
the sacral nerves.  Besides the great angle or promontory of the
sacrum, a lesser angle is formed at the union of  the sacrum and
the coccyx, when  the  coccyx is bent backwards at the time of
parturition.
  The Coccyx generally consists of four pieces of bone articulated
together until  a late period  of life, when they become  ossified
into one mass.  These bones continue in the direction  of the
lower part of the  sacral curve, so that they project downwards
and forwards, their internal surface being smooth and concave.
During  the child-bearing era  the  bones of the coccyx move
                     Section of sacrum and coccyx.

slightly upon  each other, and considerably upon the sacrum,
with which the first bone is articulated.   The first piece  of the
coccyx is the only one presenting  any marked  characters.   It
presents above a smooth surface, which is in apposition with the
last bone of the sacrum.   From the posterior  and lateral sides
of this surface small cornua project, which rest upon the sacral
cornua.  Beneath  this process a small nodule,  sometimes con- 
288
BONES OF THE COCCYX.
tracted  into a foramen,  transmits the last sacral  nerve.  The
bones of the coccyx diminish in size from above downwards, so
that the last piece is a mere nodule.  Attachments exist between
the coccyx  and the  coccygeus muscle, the  levator ani,  the
gluteus  maximus, and  the  sciatic ligaments on each  side, and
the sphincter ani at its extremity.  The coccyx has the power
of movement backwards or forwards  to the extent of an inch.
When moved forward or elevated, it decreases the pelvic outlet;
but when depressed and drawn backwards, it increases its area.
This bone is moved forwards by the contraction of the levator
and sphincter ani; and  backwards by the contraction of the
lower fibres of the .gluteus  maximus, when the thighs are fixed,
the coccygeus, and  the  dilatation of the sphincter  ani.  The
depression of the coccyx  is  carried, however to its utmost point
by the mechanical pressure of the foetus as it passes the pelvic
outlet.
  The Fifth Lumbar Vertebra articulates with the upper sur-
face of  the sacrum, and  contributes, as already mentioned, to
form its  angle  or  promontory.   This  is effected by the lower
surface of the last lumber vertebra being oblique instead of flat,
Sacrum and coccyx.
the anterior portion of the body being thus rendered  much
deeper  than  the  posterior.   In cases of  deformed   pelvis 
         ARTICULATIONS AND LIGAMENTS OF THE PELVIS.      289

this bone may become of great importance, and the other lum-
bar vertebrae also may have an  immediate bearing upon the
pelvis.  Through the medium of the lumbar fascia, the lumbar
vertebrae give attachment to the transversalis and the  internal
oblique muscles.   Some anatomists consider that the fourth
lumbar vertebra also forms part of the false pelvis, in ligament-
ous preparations, and in the living subject, because of the liga-
mentous connection which exists between the transverse process
and the crest of the ilium.
Fifth lumbar vertebra.
   The Articulations and Ligaments which unite the bones of
the pelvis, not  only give  the  necessary strength to this  part
of the body, with reference to the support of the trunk and the
movements of the lower extremities, but they contribute largely
to render the pelvis a cavity fitted  to contain and preserve the
pelvic viscera, and a canal for the jpassage of the foetus in par-
turition.   The joints and articulations are so arranged that the
internal surface of the pelvis is rendered smooth; but externally
everything is subsidiary to strength, and numerous prominences
are observed.   Bony processes, ligaments, and the attachments
of muscles are all made to contribute to this object.   The whole
pelvis may be compared to a nest, in which the rough materials
are accumulated on the outside, the cavity being rendered as
smooth and even as possible.  The  joints to be  considered are
the Lumbo-Sacral, Sacro-iliac, Sacro-Coccygean, and Pubic ar-
ticulations : they all belong to that  class of joints termed amphi-
arthrosis.   The  ligaments are very numerous, and connect the
bones of the pelvis at other points beside  those  at which the
bones are  in articular opposition.
  The vertebral surface of the sacrum  articulates with the last
lumbar vertebra, by means of a wedged-shaped mass of fibro-
                              19 
290
UNION OF THE PELVIC BONE8.
 cartilage, the thickest part of the wedge being in front, and in-
 creasing the  effect of the peculiar slope of the body of the  last
 lumbar vertebra.  This  cartilage, which resembles in structure
 the inter-vertebral cartilages, really constitutes the  most promi-
 nent  point of the promontory of the sacrum, as  it is termed.
 That is to say, if the finger be introduced into the vagina for the
 purpose of examining the capacity of the pelvis, the projecting
 point of the upper and posterior part of  the  brim is felt at the
 anterior part of  this cartilage.  The common anterior vertebral
 ligament passes  in front of the lowest lumbar vertebrae, and ex-
 tends downwards over the front of the sacrum and coccygeal
 bones.  The  transverse process of the last,  and,  according to
 some  authorities, the fourth, lumbar  vertebrae, are connected
 with the upper and external  portion of the sacrum by a thick,
 short, and strong ligament, called the lumbo-sacral, or sacro-verte-
 tebral ligament.   With the exception of this  ligament, and the
 shape of the cartilage above described, the ligaments uniting the
 sacrum to the vertebral column are the same as those connecting
 the several vertebrae with each other.
  The Sacro-iliac Symphysis unites the  articular surfaces of
 the sacrum  and ilium, both of which are covered by a layer of
 cartilage presenting numerous inequalities when not in apposition.
 The sacral layer of cartilage is somewhat thicker than that be-
 longing to the ilium.  The union  of these bones is strengthened
 and rendered complete by the ilio-lumbar and the anterior and
 posterior  sacro-iliac  ligaments.  The ilio-lumbar extends from
 the transverse process of the fifth lumbar vertebra, and the back
 of the sacrum, to the crest of the  ilium, near  the posterio-supe-
 rior spinous process.   The  anterior sacro-iliac ligament extends
 between the  anterior surfaces of  the  ilium and sacrum, in  the
 form of a thin irregular layer.  The posterior sacro-iliac is strong-
 er, consisting of  several  sets of fibres, extending obliquely and
 transversely from the rough surface of the  sacrum to the poste-
 ior  surface of the ilium.
  The coccyx is  united to the sacrum  by a  thin fibro-cartilagin-
 ous layer  interposed between  the  articular surfaces of the two
 bones, and by an  anterior and posterior ligament—the latter being
 of considerable  thickness.  The small bones of the  coccyx are
also joined to each other by thin plates of cartilage, and anterior
 and posterior ligamentous bands.  Some anatomists describe the 
LIGAMENl'S OF THE  PELVIS.
291
existence of small synovial  sacs in cases in which these  bones
move more freely than usual  upon each other  and upon the
sacrum.
  The two Sacro-sciatic Ligaments, great and small, require
notice in this place.  These unite the ilium, the sacrum, and the
coccyx to the ischium, and contribute to strengthen the posterior
articulations of the pelvis ; but they are of more importance as
a portion of the  canal and  outlet of the pelvis  itself, than as
forming part of the pelvic articulations.
  The greater or  posterior sacro-sciatic ligament  extends from
the posterior and inferior surfaces of the ilium and the posterior
part of the sacrum and coccyx, to  the  tuberosity and ramus of
the ischium.   This ligament is expanded at its extremities, par-
ticularly at its posterior  attachments.   The  small or anterior
sacro-sciatic ligament  extends from the side of the sacrum and
coccyx to the spinous process of  the  ischium.  At the sacro-
coccygean attachment  the fibres of the ligament are in apposi-
tion with the middle part of the posterior ligament; but in pass-
ing the spinous processes, the direction of  the  anterior ligament
crosses that of the posterior.   The attachment of the anterior
ligament to the sacrum and  coccyx is broad, but its attachment to
the spinous process is smaller, so that the whole ligament is trian-
gular in shape.  The space between the anterior and posterior liga-
ments and the spine and tuberosity of the ischium constitutes the
Sacro-sciatic ligaments and ilio lumbar. 
292
MOVEMENTS OF THE PELVIC BONES.
small sacro-sciatic foramen ; while the large sacro-sciatic foramen
is formed by the sacrum and ilium, and the sacro-sciatic ligaments.
The obturator-fascia ligament may be mentioned here, as being
concerned in the formation of the pelvis, without any reference
to its articulations.  It is a fibrous membrane filling up the ob-
turator foramen, except at the  upper part, where the obturator
nerves and  vessels make their exit.  The  obturator fascia is
connected with the great sacro-sciatic ligament by the process
sent up from the tuberosity of the ischium.
  The Symphysis  Pubis consists of the articular surfaces of the
pubic bones, an inter-articular  cartilage, anterior and posterior
ligaments,  and  the  superior,  and  sub-pubic,  or  triangular,
ligaments.   The inter-articular fibro-cartilage is composed of
concentric lamellae,'  This cartilage itself is imperfectly divided
into  two parts,  one for  each osseous surface, frequently con-
taining a viscid  pulp  in the  central space between them.  The
posterior ligament is the most indistinct; the  anterior consists of
numerous thick decussating fibres, which cover the symphysis.
The  superior pubic  ligament consists of  ligamentous  fasciculi,
which fill up the small space  between the bones above the inter-
articular cartilage  at the upper  part of the symphysis.  The sub-
pubic or triangular ligament  is  the most important.   It is thick
and crescent-shaped, attached to the descending rami of the pubis
and the lower part of the inter-articular cartilage.   Its inferior
border is smooth and  arched, contributing to form  the angle or
arch of the pubis, one of the great obstetric points of the pelvis.
  With the exception of the coccyx, the Movements of the
Bones of the Pelvis  upon each other in the  unimpregnated
state are extremely limited.   Some authorities have maintained
that during labor all the pelvic symphyses are relaxed to a slight  v-
extent, while others have believed that the joints remain entirely
unaltered at this time.  This  supposition  led to the now aban-
doned operation of Sigault,  for the division  of the symphysis
pubis in cases of contracted  pelvis.   Some have even believed
that during gestation osseous  matter is absorbed from the pelvis
and carried into the circulation  to supply the  wants of the foetus.
Others contend that no change  whatever occurs  in the bones or
joints of the pelvis in the course of pregnancy and parturition.
We know, however, as Denman pointed out, that in rare cases
the sacro-iliac and pubic articulations become so relaxed as to 
          EVIDENCE OF DESIGN IN THE FEMALE PELVIS.      293

cripple the subjects of this affection for a considerable time after
labor.  It is also known from dissections of women dying during
or immediately after labor, that the cartilages of the joints of
the pelvis are found  to be softer and  more vascular  than usual
at this time.   Many of the lower animals are unable to support
themselves firmly  in  the  standing  position previous  to  and
during parturition, in consequence of  a relaxation of the joints
of the pelvis ;  and Mr. Robertson has pointed  out  that in the
guinea-pig, the pubic symphysis is widely separated at the time
of labor,  to  admit of the passage of the young.  These facts
afford  good reasons for believing that in many cases a slight
amount of relaxation of the pelvic articulations does take place
in the human female during delivery.  The attachments and u-
action  of the abdominal muscles are such, that during the expul-
sive stage of labor the outlet of the pelvis becomes slightly en-
larged.
  Perhaps no part of the  human skeleton, rife  as the whole is
with adaptations,  evinces  more  evidences of  design than the
bones of the  female pelvis.   The progress of ossification shows
this in  an eminent degree.  Up to the time of puberty the car-
tilaginous division between the ilium, ischium, and pubis is com-
plete.  Under  the  stimulus of the  ovaria, the  pelvis enlarges
considerably  at, and previously  to, the occurrence of the  cate-
menia, and the separation  of the  bones which compose the
pelvis  greatly facilitates  those operations of growth, by which
its  cavity is expanded to  the mature standard.  In the other
parts of the body there is no instance of any such sudden change
after the time of birth, not even in dentition, as that which oc-
curs in the pelvis and its  contained  organs during  the two or
three years in which puberty is prepared  for and completed.
The  development of the sterile girl into the fruitful woman is
almost as  striking  as the metamorphoses which occur in the
lower orders of creation.  All the changes of this epoch have for
their great object the preparation of the organism for the func-
tions of impregnation and childbearing.  Of these, the  expan-
sion of the bones of the pelvis, before the  union of the three  v
parts which compose the os innominatum, the bony deposit be-
tween  the pubic bones at the symphysis pubis, the slow union
of the  bones  of the  sacrum,  the formation  of the  numerous
epiphyses which enlarge the pelvis and contribute to its strength 
294
ANATOMY OF THE NORMAL PELVIS.
at and before the era of puberty;  and the ossific union of the
different parts of the coccyx and of  the  whole bone with the
sacrum, only after the function of childbearing has  altogether
ceased, are amongst the most remarkable.
    The individual bones and ligaments which enter into the com-
  position of the pelvis having received a detailed notice, attention
J will now be directed to the interior of the pelvis, and to the nor-
  mal relations of the salient osseous points of its exterior anatomy.
  Under the first head will be included the Pelvic Planes, Axes,
  Angles, Diameters, and Canal, while the second will refer to cer-
  tain external measurements, a knowledge of which is necessary
  to a ready diagnosis of special internal malformations, or general
  alterations of dimension and configuration.  I  have reserved the
  consideration of the Normal Pelvis, to  the present time, instead
  of introducing it into  the early part of the work, in order to con-
  nect it with  the anatomy of the  Foetal Head, and the Mechan-
  ism- of  Labor, which will form  the subjects of the  two next
  Lectures.
    As already stated, the pelvis is divided into two parts,  a false
  and a true pelvis, the first situated above, and the second below,
  the linea-ileo-pectinca.  The relations of these  divisions  of the
  whole pelvis to utero-gestation and parturition are very unequal,
 '. and in cases where the false pelvis is malformed, the distortion
  of the true pelvis co-exists to such  an  extent as to render the
  deviations above  the  brim  comparatively unimportant.   We
  must look for the interest of the false pelvis, not in its immediate
  relations to the passage of the foetus through  the  pelvic canal,
  but in its functions as the supporter of certain viscera, as a fixed
  point for the action of numerous muscles concerned  in parturi-
  tion, and as a tolerably correct indicator of the  condition of the
  true pelvis.
    The true pelvis, or  bassin petit, as it is termed by French
  obstetricians, is   situated below  the linea-ileo-pectinea, which 
                      PELVIC DIAMETERS.                   295

circumscribes its superior orifice or inlet, and has  its inferior
opening  or outlet, bounded in part by osseous, and in part by
                           Tig. 85.
ligamentous structures.  In the middle line posteriorly the out-
let is formed by the coccyx, and by the great sacro-sciatic liga-
ments laterally and behind; the tuberosities of the ischia are its
extreme lateral boundaries, and the conterminous rami of the
ischia and pubes form its anterior-lateral confines.   The pelvic
                           Fig. 86.
Brim of pelvis. Transverse and oblique diameters marked.
canal lies between the above limits, and within this canal are
situated  the  rectum,  bladder, and ureters;  the internal iliac
arteries and veins, with their subdivisions ;  the lymphatics ; the
sacral plexus in whole, and the lumbar plexus in part; and cer- 
296
SCREW FORM OF THE  INNER PELVIS.
 tain muscles  visceral  and femoral.   In  the  unimpregnated
 female, it also contains the uterus and ovaries, and during utero-
 gestation, a varying portion of the lower portion of the gravid
 uterus and its contents.
   The Diameters of the pelvis are measurements taken in the
 three planes which have been described.  The other dimensions
 necessary to be known are the depths of the  pelvis at cfifferent
 points, and the distances between several of its»spines and tube-
 rosities.   Beginning with the diameters of the superior plane or
 inlet, we have the long or transverse diameter, the antero-poste- i
 rior or conjugate diameters, and the right and left  oblique dia-
 meters.  In the mid-plane we have the same diameters to consi-
 der, but the oblique is now the longest diameter.   In the infe-
 rior plane, the  longest of the diameters is the antero-posterior.
 In referring to the statements of the most  eminent authorities,
 an immense variety of measurements will be found, but the range
 of variation, with few exceptions, is not very great; and with
 regard to the  greatest extremes, nothing  is met with that does
 not probably result from the accidental omission or admission of
 very large or very small pelves  into the calculation.
  The Depth of the pelvic cavity or canal varies greatly  in
 different parts of the pelvis.  Behind, it measures from five to six
 inches from the sacro-vertebral angle to  the point of the coccyx;
 from  the  linea  ilio-pectinea to  the tuberosity of the ischium, :
 three inches and three-quarters; and from the crest of the pubis
 to the pubic arch, from  an inch and a half to two inches.
  At the brim of the pelvis, the antero-posterior diameter, from
 the sacro-vertebral angle  or promontory, to the crest  of  the
pubis, measures  four inches in the dried state.  The transverse
 diameter  measures  from about four inches to five  inches  and a
 quarter.   The measurement of  the oblique diameter from  the
sacro-iliac symphysis to the ilio-pectineal eminence, is from four
and a half to five inches.   In the cavity of the pelvis, from the
 middle of the  sacrum to the pubic symphysis, the antero-pos-
terior diameter  is as nearly as possible  four  inches and a half.
The oblique diameter, from the middle of the great sacro-sciatic
foramen to the obturator ligament is five inches.  The transverse
diameter  on the same plane, between the two  ischii is  about
four inches and three-quarters.   At the outlet or inferior strait
of the pelvis, the diameters are as  follows : 
                    DIAMETERS OF THE PELVIS.               297

    From the arch of the pubis to the extremity of the  coccyx,
  antero-posterior, four inches and a half—but the mobility of the
  coccyx increases this by nearly an inch; between the sacro-sciatic
  ligament and the ascending ramus of the ischium, oblique, about
  five inches; between the tuberosities of the ischii, transverse, four
  inches.  Thus, at the brim the longest diameter is the  transverse,
  the shortest is the antero-posterior.  In the middle of the pelvis,
  the oblique diameter is the longest, and the shortest is the an-
  tero-posterior.  At the outlet, the antero-posterior is the long-
  est, and the  transverse  the shortest diameter.  When  the soft
  parts are in apposition with the bones, the  oblique diameter of
  the  brim  is somewhat longer  than the  transverse.   A  line
  carried round the brim of the  pelvis measures about fourteen
  inches.
    An average struck from the  combined observations of Dun-
  can, Burns, Monro, Meckel, Watt,  Velpeau, Moreau,  Boivin,
  Baudelocque, Ramsbotham, Rigby, and Wood, gives  us the
  following results :—


                Transverse.       Oblique.      Ant. posterior.
  Superior Plane........5.2..............4.8..............4.25 j
  Middle Plane________4.75..............5.2..............4.7  £ Inches.
  Inferior Plane........4.2...............................5.0  )


    It is  this change in the  longest diameter of the pelvis, from
  the transverse to the oblique, and from the oblique  to  the an-
  tero-posterior, which gives to  the  pelvis  the principle of the
  Screw—an idea we shall  have to develop more at length when
  we come to the mechanism of labor.
    The  Planes of the Pelvis  are  imaginary  levels extended
  between some of its corresponding  points, the inclination of
^ which to each other and to the horizon it is important to know.
  Only two of  these planes have  been generally deemed  worthy
  of particular attention—namely, a superior and inferior plane,
  or plane of the inlet and outlet;  but it is necessary to consider
  a third plane, situated between the other two, and which  may
  be termed the mid-plane.   To this plane especial study should 
298
PELVIC BRIM.
be directed, because it is here  that the rotations of the foetal
head are impressed upon it, and here, under slight  deviations

                           Fig.  87.
Outlet of pelvis. Antero-posterior and transverse diameters marked.
  from the normal condition,  serious obstacles  to parturition are
  encountered.
     Tlie plane of the inlet, or superior plane, is bounded by the
  linea-ileo-pectinea,  and is inclined to  the  horizon at an angle of
v/ about  60° in the female (Naegele), 65°  in the male  (Weber).
  That is to say, in the  erect posture, and  in the unimpregnated
  condition, these are the  inclinations of  the pelvic brim, inlet, or
  superior  plane.    During pregnancy,  and   more  particularly
  towards the end of utero-gestation, when the  weight of the gra-
  vid uterus and enlarged  breasts upon  the  anterior arms of the
  levers represented  by the ossa innominata, the obliquity of the
  pelvis is diminished by the involuntary assumption of a position
  similiar to that  taken by persons in  walking down a  hill.  The
  amount of diminution cannot  be stated with precise accuracy,
  as it varies according  to the length and  flexibility of the spine,
  as well as the mobility of the sacro-iliac articulations, but it fre-
  quently amounts to several degrees.  There  is an evident adap-
  tation of  means to an end in the greater obliquity of the female
  as compared with  the male pelvis, the  approach of  the internal
  surface of the  symphisis pubis to the  horizontal position being
  manifestly conducive to  the support and retention of the compa-
  ratively heavy  pelvic viscera of the female, and fitted to coun-
  teract the tendency to  prolapse caused by  the greater area of 
i
                        PELVIC  CANAL.                    299

the pelvic canal.   This  might seem to  be contradicted by the
diminished  obliquity which  obtains during pregnancy.  The
Fig* 88.
             A, Plane of the inlet.  B, Mid-plane. C, Plane of the outlet.

  gravid uterus rises, however, out of the pelvic cavity before the
  obliquity  is materially  altered,  and  prolapse  thus  becomes
  mechanically impossible, from the increased  size and elevation
  of the uterus, when the ordinary provisions for support cease to be
  in operation.  The elevation of the sacral promontory above the
  upper margin of  the  symphisis  pubis,  in the unimpregnated
  female, will of course depend partly on the obliquity of the pel-
  vis, and  partly  on its dimensions.  In the well-formed female
  pelvis, it is usually from three inches nine lines to three inches
  ten lines; and in the upright position,  the sacral portion of the
  brim is  a little below the  antero-superior iliac spine.  It is
  necessary to study the relations of the superior plane of the pel-
^ vis to the spinal column.   The pelvi-vertebral angle—that is,
  the angle subtended by the superior plane of  the pelvis, and the
  lumbar portion of  the spine, forms an angle of about  150°.
  This angle  varies slightly in different individuals, but is  dimi-
  nished somewhat by the  anteflexion  of the  spine, and drawing
  up of the inferior extremities, which  obtains in the  obstetric
  position.  The study of the above particulars may be facilitated
  by means of a diagram.   (Fig. 89.) 
300
BOUNDARIES OF THE PELVIS.
  The mid-plane,  or strait, of the  pelvis, unlike the superior
plane, is not bounded by a line, all the points of which lie in the

                            Fid. 89.
                                T)
        A B, Horizon.            C D, Vertical.
        A B I, Angle of inclination of pelvis to horizon, equal to 60 deg.
        B I C, Angle of inclination of pelvis to spinal column, equal to 150 deg.
        C IJ, Angle of inclination of sacrum to spinal column, equal to 130 deg.
        E P, Axis of the inlet.
        L M, Mid-plane of the middle line.
        N, Lowest point of the mid-plane at the spine of the ischium.

same plane, and the  term plane  must not be taken therefore in
an exact and mathematical, but in an obstetric and conventional
sense.  Its boundaries may be stated as  follows :  Commencing
at the symphisis pubis anteriorly, at about the level of the upper
margin of the  obturator foramen, it crosses the obturator mem-
brane immediately below the point of the exit of  the obturator
nerve and  artery;  from  thence it descends  the spine of the
ischium along  the  oblique ridge on the inner surface of that
bone.  It then  traverses the lesser sacro-sciatic ligament,  and
ascends to the  level of the lower portion of the third  piece of
the sacrum.   The straight line, L M, in the diagram represents
its level in the  mesial line ; its lowest point is  indicated by the
letter N, situated at the lowest part of the  curved line, and this 
PLANES OF THE PELVIS.                301
corresponds to the apex of the ischial spines.  The general incli-
nation of this plane to the horizon is  considerably greater than
that of the superior plane—in other words it makes a less angle
with the  horizon, the difference being about 20°.  The  impor-
tance of the study of this plane will be more particularly dwelt
on  when speaking of the canal of the pelvis.   (Fig. 90.)

                             Fir 90.
A, Axis of Superior plane.         B, Axis of Mid-plane.
C, Axis of Inferior plane.          D, Axis of Canal.
E, Horizon.
  The inferior plane, plane of the outlet, or inferior strait, is
commonly described as extending between the lower margin of
the symphisis pubis anteriorly, and to the tip of the coccyx pos-
teriorly.   There  are, however, valid reasons for dismissing the
coccyx from  our calculations on this head;  for being movable,
and potentially endowed with elasticity through the medium of
its connection with the perinaeum, any influence it exerts upon
the progress of labor partakes of the  nature of a  force applied
from without, and differs toto coelo from the rigid resistance of all
other parts of the pelvis.   The motion enjoyed by the coccyx is
so great, that  before it has reached its  limit it ceases to influence
the antero-posterior diameter of the outlet, and the mechanical
conditions under which the foetal head escapes from the pelvis 
302
AXES OF THE PELVIS.
are then imposed by the apex of the sacrum.   This is proved by
the following measurements:  In a  large  female pelvis,  the
antero posterior diameter of the  outlet, measuring from the tip
of the sacrum, is 4.5  inches, and from  the  tip of the coccyx,
3.625.  The amount of motion  enjoyed  by the coccyx equals
one inch—that is to say, the coccyx  can be  pushed back one
inch from its ordinary situation by  the  pressure  of the foetal
head  and the  action  of the muscles in connection with  the
coccyx.  If we add  this inch to  the  ordinary diameter, 3.625,
we have 4.625 as the distance from the tip of the coccyx to  the
lower border of the symphisis pubis.
  As this is greater than 4.5  inches, the  distance from the last
mentioned point to the extremity of the sacrum, it is clear that
the sacrum, and not the coccyx, bounds the outlet of the pelvis,
and determines how large a body shall pass out of it. The incli-
nation of the plane of  the outlet to the horizon, if the measure-
ment to the tip of the coccyx be taken, is, according to Naegele,
from  10° to 11°.  If  the tip of the  sacrum  is taken as the
osseous limit posteriorly, the inclination will not of course be so
great, the angle being in this from 15° to 16°.  The planes of
the pelvis meet, if projected anteriorly, about  1.5 inch in front
of and below the symphisis pubis. These  several planes, it must
be borne in  mind, vary in their relation to the horizon and to
the spinal  column, but constantly preserve the same relations
between  themselves.   The sacro-iliac  articulations  are not free
enough to allow of any variation in  the  pelvic planes.   As a
corollary to this, it follows  that the axes of  the planes of the
pelvis  must be  fixed  and  determinate, and the course of the
fcetal head under normal conditions must be  fixed and deter-
minate also.
  The axes of the pelvis are  certain imaginary lines, drawn at
right angles to the several planes of the pelvis.   The axis of the
superior plane or axis of the  inlet, if  prolonged and produced
superiorly, will emerge from  the umbilicus, and, inferiorly, will
impinge upon the anterior surface of the coccyx, near its point.
This line makes with the horizon an angle  of about 30°.  The
axis of the  mid-plane, if produced inferiorly, will  fall  upon a
point rather nearer to the anus than half  the  distance between
the anus and the tip  of the coccyx ; and superiorly, will  issue
some inches above the umbilicus.  The  angle made with the 
PELVIC AXIS, THE  ARC OF A CIRCLE.
303
    horizon by this line is about 50°.  The axis of the outlet, when
    the point of the coccyx  is not  displaced by the egress of the
    foetus, falls from  the  promontory of the  sacrum to  midway
    between the tuberosities of the ischia, or to the anus if continued
    through the soft parts.  The angle  made by this axis with the
    horizon is about 80°.   But, as already stated, it is better to con-
    sider the axis  of the outlet  as the  axis of a plane  extended
    between the inner margin of the symphisis pubis  and  the  apex
    of the sacrum.  Such  a line would emerge  superiorly, a  little
    in front of the sacral promontory, and, below, would fall a little
    behind the anus.  There would also be  a small  diminution of
    the angle made by the axis of the outlet  with the horizon.  This
    represents the actual state of things during labor, when the
    coccyx is moved  back, and  the  differences just  enumerated
    necessarily follow.  (Fig. 90.)
     These axes are all of them of importance chiefly as they bear
V   upon the true  axis of the pelvic canal which represents the path
    traversed by the foetus in its passage from the maternal nidus to
    the external world.  The axis  of the canal is  a subject upon
    which very diverse opinions have been held, and most of them
    evidence a wish for diagrammatic perfection rather than a patient
    observation  of Nature.  The  study of the axes  of the pelvic
    planes of the inlet and  outlet has led to much incorrect opinion,
    the axis of the canal being held to be identical with the axis of
    these two or  three planes ; whereas, the axis  of the canal is^.
    identical  with every imaginary intermediate plane from  the
    inlet to the outlet, at the point where the axis  cuts  the plane.
    One observation will show the fallacy of representing the axis
    of the canal by the  axes of isolated planes.  The  axis of the
    outlet of the pelvis, and the direction of  the  axis of the lower
    part  of  the pelvic  canal,  are usually  confounded together,
    whereas they are totally distinct. The axis of the outlet is down-
   wards and  backwards, being at right angles with  the inferior
   pelvic plane, while the produced inferior  extremity of the axis
   of the canal, being the  axis not of one plane but of many, looks
   downwards and forwards.  It is difficult  to conceive  how such
   men as Muller and Roederer should have  fallen into the error of
   making the pelvic axis  a  right line.  Baug, Choulant, Carus,
   and Camper represent it by means of an  arc de cercle ; and the
   circle of Cams finds favor at the present time with many obstet-
• 
 304       VIEWS OF WRITERS ON  THE PELVIC CURVE.

 ricians.  Camper is, perhaps, the model of a mind addicted to
 diagrams; and,  as  is well known, he  fell  into  diagrammatic
 vagaries about other things than obstetrics.
  A rougher idea, again, of the direction of the pelvic axis could
 hardly be given than by endeavoring to express it by the  meet-
 ing of the inlet and outlet; yet this  is  held by some.  Levret
 caught a glimpse of the truth when he proposed to represent the
 value of the pelvic curve by perpendiculars drawn from  three
planes.   Had he said thirty or three hundred planes, he would
have been nearer the fact, the axis of the pelvis being in reality,
as already stated, a curved line, passing through  the centre  of
every linear plane between the plane of the  inlet  and the plane
of the outlet.   Of all recent authors, Dubois leaves least to be

                           Fib. 93.
 a 5, Axis of the path of the foetus through the pelvis,  o, Coccyx, dd, Distended perinaeum.

wished for in his description of the pelvic curve.  We must bu
careful not to dislocate the curve of the pelvis from its connec-
tion with other parts through  which the foetus  passes.  This
curve is only complete when we have added to it the axis of the
• 
                   AXIS OF THE  INLET AND OUTLET.            305

    uterus above and of the distensible soft parts below.  Col-
    lectively, the parturient line is expressed by an irregular para-
    bolic curve, fixed from the brim of the pelvis  to a line  drawn
    from the inferior margin of the symphisis pubis  to  the apex of
    the sacrum, and variable  from  the fundus uteri to the  pelvic
    brim,  and from the outlet to  the margin of  the  perinaeum,
    according to the position of the  uterus, and the  facility with
    which the coccyx is pushed back or the perinseum distended.
      The study of the axis of the inlet  and  of the outlet  of the
 y  canal has important practical bearings.  In order that the uterus
    may act with the greatest  efficiency in the first stage  of the
    labor, where the motor force is required in the  direction  of the
    axis of the inlet, it is necessary that the axis of the uterus  should
    correspond with the axis of the inlet.   If  the gravid uterus be
    anteflected or retroflected  from the true position, the progress of
    labor is impeded.   If the  axis of the uterus approaches the hor-
    izon, the  foetal head is impelled  against the promontory of the
    sacrum ;  if it approaches the perpendicular, it  is  urged  against
    the pubes.  The derangements of the axes of the uterus and pel-
    vis have the same effect as distortion of the brim, only the diffi-
    culty is easily remediable. By bending the spine upon the pelvis
    as in the  usual obstetric position, we may depress the axis of the
    uterus ; and, on the other hand, if it requires to be raised, it is
    necessary to support the uterus with a bandage or place  the pa-
    tient on her back.  It is necessary that we should recognize the
    direction of the axis of the outlet in examinations ; in introduc-
    ing the hand into the uterus; in assisting the birth of the head;
    and in all traction in midwifery operations of every kind.
      The canal of the pelvis is the most important matter in
[f  relation to this assemblage of osseous structures, and it  is espe-
    cially necessary to consider  the walls of  this canal, and  the
    direction  taken by the different portions of the pelvic parietes.
    It may be observed that the inner surface is made up of a num-
    ber of smooth inclined planes, and that the inclination of these
    planes is so arranged as to accomplish two principal objects;  one,
 j  a gradual alteration of  the direction of the longest diameter of
    the canal: the other, a more sudden change in the direction of
    the planes themselves. Between the superior and middle planes
    of the are,a of the pelvis, we may observe in the pelvic walls of
 ^  the inlet four inclined planes: of these, one is  formed by the
                                20
• 
306
DEPTH OF THE FEMALE PELVIS.
whole of the internal surface of the body of the pubic bones; and
a second, by the upper half of the sacrum.  The direction of both
these inclines is downwards and backwards.  The  two other
inclined planes are placed laterally, and  are composed of* the
ilia and  ischia,  terminating in the spinous  processes of the  ^
latter.   The direction of  these  lateral spines  is downwards,
backwards,  and inwards, so that at the  spines of the ischia
the  walls of  the   pelvis  approximate  to  each other more
closely than  they  do  at the  commencement of the  superior
lateral planes, below the  linea-ileo-pectina.  The inclined planes
of the outlet, as far as the bony pelvis is concerned, may be said
to be five in number;  one  posterior  and  four lateral.  The
direction  of the posterior, consisting of the lower half of the  \,-
sacrum and the adjacent  portions  of the sacro-sciatic ligaments,
is also downwards  and forwards.  Of the lateral  inclined planes
of the outlet, two,  consisting of the  internal surfaces of the
ischia, below the level of the spinous processes, terminate in the
tuberosities, and are directed downwards  and  forwards,  and
slightly inwards.  The  other  two lateral  planes  of  the  out-
let are formed by the descending rami  of the pubic bones,
and  the  ascending rami  of the  ischia;  they extend  from
the middle of the arch of the pubes to  the  tuberosities of the
ischia, their direction being upwards, forwards, and inwards.  If
we considered the  bony pelvis as  a complete canal, it would be
pinched inwards at the points of the ischial spines and  tuberosi-
ties of the ischia, and bulged outwards at  the sites of the great
sacro-sciatic foramina.  These circumstances, together with the
shallowness of the anterior or pubic portion, contribute to alter
the diameters of the superior, middle, and inferior planes.   The
key to the pelvic mechanism, in an obstetric sense, may be said  ,,
to be the spinous processes of the ischia.   Here it is  that the
foetal head  makes  its most  decided  change of position.   The
changes of position and direction which bring the foetal head to
occupy, at the outlet of  the pelvis, the right oblique position as
the most common presentation, are effected mainly by  the ana-
tomical adaptations  of the pelvis, aided by the  mechanism  of
the foetus, and the  position of the rectum  in the notch by the
side  of the sacrum on the left side.   (Fig.  92.)
  The normal depth of the female pelvis, is, according to Burns,
as follows :  From  the promontory of  the sacrum to the tip of
• 
           CHARACTER  OF DEEP AND SHALLOW PELVES.        307

coccyx, from 5 to 6 inches; from the brim  to  the tuberosity of
the ischium, 3.75 inches; anteriorly, from 1.5 to 2 inches.   The
variations which obtain in this respect exercise a considerable
influence upon  the  progress of  labor.   Deep pelves are often
somewhat  funnel-shaped,  and shallow pelves are  not merely
wide in appearance, but wide in relation to the size of the body.
If a pelvis  be very much shallower than  usual, the  points  of
resistance to the passage of the fcetal head are of course dimin-
ished in number, and the track of the  foetus is materially short-
ened also:  labor, under  these conditions,  is  unusually rapid,
unless there is coexistent distortion.  It is .well to bear in mind,
that the shortest pelvic diameter is that between the two ischial
spines (3.5 inches) and the longest is  an oblique diameter, ex-
tending between the sacro-iliac  synchondrosis of either side to
the tuberosity of the ischium opposite.   This  line is six inches
Fig. 92.
Side view of the pelvis.
in length, and corresponds very nearly in position with the long
axis of the foetal head in an Ordinary occipito-anterior presenta-
tion, when the head is fairly lodged in the cavity of the pelvis.
  With  regard  to the External Measurements of the pelvis, it
may be stated that the same method of ascertaining the antero-
posterior, lateral, and oblique diameters, which helps us so much
to understand the cavity, will assist us in understanding them.
The antero-posterior diameter of the pelvis, externally, is about
eight inches; the external transverse—i.e., from crest to crest of
the ilia—about  14 inches;  the oblique  i.e.,  from the antero- 
308        EXTERNAL MEASUREMENTS OF  THE PELVIS.

superior spine of one ilium to the postero-superior of the other—
about eight inches.   These diameters are all in the same plane.
There  are other  diameters in various  planes, a knowledge of
which is useful.  For instance, from the spine of the last lumbar
vertebra to the antero-superior spine of either ilium, 6  inches
7 or 8  lines; from  the symphisis pubis  to  the infero-anterior
spinous process, about 4 inches; from the  tuberosity of either
ischium to the postero-superior spine of the ilium of the opposite
side, 6  inches 6 lines;  from  the great trochanter of either side
to the  postero-superior spine of the ilium of the opposite side,
about 8 inches.  These measurements  are valuable, not because
we can determine from them the internal pelvic  diameters, but
because, unless the proportionate  dimensions stated above are
maintained, there must necessarily be an alteration in the size
of the pelvis, or serious distortion.   When speaking of deformed
pelves,  it will be pointed  out how the diminution of each of
these diameters  is indicative of certain mal-relations between
the pelvic bones. 
LECTURE  XX.
             THE  ANATOMY  OF THE FCETAL  HEAD.

  Gentlemen :—The anatomy of the foetal head, and the
anatomy of the pelvis, are the elements of obstetric mechanics;
and the behavior of the former in  the cavity of the latter will,
of course, depend  upon the  mutual relations of each.  It is to
the cranium of the foetus, however, that our attention  is now
directed.  Speaking, in general terms, the head of the fully de-
veloped foetus is au irregular ovoid mass of  very various diame-
ters, and various compressibility, according to the diameters in
which the compressing  force is applied.   It is attached to the
neck in such  a manner as to project posteriorly more than
anteriorly; and it  rotates upon this point of attachment  to the
extent of a quarter turn without any harm accruing to the infant.
The bones of the head may  be arranged into two  systems : one,
the bones of the cranium; and the other, those which compose
the face and base of the skull. The bones of the face and.base
of the skull differ from those of the calvarium in being far more
highly ossified; they are, in  fact, so advanced in development as
to be practically  unyielding; and the adaptations, therefore,
which exist between the configuration of this part of the foetus
and the maternal skeleton  are obtained  either  by the slight
compressibility of the soft parts of the foetal face, or by special
morphological conditions of the bones themselves.   The bones
of the face and base of the  skull are  early developed,  and un-
yielding in their texture, in  order to protect  the delicate organs
of special sensation and  important ganglia at the base of the
brain from  the injurious  effects of mechanical violence during
labor.  The  hemispheres of  the  brain perform functions  the
integrity of which is less  necessary to life, require no such pro-
tection, and  submit to considerable  compression within their
movable case.   It is interesting to remark, that the immovable 
310             ANATOMY OF THE FCETAL HEAD.
portion of the bones of the head occupies such a position that a
moderate force of compression applied to the opposite aspect of
the cranium tends rather to increase than to diminish its capa-
city ;  according to  the well-known law which provides that a
soherical vessel contains greater bulk in proportion to its super-
ficies than any  other form or receptacle.   The lower  jaw in the
foetus is widely different from  an adult maxilla, as may be seen
by reference to the accompanying engraving; the ramus is short
and oblique, and  the  empty alveoli of each  jaw are thus per-
                            Fra. 93
                             s
    1, 2. Occipitofrontal diameter.   8, 4. Occipito-mental.   5, 6. Cervico-bregmatic.
                        7, 8. Fronto-mental.
mitted to come into actual contact, whilst the body of the bone
is shallow; and thus by a combination of provisions, the fronto-
mental  diameter is  kept within convenient limits.  Were the
chin pronounced, and the fronto-mental  diameter consequently
much increased, it would, in ordinary presentations, almost inevi-
tably strike against the right side of the  promontory of  the
sacrum, and prove an insuperable obstacle to the movement of
rotation taken by the head  in its descent through the pelvis.
The diameters of the  facial portion of the head are its smallest
diameters, and adapt themselves to the smallest diameters of the
pelvis.  Thus  the  bi-temporal diameter, which is variable to a
very slight extent,  is little more than two inches and a half, the
bi-malar diameter is  barely three inches, and the bi-mastoid is
not much over two inches.  These diameters all pass through the
cavity of the pelvis, between the spines of the ischia, in ordinary
occipitoanterior presentations, as well as in  those cases where
the occipito-posterior presentations have  passed into the former.
The unyielding portion of the head might be represented by an 
             MEASUREMENTS OF THE  FCETAL  HEAD.           311

oval plane, having one  end at the back of the neck, and  the
other somewhat above the brow, whilst its conjugate diameter
would nearly correspond with a line passing  through the skull
from ear to ear.  It  is evident  that  whatever  error an  obstet-
rician  might fall into as regards the actual position of the head,
from failing  to take  into account the moulding the calvarium
undergoes  in transitu, none  can arise from this source as far as
the face and  ears are  concerned.   In cases of distortion or con-
traction, then, it follows that a recognized  ear, or cheek-bone
will be a better index to the actual position of the head than
any point  in its more  movable  part.   Dr. Hamilton  was of
opinion that the compression of the cerebral hemispheres during
labor produced a paralyzing effect upon the limbs of the foetus,
and tended  to  keep  them motionless  under  the action of  the
uterus—an opinion shared in  by Dr.  Ramsbotham.
  That part of the  head which is called the  skullcap consists
of  the occiput, the parietal bones, and the frontal bones;  the
temporal  bones  scarcely require  to  be noticed. *  In the vast
majority of cases, these bones are soft and semi-cartilaginous,
and connected  to each other  only by the dura mater and scalp ;
their  contiguous edges are bevelled off, and they may be made
to overlap each other to a very considerable extent.  Between
the edges of  contiguous  bones  are grooves called sutures / and
where three or more sutures meet,  there is a deficiency of bone, \s
called  a fontanelle.  The arrangements for solidity in the face
and base of the skull are not more conspicuous than the pro-
visions made for plasticity here ; in whatever direction compres-
sion is applied, it results in a  modification of the contour of  the
head, partly because the bones bend, and  partly because they
overlap in various directions.   As a general rule, it may  be
laid down, that in ordinary presentations the longer the head
remains in the  pelvis, the more ovoid  will it  become, always
provided that the pelvis is not absolutely deformed.  There is a
considerable  discrepancy between  the estimates of dimensions
given  by various writers. Dr. Meigs is very positive in affirm-
ing that the  estimate usually given of the occipito-frontal and
occipito- mental diameters is far too low.  It is not unlikely that
much may  depend upon the period when the measurements  are
taken,  for certainly the cranium of a foetus, immediately after
what  is vulgarly  called a " hard  labor," is materially longer 
312
MEASUREMENTS AND SUTURES.
than twenty-four hours later, and, it may  be presumed, than
before  it has been  subjected to the modelling process by which
it attains  its adaptation to the maternal  passages.   Confining
ourselves, however, to  average figures, which shall represent
rather  the relative diameters of the foetal head, than an exact
estimate of  each individual measurement, the following table
may be relied upon as sufficiently accurate for all practical pur-
poses.   The really  important consideration is not the absolute,
but the relative, admeasurements of the skull; we are utterly
unable, in any given  case, to determine the magnitude of the
body about  to  pass, and  are  therefore  compelled to frame our
mechanical appliances upon considerations of proportion.

            1. The occipito-frontal diameter 4.5 inches to 4.75
            2. The occipito-mental .... 5.0 "   " 5.25
            3. The trachelo-bregmatic . . . 3.75 "
            4. The sub-occipito-bregmatic  3.25 "
            5. The transverse or bi-parietal 3.5 "
            6,. The trachelo-frontal ....  3.25 "

  It will be observed that the two  first  of these  measurements
are particularly noticed as varying, and  they do, in fact, vary as
labor advances, being the direction in which the greatest  range
of alteration is admissible.  The circumference of the head varies,
of course, according to the direction in which it is taken.  Thus
the  ordinary presenting circumference, which passes under the
occiput, and round the parietal bones, to a little behind the
bregma, is about 11.5 inches,  and the occipito-frontal is rather
more than 14 inches, and  the occipito-mental is  nearly sixteen
inches.  It is unnecessary to burden  the memory with any fur-
ther details on this head.
   The sntnres with which  we are mainly concerned are the
coronal, the sagittal, and the iambdoidal;  the temporal sutures
between the temporal bones and the inferior concave  border of
the parietal bones are comparatively uninteresting, because the
ear is quite as easy, if not easier, to recognize in all cases where
it is desirable to know the position of that part of the head.  The
coronal suture—so called  because the ancients wore their tri-
umphal crowns  in that position—is the line of demarcation
between the frontal and parietal bones;  it extends transversely,
and almost vertically, over the  head, from the summit of the
squamous portion of the  temporal bone on one side,  to a corres- 
SUTURES AND FONTANELLES.              313
Donding point on the other side ;  its line is broken by the great
or anterior fontanelle.  The sagittal suture projects directly back-
wards from the coronal in the middle line, and lies between the
opposed superior borders of the two parietal bones; posteri-
orly it abuts upon the apex of the lambdoidal suture.  The lamb-
doidal suture—so called from its resemblance to  a Greek A—is
formed  by the opposed  borders of the occipital  and parietal
bones :  if two parietal bones are placed in situ, it will be  seen
that, owing to the obliquity of their posterior  borders, an angu-
lar recess is formed where they meet; into this recess the occipi-
tal angle fits, and just between the superior angle  of the bone
and the angular recess alluded to, is the small or posterior fon-
tanelle.   There is a  suture between the  two divisions of the
frontal bone which  varies in width, but is always  recognizable
where it abuts upon the great fontanelle; the  sagittal, coronal,
and lambdoidal, are however the important sutures, and of these
the sagittal is paramount.
  The f ontanelles are spaces between some of the cranial bones,
into  which  the sutures  debouch.   British obstetricians gene-
rally take cognizance only of two; an anterior or  greater, and
a posterior or lesser.  Continental writers speak of two others—
the temporal; but as the finger could hardly impinge upon them
unless the orbit were within reach also, it appears  unwise to
Fig. 94
Anterior and posterior fontanelles.
divert attention from the more to the less valuable aid to diag-
nosis.  The anterior or greater fontanelle, or bregma, is a rhom- 
314   CHARACTERISTICS  OF THE SUTURES AND FONTANELLES.

boidal space into which two fingers may be easily laid ; its long
diameter is from before backwards, and the greater half of the
rhomboid is in front of its lateral angles.   The sagittal suture
joins its  posterior angle,  the  inter-frontal enters its anterior
angle, and the two halves of the coronal suture debouch into its
lateral angles.  The posterior or lesser fontanelle is  small  and
triangular; it receives  the sagittal suture into its anterior angle,
and the  two limbs of the lambdoidal suture into its lateral angles.
The posterior fontanelle is the one with which it is most neces-
sary to be familiar.
  However easy it may seem at first sight  to  determine which
suture or which fontanelle is touched in any given examination,
beginners are very often mistaken, and there are some  circum-
stances which may embarrass others than tyros.  It may be as
well to point out a few  distinctions between each suture and each
fontanelle. The sagittal suture may be recognized by its debouch-
ing into two fontanelles ; the coronal by its joining a  large fon-
tanelle at one end, and leading to a more unyielding part of the
cranium at the other; the lambdoidal byT its joining only a small
fontanelle.  The anterior and posterior fontanelle, if they should
happen to approximate in size to each other, may yet  be distin-
guished by  the  anterior having four angles, and its  four sides
bounded by bony margins, which do not project into the space;
while the posterior has but three angles, and the bones around it
are the three acute apices of the occipital and two parietal bones.
There is  occasionally  a false fontanelle in the course of  the
sagittal suture, the result of defective ossification in the opposed
edges of the two parietal bones ; if it is borne in mind, however,
that only  two lines of suture can be traced  from such  a space, it
cannot be a source of any great difficulty.  Before the membranes
are ruptured, it maybe somewhat difficult, when they  are tough,
to appreciate all the points of difference between the sutures  and
fontanelles ; sometimes ossification is so abnormally advanced or
delayed as in a measure to destroy the characteristics  of the  fon-
tanelles  ;  and when the bones of the head overlap each other
very much during  its  passage  through the pelvis, it may be a
matter of great difficulty to recognize anything very  distinctly.
The greatest difficulty  in the  way  of accurate diagnosis is pre-
sented perhaps in those cases in which the membranes have been
ruptured early, and the head has been long in the pelvis tio-htly 
   DIVERSITY IN SIZE OF MALE AND FEMALE FCETAL HEADS-    315

girt by a rigid cervix uteri.  Under these cirumstances, the scalp
becomes swollen, puffy, and infiltrated with  serum and some-
times blood, and nothing can be felt distinctly through it; it may
be almost impossible to pass the finger beyond the puffy tumor,
so as to reach  a part of the head  covered  by natural  scalp, and
such cases have been mistaken  ere  now  for breech  presenta-
tions.
                           Fig. 95.
     Bi-parietal diameter; sagittal and lambdoidal sutures with posterior fontanelle.

  There are some general considerations connected with the size
of the foetal head which are worthy of attention.  In the first
place, it must be remembered that the average dimensions of the
male foetal  head  are  considerably greater than  those  of the
female; the excess in  the circumference which most commonly
presents is about half an inch, and this is quite sufficient to make
a serious difference both in the chances of danger accruing to the
infant and the mother.  The  question of safety to mother and
child is very much a matter of time;  whether the delay results
from rigidity of the passages as  in primiparae, or from greater
size  of the head as when the foetus is masculine, the result is pretty
nearly the same.  The  late Dr. Joseph Clarke, of Dublin, a very
distinguished accoucheur, investigated very minutely the ques-
tion  of the difference of the size of the brain of the two sexes at
the time of  birth.  He ascertained by the admeasurement of a
large number of cases, that the circumference of the male head
is greater  by half an inch, or about the twenty-eighth part of the
entire circumference, than the female head, at the time of birth.
The  fact that the male foetal head is actually larger than the
female having once  been established, all the disastrous  conse-
quences  of  which Prof. Simpson has  given  statistical  proof 
 316      PARTURIENT ACCIDENTS WITH MALE CHILDREN.

 follow as inevitable.  In cases of tedious labor-convulsions, puer-
 peral convulsions, puerperal fever, ruptured uterus, haemorrhage,
 and instrumental delivery, by far the greater number of children
 are males. In cases of pelvic abscesses, ruptured perinaeum, and
 vesico-vaginal fistula, the same undesirable preeminence attaches.
 to male children.   The following are the principal  conclusions
 of Prof. Simpson :
   1. Of the mothers that die under parturition and its immediate
 consequences, a much greater portion have given birth  to male
 than to female children.
   2. Of still-born children, a larger proportion are male than
 female.
   3. Of children born alive, more males than females suffer from
 the morbid states and injuries which result from parturition.
   4. More males than females die in the early period of infancy,
 and the disproportion diminishes from birth to some  time after-
 wards.
   5. More dangers  occur, both to mother and infant, in first than
 in subsequent labors.
   6. Of children which die in utero  before labor as many are
 females as males.
   7. Of the accidents which happen after the birth of the foetus
 itself, as many occur with female as with male children.
  There are other aphorisms on this question, laid down by the
 same  authority,  but they are only corollaries of the foregoing
 propositions, and need not, therefore, be stated.
  Besides the effect of sex in modifying the size of the foetal head
 and increasing the pain and danger  of parturition to the mother
 and child, we have to consider the effects of race and civilization
 upon the head of the foetus at the time of birth.  All enthologi-
 cal researches tend to show, that, with the advance of civilization,
 the human head has  increased  in  size.   The oldest crania in
 existence, much older than the mummies of Egypt, are the skulls
 found in various  parts of the world in diluvial caves, with  the
fossil  remains of  extinct  animals.    These  skulls apparently
belong to  other races than those  which now inhabit the countries
in which they are found ; they have a small development of the
brain, and resemble the skull  of the Carib in flatness of the fron-
 tal bone.  The heads of Peruvian and Egyptian mummies  are
 considerably below  the size of the European cranium.  Nothing 
       DIFFICULTIES WITH THE CIVILIZED AND SAVAGE RACES.   317

 within the range of human anatomy stands in a stronger con-
 trast than the cerebral size and  development of the New  Hol-
 lander, or the Bushman, and the Caucasian races. The different
 condition of education amongst different classes of the same race
 also has its effect on the size of the brain and cranium.   Hatters
 state that the  size of  the head is greater in the same classes  in
 towns, than in agricultural districts, in the educated than the
 uneducated.   Tiedemann gives from 31bs. 2oz. to 41bs. 6oz. troy
 weight, as the average weight of the  adult male European brain;
 but he found that of Cuvier weighed upwards of 41bs. lloz., and
 that of  Dupuytren 41bs.  lOoz.  [Authorities differ in respect
 to  the weight of the  brain  of  various  distinguished persons.
 The following is  extracted  from the post mortem of Daniel
 Webster in the American Journal  of Medical Science, which
 will give an  idea  of their  relative size:  Cuvier, 41bs. 5drs.
 lOgrs.; Webster,  31bs. 15oz. 12drs.; Dupuytren,  3lbs. lOdrs.
 27grs.—avoirdupois.]   The same authority gives  the  average
 weight of the female  brain  as  from 4  to 8oz.  less than the
 male;  and he found the different size of the male and female
 brain was perceptible at birth, in this according with the views
 of Dr. Joseph Clarke and Dr.  Simpson.  The  increase is not
 confined to the head alone.   Dr. Clarke found that,  on the aver-
 age, taking the whole body, males  weigh  9oz.,  or nearly one-
 twelfth of the  entire wreight more than females.  It seems a clear
 inference, that the  brain and head of the uncivilized and the
 uneducated must be, on the average, smaller than those of the
 educated and civilized ; and we have seen in the comparison
 of the male and female head at the time of birth, how small a
 difference in the size of the fcetal head is sufficient  to increase
 the dangers and, necessarily, the  sufferings of parturition.  Dr.
 Simpson is  of opinion that  the  comparative  difficulty of par-
 turition with male and female children extends to the foetus of
 civilized races, and he refers the increased suffering  of the  civi-
lized woman in childbirth to the size of the  foetal head.  Some
writers  have  expressed  the  opinion, that savage  women do
suffer as much or  nearly so, as the  women of civilized races.
  [Dr.  Livingston,  in  his  recent researches in  S.  Africa, says
negro women  generally suffer less than Europeans,  principally,
as it appears, because they consider  parturition to be an act of
nature, and less a disease than do the latter.] 
318   CIVILIZATION AFFECTING THE SIZE OF THE FCETAL HEAD.

  But the general bearing of all the knowledge we possess on this
subject, supports the view, that barbarian women  suffer far less
than women in a state of civilizaticn.  The size of the fcetal head
must be considered  the most important element in this matter,
though at the same time, there is the greatest sensibility induced
by the habits and social condition  of the civilized and highly
cultivated female to be taken into account.
  Civilization  not only influences the size, but the relative size
of the different,  parts of the fcetal  head.   In uncivilized races
the tendency is to increase the occipito-mental diameter, by the
protuberance of the occiput, and the greater development of the
lower part of the  face,  and to diminish the  occipito-frontal
diameter by  the flattening of the frontal  bone  and the low
development of the anterior cerebral lobes.  The diminution of
this  diameter  must lessen the difficulty in the  passage of the
fcetal head.  In  the case  of a negress, whose labor I had the
opportunity of witnessing, the great mass of the fcetal brain was
behind the auditory foramen, the fcetal head having the shape
represented in Fig. 96.
  Other  influences, besides civilization and education, have an
influence upon the size of the head.  The Caribs flattened the
foreheads of their children, and the continuance of this practice
through succeeding generations produced  a natural flattening of
the anterior part of the head, until  the Carib infants were  born
with flat heads.  The practice of flattening the  head prevailed
in Mexico, and, at an early date, in the eastern parts of Europe.
Hippocrates gives an account of the Macrocephali, a Scythian
race  believed to have inhabited the Crimea, of whom the Father
of Physic says:  " There is no other race of men which  have
their heads in the least resembling  theirs.  At first, usage was
the principal cause of the length of  their  head, but now nature
cooperates  with  usage.  They think those the most noble who
have the longest heads.   It is thus  with  regard to the usage:
immediately after the  child is born, and  while its head is still
tender, they fashion the head with their hands, and constrain it
to assume a lengthened shape, by applying bandages and  other
suitable  contrivances, whereby the  spherical form of the head
is destroyed, and it is made to increase in  length.  Thus at first
usage operated, so that this constitution was the  result of force •
but in the course of time it was formed naturally, so that usage 
CIVILIZED BARBARITY.
319
had nothing to do with it."  Mr. Adams, the learned translator
of Hippocrates, cites some researches of Dr. Rathke, as afford-
ing a remarkable corroboration of the preceding observations.
Certain tumuli have been  excavated in recent years  at Kertch,
and  there were found in  them several skeletons, in which the
form of the head was greatly elongated, so  as to resemble the
shape  described by Hippocrates  in the  Macrocephali.  It has
been suggested that one object had in view by the races accus-
tomed to flatten the head was, that of producing a shape favor-
able to easy parturition.   Binding the heads of children upon a
board  is practised in some parts  of Europe at the present day.
I have seen Polish infants arranged in this manner apparently
as a mere fashion or habit.  The round head of the Greek  and
Turk are believed to have been in part produced by the effect
of the national cap  and turban,  continued  through  successive
centuries.
   [" As we went round the long galleries (of the Royal Lunatic
Hospital at Charenton, France), Dr. Foville pointed out to us
several persons whose heads  were of a very peculiar form, more
or less perfectly approaching the pyramidal; the face  might re-
present the base and the occiput the apex.  Their foreheads were
peculiarly flat and narrow.  In reference to them he remarked,
that this species of head was peculiar to a particular department
of France, in the same manner  a3 the  Flat-head Indians are
peculiar to one tribe.   In this district more children  die at an
early age than in any other ;  the diseases bring principally con-
vulsions and  other maladies, which depend upon the  health of
the brain. More insane come from this than from  any other
quarter of the  kingdom, in  proportion to the population;  and
finally more cases of idiocy, epilepsy and the like than elsewhere.
What is the cause ?  Evidently the peculiar shape of  the head,
which pervades the people of that whole region, who all partici-
pate in this  deformity, in a  greater or less degree, without  a
single  exception.   So universal is it, indeed, that some painters
and  sculptors regarding  it as the natural  head of man, have
drawn from this source their beau-ideal of beauty;  and fixed
upon the sloping shoulders of their Yenuses  and Apollos, heads
gracefully rising in tapering pyramids.
  An investigation of this extraordinary  phenomenon has been
made,  and the cause  discovered, the  Flat-head  Indians  are 
320
DEFORMITY OF FCETAL HEAD.
known to alter the form of their infants' heads  by pressure on
the skull, when its bones  are in a more or less  cartilaginous
state and not yet firmly united.   From this fact it was suspected
that some such prank was practised on these children of France,
and sure  enough, it has been found* that  mothers and  nurses
have been employed for centuries in the wholesale business of
driving mad, maiming, and murdering the children of a parti-
cular district.   This enormity has been  committed  by putting a
peculiar cap upon the heads of their offspring, and fastening it
tightly there by means of a strong band; and this simple cord
has killed its hundreds  and  diseased an entire region!  With the
Flat-head Indians the pressure is in another direction, and may
affect the intellect while the nutritive organs are unimpaired.
Dr. Foville mentions an autopsy made upon one of their country-
women, who  had  the venous  circulation  so impeded that a
large plexus was formed, for the accommodation of which a deep
cavity was sunk in one of the lobes of the brain.," etc.—G.—Old
Wine in New Bottles •  or, the  Spare Hours of a Student in
Paris.   New York, 1849.]
                            Fia 96.
Skull of a Negro Foetus.
 
LECTURE  XXI.
                  THE  MECHANISM OF LABOR.

 Movements of the Fatal Head during its Passage  through the Pdvis:
   Obliquity—Flexion—Rotation—Extension—Restitution.

   Gentlemen :—Great  improvements in any department are
 commonly of slow growth.  This may be said emphatically of
 our knowledge of the Mechanism of Labor, which  with the
 motor forces engaged in parturition, stand at  the  very founda-
 tions of the science  and art of Obstetrics.  More than a cen-
 tury ago, to the honor of the  Dublin school of midwifery be it
 said, Sir Fielding  Oulde  called in question the opinion which
 had previously prevailed universally, that the head entered and
 passed through the pelvis  in the direction in which it emerges—
 namely,  the antero-posterior  diameter.   In  his  little work,
 published in 1741, he taught that the face of  the child did not
 lie upon the sacrum  of the mother, but was always, in  natural
 cases, turned to one  side  or the other.   He believed, however,
 that the chin of the  child  was turned towards  one of the shoul-
 ders, the  neck of the foetus being partly rotated upon its body.
 This error respecting the different position of the foetal head and
 trunk, was corrected by Smellie,  and  the belief in  the  oblique
 position of the head  in the pelvis gained  ground amongst accou-
 cheurs in different countries.   In 1771,  Saxtorph, of  Cophen-
 hagen, and Solayres de Renhac, of Montpellier, published almost
 simultaneously the discovery that the head not only enters the
 pelvis with the long diameter  in one of  the oblique diame-
 ters of the pelvis, but  that the  long axis  of "the head, in the
 great majority of cases, occupied the right oblique diameter;
the occiput being directed towards the left foramen ovale, and
the forehead towards  the right  sacro-iliac symphisis.  Solayres
de Renhac went, however, beyond his contemporary, Saxtorph,
in describing the mode in which the head passed through the out-
let under various  circumstances,  to which we  shall have here-
after to  revert.   These advances were  realized  by  practical 
322         naegele's INFLUENCE  UPON MIDWIFERY.

accoucheurs, especially by Baudelocque and  his disciples; but
it was not until 1818 that Naegele" gave a full  account of the
behavior of the head in  the pelvis under the various circum-
stances under which it may be placed in natural labor.  Discard-
ing all  theory, and looking closely to the operations of Nature,
he obtained an amount  of knowledge which enabled  him to
systematize the facts of previous authors, and give us an account
of the mechanism of labor, which subsequent observations have
all tended  to confirm.  No other  work,  of equally small size,
ever exerted greater influence upon any branch of medicine than
that of Naegele upon midwifery.   It may be termed, indeed, the
Euclid of Obstetrics, but  it will  not have executed its mission
until every  accoucheur, in each individual case  coming before
him, entirely masters the position of the foetal head.  Nothing
less than this should be aimed at by every obstetric practitioner.
We must not be content  with knowing that the  head presents,
but we must know the exact mode and direction in which the
head passes through the  pelvis; otherwise we scarcely  attain
beyond  the knowledge of the  midwife.  " Judgment," to use
the words of Hippocrates, can never be otherwise than " diffi-
cult," in this subject.  In  estimating relations of position, we
always  naturally refer to the position  of our own  body as the
standard of comparison.  But in case of  labor, the  accoucheur
stands in the upright position, and has to deal with the mother
and  the child in the horizontal  position ;  the foetus and the
mother being themselves  reversed, the child standing, as it were,
on its head within the system of the mother.  These complicated
positions are so difficult  to master, that I have heard men who
have attended thousands of cases, confess  themselves as only
beginning  to  be  certain of  the presentations  in particular
instances.  It is only by  a careful study of  the pelvis and the
fcetal head in the dried state, and a pains-taking observation of
the relations of -the head  and  the pelvis in every case of labor,
that will enable you to master this difficult problem.  Naegele
tells us  that he kept his finger on the head during the whole
course  of labor, when he  wished to ascertain  any particular
point.   There is still enough to be made out respecting the func-
tion of parturition  to reward every diligent student who may
devote his energies to the prosecution of this subject.  In every
direction we must analyze and synthesize the  movements of the 
MECHANISM OF LABOR.
qr>9
foetal head, and the motor forces and the mechanisms which urge
and direct it in  its course  through the pelvis and parturient
canal.
  The largest movement of the foetal head in parturition is that
through the canal of the pelvis, and the passage formed by the
vagina and  soft parts.   This movement is common to all  the
positions in which the head passes through the pelvis.  In its
performance, the  centre of the  head corresponds pretty nearly
with the axes of the hard and  soft portions  of the parturient
canal.  To  this  common movement are superadded various
movements of the head upon its bilateral axis, its  antero-poste-
rior axis, and its vertical axis, all of which vary in character and
extent according to the position in  which the head first engages
in the pelvis.  These movements and differences, considered in
relation with the  pelvis, constitute  the mechanism of labor and
the several " positions "  as they are called, in which  the head
presents and passes  through the pelvis and soft parts.  The head
lies at very various  depths  at the commencement  of labor.
Sometimes the developed cervical portion of the uterus, and the
contained foetal head, lie entirely in the pelvis, before  the com-
mencement of any uterine action.    At others the head  is high
up in the pelvis, and has scarcely, if at all, entered the brim.
As Dr. Rigby points out, the head is more frequently low in the
pelvis in  primipara, and high up in multiparous women.  The
cause of this is probably the greater rigidity of the abdominal
walls in primiparae  as compared with multipara.  In many mul-
tiparous cases, the head is, however, wholly within the pelvis for
sometime before the commencement of labor.   For the descrip-
tion of labor it is convenient to take those cases in which the
head  is high up as the standard, this gives us an opportunity of
tracing the steps by which the head descends through the pelvic
canal.
  The mechanism  of  labor  is  necessarily  somewhat  compli-
cated, and it should be the aim of  all teachers to render it sim-
ple as possible, by describing as few varities as may be consis-
tent with nature, and requisite to be understood in practice.   It
is  easy  to  multiply varieties in the position of the  head,  by
insisting upon trivial differences ;  but  dis-service  rather than
service  is  done in this way to  the advance of obstetric know-
ledge.  It is to be hoped that each successive  describer of the 
324         FOUR POSITIONS  OF HEAD PRESENTATION.

process, having the aid of those who have gone over the same
subject before  him, may do something towards rendering the
steps of this progress  more and more intelligible, and more deci-
dedly linked with practice.   There are four principal positions
in which the fcetal head presents in the pelvis, and  these posi-
tions we shall now proceed to consider.  The two first positions
are  termed Occipito-Anterior, because in them the occiput is
placed towards the pubis.   The other two are called Occipito-
Posterior, because in  them  the  occiput is turned  towards the
sacrum.
  In the First Position,  the  head, as already mentioned,
enters  the  pelvis in the right oblique diameter,  or in a  line
between the transverse and oblique diameters.  The occiput is
placed towards the left acetabulum, and the forehead towards
the right sacro-iliac sjmchondrosis.   At first, the long diameter
of the head is parallel, or nearly so, with  the superior plane of
the  pelvis, the occiput  and sinciput being about on the same
level.  There is, however, a considerable  lateral  obliquity of
the head.   The right side of the cranium  is considerably lower
than the left, so that the  most depending part of the cranial sur-
face  is  the protuberance of the right parietal bone.  As the head
descends, there is a slight rotation  upon the  bilateral axis, and
the occiput generally becomes lower in  the pelvis than the fore-
head. This descent of the occiput is called the Flexion of the Head.

                           Fig. 97.
       Brim of the Pelvis and Base of the Foetal Cranium in the First Division.

  The above engraving shows the entrance of the fcetal  head
into the pelvis in the right oblique diameter  after it has com- 
              MECHANISM OF THE  FIRST POSITION.           o2o

menced its descent.  The mastoid process of the left  temporal
bone and  the chin are at this time the highest portions of the
foetal head ; the right half of the occipital bone, and the adjoin-
ing portion of the temporal bone, being depressed.
  If we  examine per vaginam when the head is in the upper
part of the pelvis in this position, the right tuber parietaleisfelt
through the walls  of the anterior  portion of the cervix  uteri.
This is the point with which the finger comes in contact at the
most depending  part of the head.  The right ear of  the child
can be felt behind the pubes, if the os uteri is sufficiently open to
allow of its being reached.  At this time the os uteri does not
occupy the axis of the  pelvic canal, but is  more posterior and
directed  towards the upper part of the sacrum.  If the finger
is passed into the os uteri, the sagittal suture  is felt  crossing the
field of the os, in an oblique direction.   The patient lying on the
left side, the accoucheur standing or sitting behind, and bending
over her to make the examination, feels the sagittal suture run-
ning forwards and downwards in one direction, and upwards and
backwards in the other.   The sagittal suture divides the os uteri
unequally, a  larger portion of the middle and upper part of the
right than the left parietal bone being included within the  ring
of the  os.  It is this middle and  upper portion of  the right
parietal bone which  is felt in  making an  examination at this
period, and it is here that the tumor of the scalp is formed, when
this arises from the pressure of the head against the partially
dilated os uteri.  If the os uteri is sufficiently dilated to allow
the finger to  be passed  along the sagittal suture, it reaches in
front, and to  the left side of the mother, the triangular posterior
fontanelle, and the  diverging lambdoidal suture, while behind
and to the right side of the mother, it comes in contact with the
lozenge-shaped anterior fontanelle, and the coronal and frontal
sutures.  The earlier the examination is made, the more deci-
dedly oblique, or approaching the transverse direction, will the
sagittal suture be found.
  While the  foetal head is passing through the brim of the pel-
vis  so as to enter the pelvic cavity, it has been shown to occupy
the right oblique diameter.  It has already been mentioned,
that the first  movement of the head consists of a partial revolu-
tion upon its occipito-frontal axis, so as to effect the depression
of  the  right parietal bone.   This movement is  termed  the 
326       WHEN THE CAPUT SUCCEDANEUM  18 FORMED.

Obliquity of the Head.  In the next movement the foetal cranium
oscillates to a slight extent upon its bi-lateral axis, so as to cause
a dip of the vertex. This movement which brings the chin into
contact with the sternum, is called the Flexion of the Fcetal Head.
The lateral obliquity, the dip of the occipital bone, and the position
of the long diameter of the fcetal head in the right oblique diam-
eter of the pelvis in the First Position, are shown in Fig. 97.
   As the fcetal head descends in the pelvis, it performs what  is
termed,par excellence, its  "Rotation."  The long diameter  of
the  head changes from  the  oblique  to the  antero-posterior
diameter, or  nearly so.  The most  prominent portion of the
occipital  bone glides downwards and forwards upon the inclined
planes formed by the descending  ramus of the  pubis  and the
internal surface of the ilium, so that the middle  portion of the
superior and posterior quarter of the right parietal bone, and its
posterior and upper angle, become successively the most promi-
nent points of the descending head.  It is  in this latter position
the tumor of  the scalp or caput succedaneum is formed, by the
pressure of the soft parts of the outlet upon the head.  In this
position,  also, the head emerges  underneath the arch  of the
pubis.  In  the rotatory movement from  the  oblique to the an-
tero-posterior  diameter, the  head  describes about one eighth of
the circle.  In emerging from the pelvis, the  head is placed
almost as obliquely as at its entrance, the  right tuber parietale
being still lower than the left.  The head does not emerge either
with the occipital  or parietal  protuberance foremost, the part
which escapes first  being a point  between  the two, namely (as
already mentioned), the upper and posterior  part of  the  right
parietal  bone.  The following engraving represents  the foetal
head low down in the pelvis, in the first position.   The pelvis is
placed upon its left side, so as to imitate as far as possible a
resemblance of what is felt by the finger of the  accoucheur,  in
making an examination at this part of the process, as far as the
bones are concerned.
   [The young reader who has probably been taught to practise
the toucher with the woman on her back in confinement as now
taught in most of the American schools, may reverse this and fol-
lowing similarly placed cuts, noting that P indicates the pubis
under which the occiput presents.]
   I believe  this  is the first time such a representation has been 
RE-ROTATION OF THE HEAD.               327
made, and it appears to me  to  convey more  information  than
any figure of the base of the fcetal skull and brim of the pelvis
—the method hitherto  followed in illustrating the  mechanism
of labor.

                           Fig. 98.
 Outlet of the pelvis, and the Foetal Head passing through it in the First Position.  The asterisk
marks the presenting portion.—P, the Pubis.

  Another movement of the foetal head now demands our atten-
tion.   We have referred to the flexion of the  head, by which
the chin  is  brought towards the  sternum,  and  the occiput
depressed.  When the occiput has passed under the arch of the
pubis, this portion of the head becomes to a great extent a fixed
point, and the frontal bone and  face of the child  come  down,
describing an arc in their progress.  This is called the Extension
of the Head, the chin being  now separated from the  sternum,
and the forehead appearing at the lowest part of the  cranium.
  Immediately after its emergence from beneath the pubic arch,
the head usually rotates back  again to the aspect it held in the
upper part of the pelvis, the face being now turned towards the
right  thigh of the mother. This re-rotation,  which is termed the
Restitution of the Head, is effected in the following manner:
It generally happens, that as the head escapes, the  right  shoul-
der of the foetus is lowest in the pelvis, and impinges upon the 
328           CONCLUSION OF THE FIRST POSITION.

anterior surface of the right ischial  spine.  From this point it
rotates forwards towards the arch of the  pubis  under which  it
passes  out, the left shoulder resting upon the perinaeum, and
generally escaping first.  Thus the body of the foetus rotates in
an exactly opposite direction to the previous rotation of the head.
The left side of the head glides down the left ischial plane, and
the right shoulder glides down the plane  of the right ischium.
Fig. 99.
If it should  happen, which is  occasionally the case, that the
left shoulder  be lowest in  the  pelvis,  it glides down the left
ischial plane,  the shoulders  rotate in the same  direction as the
head, and the face of the child  is then turned downwards  and
towards the left thigh of the mother.  When the pelvis is large
and the delivery effected suddenly, the shoulders are sometimes
expelled in the transverse diameter of the pelvic outlet without
any rotation.  In the emergence of the head and  trunk from
beneath the  pubis,  the  direction  impressed by the perinaeum,
and the expulsive efforts is  such that the head turns upwards
between the  thighs  of  the mother,  in  front of the symphisis
pubis, as represented in the preceding engraving.
  In the Second Position, the occiput is  turned towards the
right acetabulum, and the forehead towards  the left sacro-iliac
synchondrosis, as the head passes  through the brim.  The left 
THE SECOND POSITION OF THE HEAD.
329
part of the base of the skull is  lowest, the occipital dip, or
flexion, being the same as in the first position.
  The left side of the head is the lowest, in the second position,
as the head descends, the same portions of the left parietal bone
being prominent, instead of the right. The left ear is felt behind
the pubis. The sagittal suture is now found nearly parallel to the
left oblique  diameter.   In  an examination, the finger passes
upwards  and forwards to  reach  the  posterior fontanelle, and
downwards and backwards to  reach the anterior.  The occiput
glides down the right ischial planes.   The rotation  is  precisely

                           Fig 100.
the same as in the first position, except that it is in the reverse
direction.  The rotatory movements  of the shoulders are also
reversed, the  face  of the  child generally turning downwards,
and to the left thigh of the mother.  Figure 101, page 319, repre-
sents the head passing through the pelvis in the  second position.
  Let us now proceed to recapitulate the different evolutions per-
formed by the foetal head in its passage from the pelvic brim to
the external world in the first and second positions.
  I.—The movement in the parabolic curve formed by the axis
of the pelvic canal and of the vagina.
  The  different parts of the foetal head change their position in
this progress,  but the centre of the  foetal head  may be con-
sidered as traversing the axis of the pelvis  and of the soft parts
of the  parturient canal.
  II.—The movement of the fcetal head upon its occipito-frontal
axis. 
330         ROTATION  OF THE HEAD IN THE PELVIS.

  This movement causes one side of the fcetal head to become
lower than the other  during the whole progress  of labor after
the head has entered the brim.
Fifr. 101.
 Outlet of the Pelvis, and the Foetal Head passing through it in the second position. The asterisk
marks the presenting portion.—P, the Pubis.

  III.—The  movements of the fcetal head upon its bi-parietal
axis.
  These movements  consist—first, of  the depression  of  the
occiput, and second, of the depression of the sinciput.  In the
descent of the head  through  the pelvis, the occipital  pole  is
depressed, but as it emerges under the pubic arch, the  frontal
pole becomes the lowrest point.  This oscillation of  the forehead
downwards  upon  the  bi-lateral axis, constitutes what is termed
the extension of the head.
  IY.—The  rotatory movements of the foetal head  upon its per-
pendicular axis.
  These movements constitute the rotation of the head in the
pelvis, and subsequent to the  delivery of the head, the latter
movements being  called the restitution of the head.   If the head
should be placed transversely  at the brim of the pelvis, since it
emerges in   the antero-posterior  diameter  nearly so, it makes
about one-fourth of a complete rotation, but if it be placed  in 
              MECHANISM OF THE THIRD  POSITION.           331
                     *
the oblique diameter at the commencement of labor, the rotation
is only one-eighth of a circle.
  In  the  Third Position,  the  forehead is,  at  the commence-
ment of the passage through the pelvis, placed opposite the left
acetabulum, and the vertex towards the right sacro-iliac synchon-
drosis.  The fcetal head occupies the right oblique diameter, as
in  the first position,  only  the  long diameter  of the head is
exactly reversed, the sinciput being directed forwards, and the
occiput backwards.

                          Fig. 102.
Brim of the Pelvis, and Base of the Cranium in the Third Position.
  The anterior and  posterior fontanelles are at this time gene-
rally on a level, or nearly so. The saggital suture, as the patient
lies on  the left side,  runs  obliquely forwards  and downwards,
and  upwards and  backwards, just as in  the first position.
Passed  downwards  and  forwards, the finger  comes  to  the
anterior fontanelle, and upwards and backwards it reaches the
posterior bregma.   Instead of the right tuber parietale, it is the
left  parietal  bone which is felt lowest in the pelvis.   Generally
in these cases, as labor proceeds, the vertex descends more than
the forehead, so  that it is easier to reach the posterior than the
anterior fontanelle.  When the head is thus placed in the third
position, it may  take two paths in its exit from the pelvis.   In
one,  the vertex may continue to descend, and approach towards
the  antero-posterior diameter  of  the  outlet,  the head  being
expelled with the forehead towards  the pubis, and the occiput
towards the sacrum.   The head in  this case is expelled just as  it
is in the oblique position, except that  the  positions of the fore- 
332
TERMINATION  OF THE THIRD POSITION.
head and vertex, and the anterior and posterior fontanelles, are
reversed.  If the head takes the second route, the vertex, instead
of descending  in its original position, or inclining towards the
sacrum, rotates upon its perpendicular axis, and the long diame-
ter of the head passes first  into the  transverse diameter of the
pelvis, and then into the left oblique diameter.   At the comple-
tion of this change, the head exactly occupies the second position,
with the posterior fontanelle towards the foramen ovale, and the
anterior  fontanelle  towards the left sacro-iliac synchondrosis.
The modes in which these two different terminations of the third
position are effected are as as follows:
  The spinous  process of the ischium appears to be the deter-
mining  cause of the ultimate direction of the head in the third
position.  If the occiput is driven below and behind  this point,
the head emerges from the pelvis in the position it held at the

                          Fig. 103.
 Outlet of the Pelvis, and the Foetal Head in the Third Position. The asterisk marks the present-
ing portion.—P, the Pubis.

commencement of its passage through the pelvis, or nearly so.
The forehead is in apposition with the left part of the pubic arch,
and the occiput with the right  sacro-iliac synchondrosis.  The
prominence of the occiput is in  this case a serious impediment
to the passage of the head over  the sacral surface  and through 
            FIRST  AND THIRD POSITIONS CONTRASTED.         333

the perinaeum.  When  the pelvis and the head are of-average
size, the foetal head cannot pass in this position until it has been
moulded by the pressure of the sacrum  and the uterine pains.
Before  the head is expelled, the  occiput is compressed and the
cerebral mass is thrown forwards, so that when the child is born,
the forehead is prominent and the occiput  depressed.   Some
authors say that the foetal head seldom  or never passes in this
direction, except when  the pelvis is  small and the foetal head
large; but I have  several times met with examples of the third
position in which the head had  descended to the perinaeum, in
the third  position, in cases where  the head  had been of large
size, and in which it was necessary to  apply the forceps to effect
delivery.  When the child is born in the occipito-posterior posi-
tion, the  forehead, eyes, nose,  mouth,  and  chin  successively
emerge from under the pubis, and the occiput is forced  down
the sacral and coccygeal planes, and over the perinaeum. This is
represented  in the following figure, which may be contrasted
with Fig.  99.
Fig. 104
             Expulsion of the Head in the Occipito-posterior Position.

  More frequently, the head, on entering in the third position,
passes downwards, until the occiput meets the spine of the right
ischium, when, instead of passing behind this prominence, it
glides in front of it, and, directed by the ischiatic planes, passes
downwards  and forwards until  it occupies  the second position.
The vertex in this movement travels from the right  sacro-iliac 
334
MECHANISM OF THE FOURTH POSITION.
symphisis to the right foramen  ovale.  The head is then  borne
in precisely the same way as though it had originally presented
in the second position, or the left oblique diameter of the pelvis.
  In the Fourth Position, the head  enters the pelvis in the
left oblique diameter, but the forehead is directed towards the
right  acetabulum and  the  occiput  towards the left  sacro-iliac
synchondrosis.   Just as the third position is the reverse of the
first, so is this the reverse of the second.  As  the head enters
the brim, the occiput and the right side of the base of the fcetal
head are depressed, and the  right parietal'bone is the lowest
point.   This is represented in the following figure.

                           Fig. 105.
      Brim of the Pelvis, and Base of the Foetal Cranium in the Fourth Position.

  Inferiorly, the sagittal suture runs in the  same direction as in
the second position;  but the anterior fontanelle is divided to-
wards the  right  foramen ovale, and the posterior towards the
left sacro-iliac synchondrosis.   The right parietal bone is  the
presenting portion of the head, and the part reached in examin-
ation  by the finger is the anterior and upper part of the right
parietal surface.  As  in the  third position, the vertex may either
pass into the hollow of the sacrum, and the head be delivered in
the left occipito-posterior position, or it may advance in front of
the spine of the left ischium, and  be converted  into the first
position.  The latter is the usual termination of presentations in
the fourth position, just as delivery in the second position is the
usual sequence of presentations in the  third position.
  These are the chief positions  in vrhich the head presents  and
passes through the pelvis in natural cases.   Other varieties are 
          YARI.UToNS OK  THE FOUR GENERAL POSITIONS.       335

enumerated  by some obstetric  teachers, such as the  descent of
the head through the upper part of the  pelvis, in the transverse

                            Fig. 106.
 Outlet of the Pelvis and Foetal Head in the Fourth Position. The asterisk marks the presenting
portion.—P, the Pubis.

or in the antero-posterior diameters.   This would  make four
other positions, since the occiput may be either on the right or
left  side in such cases, or  placed anteriorly or  posteriorly.
These varieties need  only  be  mentioned,  in regard to  the
mechanism of natural labor, as they rarely, if ever,  occur, ex-
cept when  the head of the  foetus  is very  small in  comparison
with  the size of the pelvis, or when the pelvis is deformed, and
its  transverse  or antero-posterior  diameters  considerably in-
creased. 
LECTURE  XXII.
                  THE MECHANISM  OF LABOR.

  Gentlemen :—The Mechanism  of Parturition, in the seve-
ral positions in which the foetal head passes through the pelvis,
occupied our attention in the last lecture.  It  wTould be difficult
to exhaust this subject in the course of several lectures.  Mechan-
ism, Position, and  Motor power, in their various relations, are
the Elements or Grammar, of the Obstetric Art. It is absolutely
necessary that they should be mastered in order to practise mid-
wifery with anything like satisfaction.  I need not dwell on the
difference between the  state  of mind of a  student  or young
practitioner who, with a case  of labor under his  hands, knows
the exact position of the head, and one who merely knows that
the head presents, without being in the least degree awTare of the
position in which it may be expected to make its exit.   The one
will wait the result with the confidence which knowledge  alone
imparts; the other will  be disturbed with fears  of something
wrong, and anticipations of occipito-posterior births, when nothing
of the kind is likely or possible, or with apprehensions of  other
complications or causes of difficulty and delay.
  The positions  in which the  head  presents  are  not  most fre-
quent in the order in which they  are numbered  in describing
the positions themselves. The presentations in the First Position
are more numerous than all  the  other positions put together.
Naegele found the first position to occur in 69  per  cent, of the
head presentations which came under his observation.' M. Hal-
magrand gives  74 per cent., Madame Lachapelle 77  per  cent.,
and Madame Boivin 80 per cent., as the proportion of the first
position in head  cases.   Dr. Simpson found the first position  in
256 cases out of 335 cranial  cases.  The variation between  69
and 80 per cent, is not very great, and  as the statistics of these
authors extended to 60.000 cases, we may be  sure  that the fre-
   336 
       naegele's  statistics of the positions  of the head.  337

  quency of the presentation of the head is pretty accurately given
  in these results.  Since the time of Naegehe's observations, the
  Third Position has been shown to be the next in frequency to the
  first.  In Naegele's own practice, he diagnosed  the third position   L
  in 29 per cent, out of 1210 cases.   Other authors describe the
  Second Position  as being met with in a greater proportion than
  that given by Naegele, and they place the  second position as
  being the next in frequency to the first.   Naegel6 explains this  u
  by supposing that the occurrence of the  third position is  fre-
  quently not ascertained until it has changed into the second posi-
  tion, and it has then been  considered to have been the second
  position originally. This is in all probability the truth.  Madame
  Boivin describes the second position as occurring in 19 per cent.,
  and Madame Lachapelle in 21 per cent.;  while Naegele*, out of
  more than 1200, cases found it only in .07 per cent.   Dr. Simpson
  remarks  that  Naegele's observations  were  made by  himself,
  while  those of Madame Boivin and Madame Lachapelle were
  made  by females attached  to the Maternite Hospital of Paris.
  We may, then, conclude that Naegel6's proportions are the most
  correct, and the observations made subsequently to his own tend
  strongly to confirm them.  Naegele found the Fourth Position to
  occur only in the small proportion of .03 per cent.  Thus we may
  consider the first position as the most frequent; the third  comes
  next in order ; and the second and fourth are the most rare.   In
  this enumeration,  cases occurring originally  in the third  and
  changing in the  second, are considered  as belonging to the third
  position.   While I have no doubt that Naegele was, in the main,
  correct in his estimate of the great frequency with which the third
  position changes into the second, I believe a larger number than   ^
i  he supposes are delivered as occipito-posterior cases.\/ Naegele
  states, that out of 96 cases in which the head presented originally
  in the third position, he  only observed it to be  delivered in  the
  occipito-posterior direction  in  3 cases, and in  all  of these  the
  pelvis was larger than usual, or the  head  was small and com-
  pressible.   Out of a smaller number of vertex  cases in the third
  position, I have met with two instances in which the labors were
  very severe, and in which the head passed with the occiput
  towards the rectum.
    In the first and third, or  the  most common positions of the
  head at the commencement of labor, it will be  observed that the
                              22
• 
 338       FREQUENCY OF THE LEFT OBLIQUE POSITION.

 head occupies the left oblique diameter; in the first the occiput
 being the most anterior  part of the head, and in the third the
 sinciput.  In both, the right side of the head is lowest in the pel-
 vis.  As far as I am aware, no other reason can be given for the
 greater  frequency of presentations in the  left oblique position
 with the right side of the fcetal head downwards, than the greater
 strength of the right limbs, and the occupation of the  right ob-
 lique diameter by the rectum.
   It is necessary that what is meant by the presenting part
 of the foetal head should be  clearly  defined.    Hitherto,  a
 good deal of confusion Iras prevailed upon this subject.   Is it the
 part found most prominent within the ring formed by the soft parts
 of the parturient canal in the different stages of labor—namely,
 the os uteri, the vagina, and the ostium vaginae ?   Is it the part
 of the head  found lowest in  the pelvis during the progress of
 labor ?  Is it the part first  met with  on  introducing the  finger
 into the pelvis, in the direction  of its axis ?  It  will  be  found
 that all  these points of view are mixed up together, in some of
 the best and  most recent works on obstetrics, with the effect of
 causing considerable  confusion.  For instance, the right tuber
 parietale is very commonly said to be the presenting part in the
 first and fourth positions, as the head passes through  the brim
 and upper part of the pelvis, because it is the lowest point met
 with on introducing the finger into the vagina.  It is,  however,
.more frequently, indeed almost invariably, felt through the ante-
 rior wall of  the cervix, and not within the ring of the os uteri,
 unless after the full dilatation of the  latter.  I would surest
 that it would be best to define the presenting part in every kind
 of cranial position or presentation, as that  portion  of  the foetal
 head felt  most prominently within  the  circle of the  os  uteri,
 the vagina, and the ostium vaginae, in the successive  stages of
 labor.
   We may consider the right and left tuberosities of the parietal
 bones as points common to the positions in which the occiput is
 found either on the  right or the  left side of the pelvis respect-
, ively.  That is, in the first  and fourth positions, the occiput is in
 one case in the early part of labor in  the neighborhood  of the
 left acetabulum, and in the other near the left sacro-iliac syn-
 chondrosis.   In both, the right tuber parietale  is the lowest
 point  of the  fcetal  head, in  the early part of labor.    In the
• 
        WHAT IS THE  PRESENTING PORTION OF THE HEAD.     339

second and third positions, the occiput is turned towards either ,
the right acetabulum or the right sacro-iliac synchondrosis.   In
both, the left tuber parietale is lowest in the pelvis.
  In the first position, when the  os uteri is open to the extent of,
say an inch in diameter, the part felt within the circle of the os
is the upper and nearly the middle portion of the  right parietal
bone.  As labor advances, the part of the head in the centre of
the dilated os uteri is the middle portion of the  posterior  and
upper  quarter of the  same bone.   AVhen the os is sufficiently
open, the right tuber and the right  ear may be  felt.  As  the
head advances through  the vagina and presents  at the outlet,
it is the upper and posterior angle of the  bone which is most
prominent.  It is upon these parts in succession  that the tumor
of the scalp or caput succedaneum is formed by the pressure of
the os uteri and the other portions of the parturient canal upon
the foetal head.   The tumor of the scalp formed upon the middle ,v-
of the upper half of the right parietal bone  by the os uteri, may
be called the primary caput succedaneum.   When the os uteri is
rigid,  the swelling marks the foetal head very distinctly, and  if
the subsequent part of the labor should be easy and rapid, there
may be no other tumor.   If the latter  part of labor should be
difficult, a swelling of the scalp  is formed over the posterior and
superior angle of the right parietal bone.  This may be called
the secondary tumor.  Sometimes the dilatation of the  os uteri
is so easy, and the compression  of the  scalp so slight, that no
primary tumor is formed. In other cases a  tumid  ridge extends
from the middle of the upper border  of the right  parietal bone
to its posterior and superior angle, or even to the upper portion
of the occipital bone.
   In the fourth position,  the part first felt within the os uteri, as
the  head  lies in the left oblique diameter, with the occiput
towards the left sacro-iliac synchondrosis, is the middle of  the
upper portion of the right parietal bone, very nearly, in fact, the
 same  point as is felt in the  first  position.   It is  here that the
 primary tumor of the scalp  is  formed.  The sagittal suture is,
 however, nearly in the direction of the left oblique diameter, the
 anterior fontanelle is  directed towards the right acetabulum, and
 the posterior fontanelle towards  the left sacro-iliac synchondrosis.
 In the first position the sagittal  suture, it will be borne in mind,
 runs nearly in the direction of the right oblique diameter. 
340  ANALYSIS OF THE TERMINATIONS  OF  VARIOUS POSITIONS.

  It has been shown that the head, when presenting in the fourth
position, may descend through, and  emerge from, the pelvis, in
two modes.  The occiput may turn towards the hollow  of the
sacrum, in wrhich case the frontal bone approaches the left side
of the  pubic arch; or, as we have seen, the occiput  may turn
forwards and make a quarter, or rather more than a quarter turn,
so as to approach the left portion of the pubic arch.
  In the first termination, the anterior and upper portion  of the
right parietal bone passes first through the vagina,  and emerges
underneath the arch of the pubis.   It is  upon this point that the
secondary caput succedaneum is formed.  Sometimes this over-
laps the posterior part of the right frontal bone, and some portion
of the anterior fontanelle.
  In the second  termination of  the fourth position, the parts of
the head present in  almost precisely the  same order as in the
first position, and the tumor of  the scalp is formed in the same
sites.   The change is from the middle and upper portion  of the
right parietal bone to the posterior and upper angle of the same
bone.
  In the second and  third positions, the  presenting parts  of the
fcetal head and the tumors of the scalp  are the same  as  in the
first and fourth, only it is the several parts of the left parietal
bone, instead of the right.   In the second position, the middle of
the upper portion of  the left parietal bone presents in the first
instance, and  movements of rotation  and advance  gradually
bring the posterior and upper portion of the parietal bone to be
the site of  presentation under the left portion of the upper
part of the pubic arch.  In the third position, it is the middle
and upper portion of the left parietal bone which presents within
the area of the  dilating os uteri.  In the  first and common ter-
mination of this position, the head,  in making its  quarter turn,
so as to bring the occiput to the right foramen ovale, brings the
same parts of the left parietal bone into presentation, as  in the
second position.   In  the second termination of the third position,
the turn to the extent of one-eight of the  circumference  of the
pelvis brings the anterior and upper part of the left parietal bone
to be the presenting part, and this is  the first portion of the head
to emerge under the pubis in such cases.
   As the vertex is not the first part to be delivered in occipito-
anterior cases, but the posterior and upper part of  the right and 
THE SCREW MECHANISM OF LABOR.
341
 left parietal bone, it follows that in the labors  occurring in  the
 first position and in the occipito-anterior termination of the fourth
 position, it is the right tuber parietale which is  first delivered.
 When this has passed through the ostium vaginae, the circle of
 the outlet intersects the head between  the two  tuberosities in a
 diagonal direction.   The same  occurs with respect  to  the left
 tuber parietale in the second position, and  in the occipito-ante-
 rior termination  of the third  position.   So, also, in occipito-pos-
 terior deliveries, the  two tuberosities do not pass through at the
 same time.  In the fourth position it is  the left, and the third the
 right, tuber which first escapes.  Thus the bi-parietal diameter of
 the head always passes through the pelvis  and  soft parts in  an
 oblique  direction, so that the  largest lateral  diameter  never
 engages the opposite sides of the canal  at the same time.
   The moulding of the foetal head during a severe labor is pecu-
 liar in the different positions.  In the occipito-posterior positions,
 the mass of the brain and the  cranium are so moulded that the
 anterior or frontal end of the cranial ovoid becomes larger than
 the occipital.  In the fourth occipito-anterior position, the right,
 and in the third, the  left, side of the frontal region is the most
 prominent.  In the first, and the occipito-anterior terminations
 of  the fourth positions, the head is moulded so  as to make the
 right side  of the head, and especially the right  side of the occi-
 pital and posterior parietal regions the  most prominent.   In the
 second, and the  occipito-anterior terminations  of the third, the
 same prominence is impressed upon the left and posterior por-
 tion of the foetal head.  Dr. Swayne, of  Bristol, has  pointed
 out that in occipito-posterior positions, a vacant space may  be
 felt under  the pubic arch, owing to  the small size of the  frontal
 part of the head before it has been moulded by the pressure  of
 parturition.
  On former occasions I have referred to the  principle of the
Screw, which obtains in the pelvis, and to the screw-like, spiral,
or rotatory movement of the foetal head in passing through the
pelvis in the different cranial positions.  It has not hitherto been
made out,  but  I believe  the mechanism of the  pelvis and the
fcetal head to be precisely that of a  body moving down a spiral
inclined plane or screw.   A screw is an inclined plane, arranged
in a spiral  form, either round a solid cylinder, or upon the inter-
nal surface  of a  hollow  cylinder.   When the one is  fitted into 
312
THE FCETAL HEAD  THE MALE  SCREW.
the other, the spiral arranged round the solid cylinder is called
the male, and that around the hollow cylinder, the female screw.


                                Fig. 107.
  R. Right parietal bone. L. Left parietal bone.
  1. 1. 1.  The different points of the right parietal bone which present successively in the first posi-
tion.
  4. The part of the parietal bone which presents at the os uteri, in the fourth position at the com-
mencement of labor.
  4 a. Tlie part of the parietal  bone which presents at the ostium vaginae, in the fourth position,
when the head is delivered in the occipito-posterior position.
  4 b, 4 6, The points of the right parietal bone which  present successively when the heacj, pre-
senting in the fourkh position, makes the quarter turn, and is delivered in the oecipito-anterior posi-
tion.
  The figures 2, 3, 3 a, and 3 b, 3 6, mark in the same way, the presenting points in the second and
third positions of the head, on the left parietal bone.
  The two diagonal lines across tjhe head mark the intersection of the head by the vulva and peri-
naeum, as the head passes out, so that  only one tuber parietale occupies the ostium vaginas at the
same time.


In the mechanics of  parturition, the pelvis  plays the part of the

female, and the fcetal head the part  of the male screw;  and it

is by the  movement  of the  one within the other, in  a  spiral

direction, that the head  passes, so as to  meet  with  the  least

possible mechanical resistance  from the pelvis and soft parts.

   The  transverse, oblique, and  antero-posterior  diameters are

successively the longest diameters, in  passing from the  brim of

the pelvis to the outlet.   The fcetal head, being of oblong shape,

can only pass by entering the brim in a position approaching to

the transverse, and  descending with  the  long diameter of the

head in relation, first with the oblique diameter, and then with 
THE PELVIS THE FEMALE SCREW.
343
   the antero-posterior diameter of the pelvis, or very nearly so.
   Such is, in reality, the direction in which the head moves.  If
   we were to place a number of pelves  one above another, we
   should represent pretty correctly the chamber of a female screw;
   and a line  drawn through the long diameters of the various
   planes would form a spiral, and mark the path of the groove, or
   thread, as it is termed, of the screw.  In the single pelvis, aline
   drawn from  the  transverse, through the oblique, and towards
   the antero-posterior diameters, would mark the path of the por-
   tion of the spiral through which the fcetal head moves  in partu-
   rition.  This, in the case of the first position, is somewhat more
   than one-eighth of a circle.  The arrangement of the fcetal head
   with  reference to the  trunk favors this  rotation.  The- spiral
   incline of the pelvis impresses itself upon the foetal cranium as
   the head of the male screw, and this  rotation is facilitated by
   the ease with which the head of the foetus moves upon the neck.
     The pelvis represents a portion of a female  screw, admitting
   a male screw (the fcetal head), of  an oblong  shape.   But the
   male and female screws in the case  of the pelvis and foetal head, 4/
v  are not accurately adjusted at all  points.   There is, however,
   a general  adjustment in the  shape of the  fcetal  head and the
   arrangement of the pelvic diameters.  It is only at the points
   where the posterior part of the parietal bone,  or of the occiput,
   comes in contact with the planes of the ischium  and pubis, that
   the thread of the male screw bites,  as it were, the thread of the
   female.  It is here that the spiral  direction is impressed upon
   the foetal cranium.   The line  of this portion of the  spiral or
   screw may be  made out by  chalking the salient point of the
   fcetal head, and moving it through  the pelvis in the direction it
   takes in parturition.   The chalk line marked upon the pelvis by
   this proceeding will  show, accurately, the track of the segment
   of the thread or groove of the female screw, through which  the
   prominent portion of  the head passes.
     The two halves of the pelvis also represent portions of two
   screws, the inclined planes of which are arranged in  opposite
   directions.  Thus, if the head be placed in the second position,
   the spiral movement is reversed from that which obtains in the
   first position, and the long diameter of the fcetal cranium moves
   from the transverse, or the left oblique, to the antero-posterior
   diameter.   In the case of labor occurring  in the first, the right 
344
SPIRAL MOTION OF  FCETUS.
 shoulder  moves  upon the right portion of the spiral or screw
 formed by the right ischium and pubis, and glides down it, just
 as the head does  in the second position.  In the second position,
 on the contrary, after the delivery of the head, the left  shoulder
 rotates upon the  planes of the screw or spiral of the left side of
 the pelvis, and passes out with a movement similar to that which
 belongs to the head in the first position.
   Perhaps the screw or spiral motion is seen still more distinctly
 in the common terminations of the third and  fourth positions.
 Here, rather more than one-fourth of a circle is completed in the
 movement which brings the  occiput from the right or left sacro-
 iliac synchondrosis, to the right or left ramus of the pubic arch.
 The movement is distinctly spiral, only that when the head pre-
 sents in the occipito-posterior position, it has  to pass through a
 spiral having a larger diameter than when  the  head  presents in
 the occipito-anterior position.  The two lines  marked upon  the
 following diagram mark  the different paths through which the
 head glides when it presents  in the first and fourth position, and
 passes towards the antero-posterior diameters.   In both it is dis-
 tinctly screw-like, or spiral.   A  similar  diagram of the  right
 side of the  pelvis would give the. lines of the spirals traversed

\                           Fig. 108.
 Outline of the internal surface of the left half of the pelvis. The two curved lines mark the path
of the head in the first, and in the occipito-anterior termination of the fourth positions.

by the head in the second  and  in  the third positions, when  the
head is born in the occipito-anterior position. 
     SPIRAL DIRECTION DEPENDENT ON THE BONY SURFACES.   345

  The contractions of the uterus and abdominal muscles consti-
tute the vis a tergo which moves the fcetal head down the planes
of the ischium and pubis.  No rotatory movement appears to be t^
given  to the  foetal head by  the pains.   The spiral direction ^
depends  entirely upon  the portion of the  spiral inclined plane
formed by  the osseous  surfaces.   If  any weight or pressure  be
placed upon  a male screw, adjusted in the chamber or box of
the female, it has the tendency to descend the spiral plane.  We
see this familiarly exemplified in the press for stamping letters,
in which a weight at the top of the  screw causes it to descend.
In practice, these considerations are  important with reference to
the direction  in  which  traction can  be  used to the greatest
advantage  in  delivery by the long or  short forceps ; rectifying
the positions  of the head in the case of presentations  in  the
third or fourth positions ;  and  in other operative proceedings. 
LECTURE  XXIII.
               THE STAGES  OF  LABOR.

  Gentlemen :—I have been accustomed to divide Labor into a
Preliminary and a  Supplemental Stage, and the three principal
stages of Dilatation, Propulsion, and Expulsion.
  In the Preliminary or preparatory Stage, the uterus and other
organs become fitted for the commencement of actual labor.
  For two or three weeks before the date of parturition there is a
subsidence of the abdominal  tumor, the womb sinks  into the
pelvis;  the  waist, in consequence, becomes  smaller,  and the
respiration and general mobility are less oppressed.   A few  days
before the accession of labor, the subsidence of the uterus is still
more remarkable, and it now begins  to contract in  an equable
and continuous  manner, as though gathering itself  up for the
coming effort.  The  contraction of the uterus is  moderate, but
it is not always paroxysmal, or attended by  uterine pain.
  In the  preliminary stage of labor there is  the persistent
contraction of the  whole of  the uterus, which has just  been
referred to; the uterus becomes firm and  ovoid, and is more
readily distinguishable from the rest of the abdominal contents
than before.  The abdominal  tumor now becomes distinctly
uterine.  Owing to the persistent contraction  of the uterus, the
mother sometimes misses the rolling  movements of  the uterus,
and imagines the child to be dead.
  Besides the persistent  uterine contraction, there is usually an
irritable state of the sphincters  of the rectum and bladder.  The
bowels are generally opened two or. three times, and there is a
frequent  desire  to  evacuate the bladder.  The effect of these
actions of the bladder and the intestines is to free the pelvis and
the lower part of the abdomen from all unnecessary incum-
brance, and thus to give  room to the parturient canal.   As the 
DILATATION OF THE OS AND CERVIX UTERI.        347
pains  commence  there is  usually  a sanguineous discharge,
termed the " show," but this is not invariably present.
  In the Stage of Dilatation, the os uteri is opened, so as to
admit the passage of the foetal head.
  In this process of expansion, the os and cervix uteri  are  to  a
certain extent obliterated, and the uterus  and vagina  become
one continuous canal.   In  a preceding lecture I have dwelt on
the mode in which this dilatation is effected, partly by the influ-
ence of the  contraction of the body and fundus  upon the os
uteri, partly by  the  fluid pressure  of the  amniotic bag  and
partly  by the active  dilatation and relaxation of  the  circular
fibres or imperfect sphincter  of the os itself.
  The direction in which the motor force  of the uterus is at
Fra 109.
      The cavity of the Uterus, with the Parturient Canal in a state of full dilatation.

first exerted is downwards and backwards, in the direction  of
the axis of the uterus, and the axis of the inlet  of the  pelvis.
The dilatation of the os uteri tends, by reflex action, to dilate
the  cardia, and  it  often  goes to produce  .actual vomiting. 
348
RUPTURE  OF THE MEMBRANES.
When the stomach is emptied of its contents, the freedom of the
respiratory movements is increased, and the dilatation of the par-
turient canal is promoted.  Sickness is sometimes present during
the whole of this stage, but, if not, it frequently appears at the
time of the  complete dilatation of  the os uteri.
  It is not a little remarkable, that in the early part of dilata-
tion the excitor nerves affected by the pressure  of the  mem-
branes and fcetal head should be chiefly in relation Math the lower
medulla and the  uterus, while those which  come to be excited
at the time  of full dilatation of the  os  uteri should affect the
medulla oblongata, and the muscles engaged in the act of vomit-
ing, including a considerable number of the muscles of  respira-
tion.  Another singular affection of the  muscular system now
occurs.  A very distinct shivering, or rigor  of the  muscles, is
often  observed at the  time when the  os uteri is  completely
dilated.  This rigor is very similar to the shuddering produced
by the dilatation  of other sphincteric muscles.  Many persons
experience this when the first morsel of food at a meal is passing
the cardia, when  the urine first passes  in micturition, or when
a catheter is  passed, or when  the sphincter  ani  first  dilates.
These rigors, accompanying the full  dilatation  of  the os  uteri,
are  sometimes so severe and continued as to excite  alarm, lest
they should  pass into general convulsions ; and this is,  in fact,
one of the  modes in which the invasion of the puerperal con-
vulsion occurs.
  The last act of the stage of dilatation is the rupture of the mem-
branes, and  the entire or partial discharge of the liquor amnii.
The membranes having acted  as an  efficient dilator of the os
uteri, as far  as it dilates by  mechanical distension, suddenly give
way, and the uterus becomes smaller in compass, contracting
more  closely and powerfully upon the foetus.  As long as  the
membranes  are unbroken, the circulation in the uterus is not
materially interfered with,  and the contractions  are  not  so
powerful as  they  afterwards become, on account of the disad-
vantages under which the uterine fibres act.  But as soon as the
waters are discharged or diminished, the uterus  contracts more
closely upon the foetus, and prepares itself for the  stage of pro-
pulsion, which we shall next have to consider.  The  circulation
in the uterus, and consequently the changes going on in  the pla-
centa, are then considerably interfered with; so that the  stage 
               EXPIRATORY PROPULSIVE  ACTIONS.           349

of propulsion  is of much greater  moment to the life of the
foetus than the stage of dilatation, which  is now brought to a
conclusion.
  In the Stage of Propulsion, the presenting part of the child
is passed on from the middle portion of  the pelvis to the ostium
vaginae.
  At the time when this stage of labor commences—namely the
point at which the liquor amnii is discharged, and the os uteri
becomes fully  dilated, the motor force of parturition is applied in
quite anew direction.   The direction in which the foetus has now
to pass is in that of the axis of the  outlet of the pelvis, which is
forwards and downwards. It is at this point that  the expiratory
muscles come into  play, particularly the abdominal  muscles,
and thus the new direction is provided for.  Before the  dilata-
tion of the os  uteri, we had to consider the foetus as an  ovoid
mass, and the axis  of this ovoid was the same as the axis  of the
uterus, and as  the axis  of the inlet of the pelvis. After the dila-
tation, we may speak  of two  axes  of the foetus—one, the axis
of the head, in its  long or occipito-mental diameter ; the other,
the axis of the body of the foetus.   Now,  this axis of the  head,
in a natural presentation, becomes  nearly the same as the axis
of the outlet of the pelvis, through which it has to traverse ; and
the foetal body  being flexible,  readily passes, as it  descends,
from the direction  of the superior to that of the inferior  pelvic
axis.  All these correspondences cannot fail to strike the atten-
tion, but they are only  a few of those which accompany this stage
of parturition.
  I have already mentioned the advantage given  to the  uterus
by the rupture of the  membranes.  The same circumstance is
equally favorable to the action  of  the abdominal muscles.  A
further  adaptation,  therefore,  becomes  visible  in  the  pre-
cise  time  at  which the  liquor amnii is discharged.   When
the bulk of the uterus  is increased  by  the liquor  amnii in
addition to the foetus, the abdominal muscles  are so  distended
that  they could only act with difficulty.  But after the diminu-
tion of the size of  the uterus by the discharge of the waters, the
abdominal muscles are more free to act, and it is now that they
are called upon to  aid  in the expiratory actions which  propel
the head  of the child through the vagina.  When voluntary
movements of  expiration  are unadvisedly  made during the 
350
EXPIRATORY ACTION, REFLEX.
stage of dilatation, they are always  awkward and fatiguing to
the patient; but during the stage of propulsion, the contractions
of the abdominal muscles are so powerful as to be no inconsider-
able stimulus to the uterus itself.  I mean,  that besides their
direct expulsive power, the pressure they exert upon the uterus
excites this organ to more powerful action.  Thus, in this stage
of labor, when  the uterine contractions flag, they can sometimes
be  renewed by voluntary contractions of the expiratory mus-
cles.
  But there is a cause for the intervention  of the  respiratory
system as well as the sign of its utility.  In the stage of dilata-
tion the ovarian and uterine nerves were the  chief amongst the
excitor nerves of the  motor actions which then occurred.  As
soon, however, as the fcetal head, protruding through  the os
uteri, begins to press  upon the vaginal surface, a new set of
excitor nerves becomes implicated. These nerves are the excitors
of  the  expiratory actions  of  parturition.   As  long  as  the
internal surface of the uterus alone is irritated, whether  by the
foetus, a polypus, or other bodies, the uterus contracts by itself;
but as soon as the  vagina is impinged upon, the expiratory force
is brought to bear. Another point worthy of  observation is that
the excitor nerves  of the uterus,  except at the extreme dilatation
of the os uteri,  when the  stomach was disturbed, were in con-
nection with the lower portion of the true  spinal  marrow only;
but the vaginal excitor nerves are in relation both with the lower
medulla and the medulla oblongata.  By the lower medulla, and
the excitor and  motor nerves in relation with  it, reflex actions of
the uterus are produced by excitation of these nerve3 ;  while all
the reflex actions  of the  respiratory system  depend upon  the
medulla oblongata.  If the spinal marrow were  divided in the
middle, there would probably be no  respiratory action in partu-
rition, unless the  pneumogastric  can  act  as  an excitor  during
labor.  Voluntary efforts, and the forcible efforts of emotion, are
often mixed up with the  pains ;  but the respiratory acts of  this
stage of labor are  truly reflex in their  nature.  The expiratory
actions  occur during the  insensibility of puerperal  convulsions,
when emotion  and volition are  both  suspended.   If they were
not reflex and physical in their nature, the exhaustion following
a strong labor would be far greater than it is.  It is a principle
of reflex action that it induces no fatigue.  Hence we see even 
EXPIRATORY  ACTION, VOLUNTARY.
351
weakly women making powerful efforts, but  perfectly refreshed
between the pains, and easy and composed after several hours of
severe labor, complaining of nothing beyond the mere  soreness
of the muscles consequent upon their energetic contractions.
   It may be well to describe minutely the motor phenomena of
the contractile part of a pain in this stage.  At  the  coming on
of each pain,  the patient takes a deep  inspiration, as a prelim-
inary.  Expiration then takes place slowly  and forcibly, in a suc-
cession of gasps, and  when the air in the  thorax  is diminished,
it  is suddenly renewed by hasty inspirations.  Each  pain con-
sists, as far as the respiratory muscles are concerned,  of several
sudden  and  deep inspirations, followed by  prolonged and
laborious expiratory efforts, with the glottis partially or entirely
closed.   At the acme of a pain in this stage of labor,  the glottis
and cardia are entirely closed, the glottis only opening partially
at intervals, and the abdominal and all the  other ordinary and
extraordinary muscles of expiration being forcibly contracted.
The  diaphragm  remains inert, as in vomiting, with the actions
of which, except that  the cardia is closed instead  of opened, the
efforts  of the  expiratory  muscles in labor  may be   compared.
Obstetric writers have taught that the  diaphragm contracts  in
this stage; but if it be considered for a moment that the dia-
phragm is a muscle of inspiration, while the  actions  of parturi-
tion are expiratory, the fallacy of such a view of the action of
the diaphragm must at once appear.  Of the contraction of the
abdominal muscles during this stage of labor there  can  be no
doubt; and the actions of the diaphragm  and abdominal mus-
cles are antagonistic.   It is true that the floor of the diaphragm,
instead of being arched as in  an ordinary state of  relaxation,
remains plane during  the efforts of inspiration, with  the glottis
closed: but this is from the mechanical distension of the chest
by the contained air, not from an active contraction of the mus-
cle itself.  Besides these actions which  are involuntary and
reflex,  the patient voluntarily aids in fixing the thorax, by hold-
ing some fixed body with her hands, or planting her feet firmly.
  More  than  this, she  increases all the  expiratory actions by
strong  efforts  of the will, and  by that emotion of labor which
impels her to brave every suffering to  effect the birth of the
child.  At length, when the pain can no  longer be  borne, the
short gasp or groan is exchanged for  a cry which  dilates  the 
352
DILATATION OF THE PERINvEUM.
glottis, and  the pain and  contractions subside.   This  cry is a
motor  action, excited by  the  emotion of pain,, and  instantly
relieves  the uterus of all extra-uterine  pressure.  Thus, the
glottis may  be compared to a safety-valve,  which is thrown open
by emotion whenever the pressure becomes more than  can
be borne with safety.  By the  influence of volition we  have
this valve entirely under  our control, to  open or  close it as
may be necessary.  When the  expiratory actions  are weak, we
can enjoin the patient to hold her breath, and when they are too
intense and  too long continued, we can encourage her to cry out,
which is  of  course equivalent to dilating the glottis, and expir-
ing the contents of  the  thorax.   During all this time the uterus
contracts powerfully.   The dilatation of the perinaeum is an im-
portant part of this  stage of  labor.  In  a former lecture  I
pointed out  the provisions which exist for the dilatation  of this
part of the parturient canal in the arrangement and attachments
of the perinaeal muscles. The dilatation, thus favored, is effected
by the wedge-like action of the head.  Throughout the whole
of labor  the passages  are plentifully lubricated by the bland
alkaline  mucus secreted  by the  glands of the  canal  of  the
cervix.
  In the Stage of Expulsion, the different parts of the foetus
are successively expelled through the ostium vaginae, the outlet
formed by the vulva, the pubic  arch, and the perinaeum.
  This stage of labor  is the shortest  of  the whole  progress, but
it is the most important and decisive of all.   The actions of the
propulsive stage  continue  with unabated  vigor.   The uterus
contracts with full power, and the respiratory muscles act  with
immense force.  The  intervals  between the  pains  diminish as
the close of the struggle approaches ; and there is often a perfect
storm of  uterine contractions, without sufficient intermission to
enable us to say distinctly where one pain ends and its successor
begins.   When the foetal  head is actually  passing the  ostium
vaginae, a new set of  actions  make their  appearance.  The
perinaeum, after being distended to the utmost, is now retracted
over the head by the  action of  the levatores ani; the sphincter
ani and sphincter vesicae dilate suddenly, the vagina contracts
upon the advancing mass, and the head glides rapidly into the
world.   The dilatation of the two  sphincters, between which the
vagina is placed, compensates  admirably for the absence  of a 
          PARTURITION, A VOLUMINOUS MOTOR FUNCTION.      353

 perfect sphincteric muscle at the outlet of the  parturient canal.
 The effect of this double dilatation is, that at the precise moment
 when there is the most imminent danger of laceration, there is a
 sudden and considerable removal of tension from the parts en-
 dangered.  The dilatation of the sphincters is partly dependent
 on the  sensation and emotion of severe pain, and partly  on the
 reflex dilatation peculiar to the sphincteric  muscles.   This  view
 of the  subject gives importance to the defecation,  which fre-
 quently occurs at this time, and which has been looked  upon
 only as a disagreeable  contretemps.   Physiology here, as in
 many  other instances, transmutes  the meanest  actions  of the
 economy, and renders them noble by virtue of their uses.  At
 the same moment that the orifices of the rectum and  bladder are
 thrown widely open, there is generally a dilatation of the  glottis.
 Even from women who restrain the expression of their emotions
 during  the rest of labor, a cry of pain escapes at this juncture;
 this  cry is necessarily accompanied by an open state of the  glottis.
 The  opening of the  glottis is not at all accidental or voluntary,
 but is as regular and involuntary as its closure during  the propul-
 sive  pains. Its effect is suddenly to take away the expiratory  pres-
 sure from the expulsive action.  Without this combined action
 of the glottis, and the  sphincters of the rectum and bladder, for
 the defence of the ostium vaginae, recto-vaginal laceration  must
 be a more common accident of parturition.  Such would inevit-
 ably be the frequent result of closure of the  abdominal and
 thoracic cavities at all points, except that of the point of exit for
 the foetus, in the final throes of labor.
   Altogether, it must be conceded  that parturition  is the  most
 voluminous of all the motor functions.  The human  uterus con-
 tracts sometimes sufficiently to render the hand of a strong  man
 powerless.  In order to illustrate the wonderful muscular power
 of the heart, the circulation in the whale or the elephant is often
 referred to by physiologists; but  enormous as  is the power of
 the heart, in these  animals, the parturient actions by which  they
 bring forth their enormous young, give us the most colossal  idea
we can entertain of any single muscular action.   In  the human
subject, too, there is a certain grandeur in the  combined  efforts
 brought into play in parturition.  In women, even of moderate
strength and stature, every voluntary muscle of the  body  is in
strong action ; the excito-motor force is in a state of the greatest
                            23 
354
HOW THE PLACENTA  IS DETACHED.
activity ; the uterus, unseen, and without any participation with
the will, is making its  immense contractions ; and  emotion im-
parts strength to both voluntary and reflex actions.
  A temporary calm follows the energetic actions which issued
in the delivery of the mother.  After  the excessive action, in
which nerve  and  muscle  seemed strained to the utmost pitch,
there comes  a sudden and  profound repose; there is perfect
freedom from pain; every fibre is relaxed ; only the uterus now
contracts, of  all the muscles which were  so lately struggling.
Like some ship which turns from a tempestuous sea into a safe
and  quiet harbor, the new mother passes from the  storm  of
childbirth into the tranquil haven of maternity.   In the pathetic
words of Scripture, " A woman when she is in travail  hath sor-
row, because  her hour is  come :  but as soon as  she is delivered
of the child, she remembereth no more the anguish, for joy that
a man is born into the world."
  In the Supplemental  stage, the placenta is detached and
thrown off, and the uterus contracted, so as to prevent the occur-
rence of haemorrhage.
  While the  body of the  child  is born  by the  motor actions I
have  been describing, the  contracting uterus  follows closely
upon it  in  its descent, and  the  action of  the liter in, excited at
this  time from the  immense  irritation of the  vagina by  the
advancing foetus, is frequently sufficient to throw off the placenta,
and lodge it  in the upper part of the vagina.   When the pla-
centa is not separated in this way by the last expulsive pain, it
remains quietly in the uterus until the  appearance of the first
after-pain.  During this interval the uterus contracts with  toler-
able firmness, under  the influence of the  excitement of the act
of expulsion.   If the placenta has been expelled into the vagina,
its presence in this situation excites, after awhile, bearing-down
pains and contraction of the vagina, similar to those of propul-
sion  and  expulsion, only  far  more inconsiderable,  generally
requiring slight  traction  of the cord to complete  its  removal.
When the placenta remains in utero, it becomes  separated from
the uterine surface by the  contractions of the uterus, and by the
arrest of the circulation  in the umbilical cord.  It  is  then
removed by a miniature copy of labor itself; there is a dilatation
of the os uteri, and there are the propulsive and  expulsive
actions of the  uterus and the expiratory muscles on a small  scale. 
           IRRITABILITY OF THE UTERUS AFTER LABOR.       355

  After the expulsion of the foetus, the first act of the uterus is
to contract, so as to prevent  the occurrence of haemorrhage.
This contraction is induced, in the first instance, by the conclud-
ing irritation of the vagina and perinaeum on  the exit of the
foetus.   It  is subsequently  insured by a succession of stimuli.
Of  these some are uterine, others are  extra-uterine.  The bulk
of the  placenta  and membranes irritate, in  the first place, the
now contracted uterine surface.   When placental separation has
occurred, the abraded surface of the uterus is intensely excitor;
and as the placental mass passes through the vaginal passage
and ostium vaginae, excitation,  which  insures full uterine con-
traction, is supplied.  It is  a  peculiarity of the utero-vaginal
canal that  at the termination of labor all  the surfaces are more
instantly excitor, and the answering motor contractions become
rapid and more easily provoked.  During severe labor, irritation
of the os  uteri, or of the vaginae, will often  increase  the pains
only in a  moderate degree ; but now the introduction  of the
hand into  the vagina, and irritation of the os uteri, will  excite
instant and forcible contraction of the uterus.  The extra-uterine
excitors of uterine action also come into play in a remarkable
manner.  As soon as the child is put  to the  breast, the slight
irritation of the mammary excitor nerves excites distinct con-
tractions of the uterus.   This reflex relation from the breast  to
the uterus  continues for several days after parturition, until,  in
fact, the uterus has  returned to the natural state.  As soon  as
the secretion of milk is established, there is, at every afflux  of
blood  to the  breasts causing the sensation  termed by women
" the draughts," an answering  contraction  of the uterus.   A
reflex  relation between  the stomach and  the uterus is also now
set up every tirhe the patient drinks her gruel, or takes her tea,
sharp contractions of the uterus, after-pains, in fact, are excited.
Emotion is another  aid to the  permanent  contraction of the
uterus.  Any  emotion  of  the mind will  generally produce  an
after-pain,  but the maternal emotion especially.   The emotion
produced in the mind of the  mother by suckling her infant
induces contraction.   A day or two after  labor, merely present-
ing the infant to the mother without its actual application to the
breasts, will excite the sensation of the draught in the mammae,
accompanied by a sudden secretion of milk and also by contrac-
tion of the uterus.   Thus  the  close of labor, the return  of the 
356
THE CLOSE OF LABOR.
uterine system to the quiet of the unimpregnated  condition, is
as plentifully provided for as the  commencement, or any of the
various stages of the process.  For some  days after labor the
contraction of the uterus is of an active sphincteric kind, but its
vascular  and other tissues rapidly diminish in size, and it  soon
becomes, to a great extent, a non-motor organ, as it was before
the time of conception. 
LECTURE  XXIV.
             THE MANAGEMENT OF NATURAL LABOR.

   Gentlemen :—The first summons to a lying-in woman should
 always be promptly obeyed.  Some women alarm themselves
 before labor has really commenced, or when their labors are
 going on slowly; others defer sending for the accoucheur until
 the labor is far  advanced,  or parturition  may  take  place so
 rapidly, that the medical man, even when using the greatest
 promptitude, may be too late,  or  arrive only just in time to
 afford  his assistance.    We  should  always act in practice  as
 though our cases  were those of the latter kind,  on the ground
 that it is much  better to be many times too soon than once too
 late.  If we  are  called unnecessarily early, we  can leave the
 patient confidently  for  a time; but the attendant is sure  to
 obtain blame should anything go  wrong before his arrival.
 Another rule for the accoucheur should be, that of never leaving
 one case for another, after he has commenced his attendance
 upon  the first,  as he is legally  and morally responsible, in the
 event of accident, for the conduct of any case  the actual atten-
 dance upon which he has undertaken.
   The matters required by the accoucheur during the  con-
 duct of a labor are, a case containing a blunt-pointed scissors,
 a silver or gum-elastic  female catheter, laudanum, sal volatile,
 and ergot of rye.  The  nurse should provide  thread for tying
the funis, an abdominal bandage, and a supply of napkins  and
towels, and hot and  cold water.
  At the first visit to a  patient in whom labor has apparently
commenced, an examination should,  if possible, be made.  This
should not be  proposed abruptly, particularly  when  the  ac-
coucheur is  not well known to his patient.  Inquiries may be
made about the state of  the bowels  and bladder, the nature of
former labors in multiparous cases, and other points upon which
                                                    35T 
358
POSITION OF THE WOMAN  IN  LABOR.
 it may be well to have information.  The accoucheur should
 not, however, on any account, leave the  patient without ascer-
 taining the nature of the case under his management.  It may
 happen that no pregnancy exists; or the case may be one of arm
' or funis presentation, requiring early interference, with a view
 to the safety of the mother or  the foetus.  But in the  most
 natural cases, it is always a comfort and groirnd of confidence to
 the  patient, and a satisfaction to  the accoucheur, to  know that
 everything is "Right," as the phrase is, when the head presents.
   The usual obstetric position in this country is that in which
 the  lying-in  woman is  placed  on  her left side,  with her head
 upon a pillow, and the  thighs and legs flexed.  She  should  be
 placed with  her back towards the edge of the right  side of  the
 bed.
   [The older practitioners of this country,  whose teaching and
 habits came from  English sources exclusively,  are in the  habit
 of thus placing  their patients; but the teaching in perhaps  all
 our  schools at the present day, in conformity with French and
 German customs, directs  the student to place the woman upon
 the  back with the knees drawn  up, and any accoucheur who  has
 made a fair trial of this position will not willingly return to  the
 former.   The advantages to the  accoucheur are convenience in
 making the examination, and its efficiency, inasmuch as the pulp
 of the finger instead of the back of the nail, meets the presenting
 portion ; the comparatively little  change of position required in
 case of an operation becoming necessary,  and finally the greater
 ease found by the patient herself.  The attendant should not,
 however, insist upon any position being rigidly maintained,  but
 should  allow such movement as may be desired by the poor
 sufferer.  Too often the attending physician seems to forget  the
 awful  suffering of his  patient while  thinking of some  petty
 twist of his own back or inconvenient position of his own arm.
 A change of position during the labor is not unfrequently  fol-
 lowed by a renewal of suspended or flagging pains.  Occasion-
 ally, as if some obstacle had been removed by the  change of
 posture, a delayed rotation is effected, and the child  is speedily
 delivered.]
   In the stage of dilatation, before the os uteri has opened, and
 when the pains are not immoderate, the patient may  be allowed
 to choose her own posture, except during an examination.   She 
PRELIMINARY PHYSICAL EXAMINATION.
359
may walk about, and occupy herself with the preparations for the
coming infant, or other casual matters.  The pains may be borne
in a sitting or standing position, as may seem  most easy.  No
voluntary efforts or straining at  this  time should be permitted.
The more freedom we allow, of course  in moderation, to the
patient during this stage, the less fatigue she will feel during the
succeeding stages of labor.   When the stages of propulsion are
proceeding, she  should be advised to  lie upon her left side in
the manner already pointed out.  This seems  to be  the most
convenient position, and the one assumed  by women in a state
of nature, or in cases where women are delivered without assist-
ance. But, even after the stage of dilatation has passed, no great
constraint should be  exercised.   If the labor  be long, women
become cramped and sore  from continuing  several hours in the
same position, and the pressure exerted by the foetus is more
distressing than when occasional change of posture is allowed.
Amongst poor women  in this  country, the  usual dress is worn
until the  completion of labor.   With  the  rich, the custom is
either to wear a dressing-gown during the stage of dilatation, or
to remain in bed during the whole of labor.  The bed should be
prepared  by  the nurse with a drawn sheet, and a leather or
piece of india-rubber sheeting, to defend it from the discharges.
   In " Taking a pain," as it is  termed, the accoucheur sits or
stands by the side of the bed, the patient's  back being towards
him. This is one advantage in  the position on the  left side, as
it enables the attendant to make the necessary manipulations
while her face is turned away from him.  With an expert and
careful nurse, the  patient will be placed on her side, and the
clothes so arranged that a  little fold of the chemise  or night-
dress will be brought  to the edge of  the bed, along which the
accoucheur can introduce his hand without impediment until it
reaches the vulva.  In other cases, the dress may be wrapped
round the legs, and the attendant has to disentangle it before he
can make  the necessary examination.   The  position  of the hips
are obvious, and the better plan for the student is to introduce
the right hand between or at the back of the heels,  and pass it
up towards the nates.   The posterior fourchette should be felt
for, the vulva separated by  the two forefingers or the finger and
thumb, and the forefinger introduced  along the vagina in the
direction  of the axis of the pelvic  outlet.  The  experienced 
360
METHOD OF MAKING AN EXAMINATION.
accoucheur will have little difficulty in passing his hand straight
to the  vulva without  any  such precautions.    Guiding  the
finger along the vagina, the os uteri is felt, in the early part of
labor, pointing towards the upper part of  the sacrum, and  the
presentation  can  be made out  as described when treating of
the mechanism of labor.
  If the os uteri cannot  be reached with the forefinger of the
right hand, the two forefingers of the left hand should be intro-
duced, as  they can  be passed higher than  the forefinger of the
right  hand.  Some distinguished obstetricians always  use  the
second finger of the right hand, because of its length ; others,
the two first fingers of the same hand, with a view to trying  the
dilatability of the os uteri and vagina.  As a rule, no  opinion
respecting the presentation should be given unless the finger  can
be passed within the os uteri, and the presenting part felt, either
by itself or through the membranes.   If the young accoucheur
contents himself  with  feeling the presenting part through the
anterior wall of the cervix uteri, without getting within the os,
he may sometimes  mistake  the  back or shoulder for the head,
and have to make some awkward explanations to the patient or
those around in case of such an error.   Besides ascertaining  the
exact   presentation,  we  acquire  by  the  first  examination a
knowledge of the  state of the os uteri, the extent of its dilatation,
its dilatability, the condition of the vagina  and perinaeum as re-
gards  sensibility  and distensibility, the amount of lubricating
secretion in  the passages, the state  of the rectum as  regards
fullness or emptiness, the capacity of the pelvis, and some general
idea of the size and state of ossification of the fcetal head,  the
tumor of the scalp, the rupture or integrity of the membranes,
the quantity of liquor amnii, the  height of the presenting part
in the pelvis, etc.   In all examinations, the fingers used should
be smeared with cold cream,  olive oil, or  glycerine.    As a
general rule, the forefinger is the one most conveniently used by
the accoucheur, but no representation which I have  seen accu-
rately portrays the mode in which it is used in an examination.
In an examination  in the early part of labor, when the os uteri
is high in  the pelvis, the arm and wrist are rotated so that  the
palmar surface of the base of the finger comes almost in contact
with the pubis, and the os uteri is explored with  the radial and
middle  surface of the  pulp of the finger.   This is,  I believe 
                   THE CULTIVATED TOUCH.                361

accurately represented in the accompanying engraving.   In ex-
aminations in the latter part of labor, when the os is dilated and
the  head low  down, the  finger may be  used  in almost any
direction with equal ease.
  When the student examines in his first case of labor, he com-
mences an education of  the sense of touch, such as is neither

                           FlO, no.
Examination in the Stage of Dilatation,.
 necessary nor acquired in any other department of practice.  In
 tactile examinations of other parts of the body, sight and touch,
 or sight, touch, and hearing, are combined ; but in the examin-
 ations of the accoucheur, touch is exercised without  any assist-
 ance from the other senses.    The obstetrician who has by long
'practice acquired the tactus eruditus in perfection may almost
 be said to have the end of his finger armed with an eye, and he
 reads the varied conditions of the internal parts which are within
 reach as accurately as the blind scholar reads the raised type in
 which books for the blind are printed.  Although the forefinger
 of the right hand is that  generally used, and which seems
 capable of acquiring the highest tactile  education, it is well to
 accustom ourselves to all the other fingers, in case of being dis- 
362
LENGTH OF NATURAL LABOR.
abled in the right hand by  any accident, or in  case of some
unusual shape of the pelvis or soft parts.
  We are commonly told to introduce the finger during a pain,
and indeed the phrase, " Taking a pain," implies that we can at
this time afford some assistance to the patient.   Hence women
more readily submit to examination when a pain is coming on
than during the intervals.  Formerly, when the principal object
in  making  an examination was  to  ascertain  the  strength and
efficiency of the uterine contractions, it was better to examine
during a pain than at any other time. But since the mechanism
of labor has been better understood, and we require to ascertain the
exact position of the head during its  progress, it is necessary to
examine in the intervals as well as during the  presence of pains.
If  we introduce the finger while the uterus is  contracting, we
should  be careful not to rupture the  membranes prematurely, as
they are tense and thin at this time.   The presence of the amni-
otic bag, and, after the escape of the liquor amnii, the corruga-
tion of the scalp, or increase in the caput succedaneum during the
pains, prevent us from making out the relative position of the
sutures as well as in the intervals between them. An examination,
therefore, should always occupy  a pain and part of an interval.
Having ascertained the nature of the presentation, and the state
of the parts  within the vaginal canal, no other manual interference
is required in natural cases, during the stage of dilatation, beyond
an occasional examination, to ascertain the rate  at which  the
labor is proceeding.  We shall, however, be  expected  to  give
some idea as to the time when the delivery may  be completed.
  A labor is considered natural as regards time when it
does not exceed  twenty-four hours from the commencement of
the dilatation of the  os  uteri to the completion of delivery.
Primiparous women frequently,  however, exceed this period,
and  multiparous women are commonly delivered in a much
shorter space of time. The full dilatation of the os uteri is consid-
ered to occupy five or six hours, but in many cases it takes less,
and in  others more than this.  The bony pelvis  being normal and
the pains natural, labor is quick in  proportion  as the os uteri
and perinaeum are dilatable, and the vagina short and capacious;
and tedious according to the rigidity of the os  uteri and perinae-
um and the length and contraction of the vagina.  Sometimes
one portion of the parturient canal is relaxed, and another con- 
RUPTURING THE MEMBRANES.
363
tracted;  under these circumstances, one part of the  labor will
be rapid and the other slow and tedious.   It is only by experi-
ence, tact, and an appreciation of all the circumstances which
modify  the  progress of labor, that anything like certainty of
prognosis of  its duration can be acquired.   In parts previously
rigid, the disposition  to dilate may be suddenly manifested ; or
the  os  uteri, after dilating favorably to a  certain extent, may
become immovable.   As regards uterine contractions,  we may
have a sudden failure of active pains, or pains in cases which had
been sluggish may become as suddenly energetic.  It behooves,
then, that the young practitioner should, as the  rule, be  guarded
as an oracle in his vaticinations respecting the time of the termi-
nation of labor in any given case.
  During the stage of propulsion, we may moderate and  guide
the  pains by inducing the patient to cry  out  if the pains are
excessively violent during  the expiratory efforts, or to hold her
breath, and add voluntary  straining to the reflex actions of the
respiratory^ muscles if the pains are feeble. In thus managing the
open or closed state of the  glottis, we can always increase or di-
minish at will the force of the uterine and  respiratory contrac-
tions.  As  a rule, the membranes are ruptured spontaneously at
the commencement of this  stage.  We should be especially care-
ful not to rupture them before full dilatation of  the os, if we can
avoid it.  When the stage of propulsion is fully formed, we may
generally rupture the bag  with advantage, if it has not occurred.
This may be done with the nail of the forefinger during the
height of a pain.   When  the membranes are  tough, several ef-
forts during successive pains are necessary before the membranes
can  be broken, but no violence should be used.  Sometimes cases
are met  with in primipara in which the quantity of liquor amnii
is so small, that  it does not, from its bulk, interfere with the
uterine action, and in which the labor goes  on  so satisfactorily,
that it is advisable not to rupture the membranes until the peri-
naeum is dilated and the  head presents at  the ostium vaginae.
When the amount of fluid is large, it very much facilitates the
progress of labor  to evacuate it as soon as the os uteri is fully
dilated.  If the membranes are punctured, accidentally  or inten-
tionally, before the stage of dilatation is completed, it frequently
happens that the os uteri, which had been dilating most favorably,
becomes rigid and contracted, and  labor is impeded for several 
3(}.l          DRAINING OFF OF THE  LIQUOR  AMNII.
hours.   On  the  other hand, cases are occasionally met with in
which the os is dilatable but the uterus inactive, and in which
dilatation may be promoted by the evacuation of the liquor amnii;
but these are exceptions to the general rule.  There is another
point in the  management of  the  liquor amnii worthy of notice.
It sometimes happens that the head is well engaged in the pelvis
before the liquor amnii begins to escape, and the proportions be-
tween the head and the parturient canal are so exact, that no
water flows away in the intervals between the pains, or during
the greater part of the pains themselves.  The head and canal
act exactly as a ball-valve, and  no fluid  can pass except at the
acme of a pain, when the force which should advance the head
is expended  in a slight dribbling of the  waters.   Much time is
often lost in  this way, and the best mode of  obviating the diffi-
culty is to drain off the liquor amnii through a small gum-elastic
catheter passed up by the side of the head.   Nausea and vomit-
ing are always beneficial during  the progress of labor.  In the
stage of dilatation they aid in dilating the os uteri by the mechan-
ical  straining which occurs, the reflex  sympathy between the
cardia  and  the  os uteri, and the general relaxing effects  of
sickness.   In the stages of propulsion and  expulsion, also,
they increase the  expulsive  efforts, and relax  the vagina and
perinseum.
  When the  dilatation of the os uteri is very difficult, the mar-
gin of  the os being hard, thin, and painful, nauseating doses of
tartar emetic are very useful.  Sometimes, when the tenderness
and spasmodic rigidity of the os  uteri are very great, an opiate
will be of great service ; or  a moderate bleeding may be prac-
tised when the patient is of plethoric habit.  I have tried bella-
donna, and a solution of atropine, in such cases, but without any
good effects.  During the stage of dilatation, and in the early
part of the propulsive stage, the direction of the axis of the uterus
should receive our attention.  It should be as far as possible kept
from anteversion, retroversion, or  obliquity on  either  side, as
these departures from  its proper axis  are certain  to  impede
labor.
  From time to  time, during every labor, the condition of the
foetal heart should be ascertained. This can easily be done by
means of a flexible stethoscope, and the knowledge thus acquired
may become of great use in  labors apparently the most uncom- 
HOW TO SUPPORT THE PERINEUM.
365
 plicated.  The accoucheur should never forget that in a case of
 labor two lives  are  under his  care, and that both require his
 attention.  In no point is the excellence of the Dublin school of
 midwifery more shown than in the care with which its best
 teachers advise that auscultation of the foetal heart should be
 practised during the progress of labor.
   The spirits of a lying-in woman should be kept up  as much as
 possible, and this is best insured by cheerfulness and  composure
 in those around her   The lying-in room should not be crowded,
 and from time to time the accoucheur should  retire, so that no
 constraint may be placed upon the bowels or bladder  of the
 patient.  She should be allowed very nearly  her usual diet, if
 her stomach can bear it.
   In the stage of expulsion, the chief points are, the regulation
 of the expulsive forces, the direction of the head, and the pre-
 servation of the perinaeum.  In the latter part  of labor, the
 glottis is to  the parturient function almost what the safety-valve
 is to the steam-engine.  By opening the  glottis, as by directing
 the patient  to cry out ; or by closing it, as by directing  her to
 hold  her breath, we can, to a very great extent, regulate  the
 expulsive efforts of the last and greatest stage of labor.
   Many conflicting  opinions  prevail as to  the  propriety of
 supporting the perinaeum.   Some years ago I pointed out that
 pressure on the perinaeum excited reflex contractions of the uter-
 us—a point which is, I believe, now pretty generally recognized ;
 and I grounded upon this circumstance, and upon the facts that,
 in cases where pressure or support is most assiduously rendered,
 laceration sometimes  occurs, while  it rarely happens when wo^
 men are delivered by themselves, an objection to the constant
 and sustained support to the perinaeum during the later part of
 labor.  I believe that long-continued pressure tends to produce i
 the accident, by increasing the  expulsive pains and by damaging J
 the perinaeum itself.  We read of cases in which the perinaeum
 was supported for many hours in succession, which must always
 be unnecessary, since, if the pains are strong enough to threaten
 laceration, the expulsive stage could not last the time described.
/ My advice with regard to the perinaeum is, that the forefinger of
 the left hand should be kept upon the anterior margin  of the
 perinaeum during the  last pains, and the right upon the head,
 with a  view to ascertain the moment when the perinaeum is dis- 
366
SUPPORT OF THE PERINAEUM.
tended to a dangerous  extent with one hand, and at the same
moment to retard the advance of the head with the other.  The
head should be pressed, in passing, close to the pubis, so as to
strain the perinaeum as little as possible. If we prevent the rapid
passage of the head, we do more to prevent laceration than can
be accomplished by the most careful pressure.
  [When the  woman lies upon the back, the support  to the per-
inaeum is made with ease to the attendant, and most  advantage-
ously to the patient, the palm of the right hand is placed on the
perinaeum, the thumb being upon the right side of the vulva and
the fingers upon the other.  The pressure is made most naturally
by the portion of the hand nearest the anus, and the head resting
thus most conveniently' upon the palm acting as an inclined plane,
passes between the thumb and forefinger, being thus guided, not
restrained, by the support given.  While  many think lightly of
the importance of support  to the perinaeum, and perhaps over-
estimate the dangers from its being illy performed, my practice
and counsel is never to neglect it during the presence of pain,
both for the actual benefit which may be  afforded, and  for as-
suaging the sufferings of the mother. A noticeable relief from the
extreme agony caused by the rapid dilatation of the perinaeum, is
felt as the  result of well directed support.   The only cases of
rupture of the perinaeum that have been brought to my notice,
have occurred either when no physician was present at the birth, y
or in conjunction with the use of instruments ; in one case where
the double-curved forceps were introduced in a reversed position
by an inebriated attendant.]
  The knowledge of the mechanism of labor is of importance,
not only with reference to diagnosis and the use of instruments,
but in the management of natural labor.   Sometimes, the de-
scent of the head through the pelvis is retarded by the imper-
fect flexion of the head, or dip of the occiput.  When the two
fontanelles are on the same level, or nearly so, the occiput may
be  brought down by traction exerted with  the finger  on  the
ridge formed by the lambdoidal suture; by the use of the vectis
or by upward pressure on the frontal or anterior portion of the
parietal bones.  Rotation of the head may be assisted by gentle
pressure upon the occiput, or  the portion  of  the parietal  bone,
next to the ischial planes upon which the head is descending.
At the time of the exit  of the head, its extension, or  the separa- 
         DANGEROUS EFFECT OF A ONE-SIDED PROVERB.      367

tion of the chin from the sternum, and the descent of the forehead
and face over the sacral and perineal surfaces, may be aided by
exerting slight  pressure upwards upon  the vertex, and  traction
downwards upon the frontal bone.  As soon as the head is libe-
rated, it should be ascertained if  the cord be twisted round the
neck, and the loop should as gently as  possible  be passed over
the head in order to free the funis from pressure.  [If this cannot
be done and evident delay results from the tightly drawn cord,
it may be cut by passing a probe-pointed scissors under it, care
being taken not to wound the child, and the severed ends should
be tied as speedily as possible.  This frequently ends the labor
and saves the child from the danger of death by asphyxia.] The
rotation of the shoulders in the reverse direction  to that taken
by the face so as to bring the shoulders into  the opposite oblique
direction to that occupied by the head, may be aided by placing
one hand upon the back of the neck, and the other upon the ster-
num as the shoulders are passing.  As the body of the child passes,
it should be turned somewhat over the pubis.   Those aids can
only be afforded after a perfect knowledge of the mechanism of
labor has been acquired, but  they may then be made very
considerably to facilitate the progress of delivery.
  The old axiom, "Meddlesome midwifery is bad," has had great
force in obstetric  practice, but it is, perhaps, better adapted to
ignorance or partial knowledge, than to perfect comprehension
of the mechanical  and motor phenomena of natural labor.  I
have no doubt the time will come when these will  be so well
understood that the finger of the accoucheur will be in accord-
ance with every change in the passage of the child during par-
turition.  Proverbs are always one-sided.   The phrase quoted
has,  no doubt, been useful in preventing improper interference,
but it has also a tendency to the prevention of interference when
this is both useful and  necessary.
  During the propulsive and expulsive stages it is usual for the
patient to aid the respiratory efforts, by fixing her feet and pull-
injr at a towel with  the hands, or holding the hands of the nurse.
And this exertion must be encouraged or  discouraged, accord-
ing to the power of the pains.   [The advantage of the posi-
tion upon the back  is especially manifest in its convenience for
bracing the feet and making voluntary exertion.  Its inefficacy
during the earlier stages of labor, before the os uteri is dilated, 
368                How T0 TIE THE cord.
should be remembered, and the patient  not unnecessarily wea-
ried by this inutile voluntary muscular effort.]  When the head
is passing  through the vulva, the right knee  should  be raised
so as to facilitate  its passage.   Throughout the whole of labor
the woman derives comfort from pressure exerted by the hand of
an attendant r>^r:  the sacrum during the pains.   I have not, on
tf\      :>!:!    ..■•, . m, said anything respecting the use of chloro-
form      :r    L.bor, asl propose to devote a special lecture
to •;•'   ■■> ■■('..  . ' i ;t>stetric Anaesthesia.
  A        !        he  child,the umbilical cord requires to be
tied.  '"'"'■           should be formed of thread, doubled seve-
ral  t     ^ -x^ip-wicking, bobbin, or tape.]   It should be tied
firmly about two inches and a half or three inches from the um-
bilicus,  and a second ligature should be  applied  at a little dis-
tance from the first, towards the placenta.  [It is the practice of
the French hospitals, so far as  I observed, and taught by  Cazeaux,
to cut the cord before applying the ligature. This is done about
six or twelve inches from the child, and as soon as the section is
made, holding the fcetal extremity between the thumb and finger
to allow it  to bleed a little, which has the double effect of reliev-
ing the turgid vessels of their superabundant blood and giving
the child a whiter appearance, more in accordance with the pre-
vailing  ideas of propriety and  beauty.   The second ligature is
rarely applied. It is supposed that there is more danger of  the
child's being asphyxiated, than injured by  haemorrhage.]  Con-
siderable force must be used in tying the cord, in cases of a large
funis, from the deposition of an unusual quantity of the gelatin-
ous matter constituting the bulk of the cord.   Otherwise,  the
vessels  may not be compressed, and bleeding  may occur.   In
cases of large  cord, it is always well to look at  the funis a short
time after  the application of the ligatures and division of  the
funis, to see that no haemorrhage is going on.  The second liga-
ture is intended to prevent haemorrhage from  the divided cord
in cases where there are twins with a single placenta, or where
the vessels  of  two cords inosculate, as  they sometimes  do.  In
dividing the cord, a  pair of blunt-pointed scissors should be
used, and the division should  never take place under  the bed-
clothes, as  the penis, or fingers, or toes have been sometimes in-
jured during the separation of the funis.   The  hand of the ac-
coucheur should now be placed upon the abdomen to ascertain 
HOW TO DELIVER THE PLACENTA.
369
the existence or non-existence of twin-pregnancy.  After the
expulsion of the placenta, the abdomen should be again examined,
to learn whether the uterus is contracted.  It ought to be felt
above the pubis, or at the pelvic brim, of the shape, and almost
the hardness, of a cricket-ball.
  As soon as the child is born, the first attempts at respiration
usually occur immediately, the first inspiratory movements being
excited as a reflex action by the influence of cold upon the sur-
face.  The diaphragm  is the special muscle of inspiration, and
this is the first to act in the establishment of respiration in the
new-born infant, as it is the last  to relinquish  its functions in a
case of death from asphyxia.
  A short period of repose follows upon  the birth of the child,
but in the course of a few minutes uterine contractions are again
felt.   The placenta may have been detached by the pains which
effected  the delivery of the head and  trunk, or it  may now be
separated from the uterus.  When the  pains recur at the time
mentioned, gentle traction should be  exerted upon the cord, the
hand of the nurse being placed upon the  abdomen, and exerting
gentle downward pressure.  If there  should  be no pain, the fin-
ger should be introduced into the vagina, and  the stringy inser-
tion of the cord into the placenta will generally be felt ;  or, if
not, the fundus uteri should be irritated by the hand externally, so
as to cause contraction.  In extracting the  placenta, slow and
gentle traction only should be used, as  by this means the whole
of the membranes, and any coagula which may have formed, are
likely to come  away with the placenta.   The  cord should  be
drawn downwards by the left  hand, the fore-finger of the  right
being placed upon the insertion of the cord, as  it is here that
laceration occurs, when it gives way.   Of course, if the cord is
breaking, the traction should cease, and the placenta ought to be
drawn forth by the fingers.
  [As soon  as any resistance  is felt,  he ought  to slip up two or
three  fingers of the other hand, along  the upper surface of the
cord, as far as the os uteri; the points of these fingers which are
intended to press the cord backwards, are brought together so as
to receive the latter in the entering angle thereby formed, around
which it  plays like a pulley.   To understand the advantage of
this manoeuvre it is  only necessary to  bear in mind that the
tractions made by one hand alone would  correspond to the axis
                             24 
370
MECHANISM  OF  PLACENTAL DELIVERY.
of the vagina, which forms  an angle with  that of the uterus ;
whence it happens that the placenta,  instead of being drawn
towards the  centre of the orifice it has to traverse, would abut
against its anterior border, and the  corresponding parts of the
cervix, upon which all the tractive efforts are spent. The patient
should be directed to bear down while the  tractions  are  made.
As the placenta closes the orifice, and gets into the excavation,
the operator changes the line of traction and gradually carries the
cord forward, so as to make  it always Correspond with the axis
of the pelvic  canal.  Under this joint influence, the placenta
soon reaches the vulva, where it is seized by the thumb and fin-
gers and twisted round several  times, so as  to complete  the de-
tachment of the membranes and form them into a solid cord, for
the double purpose of preventing their laceration and of secur-
ing their entire removal.—Cazeaux.]
   As a rule, the placenta should be examined, to be sure that no
portion of it remains in utero. After the delivery of the placenta,
a bandage should  be  applied to the abdomen, with a view to
gentle compression of the uterus and the support of the  vascular
system of the  mother, after  the tension of the abdomen during
pregnancy.  No doubt, by forcible compression after parturition,
injury may be done to the uterus ;  but I have known  cases of
mortal  fainting  occur  in cases where no other cause of death
could be assigned than  the neglect of bandaging.   I therefore
recommend it.
   [The bandage, or roller, applied  generally after labor, is very
often productive of more injury than benefit.  In cases of severe
flooding, it is  generally inadmissible, and for the simple reason
 that it is in the way.   Its presence prevents the manipulation 
            HOW TO, AND  WHY PUT  ON A BANDAGE.        371

of the abdomen, the  application of ice, the douche, etc., and
prevents the attendant from obtaining the very important infor-
mation  of the presence  or  absence of uterine contractions.
There are  some who hasten to put on the bandage after delivery,
as if the life of the patient  depended upon it.  Nature puts no
bandage upon the cow, or the sheep, and in the Lying-in Hos-
pitals of Paris, the midwives put  none on the women.  The
cows and  sheep have no  haemorrhage, and out of some seven
hundred women that I saw confined at l'Hopital des Cliniques,
under the charge of Dubois, I did not see one solitary case of
flooding.
   A woman after confinement needs a bandage just as much as,
or rather upon the  same  principles that guide  its use, in  case
of tapping for ascites.   After  all  danger of  haemorrhage is
passed, a bandage may be applied for support to the abdomen.
   When properly done, it  should be about half a yard wide, and
applied much  lower down than  usual; the  first pin  should be
placed at the lowest border, near the commencement  of the up-
per third of the thigh.  Over the uterus the pressure  should not
be great, but tighter above it, so  that the result is, that the uter-
us is rather pressed  down than upon.
   Sometimes it is desirable to place a pad  under the bandage
(and nothing  is better  than a  rolled up pair of long woollen
stockings), but this should not be upon the uterus, but above it,
so as to prevent the uterus from  expanding, while at the same
time it affords some pressure upon the descending aorta, imme-
diately before its bifurcation.]
   When the bandage has been applied, the mother is  allowed to
rest  while the child  is being dressed, when she is made comfort-
able by the nurse.   The child should be put to the  breast within
a few hours after delivery, but should not suck frequently until
the secretion of milk is established, otherwise the mother suffers
more than is necessary  from after-pains, particularly in multi-
parous cases.
   The child may, from a variety  of causes, be born in a state of
Congenital Asphyxia, in which instant and energetic efforts
become necessary for its restoration.  The chief causes of this
condition are such a continuous contraction of the uterus during
labor as to interfere with the  due supply of blood  to  the
maternal side of the placenta, partial or entire placental detach- 
372
SIGNS OF  CONGENITAL ASPHYXIA.
 ment before the time of birth, and continued pressure upon the
 umbilical cord.   The child may also be asphyxiated by being
 born, in the absence of the attendants, enveloped in the mem-
 branes, or " Caul," so as to render respiration impossible.
   The signs of congenital asphyxia are failure of the foetal pulse,
 and spasmodic movements of the presenting part of the child
 occurring for some time before death at tolerably regular inter-
 vals.    When the child is born asphyxiated, the surface is very
 dark, from the injection of the capillaries with venous blood.  It
 becomes necessary to understand the nature of  the intermittent
 spasmodic movements just mentioned, with  a view to treatment.
 When the blood of the foetus becomes entirely venous, it stimu-
 lates the medulla oblongata, as  proved by the  experiments of
 Schneider, Yolkman, and others,  so as to produce gasping efforts
 of a respiratory character.   These movements are termed Cen-
 tric, to  distinguish them from the Eccentric or Reflex  move-
 ments, dependent on  external stimuli.  They occur in utero, in
 precisely the same way as when the foetus is exposed to  the ex-
 ternal air.
  The  first  movements  of children who are born in a state of
 asphyxia, and  who are  recoverable,  are of  this  kind, and these
 centric  movements wTill sometimes of themselves slowly  estab-
lish  healthy respiration, the intervals  between the  gasping
 efforts  becoming  smaller, and the movements  themselves  be-
 coming changed into the ordinary reflex respiratory movements.
It is seldom that  a child can  be restored  after the cessation of
these centric movements, notwithstanding  that the heart will
frequently  beat for some time  after they  have ceased.  The
younger the foetus, the longer is the time occupied in the  act of
dying, and  the greater the chance of resuscitation.
  The ordinary means of establishing Respiration in cases of
partial asphyxia consist  of sprinkling cold water on the face or
chest of the new-born child; slapping it on the sides or breech ;
pinching the ears, or irritating the eyelids or anus; rubbing the
nares and mouth with a little brandy or sal volatile.  If the
child is very black, a small quantity of blood should  be allowed
to flow from the  umbilicus before tying the  cord.   In more
serious cases, or when the above  means are not sufficient, the
child is generally  put in a bath of about the temperature of  the
blood, or wrapt in warm  flannel  and  kept near a fire.   Alter- 
            HOW TO  EFFECT  ARTIFICIAL RESPIRATION.        373

nating  with  this raised  temperature, the  child  should be
sprinkled with cold water, and the limbs and body of the child
rubbed assiduously with brandy or spirit. Great care should be
taken, in  all cases of asphyxia in new-born infants, to cleanse
the  mouth, nares, and fauces.  Artificial respiration may be
practised, either from  mouth to mouth, or by means of a tube
inserted into the mouth or nostril.   During these operations the
thorax should be alternately squeezed by the hand, and allowed
to relax. Artificial respiration is not, however, of so much value
in congenital as in other forms of  asphyxia, from  the fact that
the foetal lung has  never been distended with air.  The plan
suggested by Dr. Marshall  Hall has excited much attention of
late,  and is said to have been successful in a great number
of instances.   If it should prove efficacious in cases otherwise
irrecoverable it will  become an invaluable boon.   Dr. Hall's
method consists in placing  the foetus on its face, with the fore-
head raised, and  rotating it from  side to  side, so as to induce
movements  similar to those of natural respiration, and to favor
the escape of mucus  from the air-passages.  These movements
should be combined  with continuous frictions of the limbs, so as
to keep up the circulation as well as possible in the  absence of
respiration.   In  cases  of congenital asphyxia, when the  child
has  been' recovered, the  child should  be watched carefully
during the first twenty-four  hours  of life, as there  is a tendency
to the occurrence of  what has been termed  secondary asphyxia;
and the child will frequently be observed to change color from
imperfect oxygenation  of the blood.  Frictions, and the free ex-
posure of the child to  the air, are  the best means of preventing
this accident.  Dr.  Hall  is opposed  to the use of the warm
bath in resuscitation  from asphyxia, on the ground that it pro-
duces faintness and exhausts the remaining powers of life. 
LECTURE  XXV.
           MANAGEMENT OF THE PUERPERAL STATE.

  Gentlemen :—In the puerperal state, the patient has to recov-
er from  the shock of labor  itself, and  to  pass  through  the
disordered conditions incident to the state of the uterine cavity
and the walls of the uterus after parturition, and to  the establish-
ment of mammary secretion.
  The influence of the shock of  labor is visible  in the lowered
state of the pulse which obtains some hours  after labor,  the
debility felt by the patient, and  the intolerance of light, noise,
and other stimuli previously borne with ease.  The shock itself
depends on the  exhaustion of the nervous  system by the  pro-
longed muscular efforts, the physical pain, the loss of blood
during the separation  and expulsion of the placenta, and  the
removal of the pressure exerted by the gravid uterus during the
latter months upon the organs of the body.  The influerice of the
shock of parturition is best relieved by an  opiate when the labor
has been  severe, or  natural sleep, quiet, a darkened room, and
the prevention of all  excitement as far as possible.   If  the
patient  be greatly exhausted by labor, a little stimulus  may be
administered after delivery; but with this exception, nothing but
gruel, tea [panada], and similar matters  should be allowed
during the first twelve hours.
  After  the completion of labor, the most  important considei-
ations respecting the child-bed patient, are those which relate to
the internal surface of the uterus.  When  describing the gravid
uterus, I dwelt upon  the involution of the  muscular structure of
the organ after parturition, by the degeneration, disintegration,
and removal of the large muscular fibres, and the substitution in
their place of the rudimentary cell-fibres proper to the  uterus
in the unimpregnated state, so that it is not  in this place neces-
sary to refer further to the post-partum changes in the parietes
of the organ.
     8T4 
          CONDITION OF THE UTERUS  AFTER DELIVERY.       375

  If the portion of the internal surface of the uterus be examined
within a few days after labor, it is found to be raised somewhat
above the other parts  of the  uterus, because  of  the increased
thickness of the organ in this situation, and the remains of the
decidua serotina.   The open mouths  of the veins are still visible,
and small pieces of coagula are  hanging from them into the
cavity of the uterus.   Since the time of Harvey, who was one
of the earliest to make the comparison, the state of this part of
the uterus after parturition has often been likened  to a stump
after amputation,  or a new-made wound.   The comparison  is
only correct to a limited extent.   The small, curling arteries and
the veins of the uterus have certainly been divided in the sepa-
ration of the placenta, but, except at these points, no structural
lesion occurs.   The portions of the internal surface between the
arteries and veins are  occupied by the remains of the decidua
serotina, or that part of the developed uterine mucous membrane
lying  between  the uterine parietes and the placenta.  There is
no formation of pus upon the  surface from which the placenta
has been removed, as in the healing of an ordinary wound.  The
portions of coagula hanging from the venous openings separate
and are discharged, or remain to plug up the vessels, and the
veins  and arteries  close by a process of gradual  contraction
and obliteration,  under the influence of the  contracted uterus
and the diminished supply of blood to the  organ.  What I mean
to say is, that  there is no evidence in healthy  cases of any
inflammatory action or suppuration at the placental site during
the return of the uterus to the size of the unimpregnated  state.
Besides the  coagula hanging from the mouths of the veins, coa-
gula probably exist to  some extent, in  almost all cases, within
the cavity of the uterus, as the remains of the blood poured out
during the act of the separation of the placenta or immediately
afterwards.   Having thus described  the  condition of that part
of the  internal surface of the  uterus from which the placenta
has been separated, we  are now in a position to speak of the
Lochia—a  sanguinolent discharge from the vagina, which con-
tinues after labor for a time, varying from three or four days to
a month, but which generally diminishes or  disappears   about
ten or fifteen days after delivery.
  The lochial discharge consists of sanguineous matter derived
from the surface of the uterus at that portion  to which the pla- 
376   SIMILARITY OF THE MENSTRUAL AND LOCHIAL FLUX.

centa has been attached, and of sanguineous debris formed in the
breaking down and discharge of the whole of the uterine deci-
dua.   The breaking down of the small coagula from the mouths
of the  uterine veins,  and coagula found  in the cavity of the
uterus, furnish some of the discharge, but the greatest  part is
furnished from the decidual lining of the cavity of the body of
the uterus.   From the evidence of numerous  preparations and
specimens which I have examined, I am convinced that  the
whole of the decidua which does not come away with the pla-
centa, loses its vitality, becomes broken down, and is discharged
during the first  week or two of the  puerperal period.   I have
seen  the whole  of the internal surface  of the  uterus  covered
with the bloody exudation thus  formed, and the  uterus may be
found in every stage of progress of throwing off the decidua,
from the perfectly smooth internal uterus, from which the whole
of the decidua has been detached, and the organ studded with
patches of decidua, or completely covered with  this  membrane.
I look upon this  exfoliative shedding of the mucous  membrane
or uterine decidua, as in many respects analogous to  the change
which takes place in the uterine mucous membrane at the cata-
menial periods, and the lochial and menstrual discharges appear
to be essentially  the same, except that the lochial flow is more
profuse than the menstrual.  In animals, there is no  lochial dis-
charge, because the placental cotyledons, or that portion of the
placenta which fulfills the function of the decidua in the human
subject, are permanent.  No  doubt the  basement or germinal
portion of the uterine mucous membrane remains both after the
catamenia and the lochia, and gives size  to the formation of the
new mucous membrane found after menstruation and parturition.
The  lochial discharge is found to possess a peculiar smell.  At
first it is of  the  color of pure blood, mixed occasionally  with
coagula.   It is discharged with the greatest readiness during the
time of micturition and defecation, or while  the uterus is con-
tracting, as  in after-pains.  After a few days, the sanguineous
character of the discharge  diminishes,  the  flow becoming
greenish and frequently having a disagreeable smell.  It is now
called  the " green waters," and the next change is to a whitish
secretion, which  gradually ceases.   The green color is caused by
the  chemical action  of the utero-vaginal secretions upon the
diminished  amount of blood globules now present  in the  dis-
charge. 
RELIEF OF AFTER-PAINS.               377
  It is of importance that the lochial discharge  should  be free.
In the event of deficiency, friction of the abdomen should be
practised", with a view to excite contraction of the  uterus and
the expulsion of any collections in its cavity.   Warm water, or
infusion of camomile flowers, should be injected into the vagina
two  or three times daily, and  in cases where  any  mischief is
apprehended, the cavity of the uterus itself may  be  washed
out.   After delivery,  a warm napkin should  be applied to  the
vulva.  Napkins are  worn during the whole continuance of  the
lochial flow, and the nurse should change them frequently.   The
change of the napkin promotes the lochial flow, besides being
necessary to  cleanliness, as the  uterine discharges very speedily
decompose, and become intensely disagreeable.  I have some-
times been obliged to order a bag of animal charcoal, or a piece
of prepared  charcoal sheeting,  to be placed in the bed  to neu-
tralize the lochial effluvium.
  The After-Pains are the natural attendants upon  the uterine
contractions which occur after  parturition.  The uterus is usu-
ally felt in a state of persistent contraction;  but from  time to
time  this contraction is increased,  and  is attended by  pain.
After-pains increase in severity with every labor; so that pri-
miparous women suffer little from this cause, while multiparous
women are troubled with them in proportion to the  number of
children they have  borne.   They commence soon after labor,
and in the worst cases last  three or four days,  being produced
spontaneously, or by any reflex irritation, such as the draught in
the mammae, the sucking of the child, taking food or drink into
the stomach, and the action of  the bowels or bladder.   Within
certain limits, these  pains  are very salutary,  tending to  the
expulsion of irritating materials from the uterus and  the perfect
involution of the organ, as the  reduction of the organ to its pro-
per size is called.  Sometimes they occur violently immediately
after  the completion of delivery, when the finger  should  be
passed into the vagina, and the os uteri examined, with a view
to the removal of any coagula which may remain in  the uterus
and vagina.  When no retention exists,  but the pains are neural-
gic in character, an opiate,  and a warm linseed-meal  poultice
upon  which a little laudanum has been sprinkled, applied to  the
abdomen, afford great relief.  I have sometimes found  that an
anodyne embrocation applied  to the  breasts is of  service in
relieving distressing  after-pains.  The sources of uterine irrita- 
37S            WHEN  IS THE SECRETION OF MILK?

tion should be avoided at much as possible.  When slow and
long-continued, after-pains can never be neglected with impu-
nity, as they sometimes run on to inflammatory disorder.
  In most women there is  some  appearance of Milk in the
breasts before the coming on of labor.  The areola  acquires its
deepest shade during and immediately after parturition, and at
this time, in  women  of dark hair and complexion, an almost
black zone surrounds the nipple.  There is sometimes a pretty
free secretion of-milk from the beginning, but it is generally the
third day before the secretion is fully established.  The mam-
mary secretion is, probably, dependent upon the internal condi-
tion of the uterus already described, being excited as a reflex
phenomenon by uterine irritation.  The breasts in turn excite the
uterus, and these organs mutually contribute to the return of the
uterus to the unimpregnated condition, and  to the establishment
of the  mammary secretion.  When the milk is first secreted in
quantity, there is a great determination of blood  to  the  glands,
producing  considerable heat, pain, and swelling, which last  for
two or  three  days  in  favorable  cases.   The mammae  often
become greatly distended, not only from the secretion and reten-
tion of milk, but from tumefaction of the gland itself.  The milk
first secreted, termed the colostrum, i3 more irritating than that
subsequently formed, and acts as a natural aperient, clearing the
bowels of the child from the remains of the meconium or the 
TREATMENT OF THE BREASTS.
379
secretions accumulated in the intestines during fcetal life.  Some-
times women suffer considerable pain from the mere weight of
their breasts, in  which case they require  to be supported by a
bandage placed round the neck.  As soon as the milk is secreted
plentifully, the child should be often put to the breasts, and they
should besides, be drawn, if necessary, by the nurse, so as to
prevent accumulations of milk in the ampullae, or the galacto-
pherous ducts.  Frequent  frictions with  olive oil  [still better
castor oil] or a mild camphorated liniment, are also very useful,
as favoring the flow of milk through the tubes, and diminishing
the tumefaction  of the glandular  lobules.  If the breasts are
very hot and painful, an evaporating lotion should be  applied
constantly.  [The  difficulty which many  experience in  making
applications  to  the  breast which will not be  displaced, by
turning, induce  me  to  add  here  the figures on  this and the
preceding page.]  The nipple should always  be wiped  care-
fully  after each  drawing of  the breast,  or  the  sucking of
the infant.  As regards the frequency  of  application of  the
child  to  the  breasts,  a certain  amount  of  caution should be
observed.  If there be a profuse secretion,  and  the glands are
not relieved, inflammation and suppuration  occur;  if the child
should be  applied too  frequently,  the secretion  is greatly
increased, as each act of sucking is at once a relief and a stim-
ulus to the gland, and the patient may be weakened by galac-
torrhoea.   Again, if the  glands are  swollen, but without any 
380
PAINFUL AFFECTIONS OF THE NIPPLE.
great secretion of  milk,  and the child is  constantly applied,
great pain is produced, and the tubes and glandules may become
actually inflamed, and suppurate from this cause.   Mammary
abscess during  the puerperal  month  may arise  from  three
causes:—1, the irritation of sore nipples ; 2, the distension of the
gland, or some portion of its substance  and tubes ; or 3, the
irritation of a  feebly  secreting gland, by constant  attempts at
suckling the child.  When we desire to diminish the quantity of
milk, I generally give  sulphate of  magnesia, with  or  without
dilute sulphuric acid,  so as to keep up a moderately free action
of the bowels, and have the breast relieved by frequent frictions,
resorting to drawing or  suckling as little  as possible.  These
means, with in some cases a diuretic, and restrictions as  regards
diet and drink, I have never known to fail.  When we desire to
increase the secretion of milk, warm fomentations, and  the
application of  the leaves of the  castor-oil plant, with fomenta-
tions by the water  in which they have  been boiled :  or the use
of a castor-oil  embrocation, after fomentations with plain water,
are very efficacious.
  [I have found painful affections of the nipple to be the most
frequent cause of broken breast, the mother  feeling it almost
impossible to nurse  the child, thus allowing  an accumulation of
milk, which ultimately produces abscess.  The nipple should be
hardened by daily frictions for many weeks  before the expected
time of parturition, using borax and brandy, Epsom salts  dis-
solved in water and other astringent  washes.   If the nipple be
cracked and fissured,  I have noted more benefit than from any
other source, by washing them with a weak lead wash, followed by
a poultice.   The recently much  vaunted collodion, which forms
a pellicle over the  crack, being drawn off by every  nursing
greatly  aggravates the ill.  When there is no fissure or abrasion
there is sometimes  excessive sensibility of the  nipple, which is
much benefited  by bathing  with tincture  of  myrrh and rose
water in equal parts.  Sometimes a  piece of cotton,  moistened
in wine of  opium, applied a half hour before nursing—the nip-
ple afterwards, in  this as after  all applications, being carefully
washed with castile  soap and water—much mitigates the suffer-
ing. The tincture of benzoin hardens  the  nipple  and will be
found occasionally of great service. If the end  of the nipple is
cracked (seemingly filled  with proud flesh, resembling papillae, 
A CAUSE  OF  PUERPERAL MANIA.
381
scarcely noticeable until drawn out by the sucking of the infant,
and excessively  sensitive), touching them down to  the bottom
with a sharpened point of nitrate of silver, will often be followed
by a change of action and speedy recovery.]
  The state of the breasts incident to the establishment of the
milk, and  the condition of the internal surface  of the uterus,
often  produce a considerable amount of constitutional irritation
and fever, known as Milk Fever, Ephemera, or Weed.  This
is attended by slight  shivering, followed by  a quick pulse,' and
is generally relieved by the full secretion of  milk and free per-
spiration.  It seldom requires any other treatment  than careful
management of the  breasts, attention to the lochial secretion,
and the  use  of  saline aperients and  diuretics.   It seldom or
never lasts more  than two or three days, unless it runs on to
more serious disorders of  mammary  abscess, which we  shall
have  hereafter to consider.
  The Diet of the puerperal woman is an element of much
importance.  Up to the time  of the establishment of the full
secretion of milk, the  tolerably free action of the  bowels, and
the subsidence of the febrile reaction which commonly occurs at
the lacteal crisis, the  diet should be moderate  in quantity and
unstimulating.   No animal food should be taken, as the rule, up
to this period.   Cases sometimes occur in which  the exhaustion
is so great that animal food and stimulus are required from the
first.    After this time, feeding may  begin, and  a  generous
diet gradually  introduced.  It must  be remembered, that the
patient has to recover from the long drain which pregnancy is in
itself, and to prepare for the drain of lactation.   The secretions
and excretions being .carefully regulated, women may live well
after the  first few days from the date  of labor.  The constitu-
tion has to get  rid of old material, and to repair losses.  These
indications are best fulfilled by excretion and nutrition.  Many
women  make  bad nurses,  suffer unduly from  lactation, and
become nervous and irritable, from being under-fed during the
puerperal  period.  Most of the cases of puerperal mania which
I have seen, have resulted from exhaustion produced during the
first two or three weeks after labor.
  Rest, especially in the early part of the puerperal state, is of
great moment.   Those who get up too early, suffer from haemor-
rhage and prolonged lochial discharge, owing to  the absence of 
3S2             VALVES IN THE UTERINB VEINS.

valves in the uterine veins [the presence of valves in the uterine
sinuses, resembling in shape the ileo-coecal valves, was demon-
strated to the New York Academy of Medicine April 15, 1857,
by Prof. Alonzo Clark, and the reason of this subsequent haemor-
rhage was attributed to their being dragged open  after closure
by the subsequent enlargement of the uterus], and the momen-
tum of the blood downwards.   They are also liable to prolapsus
from the weight of the uterus, and the relaxation of the uterine
ligaments, and the soft  parts of the pelvis generally.  With res-
pect to the poor, no absolute limit can be placed because of their
urgent necessities; but, when it can be done, the patient should
remain ten days in the horizontal position,  and, after that  time,
should rest during a portion of the day, until the end of the month.
  After parturition, it  is natural for  the Bowels to be consti-
pated.   This, in part,  arises from  the exhaustion induced by
labor  in all the organs under the influence of the spinal cord,
and, in part,  from the small  quantity of  food usually taken
within the first two or three days of the puerperal period.  Left
to themselves, the bowels would probably  pass  a  week or ten
days in a state of inactivity.    It is usual and  proper to give a
mild aperient dose  on the third day after the labor,  and the
medicine  in  most common  use for this  purpose is  castor oil;
a seidiitz  powder, or a draught of  sulphate and carbonate of
magnesia, in  mint-water, will generally suit when castor oil
cannot be taken.   The  idiosyncrasy of the patient should, be con-
sulted upon this point,  and any aperient avoided which is likely
to cause gastro-intestinal irritation.
  On paying our first  visit to a lying-in patient, which should
always, if possible,  be within twelve hours  of her delivery,
one of our questions should be with respect  the  State of the
Bladder.  In long and painful labors, especially  in primipara,
it not unfrequently occurs that the bladder is quite paralyzed to
the influence of  volition, and the patient finds herself unable to
pass urine.  The paralysis  appears to depend on  the  pressure
exerted upon the neck  of the bladder  by the fcetal head, and  to
affect the  sphincter vesicae chiefly.  The effects of pressure are
probably aided by the influence of the shock of labor upon the
lower part of the spinal marrow.  The difficulty generally dis-
appears spontaneously after a few days, the bladder  recovering
its tone and irritability.  Sometimes a little urine is passed, but 
               ORDINARY CARE  AFTER DELIVERY.            383

the bladder is unable to empty  itself thoroughly.   Besides  ask-
ing the question, it is proper, if there should be any doubt upon
the subject, to place the hand upon the  hypogastrium, when, if
the bladder be  distended, its elongated oval outline is  readily
felt above the pubis.   The remedy is the use of the catheter for
a few days.   It is of great importance to diagnose this affection,
as a distended bladder may be mistaken for other  diseases, and
the patient put through a course of inapplicable treatment; or
the organ may be ruptured, and lead  to  a fatal  result.   The
quantity of foetid ammoniacal urine drawn off in some of these
cases  is  quite astonishing.
  [The self-retaining catheter of Dr. Sims will be found of great
utility where there is temporary paralysis of the bladder, parti-
cularly if the patient, as often in thinly populated places,  cannot
be visited frequently by the physician.   Especially if there be
cause to suspect any injury of the bladder from pressure, the use
of the instrument here delineated, will cause it to be constantly
contracted, and may thus avert a threatening fistula which might
occur if the bladder was allowed to remain distended.]
  It is necessary to say  a few words  respecting the manage-
ment of the Infant during the puerperal period.
  After delivery, it is expected that the accoucheur should make
such an examination of the child as will enable him to say that
the  infant is perfect and well-formed.  The state of the genital
organs,  the hands and  feet, and  the mouth and oral  cavity,
should be observed.  At our first visit, we should inquire whe-
ther the child's bowels have been relieved or not, and whether
it has passed urine.   The bowels  are generally purged  by the 
381
HEMORRHAGE FROM THE FUNIS.
irritation of the meconium and the effects of cold upon the sur-
face.  If the bowels have not been  moved, or the evacuations
are insufficient, a teaspoonful of castor oil should be given.  In
cases of retention of  urine, the bladder can generally be made
to act by sprinkling a little cold water upon the hypogastrium,
by applying a hot sponge to the genitals, or by  the use of a
warm bath.  Sometimes the phymosis natural to the male infant
is so great  as to interfere with the flow of uriue, or micturition
is always attended by pain.   In these cases, relief is obtained
by dilating the aperture of the prepuce by a probe.  The child
is generally kept in the  same  room as its mother, and the sub-
dued  light  proper to the  lying-in woman is well  suited to the
delicate eyes of the child.
  The management of the Funis is usually very simple.  It
is wrapped in a piece of singed linen by the nurse, and the pro-
jecting portion dies and falls from the umbilicus within a week
after  delivery.   The stump heals  spontaneously: and after a
time the navel is drawn in by the action of the urachus, and the
remains of the vessels passing from the umbilicus to the liver.
Sometimes the site of separation  becomes sore, large granula-
tions  sprouting from its surface, requiring  the application  of
sulphate of copper,  or some other astringent.   In some cases
these florid  growths have  required  removal  by the scissors.
Haemorrhage has in rare instances occurred from the stump of
the funis, requiring ice, astringents, and pressure for its  relief;
and it has happened that children have been lost from this form
of bleeding.  [An elaborate and  interesting paper on  this sub-
ject is in course of preparation by my friend Dr. J. Foster Jenkins,
now  of Yonkers, N. Y., by the appointment of the American
Medical Association.]  Traumatic tetanus from the division of
the funis is rare in  this country,  but it is a disease of not infre-
quent occurrence in hot climates, as the East and  West  Indies;
and it occurs in other  localities,  as in the Faro Islands, where
 ventilation and cleanliness are greatly neglected.
   A  few days after labor, it is very common for the child  to be
 affected with Jaundice.  This arises from the  great  change
 effected in the circulation of the liver by the  establishment of
 respiration and  the arrest of the current of blood between the
 funis and  the liver.   This  form of jaundice  disappears as the
 liver becomes accustomed to the  conditions of extra-uterine life 
FOOD FOR THE CHILD.                385
and the flow of bile is established.  When it  does not pass off
readily, a dose or two of grey powder, and a little castor oil, are
sufficient to cure it.
  It is hardly necessary to insist upon the Breast Milk as the
natural food of the infant, yet an enormous number of child-
ren die anually, within a few weeks after birth, of marasmus
caused by want of breast-milk.   The medical attendant should
invariably contend for the suckling of the child, or the engage-
ment of a healthy wet-nurse.  This should be arranged as early
as convenient, as much injury is sometimes done in a short time
to the tender stomach of the child by attempts at artificial feed-
ing.   Pathological inquiries show that the gastric mucous mem-
brane  has a tendency to soften  under a  deprivation of proper
nourishment, and this softening  is attended  by marasmus and
fever, ending in death.  When  artificial feeding  is inevitable,
the child will have the best chance of life from the use of fluid
food only.  Asses' milk or cows' milk, diluted at first with an
equal quantity of water and sweetened with sugar, the quantity
of water being  diminished as  the child becomes older, form
the best infantile nourishment under these circumstances.  The
milk  should  always be  fresh,  and some experienced nurses
greatly prefer  boiled milk for children.
   Many of the matters treated of in the present and the preced-
ing Lecture may be thought to  pertain to the nature of " com-
mon things ;" but attention is not the less necessary to them, if we
would conduct patients safely through parturition, and the puer-
peral state in natural cases. It should always be borne in mind,
that at any stage of the  processes  through which  the  patient
passes between the commencement of labor and puerperal con-
valescence, the most simple case may be converted  into one of
difficulty and danger.
25 
LECTURE  XXYI.
                 PRESENTATION OF THE FACE.

  Gentlemen :—In the preceding Lectures we have  treated of
the mechanism  and management of cases in which  the  head
presents in its different positions.  We have  now to pass  from
cranial presentations to those of the face.   The transition from
vertex to face presentations is  easy and natural, because of
the identity of the parts concerned.   It will be found con-
venient to direct  attention to the following considerations in
connection with presentations of the face—namely, the mechan-
ism, the diagnosis, and the management.
  There is a very close analogy between the mechanism of face
and vertex presentations.   Let the fronto-mental diameter of the
fcetal  head be substituted for the occipito-frontal at the brim of
the pelvis, and the similarity as well as the  difference will be
readily appreciated.  It will be fresh in  your memories that
three  kinds of  obliquity were spoken  of in the passage of the
head  through the  pelvis in vertex cases:  1.  An obliquity con-
sisting of the position of the long axis of the fcetal  head in one
of the oblique diameters of the brim.  2.  An obliquity, consist-
ing of a dip of the posterior extremity of this axis in the cavity
of the pelvis.  3.  An  obliquity,  consisting of a dip  of one or
other extremity of the bi-parietal diameter  of the cranium in the
pelvic basin.  A similar triple bias, or obliquity, obtains in face
presentations.   Thus the  fronto-mental diameter of the face,
which represents  the  occipito-frontal of  the head,  in vertex
cases, is oblique  as regards the diameters  of the  brim, and
oblique as regards the superior plane  of the pelvis, while there
is a dip of the  anterior extremity of the  bi-temporal diameter
of  the face, in the pelvis, corresponding  to  the dip  of the bi-
parietal diameter of the head in vertex cases.   The chief defect
in the analogy of  face and vertex  presentations is, that while in
      8S6 
             PKCULIARITIF.S OF FACE PRESENTATIONS.         387

the latter the posterior extremity of the long diameter of the
head is from first to last lowest in the pelvis, in the former there
is a change effected, the frontal end of the fronto-mental diame-
ter being lowest at the commencement, and the mental extrem-
ity lowest at the end of labor.   This defect  is,  however, more
apparent than real, because the face rotates so much in the  pel-
vis as to  make the chin represent the occiput in the act of the
disengagement of the  head.  In addition to the  parallelism
already mentioned, there are  certain linear guides  to the posi-
tion of the face which in a manner represent  the sutures of the
cranium.  Thus the mouth may be said  to replace the  anterior
fontanelle at  the commencement of labor.  The bridge of  the
nose corresponds to the sagittal suture;  and the ridges of the
orbits to  the coronal or lambdoidal sutures,  as the case  may be.
The grand difference  between vertex and face cases is, that in
the former the  head is flexed—that is to say, the chin is bent
down upon the breast, the occipital extremity of the head thus
becoming the most advanced or  depending portion of  the
cranium ; while, in face presentations, the head is extended, the
chin being separated from the chest as far as possible, and the
head thrown back on the nape of the neck.  Now, it is obvious
that there may be many intermediate positions between extreme
flexion and  extreme extension;  but, as a general rule, one or
other of these extremes does actually obtain, and  semi-extension
is of rare occurrence.  When it does exist, brow presentations
are produced, and they are amongst the most  difficult of cranial
labors.   Extension of the head increases as labor advances, so
that when the head is  in the  act of disengagement, the chin is
further separated from  the breast than at  any other period of
labor.  The manner in which such a decided  irregularity as the
extension which produces face presentations is brought about, is
somewhat obscure; but we are in possession  of some physiolo-
gical facts and principles which will account, to a certain extent,
for a portion of these, as well as  of other forms of mal-presenta-
tion.  Before, however, going on to state these, it is interesting
to remark, that flexion is the  normal condition  of the foetus—
every limb, every finger, the  trunk, and, in fact,  every movable
member is flexed, and  the extension of the head, in face cases,
must, therefore, clearly be the result either of unusual mechani-
cal or vital conditions, intrinsic or extrinsic to the foetus.   The 
388
CAUSE OF FACE  AND MAL-POSITIONS.
 application of the foregoing and following considerations extends,
 it should be said, not merely to face  presentations, but to mal-
 positions in general.  Dr. Fleetwood Churchill and Dr.  Simp-
 son arrange the  causes  of  mal-presentations pretty nearly as
 follows:
   1.  Face presentations and  mal-positions generally, are the
 result occasionally of premature  labor, in which the moulding
 influence of the shape and contractions of the immature uterus
 and the reflex contraction of the limbs of the foetus, are not
 effective.
   2. They are the result of death of  the foetus in utero;  or, in
 other words, of loss of  muscular  tone and the  adaptive  reflex
 movements, and an alteration of the specific gravity of the foetal
 head.
   3. They are the consequences  of the application  of unusual
 excito-motor stimuli to the foetus and uterus.
   4. They are the result of causes mechanically displacing the
 whole foetus, or the presenting part, at the commencement of
 labor.
   With regard to these  statements it  may be remarked, that in
 cases  of premature labor it is doubtful whether the excito-motor
 functions are so well-developed as to determine the position of
 the foetus in utero, while the small size of the foetus must to a
 certain extent abrogate  those  mechanical relations upon which
 the application of normal stimuli depend.  With regard to death
 of the foetus in utero,  it is right to  state, that  although  the
 absence of reflex motions may have a share in producing abnor-
 mal presentations, yet there is reason to doubt whether a mere
 physical explanation may not suffice for a certain  portion  of
 them.  I have on a former occasion referred to some  very inter-
 esting papers, by Dr. Matthews Duncan, of Edinburgh, on this
 subject.  If normal stimuli determine the natural  presentation,
 abnormal  stimuli must  of course be admitted as the efficient
 causes of some errors of presentation;  but to analyze the  exact
 nature of such cases, and to determine  how and when they are
 produced, is out of our power; their history must, in fact, be a
 matter of pure conjecture. The fourth series of causes mentioned
 are more within the scope of actual observation, and  may some-
 times  be traced with considerable accuracy: thus, a vertex pre-
sentation may obtain before the fcetal head has become eno-a«-ed 
FREQUENCY  OF FACE PRESENTATIONS.
389
in the inlet of the  pelvis, and it may be altered by premature
and sudden rupture of the membranes, especially if the quantity/
of liquor  amnii be unusually great.  Thus  much in relation to
face presentations generally; let us now trace the mechanism, in
each variety,  from the  commencement to the termination of
labor.
  There are four presentations of the face, as of the vertex, and
they are similarly numbered.   In the first,  the forehead is to-
wards  the left acetabulum;  in the second, towards  the  right
acetabulum ; in the third, towards the right sacro-iliac synchon-
drosis ; and in  the fourth, towards the left sacro-iliac synchon-
drosis.  These positions are  the exact analogues  of the  four
vertex presentations respectively, and may be looked  upon as
vertex cases in which the head has become accidentally extended.
In practice, it will be found that the third and fourth face pre-
sentations are so extremely, rare as hardly to be worth enumer-
ating, and  consequently our  attention may be confined to the
first  and second only.  The first is the  most frequent, being to
the second, according to Naegele, as  twenty-two to seventeen.
As regards the frequency of face-presentations, Dr. Fleetwood
Churchill has collated  the proportion in  nearly a quarter of a
million of cases, and he finds that this mal-presentation occurs
once in about 231f cases.
   In  the First Facial Position, if  the  finger  be introduced
into the os uteri at the commencement of  labor, it will impinge
upon  the  bridge  of  the nose ;  carrying the finger forwards
and  to the left, it arrives at the forehead, which is found oppo-
site the left acetabulum ;  and just beyond the root of the nose
the frontal suture may be traced upwards  and  forwards, widen-
ing in its  course  towards the great  fontanelle.  This opening
can, however, seldom be  reached ; and, indeed, the farther out
of reach it is, the more favorable  is the position of the head.
Tracing  the nose backwards and  to the right,  the  mouth is
reached, and  the alveolar ridges may be distinguished.   Still
further backwards, the  chin  may be  found in relation with the
right sacro-iliac synchondrosis.  The line represented by the
bridge of the nose does not, however, cut the os uteri equally, it
is more posterior than anterior, and consequently the right side
of the face occupies the anterior  and  greater segment of the
mouth of  the uterus.   The primary caput succedaneum will in 
390
MECHANISM OF FACE PRESENTATIONS.
this presentation be found upon  the upper half of the right side
of the face, and will include a surface corresponding  to  the

                           Fig. ill.
Presentation of the face at the pelvic brim.
right  eye, malar  bone, and  adjoining  parts.  Thus  the upper
and right aspect of the face  is lowest  in the pelvis.  As labor
advances, and the head descends in the pelvis, the head gradu-
ally turns, so as to bring the chin forwards from the right sacro-
iliac synchondrosis to  the  right obturator foramen ;  and  in
accomplishing this rotation from right to left, the chin is brought
lower in the pelvis.   The spine of the ischium in  face, as  in
the ordinary vertex presentations, is the directing agent, and the
chin of  the  foetus  is the part acted upon in the latter.   In the
first cranial  position, it will be remembered that the left side of
the posterior extremity of the  head glides down the inclined
plane formed by the  anterior surface  of the left ischial spine,
and that the head has thus a rotation imparted to it from left to
right. In the facial presentation under  consideration, it is in the
left side of the chin which comes in contact with the anterior
surface of the spine of  the right ischium, and thus the rotation,
although of an exactly similar nature,  is in the  reversed direc-
tion, i.e., from right to left.   In both pases, however, the same 
FLEXION IN FACE PRESENTATIONS.
391
general statement applies—namely, that the opposing surface of
the foetus is thrown downwards and forwards under the arch of
the pubis.  As the chin advances and turns forwards, the arch
of the cranium is directed backwards towards the hollow of the
sacrum, and thus the head is completely lodged in the cavity of
the pelvis.  The right  cheek and angle of  the mouth are now
the presenting parts, and the chin is  just about to emerge from
Fis. 112.
           Emergence of the head from the pelvis in face presentation.

under the arch of the pubis.  The next step is emergence of the
chin, not exactly in the middle line, but still directed somewhat
to the right, as in vertex presentations, where  the  antero-poste-
rior  diameter of the head is never exactly in relation with the
antero-posterior diameter of the outlet of the pelvis.   By the
liberation of the  chin, room is gained ; and now  a process of
flexion takes place analogous to the extension of vertex presen-
tations : the chin becomes temporarily almost fixed, and the
head rotates upon its transverse axis, so as to bring the vault of
the cranium out with a sweep over the perinaeum, the  occiput
being the  last part expelled.  During the flexion described,
there is  an advance of  the head en masse, but it  is not so con-
spicuous as the flexion.  If the face  remains long in apposition 
392          TERMINATION OF FACE PRESENTATIONS.

with the os externum, a secondary tumor forms on the cheek;
but instead of being on the upper, it is on the lower half of the
face, and involves more of the opposite side of the face than the
primary tumor does.  This is evidently in consequence of the
depression of the chin, and the  change from  an oblique to an
almost antero-posterior position of the long diameter of the face.
The head having been expelled,  the rest of the body behaves as
in first vertex presentations.   The right shoulder, being lowest
in the pelvis, is propelled against the anterior surface of the
spine of the right ischium, and  rotated from right to left, so as
to place the shoulders nearly in the antero-posterior diameter of
the outlet of the pelvis.  The  right shoulder is thus born first,
and the left sweeps  over the perinaeum.   The hips are born in
the same manner.  The engravings, No. Ill, 112, and 113, repre-
sent  the presentation of the  face  at  the  brim of the pelvis, at
the outlet, and passing through the external parts.

                          Fie. 113.
        Passage of the head through the external parts in face presentation.

  In the Second Facial Position, the details of the mechanism
are exactly similar, only that the forehead is directed towards
the right acetabulum, and the chin towards  the left sacro-iliac
synchondrosis, and all  the rotations of the first position  are 
           INTERMEDIATE PRESENTATION OF THE FACE.       393

exactly reversed. In fact, by using the word "right" for "left,"
and  " left" for " right," the  description of the mechanism of
a first  facial position applies with the utmost precision to the
second also.
  In the first position  of the face, we may,  while it passes
through the pelvis, compare the situation of the chin to the situ-
ation of the vertex in the third position of the head.   The same
rotation of the part first to emerge through the pelvis, from the
right sacro-iliac synchondrosis  to the right side of the pubic
arch, is usually effected in both.   We may also compare the
second facial position to the ordinary termination of the fourth
vertex presentation, the  chin  in this case rotating from the left
sacro-iliac  synchondrosis to the left side of the pubic arch. In
face  cases,  the mental protuberance is the  thread of the screw
which  is in contact with the ischial planes,  and the rotation
amounts to about one-fourth of a circle.   As the chin passes out
of the pelvis in the first facial position, it is in the same position
as the vertex in the second cranial position; while in the second
facial position, the chin emerges in the same path as the vertex
in the first  cranial position.
  Certain varieties of face presentations have been described,
in one  of which the chin has been spoken of as  sweeping  over
the perinaeum.   Smellie and Hamilton both include such cases
in their systematic  account  of face labor; but with a normal  )
pelvis and  foetal head of the ordinary size, such a mode  of ter-  >
mination is utterly impossible without the aid of instruments.
There  is an intermediate  presentation in  which the head  is
neither completely  flexed, as in vertex  cases, nor  completely
extended, as in face  presentations : this was alluded to  before,
and is the brow presentation.  On examining these cases at the
commencement of labor, the frontal protuberance of the right
or left side will be  found to  be as nearly as possible the pre-
senting part.  The diameter of the foetal head which enters the
right or left oblique diameter of the pelvis, is that between the
chin  and the great fontanelle;  the  chin may be towards the
right or left ilium.  In  the first, the presentation will  be the
analogue of a first vertex or face case, and the latter  of a second
vertex or  face position.   As labor advances, the  head sinks
down in the pelvis, and the right or left side of the face becomes
most anterior and lowest in the pelvis, according to whether the 
394       MISTAKES IN THE DIAGNOSIS OF THE FACE.

case represents a first or second face case.  The finger now easily
arrives at the great fontanelle, which is anterior, and to the left
or right,  as the case may be, and in the  opposite direction the
chin may be found.   Both the anterior fontanelle and the chin
are higher in the cavity of the pelvis than the forehead.  Unless
the pelvis is very large, or the head of the foetus very small and
yielding, the  case  now comes to a stand-still, the  arch of the
cranium  being forced down upon the pubis, and the  chin hooked
against the upper  border of the  great sacro-sciatic ligaments.
These cases  require the aid of the forceps, and  are  difficult  to
manage,  on account of the fact that these instruments can only
be applied in this position to the face, over which they slip  very
easily.
  The diagnosis of face presentations may be considered  to
rest upon the absence of certain signs peculiar  to other presen-
tations, and upon the recognition  of parts actually belonging to
the face.  The face may be distinguished through the mem-
branes as a very uneven surface,  totally  dissimilar  to the hard,
smooth, globular mass of the vertex.   If  the head is very  high,
and the membranes tense and tough, it is  not  so easy to recog-
nize the parts. It is still more difficult to determine  the position
through the walls of the cervix uteri.  In a latter stage of labor,
continued pressure may so modify the contour of the face, and
induce such swelling of the  features, as to simulate very much
the general aspect of a breech presentation.   In this case, the
malar bones, with  their soft coverings, may be mistaken for the
ischia and buttocks, the mouth may be so swollen as  to be easily
confounded with the anus, or the  eyes may be confounded  with
the vulva of a female child.   When no peculiarly untoward
circumstances are  present to obscure the real nature of the pre-
sentation, it is tolerably easy to  recognize, the frontal suture
narrowing towards the root of the  nose, the ridge  of the nose,
the orbits on each side, with  their bony circumferences, and,
beyond the nose, the large cavity of the mouth and the  firm
edges of the  alveolar processes.    If any doubt  exists as  to
whether  the  face  or breech  presents, the difficulty  may  be
cleared up in certain cases by an appeal to the surface of the
abdomen : thus, in thin women, the parietes of whose abdomens
are lax, and in whose uteri there may happen  to be but a small
quantity of liquor  amnii, the  head  may  occasionally be recog- 
       DANGERS OF INTERFERENCE  IN FACE PRESENTATIONS.   395

nized externally as a spheroidal mass at the fundus of the womb,
and this, of course, negatives the possibility of a face presenta-
tion.   On the other hand, the character  of the meconium may
become diagnostic ;  for although  it may  be  met with both in
pelvic and cephalic presentations, yet, in the latter, it is in a
diluted state, and is very different from the tenacious meconium
of a breech case, which has  not  been mixed with the  amniotic
waters.
  We now arrive at the management of face presentations.
In former  times  a  great variety  of contrivances were  in favor
amongst obstetricans for facilitating delivery in face cases.  The
foundation of this love of interference was evidently the strong
conviction,  which  anciently prevailed,  of the preternatural
nature of the presentation, and  this scientific prejudice found its
practical  development  in  procedures essentially meddlesome
and  bad.  The  first of these unphilosophical  procedures  was
that of turning; it was of course  only recommended when the
head was high in the pelvis and the liquor  amnii as yet  undis-
charged.  Almost in the present  generation turning has been
recommended in  face cases by high  authorities.  It is a well
ascertained fact now that, even  putting out of the  question the
danger which may accrue to the mother  from  the operation  of
turning, the result to the child  is that the chances of death are
more than doubled.  The greater control which the accoucheur
has over the progress of labor is certainly an attractive feature
in the mode of practice ; but as very rapid  delivery is by no means
the great desideratum of obstetrics, it is as  well to relinquish
the control for the sake of additional safety. It should  never be
forgotten, too, that in all cases of version,  however skillfully per-
formed, there are certain risks to the mother,  arising out  of
mechanical violence, inflicted either by the operator, or by the
uterus upon itself; while shock  and irritation, perhaps  running
on into  inflammation, are but too frequently the  results of
manual interferences, in which no mechanical  violence what-
ever  has  been applied to the parts.   Turning  can  only be
admissible when there is such a complication  as necessitates
our putting the safety of the  child out of the question,  and
balancing the operation of version against some  more violent
natural or artificial termination  to the  labor.   Dr.  J. Clarke
adopted another plan, which  was  to  wait until the head  had 
396
PROCEDURE  IN FACE PRESENTATIONS.
descended into the cavity of the pelvis, and then to exert steady
pressure, in a direction upwards and backwards, upon the  pre-
senting cheek during each pain ; by this means he averred  that
he succeeded in lodging the face in  the  hollow of the sacrum,
and that the labor then terminated as in vertex cases.   What-
ever may have been the results of this practice in the  hands of
Dr. Clarke, it  is obviously attended with  considerable risk; in
the first place, success is very doubtful, and  it is far  more pro-
bable that a brow presentation will be brought about  than  that
a rectification will be produced ; and in the next place, the pro-
cedure is a violent one as regards the  child.  A moment's con-
sideration of the  mechanical relations of the  parts concerned
will show that, as soon as any elevation of the chin is obtained,
the arch of the cranium will be brought down upon the  pubis ;
and  should  the  uterus  act with any vigor, he will be a dex-
terous operator who terminates the case without the forceps or
some  graver procedure still.  A more pernicious mode of prac-
tice than either of the above was first recommended by Baude-
locque, and received the sanction of Lachapelle, as well as some
British obstetricians.  The  operation was  founded upon a mis-
conception of the mechanism of labor in  face cases of the fol-
lowing nature.  It was  supposed that whenever  the  chin  was
towards the sacro-iliac synchondrosis of either side,  the head
must necessarily  pass out of the pubis with the  chin directed
posteriorly.  Whenever such cases had been actually  observed,
they had certainly been seen to be attended with a great risk to
the foetus and suffering to the mother; but the  grand  error was,
that not only are mento-posterior presentations,  as a general rule,
changed  into  mento-anterior ones, but that, instead  of  mento-
posterior positions being exceptional and peculiar, they are the
most frequent  of face presentations.  The fact that the chin was
generally towards one or other sacro-iliac synchondrosis was not
known, and the rotation of  the chin forwards in nearly all cases
was  equally undiscovered.   It  was  thought  that an original
anterior position of  the chin was the only favorable position  in
face  cases, and knowing as  we now do as  to the infrequency of
this  presentation, it can hardly be a  matter of surprise to  us
that  such frequent manual interference was resorted to, and that
such an unfavorable prognostic was applied to face presentations
in general.  The operation was performed  quite  in  the early 
DANGERS  OF BAUDELOCQUe's OPERATION.
397
stage of labor, and before the membranes were ruptured. It was
recommended to introduce the hand into the vagina, through the
os uteri, and into the space between the brim of the pelvis  and
the forehead  of the  foetus;  the palmar surface  of the fingers
being kept towards the head of the child.  The next step was to
rupture the membranes and hook the fingers  over the  arch of
the head, and drag down the occiput if possible—indeed this is
the object of the procedure—and thus convert the face presenta-
tion into an ordinary vertex  one. The objections to this method
are numerous.  Since Naegele wrote his celebrated treatise on
the mechanism of labor,  it has been generally known  that not
only is the chin at first generally directed  backwards, but  that,
in nearly all cases, it turns forwards under the arch of the pubis
as a necessary result of normal relations between  the pelvis, the
foetal head and the expulsive powers.   Having thus  eliminated
a large proportion of cases from the category of those requiring
artificial  assistance,  let us inquire, What are the dangers of
Baudelocque's operation ? It must be granted that the intro-
duction of the whole hand at the commencement of labor,
before  the external organs  of  generation  are dilated  and
softened,  must  be  an  extremely  painful  procedure for the
mother, and the efforts used for the introduction of the  hand
into the uterus  can hardly fail  not only to be painful but to  give
rise to serious accidents.   M. Moreau saw a case  in which  rup-
ture of the uterus, followed by immediate death, was the result
of this operation, and the circumstance is  the more worthy of
notice, because the operator  was a person well used to  obstetric
manipulations.
   In the  next place, the sudden  escape  of the liquor amnii
before the  head has become  engaged in the superior strait of the
pelvis is very likely to result in descent of the funis, a circum-
stance which places the foetus in extreme peril.   Again, an arm
may descend,  or  even   two   may come  down, and create
additional  difficulty in the further  progress of the case ;  and,
finally, it is an inseparable result of these tentative  efforts, that
when they fail to produce a vertex presentation, recourse  must
be had to the forceps or pelvic version.  It may be added, that
the  early evacuation of  the  liquor amnii is  a circumstance
extremely objectionable in itself, as subjecting the foetus to the
immediate pressure  of the uterine walls, and  abrogating all 
398          TREATMENT OF FACE PRESENTATIONS.

those arrangements which conduce to easy delivery in a  spon-
taneous vertex  presentation.   If  the operation  were easy and
inoffensive, and if it placed both  mother  and foetus, after its
accomplishment (always  supposing it to have been  accom-
plished), in the  same condition which would have obtained in a
spontaneous vertex position;  if, in  a  word, the  least analogy
existed between a labor where the vertex presents spontaneously
and one in which it had been dragged down, it would be proper
to resort to Baudelocque's method;  but inasmuch as failure is
probable,  the condition produced  not identical, the  danger to
mother and child from the operation itself not  small, and  the
alternative after failure another and  still graver  operation,  the
whole proceeding is totally inadmissible.
  In actual  practice, it will be found  that the  treatment of
face cases  is extremely simple.   We may  assist the chin in
making its rotation forwards and downwards, by introducing the
finger into the  child's mouth,  making traction upon  the lower
jaw, and bringing it under the arch of  the pubis.   Meigs lays it
down as the great  rule of practice in face  cases,  that the chin
should be brought towards the pubis as the face emerges from
the pelvis.  This is an  analogous procedure to that of bringing
the occiput down in vertex cases,  either directly, by the fingers
applied to the back  of the  head,  or indirectly, by pressure
exerted upon the forehead.   The principle is the  same in both
cases—viz., to favor the birth of that part which tends to be
born first.  Should the head fail to rotate in the pelvis the  for-
ceps will generally be necessary, or the head must be  dislodged,
and  the child  delivered by turning.  Where delay  arises, not
from faulty position, but from disproportion in bulk between the
head  of the foetus and the  pelvis  of  the mother, or from
inadequate  uterine contraction, the same rules  of  treatment
apply as in cases of impactment or inertia uteri, where the ver-
tex presents with this  modification, that as the parts engaged in
the pelvis are  more  solid, less advantage will be  gained by
delay in so far as moulding of the head is  concerned, and more
danger will accrue to the mother from pressure upon the rectum
and bladder.  The foetus itself is more  endangered, too, by lone
engagement in the pelvis, in face  than in  vertex positions, the
vessels  of the  neck  being  often  injuriously  pressed upon.
During the progress of a face case care should be taken to keep 
NECESSITY  OF  CARE IN EXAMINATION.
399
the pelvic viscera empty, and to preserve the membranes entire
as long as possible.  In making examinations, the delicate struc-
ture of the organs within reach should be remembered, as cases
not unfrequently happen in which the eyes have been seriously
injured by careless manipulations.  Examinations should not be
more frequent than  necessary to determine the exact presenta-
tion at first, and the subsequent rate of progress.   The apart-
ment should be kept cool, and the patient's  courage  supported
by a cheerful and confident  demeanor on  the  part of the
accoucheur.  The perinaeum should be carefully guarded, but
not pressed upon.   After birth, the  features  of the child will
generally be found hideously distorted, the  mouth  dragged to
one side, and one or both  eyes  occluded.  Fomentation with
warm water, decoction  of poppy-heads  or marsh-mallow, will
be all that is necessary, as the  parts will gradually return to
their normal condition.   The parts of generation of the mother
require  similar application and great cleanliness. 
LECTURE  XXVII.
               PELVIC  PRESENTATIONS.

  Gentlemen :—Having considered those presentations in which
the cephalic extremity of the  foetus  is situated inferiorly,  we
may naturally pass to those in which the pelvic extremity of the
child holds the same position.  It has been a matter of contro-
versy whether pelvic presentations should be considered natural
or preternatural.   Whatever arguments have been urged on
either side, however, the same detriment has not accrued to prac-
tice as from erroneous theoretical opinions with regard to  the
nature of face presentations, inasmuch as all have  been agreed
pretty nearly as to the time and manner of rendering assistance
in these cases.  Practical conclusions  not having been deduced
from  the  one or other view of the question, all interest in it
vanishes, and we are left free to consider only that which is use-
ful.  It is by no means necessary to enter into detailed separate
descriptions of the various forms of pelvic presentation ; they
are in reality, but trifling varieties of  the same order of labors,
and differ very little except in some particulars of management:
their mechanism is essentially the same, and  the  fundamental
rules of treatment  which apply  to the one variety apply with
equal force to the other.  We may look upon the pelvic  extrem-
ity of the  foetus as composed of certain elements, which may
present alone,  or  in certain combinations.   The most complete
variety is where the  breech engages itself in the  pelvis first;
then the knees may present, or the feet, or a single foot or knee.
A needless subdivision of breech presentations has been  made
by some authors, and the pelvis of the foetus has been described
as occupying almost every conceivable position at  the brim of
the maternal pelvis.   The complexity thus given to the subiect
of the mechanism of pelvic labors was, however, first cleared
      400 
ANALYSIS OF PELVIC PRESENTATIONS.
401
away by the same careful observer to whom we are indebted for
nearly all that we know, exactly, of the intra-pelvic movements
of the foetus.  Naegele* reduced all pelvic presentations into two
orders ; in the first, the back of the child is towards  the  abdo-
men of the mother;  in the second, the abdomen of the child is
towards the mother's  abdomen.   These may be called respec-
tively the dorso-anterior and the abdomino-anterior positions. In
neither case, however, is the back of the foetus  situated quite
anteriorly or posteriorly, but rather obliquely, so that one hip is
more anterior than  another.  The  dorso-anterior position is,
according to the same authority, more frequent than the reverse
presentation, in  the  proportion of three to one.   Let us now
examine the mechanism of pelvic labors, first premising that
they  ensue according to the fixed  laws, as cranial  labors do,
with only this difference, that deviations from the usual course
are perhaps rather more frequent, and attended with less risk
than when the head presents.
Fig. 114
Pelvic presentation in the first dorso-anterior position.
  In dorso-anterior pelvic presentations, the relation of the foetus
to the maternal pelvis, is,  generally speaking, as follows:  the
tftmsverse diameter of the child's hips occupies the left oblique
                             26 
402
ROTATION OF THE BREECH.
 diameter of the pelvis, its sacrum is directed towards the left
 acetabulum, its left  trochanter  towards the  right acetabulum,
 and its right trochanter towards the left  sacro-iliac synchon-
 drosis.  Upon examining per vaginam,  as  the breech is enter-
 ing the superior strait of the  pelvis, it  will be found that the
 os  uteri is occupied  by a double  tumor, soft, but  elastic dur-
 ing the intermission of a pain, the  several parts to which refer-
 ence will be made, when speaking of  the diagnosis, may be
 readily distinguished,  and it will be  found that the sulcus
 between each segment  of the tumor is oblique, and situated
 more posteriorly than anteriorly; or, in other words, one but-
 tock, the left,  occupies the anterior  and greater half of the
 mouth of the uterus.   It will  be observed, also, that this but-
 tock, which is most anterior,  also stands lowest  in the pelvis,
 and is, in fact, the presenting part.   As labor  advances, and the
 hips  descend, the  left hip is still lowest in the pelvis, and
 steadily directed somewhat to  the right: what now takes place
 is a matter of dispute.  The great majority of  obstetricians con-
 tend  that a  rotation analogous to the rotation of cranial labors
 takes place, that the left hip turns more and more forwards, until
 it comes to be nearly under the pubic arch, and that the hips and
 shoulders thus emerge from the pelvis, nearly  in the antero-pos-
 terior diameter of its outlet.  This statement is made confidently
 by persons of great and deserved repute, but M. Naegele, never-
 theless, flatly contradicts it, and makes  it the subject of some
 pleasantry ;  his  words are  nearly  as  follows: " In its farther
 advance (the breech)  into the pelvis, it is always found in an
 oblique direction, the  hip directed forwards standing lowest.  In
 this oblique position, with reference to its transverse and perpen-
 dicular diameters, it is forced through  the inlet, the cavity, and
 the outlet of  the pelvis; and in general none of these  rotations
 occur, erroneously  described in many manuals and compendia
 as appertaining to  this species of labors.   There are some, cer-
 tainly, who, compass  and skull in hand,  measure the diameters
 of the bony pelvis, and then on  the writing  desk so  turn and
 extract  a mannikin, that  the  transverse diameter of the hips
 always passes in that  direction, which, according to calculation
 on the bony  pelvis, they  account the largest."  The truth  as
 usual,  would appear  to lie between  the contending parties.
That there is  a slight rotation can hardly be doubted,  but it is 
             ROTATION OF THE BODY  OF  THE FCETUS.         403

not  so  constant nor  so  well  marked as the rotation  of the
cranium.   There is not the same difference between the diame-
ters of the breech  of the foetus as between the diameters  of its
head, and  consequently there  is not the same necessity  for a
movement of adaptation ; we shall find, however, that the head
obeys the  same mechanical necessities in its transit, in pelvic
labors, as when  it presents at first.   Supposing the breech now
to have become entirely engaged in the  cavity of the pelvis, the
left hip will be found just within the vulva, and the right hip
beginning to press down on the floor of the pelvis posteriorly,
and somewhat to the left side.  The left hip then becomes nearly
fixed under the pubic  arch, and a movement of flexion  takes
place analogous to the flexion of face and the  extension of ver-
tex labors ; the right hip sweeps over the perinaeum, the pelvis
of the foetus rotating, as it were, upon its antero-posterior diame-
ter.  As soon as the right hip has escaped from the tight embrace
of the perinaeum, a movement onwards en masse takes place, the

                           Fig. 115
          Passage of the shoulders, and partial rotation of the thorax.

feet usually slip out, and presently the knees become disengaged;
and the inferior half of the child's body is thus born. The abdo- 
401
DELIVERY OF THE ARMS.
men of the foetus is now turned  towards the inner side of the
rio-ht thigh, or, supposing the woman to be  in  the  ordinary
obstetric position, upwards.  The rest of the body follows in the
same manner, the shoulders entering the left  and oblique diame-
ter  of  the  inlet.   The  manner  in which  the arms  are born
depends upon whether they remain folded upon the chest of the
foetus, or are displaced  during  the progress of labor.   In  the
first instance they slip out as the thorax is expelled ; in the lat-
ter  they are extended upwards on each  side of  the head, or one
may even become locked behind the head, and between it and
the pubis;  and serious  inconvenience  may  arise  from such an
accident.  If the arms remain extended by the side of the head
as the latter passes through the pelvis, the difficulty of the case
is of course enhanced.  The left shoulder of  the foetus, like  the
first hip, becomes first engaged in  the outlet of the pelvis, and
the right  shoulder  distends and sweeps over the  perinaeum.
Durinc- the whole progress of labor, the foetal head will in most
cases remain flexed upon the chest.  As the shoulders are about
to emerge,  the head enters the opposite oblique diameter of the
pelvis to that which the  hips and shoulders  have occupied;
thus the forehead is towards the right sacro-iliac synchondrosis,
and the occiput is directed towards the left acetabulum.  The
occipito-frontal diameter of  the foetal head is  not,  however,
exactly that which comes  into relation with the  right oblique
diameter of the pelvis, for the chin is depressed and the occiput
is the highest point of the foetus ; it is the  sub-occipito-frontal
diameter which presents, and thus sufficient room is  gained to
allow the head to become easily engaged in the  cavity of the
pelvis, and to  permit the face to  be rotated  into  the hollow
of the  sacrum.  The under surface of the  occiput now rests
against the inner surface of the symphysis  pubis, the mass of
the face occupies the sacral concavity, and the chin may be felt
some little  way within the perinaeum.   In the  further  expulsion
of  the head the occiput is  almost a fixed point, and the head
rotates -upon its transverse axis in such a manner that  first the
chin sweeps over the perinaeum, then the face, the forehead, and
the arch of the cranium ; and finally, the bulkiest part of the head
having been expelled,  the rest  is  pushed out  by the  elasticity
of the perinaeum and the action  of the vaginal muscular fibres.
  In the second variety of dorso-anterior positions, the hips 
          SECOND  VARIETY OF BREECH PRESENTATIONS.      4Q5

of the child occupy the right oblique diameter of the brim of
the pelvis; the right buttock presents, if it is a breech case,  and
Fia. 116.
Descent of the head.
occupies the  greater and anterior segment of the os uteri • and
the left buttock sweeps the  perinaeum.   The right  side of the
foetus is directed steadily somewhat to  the left acetabulum and
its abdomen  turns downwards, or towards the left thigh of the
mother.  The head enters the left oblique diameter of the pelvic
inlet, the forehead being towards the left sacro-iliac synchon-
drosis ; the face turns into the hollow of the sacrum, as in the
first instance, and the whole progress of the case is,  in fact the
converse of what happens in the first position ; just as the second
is the converse of the first vertex or face presentation.
  Abdomino-anterior positions of the foetus, with the breech
or lower  extremities presenting, are  of two Icinds.  In the first
and most frequent variety, the hips of the child occupy the right
oblique diameter of the  inlet, the left trochanter is towards the
left acetabulum of the mother, the left hip presents and stands
lowest in the pelvis  from first to last, and the whole  body, as
far as the shoulders, is expelled, looking forwards to the right. 
406
ANOMALIES IN PELVIC LABORS.
The head enters the left oblique diameter of the inlet of the pel-
vis, the occiput being towards the left sacro-iliac synchondrosis.
As the head descends, in the pelvis, the occiput rotates forwards
from left to right until at last the face is lodged in the hollow of
the sacrum, just as it rotates in fourth vertex positions.   Those
parts of the foetus which were already born may now be seen to
rotate in a corresponding direction and degree to the intra-pelvic
rotation of the head ; thus the anterior  surface of the  child's
body, which at first looked forwards and to the right, now looks
backwards and  to the right,  and  the  case  then terminates
exactly as the first sub-order of dorsal anterior  positions.
  The  second variety of abdominal anterior positions is
where the hips of the foetus lie in the left oblique diameter of
the inlet,  the right trochanter  being towards  the right  aceta-
bulum.  The right buttock is here the presenting part, and stands
lowest in the pelvis.   The head enters in the right oblique dia-
meter of the inlet, with the occiput towards the right sacro-iliac
synchondrosis, and undergoes the same kind of rotation as the
preceding variety—that is  to say, the occiput turns forwards and
from right to left, and the face is thus thrown into  the concavity
of the sacrum.  The  anterior surface of the child's body,  which
was at first turned forwards and to the  left, is at the same time
rotated so as to look backwards and to the left.   The mechanism
of this variety is in fact the exact converse of the preceding.
  There remain two anomalies in the mechanism of pelvic
labors, which are very interesting;  one of these  relates  to  an
unusual termination of cases in which the abdomen of the infant
is anterior, and the other relates to the  position and  rotation  of
the fcetal head.   It sometimes  happens,  says  Naegele,  in
abdominal anterior positions where the foetus is premature,  small,
or a twin, that the abdomen, which was  at first directed forwards
and to the left, or forwards and to the right, is suddenly, and
during a single pain, turned so completely round that the abdomen
looks backwards and to the right, or backwards and to the left.  It
is difficult to account for such a singular revolution of  the fcetal
body.  The other anomaly alluded to is where the head, instead of
being fixed upon the chest, is extended, the occiput being pressed
down upon  the  nape  of  the neck.   In  such cases  the ver-
tex rotates backwards into the hollow of the sacrum, the under sur-
face of the lower jaw is brought into relation with the symphisis 
             DIAGNOSIS OF BREECH PRESENTATIONS.          407

pubis and the head emerges in such a manner, that, first, the occi-
pital protuberance sweeps over the  perinaeum, then the arch of
the cranium, and then the forehead and face.   The foregoing
account of the mechanism of pelvic labors applies in-every essen-
tial particular to each variety.  There are, however, one or two
subsidiary differences depending upon whether the nates, knees,
or feet present.   When the breech presents, the birth of the body
is slower, but the head follows more readily; when  the knees
descend, they sometimes create delay by becoming fixed  against
some point of the bony pelvis,  more especially against the lower
part of the sacrum; and when the feet  present, the birth of the
lower half of the body is comparatively rapid, while delay ensues
in the passage of the shoulders and head.  In labors  where the
breech or  knees present, reliance  may be placed upon the posi-
tion of the presenting part, as an index  of the  actual position of
the foetus; but when the feet present, it must be borne in mind
that they are very mobile, and  only affect a determinate position
when the nates  enter the brim of  the pelvis.  In some cases of
pelvic  presentation, it has been  remarked  by Drs. Hardy and
M'Clintock,  that the anterior-superior spinous process  of the
ilium presents, in the first  instance, and may cause some confu-
sion.
  The diagnosis of pelvic presentations  rests upon signs,
some of which are common to each variety, while there are par-
ticular signs  by which each special presentation may be deter-
mined.  The first thing to which the  attention is directed in
pelvic presentations is the  absence of  those familar  conditions
which obtain when  the head of the foetus is at  the brim of the
pelvis ; and,, failing to recognize these, the accoucheur naturally
looks for data upon  which to found a positive diagnosis in lieu
of his negative one.   Popular  opinion, amongst females at least,
attaches much importance to  the external  configuration of the
abdomen, and hence the slightest deviation from the usual form
or size excites in women strong apprehensions of mal-position of
the child.  As long, however, as the long axis of the ovoid mass
formed by the foetus  corresponds to the long axis of the  uterine
cavity, it will make but little difference in the external appear-
ances whether the cephalic  or pelvic  extremity of the foetus is
directed downwards.  Even in transverse presentations it is sur-
prising how little affected  is  the  figure by the position of the 
408       CHARACTERISTICS OF BREECH  PRESENTATIONS.

contained infant, and to expect therefore any guidance in the
minute difference in form and size between the upper and lower
extremity of the foetus is chimerical  in the extreme; it is only
in very exceptional cases  that an external examination throws
any light  upon the subject, and  even then  it is not from the
general appearance we judge,  but because we can occasionally,
under  favorable  but  peculiar circumstances,  recognize  the
rounded mass  of the fcetal  head, through the walls of the abdo-
men, lying at  the fundus uteri.  It has been  said that when the
breech presents, the lower end of the utero-foetal tumor sinks
further down into the pelvis at the commencement of labor than
when the head presents, and this has been said to occur whether
the case is a primiparous one  or  not.  The fact, however, if it
be one, will  not assist us very materially ; for the depth to which
the presenting part sinks in the pelvis, independently of uterine
contraction,  is principally the result of circumstances uncon-
nected with  the foetus, such as the size of the pelvis and the
tension of the  abdominal walls.  In knee and footling cases, the
presentation is certainly further out of  reach  at the commence-
ment of labor than when the head is at the brim of  the pelvis,
and indeed it  not unfrequently happens in footling cases that it
is extremely difficult to find any presentation at all, unless the
whole hand  is  introduced into  the vagina.   The form of the bag
of membranes  is an item better worth attention ; it will be found
not to  have that rounded  form which obtains under ordinary
circumstances, and it projects more into the vagina.   In footling
cases the bag is quite long, and shaped like the finger of a glove,
and in  all pelvic presentations it is not so tense  as when  the
head presents.   Another circumstance worth  attending to is the
mobility of the presenting part, which in pelvic presentations is
generally more resilient, and  bounds up in  the waters  of the
amnion more readily than the head does.   The sensations of the
mother have also been  spoken  of, as furnishing an indication of
the position of the foetus, not  to be neglected. In vertex  pre-
sentations, the feet of the infant are of course directed towards
the fundus uteri,  and the  sensations of struggling felt by the
mother are generally referred to the upper portion of the uterus,
and more especially to where it is in contact with the abdominal
parietes.   When the pelvic extremity of the foetus is its depend-
ing portion, these sensations are said to be in a great measure 
            DIAGNOSTICS  OF  BREECH PRESENTATIONS.        409

absent, or if perceived, to be referred to a much lower situation.
Very little reliance can  be  placed upon auscultation in deter-
mining pelvic presentations.  The fcetal heart beats so  nearly
midway between the  one extremity of its  body and the other,
that but little alteration in the distance from the pubis, at which
it is best heard, is effected, whether the cranial or pelvic extrem-
ity  of the foetus depends.   When it is  remembered that con-
siderable variation in this respect obtains in cranial presenta-
tions, it must be conceded that, however useful auscultation may
be in other circumstances, we can expect but little assistance
from it here.   In the first dorsal anterior position the foetal heart
may be heard loudest a little to the right of the mesial line,, and
somewhat below the level of the umbilicus ;  in  other positions
the sounds of the heart  are somewhat obscure,  and, in short,
auscultation is not to be relied upon.  The  manner in which the
liquor amnii  is discharged is peculiar, though not so character-
istic in breech as in  knee and footling cases.  When the head
presents, the  membranes rupture, and a sudden  gush  of water
follows, which as suddenly  stops; this is because the head is
forced down upon the os  uteri, and acts as a ball-valve.
  In pelvic presentations, the gush  is not so sudden, and the
waters of the amnion  continues to flow until the  uterus is emp-
tied of all its contained fluid.  As might be naturally expected,
the character of the pains alters as soon as  the membranes have
burst, and from this time until the whole body is expelled, and
nothing remains but the head  in the cavity of the pelvis, the
uterine contractions  are  more  clonic,  continuous,  and closer
together than in cranial  labors; the  absence  of fluid from the
uterus multiplies the  points of contact  between  the foetus and
uterus, and increased excitation results in increased motor action.
The chief and conclusive evidence of pelvic presentation is, of
course, the recognition of the individual parts  which offer them-
selves to the touch per vaginam.   In breech cases, very little can
be accurately distinguished before the membranes are ruptured,
beyond the movable coccyx and rugosities of the sacrum; these can
generally be felt behind one or the other acetabulum.  As  soon as
the liquor amnii has escaped, however, the finger of the accoucheur
comes into direct contact with the parts  of the  foetus.   The os
uteri will be found occupied by two smooth elastic tumors, divided
by a cleft, which extends in one  direction towards the  coccyx 
410         PECULIARITIES  OF PELVIC PRESENTATIONS.

and sacrum, and in the other, is continuous as far as  the  finger
can reach.   In the track of this cleft, the anus  may be distin-
guished ; it differs from the mouth in being smaller, in not con-
taining alveoli and a tongue, and in contracting upon the  finger
if any attempt is made at introduction.  In dead foetuses, the
anus is relaxed, but the distinction may be easily made  by refer-
ence to the other differences.   The vulva of  a female child may
be distinguished from the mouth in the same manner.  Further
from the coccyx than the anus, the genitals may  be recognized;
and in the case of a male  child, the scrotum, which  sometimes
hangs down much tumefied,  is a very distinctive feature.  The
meconium which comes away upon the finger in  breech cases is
tenacious and adhesive. If the breech remains long  in the pas-
sages considerable tumefaction takes place, and the diagnosis  is
to a certain extent obscured ; but prolonged  and  careful exami-
nation will generally suffice to overcome this difficulty.  The
knee may be recognized by its presenting for  examination two
rounded tuberosities, with a depression between them  and the
flexure of the leg and thigh, which can easily be reached.  The
knee is  liable  to be confounded with the heel, the elbow, and
the shoulder ; it  differs from  the heel in having two tuberosities;
from the elbow  in  having a  depression, instead  of the sharp
point of the olecranon, between its tuberosities ; and  from the
shoulder in having two tuberosities in the place oione, from which
the bony ridges of the clavicle and scapular spine may be traced.
The  foot is liable to  be mistaken for the hand, but it may be
identified by the following peculiarities :  In the first place, the
line  of the  toes is regular and even, while the fingers  are of
various lengths, and form an irregular line.   The  great toe lies
close to the other toes; the thumb, on the contrary, divaricates,
and is opposed to the other digits.  The foot  is thicker than the
hand, and its inner border is much rounder  than its  outer bor-
der.   Tlie rounded  instep of  the foot has no analogue  in the
hand.  The heel projects  in the opposite direction to  the toes.
The foot is  at a  certain angle with the leg, while the hand  is
continuous  in the same direction with the arm ; and finally, the
foot  is weightier, and  not so mobile  as  the hand.   In breech
cases, it is easy to determine the exact  position  of the  foetus and
there is no great difficulty in doing so when the knee presents •
but in footling cases it is not so easy.  If only one foot comes 
               INTERFERENCE IN BREECH CASES.            411

down, it is as well not to be positive until the hips enter the brim
of the pelvis ; but if both  descend, and cross each  other, the
anterior surface of the body must  be in the direction of  the
toes.  When one foot comes down, it should always be identified
as right or left.
   Having fully satisfied ourselves of the exact  position of the
foetus, we have little to do until towards the conclusion of labor.
The accoucheur should be an observant spectator of the operations
of Nature, thoroughly cognizant of what those  operations are,
and capable of appreciating at once the slightest departure from
their normal course.  The first care should be, not to rupture the
membranes.  In  knee and  footling cases this  caution is even
more necessary than when the breech presents.  The bag  of
membranes  is required to the last moment, as a dilating agent;
no part of the  foetus in pelvic presentations will dilate the pas-
sages so equitably or so  efficiently as the waters of the amnion.
A solid body, not possessed of the globular form of the cranium,
will exercise pressure in certain directions, according to its specific
form: water presses equally in  every direction, and  the waters
therefore we should endeavor to retain within the membranes as
long as possible.   This is a cardinal point in the management of
pelvic labors.   Ancient practice in this particular was very dif-
ferent from  modern, and opposed so obviously even  to d priori
considerations, that it is difficult to conceive the necessity of the
hard  teachings of experience to show its defects.  Dr. William
Hunter, at one time, used to convert all breech cases into  foot-
ling ones; subsequently he  was less disposed to  interfere  with
nature, and  he then found  his  proportion of deaths in pelvic
labors very much diminished.  Smellie's advice sounds some-
what singular in modern ears ;  he says, " If the knees or feet of
the child present to the os internum, which is not yet sufficiently
dilated  to let them and  the body  come down, let the operator
introduce  his  hand into the vagina, push up and stretch the os
uteri, and bring along the feet."  Supposing the membranes to be
ruptured, the best rule is to let Nature take its own course until
the body is born  as far as the umbilicus ; only guarding the
perinaeum, and relieving it of tension by favoring the flexion  of
the trunk.  The less we interfere the less rapid will the descent of
the foetus be;  and it is very important to secure, if possible, a
slow passage of the pelvis and  trunk, and consequent  complete 
412          ASSISTANCE IN  PELVIC  PRESENTATIONS.
dilatation of the passages.  If the knees descend and accidentally
get locked in the cavity of the pelvis, they must of course be lib-
erated ;  but this is an accident, and not the usual course of events.
The laissez faire system does nor apply, of course, to cases  of
inertia uteri; if  the breech or hips of the child do not advance,
from  defect of uterine contraction, either  the  uterus  must be
excited,  or traction  must be made upon the  foetus.   Various
methods of applying tractile force have been adopted : the finger
may be hooked in the groin, or a silk handkerchief passed round
the flexure of each thigh, or the blunt hook may be used.  A
dexterous obstetrician will generally succeed with the  unaided
hand, and, indeed, the blunt hook is an unnecessary formidable
instrument for such purposes ; it bruises soft parts,  and is  very
likely to fracture the thighs  of the foetus.  When the umbilicus
clears the perinaeum, the dangerous  part of the labor begins; an
abnormal element—viz., compression of the funis—is introduced
into a process otherwise normal; and now our art must be exer-
cised  and imposed between the  foetus and impending death.
The first interference necessary is  to draw down a  loop of the
cord; this is done  with a  view to obviating any compression
which may arise from straightening out  of the spirally-coiled
umbilical vessels, in the further descent of the trunk.  An effort
should then be made to draw the cord into one of the recesses on
either side of the  promontory of the sacrum, as this position is
one in which there is less risk of  pressure than in  any other.
The strength of the funicular pulsations should now be narrowly
watched, as it bears a direct ratio to the chances of  live birth ;
as long as the cord beats steadily, no  interference is  necessary,
and indeed should  be avoided.  It is  very tempting to see the  *
legs dangling, out  ready to  be  grasped, and to know that the
foetus may be seized and dragged forth without much delay, and
the bystanders will generally applaud the zeal of the accoucheur
who endeavors to hasten the birth  under these circumstances;
but it sometimes happens that premature efforts  at traction dis-
lodge the arms  from their position on the child's  breast, and
throw them up on each side  of, or even behind, the head; and it
again results, at other times, that the head becomes extended
that the arch of the cranium is rotated into the hollow of the sa-
crum, and that the child  is lost from consequent delay in the
passage  of the head.  Until there  is a valid reason, then, for 
THE FUNIS IN BREECH CABES.
413
interference,  arising out of the condition  of the foetus or the
mother, nothing should be done.  As the chest  is being forced
out, it is necessary to be observant of the position of the arms;
if they are in their natural position they will slip out of them-
selves, but if they are extended on each side of the  head it will
be proper to  bring  them down.  It  is best to  bring down the
arm nearest the perinaeum first, as there is more room for mani-
pulation in that  direction.  One of the  two fingers should be
hooked round the humerus, near the elbow-joint, and  the  arm
should then be drawn gently over the face and chest, not dragged
directly downwards.  Inattention to this precaution may pro-
cure the disagreeable accident of fracture of the humerus.  This
is not a very  uncommon  accident in midwives' midwifery, and
indeed it was of old a rule  of practice amongst them  to break
the arms,  as an expeditious and simple method  of meeting this
difficulty of pelvic labors.  The other arm  should be dealt with
in the same manner.  As the shoulders are born the perinaeum
again requires care, and as  soon as  they are liberated  the face
will generally rotate into the hollow of the sacrum.   The largest
and most unyielding part of the foetus  has  now to be  expelled,
at a great mechanical disadvantage.  The uterus is so far empty
as to  have lost much of its power  over  what remains behind,
and the birth of the head is, in fact, principally effected by the
diaphragm, abdominal muscles, and muscular structures within
the pelvis.   Danger accrues to the  foetus  more than ever now,
from pressure on the cord;  and the placenta is so jammed down
upon  the  head of the  child as in a great measure to destroy its
function as a respiratory organ.  This  is  the stage  of  labor in
which life is  generally lost, in which the natural powers avail
least,  and in which the intervention of art  is therefore most
needed.  It is necessary still, howeverj  to be guided  by  the
actual condition of the child ; if the cord beats steadily it is bet-
ter  to  wait for a time than to interfere hurriedly.  The signs  of
danger to  the child are increased quickness  and feebleness of the
umbilical pulse, and occasional gasping respiratory movements.
Whenever it  happens that, once or twice in the  course of a min-
ute, inspiratory movements of the muscles of the chest and abdo-
men are observed, the head of the child remaining as yet in the
pelvis, we may be  sure  that the child is  dying of asphyxia.
These movements are caused, as is proved  by the  experiments 
 414        TERMINATION OF PELVIC PRESENTATIONS.

 of Volkmann and Schneider, and the observations of Dr. Mar-
 shall Hall, by the centric irritation of the medulla oblongata by
 the carbonized blood of the foetus, in cases of pressure upon the
 placenta or funis.  No other  sign of danger  to the foetus is  so
 trustworthy as the occurrence of these jerking spasmodic attempts
 at respiration.
  The necessity of interference being clear, there is no great diffi-
 culty in rendering it.   A finger or two of the left hand should be
 introduced into the child's mouth, or laid one on each superior
 maxilla, and the face should be drawn steadily down towards
 the fourchette of the perinaeum ; at  the  same time, the  occiput
should be pushed up by a finger or two  of the right hand intro-
 duced behind the symphysis pubis.  This manoeuvre will bring
 the shortest possible diameter of the fcetal head into relation
 with the antero-posterior diameter of the outlet of the pelvis.  The
head will emerge  now, with  the aid of  gentle traction, towards
the knees of the  mother, and the birth is complete.  Whether
the position of the foetus is a dorso-anterior one, or an abdomino-
anterior,  the  management varies hardly  at  all.  The  occiput
rotates forwards from its posterior position just as in thirds and
fourth vertex cases; and nature will generally adapt the head to
the pelvis much better  than the accoucheur.   No force should
be used  in the  extraction of the head.   Above all, traction
should never be exerted upon  the shoulders, as very slight ex-
tension of the neck is sufficient to destroy the child.  The stretch-
ing of the upper part of the spinal marrow is very dangerous to
the life  of the  infant.  Where  the  head in breech cases  is
impacted at the outlet of the pelvis, it is sometimes possible to
pass up two fingers to  the mouth of the child, and to admit a
sufficient  quantity of  air to  allow  of  respiration before the
delivery of the head.   This was first recommended by Pngh, and
Dr. Bigelow, acting upon the same principle,  recommended the
use of a  flat flexible tube  for the same purpose.  The  forceps
should always be  had in readiness in breech  and footlino- cases.
When the head cannot  be delivered, or respiration set up by the
processes described, and when the danger of the child is imminent
the forceps should invariably be used. A delay of a minute or even
a few moments may sacrifice the life of the foetus.  The forceps
is still more likely to be required in footling than in breech cases.
When the child is dead or premature, particularly in the former 
AFTER CARE OF THE F03TUS.
415
case, less precaution is of course necessary in extracting the
head.
                    Manual extraction of the head.

  Delay and difficulty may occur at various stages in the pro-
gress of pelvic labors; thus* there may be ascites, or  accumula-
tion of urine in the foetal  bladder; or the child may be tym-
panitic ; or there may be hydrothorax, or hydrocephalus.  Any
of these accidents may render evisceration necessary.  Anchy-
losis of the coccyx with the sacrum, or a flat or too incurvated
condition  of the latter bone, will sometimes prove  a  serious
source of delay and danger  to  the foetus.  Sometimes the os
uteri seizes the neck or head of the child, and retards delivery.
It is proper, in cases where the breech or lower extremities pre-
sent, to be prepared with the necessary means of restoring sus-
pended animation.  An abundant supply of hot water for baths,
and a gum-elastic catheter for inflating the lungs, should be at
hand. If there is much cerebral congestion, it will be advisable
to allow two or three drachms of blood to escape from the funis.
Friction of the surface of the  body, aspersion with  cold water,
[alternating with the warm  bath, to produce the nervous shock,
as recommended by Marshall Hall], and  galvanism, maybe had 
416
STATISTICS  OF BREECH CASES.
recourse to with benefit.   [The " ready method " should not be
forgotten in the asphyxia neonatorum.]
  It is always interesting to note the Influence  of mal-pre-
sentations upon  the life and subsequent  condition  of  the
mother and foetus.   As far as mother is concerned, it can hardly
be said that there is any appreciable difference in the risk of
cephalic and pelvic labors.  Non-expulsion of  the head  is  the
circumstance most likely to prove  detrimental  to  the mother ;
and bruising of the parts within the pelvis from impactment, or
the supervention of inertia uteri followed by flooding, are  the
forms of danger to which she is  exposed.   The danger which
accrues to the child is, however, very considerable.  In breech
cases the deaths are as 1 to 3j, and in footling cases  as 1 to 2£.
The gross proportion of deaths in all presentations of the pelvic
extremity of the foetus is about 1 to 3.   Death  takes place from
asphyxia, either produced by compression of the cord or of  the
placenta, or from early detachment of the placenta, or coma is
produced by obstruction of the veins of the neck, and, lastly,
the infant may perish from shock  or  exhaustion.   Instrumental
interference is based, of  course, upon  the same general princi-
ples which apply to  other forms  of parturition.   Spontaneous
pelvic  presentations are less dangerous both to mother and child
than the artificial pelvic presentation procured by the operation
of version.  According to Dr. Fleetwood Churchill's collection
of nearly 200,000 cases, the breech presented in the  proportion
of about 1  in 59^ ; footling or knee presentations were about 1
in 105 cases. 
LECTURE  XXVIH.
            TRANSVERSE  PRESENTATIONS.

  Gentlemen :—In the preceding lectures we have considered
those presentations in which the cephalic or pelvic extremities
of the fcetal ovoid are  found at the os uteri.   We have now to
treat of those presentations in which the long diameter of the
foetus is opposed to the  short  or  transverse diameter of the
uterus.   These cases are termed Transverse or Cross births,
and include the presentation of the shoulder or some other part
of the superior extremity,  and the presentation  of any part of
the  dorsal or abdominal surfaces  of the child.  The most
important, and at the same time the most frequent, are those in
which  the shoulder, elbow,  or hand present, all of which  are
spoken of as  arm presentations.  To these cases we may chiefly
direct our attention, as the cases in which some portion of the
body presents are treated  according to the same  principles as
arm cases.
  In arm presentations, two principal positions are recog-
nized,  depending  on  the relations which exist  between  the
abdomen and dorsum of the foetus, and the back and abdomen
of the mother.   In the majority of transverse births, the back of
the child is directed towards the abdomen of the mother; in a
small proportion, the back of the foetus is towards the maternal
spine.   These varieties may be  termed the Dorso-anterior, and
Abdomino-anterior positions. They occur in the proportion of two
of the former to one of the latter. Besides the abdomino-anterior
and abdomino-posterior positions, there are four subsidiary varie-
ties in the position of the child in arm cases, depending on the
situation of the foetal head on the right or left side of the mother.
In the dorso-anterior position, the head may be on the  left side
of the mother, in which case the right shoulder or  arm is  the
presenting part; or it may be towards the right iliac fossa, when
                            27                      417 
418
VARIETIES OF ARM PRESENTATIONS.
the  left  upper  extremity  is  the  presenting  part.  In  the
abdomino-anterior positions, the  head  may be directed  to  the
Fis. lis.
Arm Presentation in the Dorso-anterior Position.
right or left side of the mother.  When it is to the left, the left
arm,  and when it  is to  the right, the right  arm of the foetus

                            Fie* 119,
Ann Presentation in the Abdomiro-anterlor Position. 
              DIAGNOSIS OF ARM  PRESENTATIONS.          419

presents.  As far as I am  aware, no observations have been
made to determine the relative frequency with which the child's
head lies to the right or left side in arm cases.  But this is pro-
bably a point of little importance, as the management is  the
same in all these variations of position.  Numerous complica-
tions are met with in transverse presentations.  Besides the pre-
sentation of any part of the body, the arm and head, both arms,
the funis and arm, or an arm  and foot, may descend  together.
Perhaps we scarcely ought to consider the descent of the arm
and head, or of  the hand  and foot,  as  strictly transverse
presentations, since it is a mixture of the transverse  and  the
cephalic or pelvic, and may terminate in the case  of the hand
and head, in cephalic, or in that of the hand and foot, in pelvic
delivery.
  There are no  distinct  signs of the  occurrence of transverse
presentation before the  commencement of labor which can be
depended on, though we know that in many of  these cases  the
preternatural position is assumed  some time  before the date of
labor.  In some  cases, the width of the uterus and abdomen is
noticeable; but  when this is the  case, it is  difficult to form  a
diagnosis between  the child lying in the transverse diameter of
the uterus and  twin  pregnancy.   In many  cases there is no
deformity in the shape of the uterus.  In some women, the sub-
jects of cross-births, uterine cramps and  spasms are complained
of; but in others nothing of this kind occurs, and labor comes on
slowly, and, one may almost say,  more insidiously than in other
cases.   Owing to the absence of the head from the os uteri, the
dilatation goes on more slowly and painlessly than  usual.  This
is a disadvantage, inasmuch as labor is hardly suspected, and the
accoucheur may not be sent for until considerable  progress  has
been made.   It often happens in transverse,  still more  than in
pelvic, presentations, that no part of the child can  be felt in an
examination  in  the  early  part of labor.  In arm cases,  it is
generally the shoulder which is  the primary presentation, the
arm and hand coming down as the labor progresses.  When the
shoulder presents, the transverse position of  the long  diameter
of the child frequently keeps it above the brim of the pelvis for
a considerable time after the commencement of the dilatation of
the os uteri.  When the arm or hand is felt, much care should
be taken to complete the examination, so as to ascertain whether
the hand is descending with the head, or whether the shoulder 
420 EARLY RECOGNITION  OF ARM PRESENTATIONS IMPERATIVE.

engages  the  pelvic  canal.   The  diagnosis of  arm cases is
frequently difficult, and we should not give a positive  opinion
until we can examine satisfactorily through the os uteri.  We
may sometimes suspect the nature of the  case  by examining
through the anterior wall  of the cervix, before the dilatation of
the os, but it is better under such circumstances never to give a
positive opinion.   The  diagnosis  between the breech and
shoulder, the knee and elbow, and the hand and  foot, has been
given in the last lecture, so that it  is  unnecessary to repeat it
here ; the chief difficulty is in the diagnosis between the elbow
and the knee, when both the leg and forearm are  bent upon the
thigh or arm.   In cases of doubt, it is best to bring the  hand or
foot gently down, when the difference between the  upper and
lower extremities can easily be made out.   No harm is done by
this manipulation, either in knee or elbow cases.   When  there
is a suspicion of arm or pelvic presentation, the patient should
never be left until the nature  of the  case is clear ;  but this is
particularly the case when the arm is the presenting part.   It
is, as we shall see, of the highest importance that arm presenta-
tions should be recognized as early as possible.  Perplexing
cases do however occur, in which the head presents, in  the first
instance, but is afterwards converted into a presentation of the
arm, in a manner to be referred to presently.  These  are cases of
deformity of the brim of the pelvis.
  The  canses of transverse presentations have  been  men-
tioned when treating of the natural attitude and position of the
foetus in utero, and the causes of pelvic presentations. [Also by
Dr. Barnes, page 435.]  The  arm may present because of the
death of the foetus ; obliquity  of the gravid uterus; contraction
of the pelvic  brim; violent  uterine  contractions; twins; and ■
excessive movements of the foetus itself.  These are  the princi-
pal sources of transverse presentations.  In the case of a dead
foetus, the loss of the adaptive movements of the  child  and the
alteration in the specific gravity of the head are evidently the
sources of the frequent pelvic and transverse presentations met
with in such cases.  In obliquity of the gravid uterus,  we can
easily understand that the  corresponding oblique position of the
foetus may  lead to the lodgment of the head above  the  brim
and its protrusion into the right or left iliac  fossa, while  the
shoulder descends.  We have  direct evidence that contraction
• 
ARM PRESENTATIONS WITH TWINS.
421
of the pelvic brim is a cause of arm presentation  in  cases in
which, with  slight pelvic deformity, the head presents  in the
first instance, but  the shoulder and  arm subsequently descend.
Cases of this kind  have often been met with several times suc-
cessively in the same patient.  In  these cases the head  cannot
easily enter  the brim; the  force of the uterine contractions
doubles the neck  of the child, and  the  shoulder, as a smaller
part than  the cranium, is urged  into the pelvis.  It is  highly
probable that irregular or violent contractions of the  uterus
before or at  the commencement of  labor may  cause shoulder
presentations.  This explanation  is  the  only  one apparently
applicable to cases which are met with in which, without pelvic
deformity, the same woman suffers in successive labors from the
presentation of the child's arm.  In these cases  excessive and
painful movements, which are evidently those of the uterus, are
complained of. No doubt in different women different degrees
of uterine excitability exists,  and we are obliged to look  to the
mother  for the cause, in cases of repeated mal-presentation.
Excessive movements of the  foetus, and great distension  of the
uterus with liquor amnii, so as  to deprive the foetus  of the
moulding infiuence of the normal ovoid uterus, are other  causes
of arm as of  pelvic presentations.  In twin cases, it frequently
happens that one child is delivered with cephalic presentation,
and the other with the breech or arm.   It sometimes occurs in
twin cases that both children descend with arm presentations.
  The following is a history of what generally occurs in arm
cases, when the pelvis is of average capacity, the child  living,
and of ordinary size, and when no  assistance is given:  The first
stage of labor, as already mentioned, is slow, and the pains are
inefficient until the shoulder  fully engages the os uteri.   After
the rupture of the membranes, which may occur at any time,
there is  usually a pause  in  the progress of labor.  The liquor
amnii is  quickly discharged, but some  time elapses before the
presenting part of  the child comes to exert full pressure  on the
os and cervix uteri.  When the shoulder and upper part  of the
body of the child  is  low in the pelvis before the escape  of the
liquor amnii, the pains  are at once  increased in  severity, and
tlie fruitless efforts at the  expulsion of the foetus soon become
dangerous  both to the child and  the mother.  The shoulder is
the point,  as it were, of a large  wedge, one side of which  is 
422
NATURAL DELIVERY ARM CASES.
formed  by the neck and head, and th'e other by the arm and
pelvis of the child.   Its passage through the pelvis in this posi-
tion is  impossible.  If the case proceeds, the pressure on the
foetus becomes immense, and its long continuance frequently
destroys the child by arrest of  the circulation  in the placenta
and funis, or mechanical compression of the body.   The danger
to the mother is very, great.   Either the vaginal discharges be-
come offensive, and inflammation and  sloughing of the parturi-
ent canal occurs; the woman dies of  exhaustion, worn out by
the long-continued struggle; or the uterus is ruptured, and she
perishes in this manner.   Probably, at the present time, a case
hardly occurs in which a patient suffering from arm-presentation
passes on to the extreme  catastrophe  without some assistance ;
but, when rupture of the uterus does not occur, cases are some-
times seen which have spread over several days.  It may be
said, that when the foetus is mature, and the pelvis of ordinary
size, death, both to the mother and foetus, is well-nigh inevitable,
in cases of arm-presentation, when no  assistance is given.  In
protracted arm cases, it frequently happens  that  the uterus is
exhausted by its exertions before the time of  delivery, and that
frightful post  partum haemorrhage occurs from atony of  the
uterus.
  But there are natural modes of delivery in certain  cases, and
under certain  conditions, in arm cases.   Denman found that
in cases  of this kind, when the pelvis  was large and the child
dead or premature, the long-continued efforts of the uterus
were sometimes equal to delivery without danger to the mother.
He observed that  in some cases the  arm and shoulder passed
above the pelvic brim during the continuance of the pains, and
the body and the  pelvis  came down, the child being delivered
by the breech.  This mode of delivery was termed by Denman
" Spontaneous Evolution," version, or turning,  and the ex-
planation of this great obstetrician was received by his  contem-
poraries.  After a time, however, the  explanation  of Denman
was called in  question by an accurate observer, Dr. Douglas,
of Dublin.   This physician observed  cases in which, the foetus
being immature or dead, and capable of doubling upon  itself,
the arm and shoulder remained down,  but became fixed against
the arch of the pubis.   The shoulder being fixed against  the
pubis, he observed the body and spine of the  child  to  become 
SPONTANEOUS EXPULSION.
423
bent, the nates to descend to the perinaeum, and the lower half
of the child to sweep down the sacrum and soft parts of tht»
Fid, 120.
Commencement of Spontaneous Expulsion.
parturient canal, until the breech and inferior extremities were
expelled.   The  other arm then  came down, and the head was

                           Fig. 121.
Further progress of Spontaneous Expulsion.
delivered as in breech cases.    Dr. Douglas termed this  ma-
noeuvre  " Spontaneous Expulsion," in contradistinction to the 
124       EXPULSION AND EVOLUTION, SPONTANEOUS.
" Spontaneous Evolution " of Denman.   Other  observers  cor-
roborated the explanation offered by Douglas, and Denman was
Fi& 122.
Termination of Spontaneous Expulsion.
supposed to have  been in error when he said that the arm re-
ceded before the descent,of the body and breech.  Later authors
have, however, ascertained  that both  Denman  and  Douglas
were right, and that in one class of cases the child is born in the
manner described without recession of the arm, while in another
the arm does not recede, but the shoulders become fixed to the
pubic arch, forming a ginglimus or hinge  in  this direction,
while  the  breech  and  body sweep down  the sacrum  and
perinaeum.   These terminations form, however, the rare excep-
tions in breech  cases, and  though it is necessary to understand
them, they must never be expected or waited for in the  manage-
ment  of  breech cases.   The preceding  engravings  illustrate
the process of  spontaneous  expulsion, which  occurs more fre-
quently than spontaneous version.
  The treatment of arm and shoulder presentations is  one
of the most important  within the range of obstetrics.  The  con-
duct of these  cases calls for all the knowledge  and judgment of
the accoucheur, as  his proceedings  must vary  considerably 
AID LN ARM PRESENTATIONS.
425
according to the stage of labor and the particular complica-
tion of each individual case.   It  may be said of all cases of
arm and shoulder presentation made out at the commencement of
labor,  that  every care should  be  taken  to preserve the liquor
amnii from discharge.  With this view, the necessary examina-
tions should be made as gently as  possible, taking care to exert
no pressure upon the membranes when they are made tense by
a pain.   The patient should be kept in the horizontal position,
and cautioned against  making efforts at  bearing down, either
during the pains, or in evacuating  the rectum or bladder.  In
cases where the shoulder presents alone, or where the arm hangs
in the vagina and the shoulder engages the os uteri, the  only
remedy when the child is alive  and at the full period, is the
operation of turning.  The earlier  this operation is  performed
the better, unless in cases where the child is so fully engaged in
the pelvis, or the uterine actions are so powerful, that means are
necessary to relax the  uterus, in order to  make  the operation
practicable,  and to avert as far as possible the danger of rupture
of the uterus, or  inflammation of the  parturient canal.  When
the hand and head present together, no great effort at putting
up the arm or hand should be made, if the head has not fairly
entered the pelvis, as by so doing the head may be pushed aside
above the brim, and the case converted into one of  purely arm
and shoulder presentation.   The arm and head form a less for-
midable complication than the conversion of such cases into the
descent of the shoulder, as the hand and head may be delivered
together with safety to mother and child.  When the hand and
head have entered the pelvis,  and present at the os uteri, the
hand may sometimes be passed up by the side of the head, in
an interval between two pains, and if kept above the head until
the pain comes  on, it is  swept above the brim, and the head
descends alone.   When the foetus is unmistakably dead, and the
shoulder or  arm and  shoulder present, the operation of  turning
should be avoided, if possible,  on account of the  danger the
mother  incurs by its performance.  When the foetus is prema-
ture and putrid, it may be brought down, as Dr. Joseph Clarke
first suggested, by hooking the crotchet upon the pelvis.   When
the child is dead, but at the full term, and firmly wedged in the
pelvis, the best practice is to eviscerate the chest and abdomen,
and then to bring down the pelvis of the  foetus by the crotchet. 
426
TURNING IN ARM PRESENTATIONS.
In the case of dead children at the full term, when  the  case is
made out early in labor, turning is an easier operation, and less
troublesome and dangerous to the mother,  than protraction of
the case, and evisceration  and extraction.   In rare cases, when
the pelvis  is very capacious, and the  action  of  the  uterus
powerful, and the foetus small,  or dead, or premature, the accou-
cheur may  sometimes be  called, when, the shoulder and arm
being felt at the pubis, the ribs and body of the child occupying
the lower part of  the pelvis and pressing upon the perinaeum,
and some advance of this part of the child occurring at  each
pain, it is evident that the spontaneous expulsion of Douglas will
terminate the delivery.   Sometimes this spontaneous expulsion
of the child takes place with great rapidity.  I was once sum-
moned to turn a child, at no great distance from my own house,
but before I arrived the  woman had been delivered spontane-
ously.  In  rarer  cases  the  arm and  shoulder will ascend, and
the nates come down, under the influence of the pains, as in the
spontaneous version or evolution of Denman.  As  regards the
great and most common procedure necessary in transverse pre-
sentations—namely, turning, the circumstances of the operation
are very much varied, according as the amnion is ruptured  or
not; or the  presenting part high or low in the pelvis; and the
length of time which has elapsed in these cases between the com-
mencement of labor and the performance of the operation. In
transverse cases, auscultation of the fcetal heart is imperative,
as upon the life or death of the child may depend the alterna-
tive of evisceration or  turning.   In  many  arm  and shoulder
cases, the child has been dead for some time before the com-
mencement of labor, and the cuticle is falling off or the limb is
putrid.  In others, a loop of funis is down with the arm, and its
pulseless and flaccid state  informs us of the death of the foetus.
The peculiarities  incident to  turning in transverse  cases under
every variety of circumstance will have  to be considered when
we come to the operative part of the present course.   It  may be
mentioned, that when the arm presents in the case of the second
child in twin cases, the  same treatment  is  to be  followed as
though a single child had presented with the arm.  The opera-
tion of turning is generally easy in such cases from the smallness
of the child and the dilatation of the passages.   No  doubt in
arm cases the easiest and the most difficult  conditions  for the 
STATISTICS OF ARM PRESENTATIONS.
427
operation of turning are met with.  In a case where the liquor
amnii remains undischarged, and the arm is found at the  os
uteri, the foetus is  moved as  easily as a boat in water, the hand
of the accoucheur can be introduced with comparative ease, and
turning is a simple operation.   But when the patient has been
in labor, and the liquor amnii discharged, it may be for twenty-
four, forty-eight,  or more hours, the  shoulder is jammed into
the pelvis, and held as if in  a vice.   It is  most difficult either
to introduce the hand, or to move the child, and turning is one
of the most  difficult, if not the most difficult, operation  in
obstetrics.   The  mortality to the mother and the child, but
particularly the child, under  these circumstances, is very great.
Dr. Lee, in his " Clinical Midwifery,"  relates fifty-nine cases, and
records the death of the  mother in eleven, and the death of the
child in thirty-two cases.  These cases were  amongst the most
severe that could be met with in consultation practice; and such
results should imprint upon accoucheurs  the necessity of  an
early diagnosis, and prompt action in this form of dystocia.  Dr.
Fleetwood Churchill has  collected the statistics of 112,140 cases,
in which the superior extremities presented  484 times, or, taking
the average, once  in  231f cases.  In 242 cases of presentation
in which the results to the mother and child were recorded, 127
children were lost, or rather more than 1  in 2,  and 26 mothers
died, or about 1 in 9.   All statistics  tend  to show  that in this
complication, more  than in any other, danger both to the
mother and  child  increases  with the  prolonged duration  of
labor. 
LECTURE  XXIX.
             PLACENTAL  PRESENTATION.

  Gentlemen :—In  the  present Course of Lectures I  have not
attempted to make any rigorous classification of the varieties of
difficult or  complicated parturition.   The subject  does not,
indeed, admit of arbitrary arrangement.   My object has been
not to abandon method entirely, but to group similar conditions
of labor together, so that mutual light may  extend  from one
subject to another, by successively treating of  those normal and
morbid  states which possess  certain points   of  resemblance.
Nothing can  be  more natural than to group together the dif-
ferent modes in which the foetus presents and passes through the
pelvis.  But we now come to the subject of Placenta Praevia,
which is related both to  the varieties of presentation, and in  its
most dangerous symptom, to the different forms of haemorrhage.
Still, as it is undoubtedly one  of the forms of presentation, and
as its  attendant haemorrhage is peculiar  and in many respects
distinct from ordinary flooding before or  after delivery, I have
preferred to consider it at the present time, after having treated
of the different  forms of presentation belonging to the head,
trunk and extremities of the foetus.
  The placenta may be  attached over the whole of the  os and
cervix uteri, or it may be implanted over  some part of the mar-
gin of the os, so  as  only partially to occupy the aperture.  The
causes of placenta praevia have not been determined.   It is pro-
bably produced by the impregnation of the ovum after it has
descended to the upper part of the cervix uteri, this  beino- the
last point at which the ovum retains its capability of impregna-
tion and attachment to the uterine surface.   The placenta may
be attached to any part of the  body of the  uterus  between the
cervix and the fundus, but unless it encroaches upon that part
of the cervix concerned  in the development  of the lower seg- 
CAUSE OF PLACENTA PREVIA.
429
ment of the uterus, or the dilatation of the uterine aperture at
parturition, no ill consequences ensue.
  Up to the fifth month, the development of the ovum proceeds
in the ordinary manner  in placenta praevia, and if abortion
occurs before this time there is nothing which indicates the site
of the placenta.   After this  date the development of the cervix
proceeds, and, in its expansion, partial separation of the placen-
ta from its attachment  is prone to occur.   This  separation is
attended by the frightful and sudden haemorrhages which char-
acterize placental presentations.  The irritation of the uterus by
the  placental attachment to  the  cervix, and the  separation
which occur, often  lead to abortion or  to delivery  before the
natural term in these cases.    Sometimes patients  go on  to the
full  term when  suffering  from this  complication, without the
occurrence of haemorrhage before the commencement of labor.
  The symptoms of  placenta previa are sufficiently distinc-
tive.   Occasional haemorrhage occurs,  generally between the
seventh month and  the end of gestation.  The discharge com-
monly takes place suddenly,  without  pain, and ceases  after
a while, or the drain may continue for a  considerable  time.
The nearer the patient is to the full term, the more violent is the
loss  of blood.  The gush may  take place after some exertion, or
when the patient is following  her usual avocations, or when she
is asleep.   The  loss is  sometimes  so sudden and  so enormous,
that  the woman is dead before the medical attendant can be
summoned.  Generally, there  are several sudden losses to a less
extent, before the advent of labor.   Flooding may recur at vari-
able  intervals, of a few days,  a week, a fortnight, or it  may
break out at the dates of the catamenial periods.  Placental
presentation should always be  suspected, whenever haemorrhage
occurs in the latter part of pregnancy.   Sometimes labor comes
after the discharge;  at others, there are no traces of uterine
action until after several attacks of flooding.   There are no sen-
sations belonging to the patient herself  which indicate malposi-
tion of the placenta, but  the uterine soufflet is heard in these
cases with  most  distinctness in one of  the iliac regions, or the
hypogastrium.   When we  examine internally, if the os uteri
has dilated, the soft mass of the placenta can be  felt between
the finger and the presenting  part of the child.  The soft pla-
centary layer may be felt in  the entire field of the  os uteri, or 
430
HEMORRHAGE OF PLACENTA rRJEVIA.
occupying only one margin of the os.  If the flooding has been
very  severe, a portion  of  the  placenta, or the greater part of
the organ may be  felt protruding through the os uteri.   When
the os is quite  closed,  the placenta can sometimes  be  distin-
guished through the walls of  the  expanded cervix, particularly
if the head presents, and the placenta lies between the finger and
the foetal cranium.  In the case of breech or  shoulder presenta-
tion, the detection of the placenta is more difficult.  If the os
uteri should be so high up in a case of suspected placental pre-
sentation, as to  be beyond the reach of the finger, the whole
hand should be carefully passed into the vagina, so as to enable
us to reach the os and make the necessary examination.   Fatal
results have often happened from inattention to this point.   There
is hardly any other critical emergency in midwifery in which an
early  diagnosis and prompt treatment  are of such importance.
The separation of the placenta  may be small in extent, or the
whole or nearly the whole of the organ may be detached.  What
usually  happens is, that  at  each recurrence of haemorrhage,
small  portions of the placenta are detached, up  to the time of
labor.  Before the commencement of labor, and when no symp-
toms of abortion are present, the cause of  detachment is the
developmental expansion of the cervix uteri; but when labor
has set in, the active dilatation of the os and  cervix effects the
placental separation.  The most violent and dangerous cases are
those in which little or no haemorrhage occurs unto the full term,
when  sudden and extensive detachment takes place, the utero-
placental vessels having reached their full development.  The
woman may, under these circumstances, be deluged with blood,
and reduced to the utmost extremity of danger in a few minutes.
Where partial and repeated  separations occur, the uterine ves-
sels which have been laid open contract, and the blood coagu-
lates in that part  of the placenta which has been separated.
This process may be repeated  several times before the coming-on
of labor, and while the placenta is only partially attached over
the os uteri.  In rare cases it  happens that the whole of the cer-
vical portion of the placenta  is  detached in  this manner, and
little or no haemorrhage occurs at the time of labor.   In 'other
cases of partial placental presentation the  cervical portion of
the placenta is completely detached at the time of labor and no
serious haemorrhage occurs after the first outbreak.  Still more 
TRUST TO NATURE IN PLACENTA PRJEYIA.         431
rarely, when the uterine action is very powerful, the pelvis capa-
cious, the foetus small or of moderate size, and the patient mul-
Fro, 123.
                      Entire placenta prcevia.

tiparous, the whole of the  placenta is detached, and the foetus
and membranes expelled with such rapidity that no dangerous
loss occurs.   These cases have  led  some to imagine that in
entire placenta praevia, Nature may be trusted more than she is.
But the conditions are so unfavorable to the safety of the patient,
that such reliance is worse than on a broken reed.  This conjunc-
ture offers no place for a Fabian plan of treatment.  To wait, is
generally to kill.  In case of placenta praevia we  have the cir-
cumference of the os and cervix studded with  large vessels, the
mouths  of  which  gape widely open as  the placenta separates
and the  os  and  cervix dilate.  And this separation  and dilata-
tion must occur.  There is no escape from them and the slow and
gradual  way in which  the  preparation for the exit of the foetus
is  generally made, and which in  ordinary cases tends so much
to the safety of mother and  child, is here their destruction.   The
haemorrhage  in cases of placenta praevia has been called " un-
avoidable "  haemorrhage,  by way  of distinguishing  it  from 
432
MATERIALS FOR PLUGGING THE VAGINA.
   haemorrhage from  the fundus uteri  occurring  before  labor,
   which has been  termed " accidental."  In the one case separa-
   tion and haemorrhage may, in the other they must, occur before
   the completion of delivery.
     The chief  methods of treatment followed in cases of
   placenta praevia are—1. The  use  of the  plug,  or tampon.
   2. Puncturing the  membranes.   3. Turning the child. 4.  The
   partial or the entire separation and extraction of the placenta.
   I propose to point out in detail the cases and conditions in
   which these several modes of practice are applicable.
     Plugging the vagina is  adapted to cases in which,  after
   the first loss, a continuous drain, varied  by slight eruptions of
   blood, is going on, particularly when this occurs at the sixth or
   seventh month.  By plugging the vagina with  moderate force,
   the lower segment of the uterus is compressed between the plug
   and the contents of the uterus, and an impediment is  offered to
•  the escape of blood, and  coagulation of the blood effused is
   promoted.   Care must  be  taken that the plugging  be not too
   forcible,  otherwise  uterine contraction  and further separation
   may be excited by the  irritation of the plug.  The best methods
   of plugging the vagina are by introducing strips of lint, pieces
   of sponge, or a silk handkerchief, dipped in vinegar and water,
   or iced water.  Pieces of ice, wrapped  in lint  may be  intro-
   duced.  There  is   a  great advantage  in the  sponge-plug—
   namely,  in its expansion  from  absorbing the   blood, or  the
   secretions of the  vagina.  But this is, to a great extent, counter-
   balanced by the  rapidity with which sponge,  from  the animal
   matter it contains, becomes foetid  in the vagina.   It  cannot, on
   this account, be allowed to remain in  the passage more than a
   few hours.   It is, therefore, the  best  temporary plug, but  it is
   not adapted to cases in  which  continuous  plugging  is required.
   [The colpeurynter, already alluded to on page 180, should not be
   forgotten as affording  speedier and more efficient  relief than
   any other form of plug, and moreover, may be easily withdrawn
   and replaced  as,   required.]  As an ordinary plug, nothing
   exceeds in utility strips of lint,  introduced one after another
   until the vagina  is filled up.   Even in plugging with  lint or a
   silk handkerchief, the plug requires to be changed from time to
   time, as, whatever the plug, the retained blood and discharges, to
   which air is necessarily admitted, have a tendency to become 
              TREATMENT OF PLACENTA PREVIA.           433

rapidly  foetid.  Whatever  the  treatment  adopted in placenta
praevia, one precaution should  always be adopted—namely to
keep the patient in the horizontal position, with the pelvis some-
what raised.  The temperature  of the room should be cool and
equable, and the diet light and  unstimulating, except when the
patient  is suffering from the  direct effects of loss  of blood.
Under these circumstances, brandy, ammonia, and beef-tea may
be administered  freely.  I do not believe that in unavoidable
haemorrhage, internal astringents, such as gallic acid or the ace-
tate of lead, are  of more than the slightest  use, and they tend
to divert the attention of the practitioner from more important
measures.   With  this exception, the treatment of placenta
praevia in the fifth or sixth month, when the os uteri is undilated,
and the flooding not dangerous in extent, is hardly distinguish-
able from flooding in  ordinary abortions.  When haemorrhage
has once occurred, the  patient should  be kept as quiet as
possible, lest a  further separation should be produced.
   Puncturing  the membranes and  evacuating  the liquor
amnii in placenta praevia is a practice of very ancient date.  It
is occasionally useful, and is  adapted for cases  in which the
haemorrhage is not of the most alarming  character,  where the
os uteri is either closed or only  dilated to a slight  extent, where
the pains of labor have already commenced, or where it is con-
sidered advisable  to induce  premature labor in  this  manner,
where the liquor amnii is in  large quantity, where  turning is
impossible,  and  where the child  being  alive, it is judged best
not to attempt the separation of the placenta.  This operation
is preferred in cases of partial attachment of the placenta over
the os,  where  the membranes can be ruptured either by the fin-
ger, or  a probe or trocar at the  part free from  placenta ;  but it
has sometimes been performed with the effect of arresting the
haemorrhage, through the placental mass in cases of complete
attachment over the os uteri.  Puncturing  the membranes in
placenta praevia does not arrest flooding simply from  diminish-
ing the size of the uterus and exciting contraction, but by les-
sening its size and vascular supply, and bringing down the head
or presenting part of the child,  so as to act as a plug to the pla-
cental site.  The disadvantages of puncturing the membranes
are, that turning is thereby rendered difficult,  and the risk of
sacrificing the child is increased.  In cases  where the labor is
                             28 
WHEN TURNING IS PROPER IN PLACENTA PREVIA.
premature, and  the child non-viable,  these  objections do not
apply at all; nor in cases where the child is dead, as craniotomy
could then be performed.  It is, however, questionable whether
in these cases the extraction of the placenta should not be pre-
ferred.
  In my opinion, turning is the great operation in  placenta
praevia, when the child is living and viable—that which, if per-
formed at the proper time, affords the greatest chances of safety
both to the mother and the child.  But there are circumstances
in which  turning is the best practice when  the safety of the
mother alone is concerned, the child being already dead.   The
conditions favorable to turning are, a dilated  or dilatable state
of the os uteri, the retention of the liquor amnii or a moderately
relaxed state  of  the uterus, a pelvis  of average capacity, the
absence of dangerous  exhaustion, or a temporary cessation of
the haemorrhage.   If the placenta be attached to one side of
the uterus, the hand should be introduced on the side opposite
to the placental site; or if it extends over  the whole os, the
hand should be passed in the direction in which the attachment
is least considerable, or when the separation  has already taken
place.   The advantages of turning are, that without materially
increasing the danger of the patient, and in a very short space
of time, the feet and body of the child may be brought down
so as to act as a  tolerably efficient plug  to  the os and  cervix  ^
uteri.  During the early part of the  operation, the  hand and
arm of the accoucheur form a tampon.  Turning is generally
easy  in placenta  praevia,   at  the  full term, as  compared
with  other cases in which it is  required, because  the  con-
tractions of the uterus  are commonly less powerful than usual.
The flooding itself tends to dilate  the  os uteri, and  to weaken
uterine action.  It  is, therefore, a less severe operation to  the
mother than in many other cases in which it is called for.  This
is particularly the case in multiparous  women.  As regards the
state of  the  uterus, primiparous  women,  as  in  other  cases
requiring turning,  offer greater  difficulties  than women  who
have borne children.   When  the  operation  of turnino- is per-
formed early, the proportion  of mothers saved is large, and  a   ■
considerable  number  of  children  are born  alive.   Turnino-
should always be performed in placenta praevia, when it is coi>
sidered advisable, the instant the operation is rendered practica- 
DECISION IN PLACENTA PREVIA.
435
ble by the condition of the os and cervix uteri.   In cases where
the os uteri has been dilated for  many hours, sufficiently to
admit of turning, and blood or strength has been lost in the
interim, we  should blame, not the operation, but the delay, for
a great proportion of the fatality to the  mother and  child.  In
some cases of partial placental presentation, the head may  be so
low that the use of the forceps will be preferable to turning; or
this operation may become necessary after the spontaneous or
artificial expulsion of the placenta.   In other cases, as when the
head is low, and the child dead, or when the pelvis is deformed,
craniotomy may be called for.  Dr. Radford has advised the use
of electricity, in connection with the other methods of treatment
in these cases.
   [Perhaps the greatest element requisite for an accoucheur is
decision.   He should  be able to recognize what is possible and
what  impracticable, particularly in the form  of trouble here
under consideration, he should early know what he can do, and
what he cannot effect.   In  a case to which I was recently called
in consultation, the woman had haemorrhage for some twenty
hours continuously, beside  haemorrhages a  month, two weeks,
and a week  previously.   She was reduced to so low an ebb that
I questioned if she  could survive the loss of a single wine-glass
full more of  blood.   I  dared not venture the  dangers  from
delay,  and fresh haemorrhage consequent upon turning, but the
os not being dilated  so as  to use forceps, being two inches in
diameter, I  perforated  the head  and delivered with  great
rapidity, without the loss of a drop  of blood, and saved a beau-
tiful young lady from "the grave, whither it was supposed by her
attending physicians she was inevitably doomed.  In a similar
case, in the care of a gentleman who found fault with this opera-
tion, by attempting too much  to save  an already ex-sanguine
child, after thrice failing to deliver w.ith the forceps, then  turn-
ing, and finally  opening  the  head of the child to effect its
delivery, operations lasting more than  half an  hour with still
continuing haemorrhage, the mother died in ten  minutes after.]
   I have now  to refer  to the artificial extraction  of the
placenta before the birth of the  child, which has certainly
been one  of the  most prominent  points  in  obstetric  practice
during the last ten or twelve years.   It is one the settlement of
which is of great interest, as nothing  can be more unsafe than 
  436         SIMFSON ON DETACHING THE PLACENTA.

  halting between two opinions upon such a subject.  From  an
  early period, it had been remarked by accoucheurs that cases of
  unavoidable haemorrhage were occasionally met with, in which
  the placenta was expelled spontaneously before the birth of the
  child, and that the haemorrhage was arrested by the separation
  of the placenta.  The first person who  seemed to have pointed
  out the deduction of a rule of practice from such cases was Mr.
  Chapman, of Ampthill.  The  placenta  was removed in some
  cases of placenta praevia, by Mr. Kinder Wood, of Manchester,
  and subsequently by Dr. Radford.  Probably, cases have always
  occurred in which accoucheurs, finding the placenta loose in the
  vagina,  or  almost  entirely detached, have  removed it.   Dr.
  Simpson took up this subject in 1844, and, with his usual ability
  and force, pointed out what he considers the  advantages of this
  operation,  the principles  upon  which it is and  the cases  to
  which  it is applicable.  The  tenor of Dr. Simpson's earlier
  writings was such as to lead  to  the belief  that he wished  to
  supersede  in great measure the  operation of turning, by the
  separation and extraction of the placenta.  This impression has
v continued  to a great extent up to the present time, and  it is
  upon this impression chiefly that its opponents have attacked
  and denounced the operation.  In one of his latest publications
  on the subject, in The  Lancet, 1847, vol. i., he  has corrected
  this,  and insists upon the limitation of  the extraction of the
  placenta  to  cases  " when the  other   recognized  modes  of
  management were  insufficient  or unsafe, or altogether impos-
  sible of application,"  or when the old methods of practice
  " were attended by extreme hazard or extreme difficulty."  Dr.
  Simpson combined with his advocacy of this practice an exposi-
  tion  of his views as  to  the source of the haemorrhage in pla-
  centa praevia, which met with great opposition.   Dr. Hamilton
  advocated the doctrine that the haemorrhage in placenta praevia
  " proceeds from the separated portion of the placenta more than
  from the ruptured uterine vessels."   Dr. Simpson indorses this
  view to the full extent, and I suspect it is this, as  much  as the
  rule of practice itself, which has  excited the opposition which
  has been manifested.  According to this  hypothesis  the  blood
  lost in separation of the placenta flows from the placental cells
  the supply to these cells being kept up by vessels supply in o- the
■  undetached  portion  of  placenta.  It is  supposed that as the 
      SOURCE  of the hemorrhage of placenta previa.   437

separation proceeds, the veins of the uterine surface from which
the placenta is detached, are closed so as to prevent any retro-
gressive haemorrhage from the uterus.
  Dr. Simpson's theory of the source of the haemorrhage, upon
which he to  some extent rests his  practice of separating the
placenta, is, I believe, altogether  untenable.  No proofs of the
escape of  the  great quantities of blood lost in these  cases, from
the placental surface, can be  given.   The theory mainly rests
upon the  anatomical arrangement of the uterine arteries, the
placental  cells, and the  openings upon the  placental  surface.
No doubt there is an unobstructed channel for the flow of blood
from the  curling arteries, through the placental  cells  and the
openings found upon the placental surface, when this has been
separated from the uterus.  But there are, as  it appears to me,
valid reasons why we should believe that the sudden and great
gushes of  blood poured out in placenta praevia do not escape in
this way.  The uterine arteries are of comparatively small cali- t
bre,  and the  openings upon the placental surface are  neither
large nor numerous.  Supposing one-half of the placenta to be
detached, it is highly improbable, I  should  almost  say impos-
sible, that the profuse loss frequently met with in  these cases
could come from the uterine arteries entering the undetached
portion of the placenta, even if they were all discharging blood
simultaneously.  In the  cases of profuse loss which sometimes
occur, when only a small portion of the placenta is detached, it
is equally difficult to suppose that the blood could escape from
the  openings  met  with on a square  inch of placental  surface.
There are, on  the other hand, valid reasons for believing  that
the uterine veins are the real sources of haemorrhage in placenta v
praevia.  The size of the venous openings, the valveless  state of
the uterine veins, the channel being unimpeded from the right
auricle  to the open mouths of the sinuses, furnish anatomical
arguments in favor of this  source for the flow of blood which  are
stronger than those  derived from the anatomical arrangement of
the uterine  arteries, and the placental sinuses, in  favor of  the
opposite view.  Then we have the  facts connected  with post-
partum  haemorrhages.   The only haemorrhages comparable for
suddenness and extent to the losses in  placenta praevia are those  ,
which  occur after labor, and  the  expulsion of the placenta, in
cases where it has  been  attached to  the  fundus  uteri.  Here 
 438   is  the bleeding from  the placenta or  uterus ?

there can  be no question but  that the haemorrhage takes place
from the open mouths of the uterine veins. I have not observed
any difference in the color or character of the blood in post-par-
tum haemorrhages and those caused by  placental presentation,
and the weight of  evidence  is in favor of the venous character
of the blood lost in placenta praevia.  It  is noticed  that in this
form of flooding the  loss is increased during the pains, as it is
believed, by  the  enlargement of the  uterine  openings by  the
dilatation  of the  os and cervix  uteri, whereas, in haemorrhage /
from the  fundus, the  flow of blood is arrested during the con-
tinuance of pain and contraction.  When the separated portions
of placenta  have been examined, it has  been found that  the
sinuses and cells have been filled with  coagulated  blood.  In
some cases,  in which the placenta has been  detached and ex-
pelled artificially  or spontaneously, flooding has occurred after
the expulsion of  the placenta.  Here the blood must have been
in great part from the uterine  veins, yet the flooding presents
no difference to that occurring from the partial separation of the
placenta.  The inference from all these facts appears to be, that
in the haemorrhage from placenta praevia the  blood  escapes in
great part from the uterine  surface, and  not from the maternal ^
surface of the placenta.   There can be  little doubt that some
blood must  exude from the surface of the placenta in cases of
partial separation, whether the placenta  be attached to the fun-
dus or cervix; but I contend  that this is not the chief source of
flooding in placenta praevia.
  While I thus take exception to Dr. Simpson's theory of  the
nature of haemorrhage in placenta praevia, I do not question the
correctness of the fact upon  which he  lays  so  much stress-
namely, the frequent,  and indeed common," arrest of the haemor- j
rhage on the entire detachment of the placenta.   Dr. Simpson's
theory does  not appear to me to  be necessary to the explanation
of this matter.    In my work " On Parturition," I pointed  out
that tlie separation of the placenta furnishes a source of irrita-
tion which excites the uterus generally, and the muscular  strue- "
hire at  the  site of  the placenta especially,  to contraction  and
that in this way haemorrhage was prevented.   This is probably
the  reason   why, in  twins   with separate placentae, there is
frequently no haemorrhage between the expulsion of the first
placenta and the birth of the second child.   It is reasonable to 
            EXTRACTION OF THE PLACENTA  ADVISED.        439

suppose that the same thing occurs in placenta praevia, after the
separation and extraction of the placenta, in the intervals which
occur  between the pains.   The tendency to haemorrhage from
dilatation of  the  orifices  of  the veins  during the pains  is is
corrected by  the  descent  of the head  or  presenting part, and
mechanical  compression of the uterine walls.
  Dr. Simpson unequivocally demonstrates that in a great num-
ber of cases recorded by various authors, both before and since
the publication of his  views, the placenta has been detached
and the haemorrhage arrested.   There can, indeed, be no ques-
tion upon this point.  Those most opposed to Dr. Simpson, Dr.
Robert Lee, for instance, record cases in which the haemorrhage
ceased after the  spontaneous expulsion of the placenta.  The
cases  to which, in his most recent writings, Dr. Simpson would
advise separation and extraction, are those  in which the evacua-
tion of the  liquor amnii is of no avail, when  the state of the  j
patient is such as to call for interference, but where turning,  or
other  measures of  delivery, are  impracticable,  from rigidity,  or
non-development of  the os and cervix uteri, or distortion of the *"
pelvis.  He would also employ it in the  case of dead,  prema-
ture, or non-viable children, particularly when the  uterus has
contracted, or is  so  imperfectly developed as not to admit  of
turning.   It is questionable if rigidity can be  a valid  plea for
this operation, except in very rare cases.   When the os uteri is
sufficiently open to allow of the  admission of the fingers for the
purpose of separating the  entire  placenta, there will generally
be room  enough for the admission of the hand.   I  believe the
separation and extraction of the entire placenta the best practice
in those cases in which  it is attached all round  the os uteri, and
in which the exhaustion is  so great as to render some more rapid  ,
attempt at assistance than  the operation of turning imperative.
In some of these cases the patients would be killed by turning, if
the haemorrhage were going on simultaneously with the operation.
  The extraction  of the placenta  offers a means of arresting
haemorrhage, and after  a short  rest the patient may be  suffi-
ciently rallied to bear turning ; for it must be remembered, that
in many of  the cases in which the placenta has been extracted ^
artificially, turning has been necessary to complete the delivery.
In all cases where the child is alive and viable, delivery  should
be effected,  by turning  or  the forceps, as soon as possible after 
440
STATISTICS  OF PLACENTAL EXTRACTION.
    the extraction of the placenta, if the state of the patient is such
    as to bear the operation.   Extraction  may be sometimes useful
    in cases where turning is  impossible,  as in cases of contraction
    of the uterus or pelvic  deformity, and when the removal of the
    placenta  may  arrest haemorrhage and facilitate the  operations
    of turning,  craniotomy, or evisceration.   It may also be prac-
    tised in some  cases of  dead or  premature children, when the
    haemorrhage is going on, and turning is difficult from any cause.
    When the flooding is not profuse, and  when the uterus is roomy
    and the waters undischarged, the extraction of the placenta be-
    fore the child offers no great advantage.  The whole subject has
    been ably handled by Dr.  Chowne, and Dr. Fleetwood Church-
    hill gives a very candid exposition  of the disadvantages of the
    operation.
      It is necessary to refer to the statistical arguments which have
    been advanced in favor of the operation.  Dr.  Simpson has
    given a table of 654 cases, collated  from various  authors, from
    Mauri ceau to the present day, in which the treatment consisted
    of  turning,  etc., the child being extracted before the placenta.
    This he contrasts with another table  of 141  cases, in which the
    placenta was removed or expelled before the child.  In the 654
    cases, 180 mothers, or 1 in ST%, were lost.   In the 141 cases, the
    maternal mortality was 10, or only one in 14, which apparently
    gives a very large balance in favor of  the extraction of the pla-
    centa before the child.   But it has  been argued by Dr. Barnes
    that we cannot fairly suppose cases  in which the placenta  is
j   extracted artificially will prove as favorable as those in which it
    has been detached and expelled without assistance.   The cases
    in which the placenta is expelled by  the natural efforts are those
    in which the pains  are powerful, the  placenta being expelled
    suddenly and the child speedily born.   In the case of artificial
    detachment and extraction, no assistance from the uterus can be
  <-  reckoned on.   The difference is  very  great  between the spon-
    taneous separation and  expulsion and  the artificial detachment
    and extraction of  the placenta.   The published cases of extrac-
    tion of the placenta are too few to found upon them any precise
    conclusions; and it must also be remembered that the advocates
    of any novel mode of practice are more prone  to  publish  snc-
  >  cessful than unsuccessful cases.   The  statistics of Dr. Radford
    of cases  in which the  placenta was removed  by the hand are 
           SPONTANEOUS EXPULSION OF  THE PLACENTA.      441

not so favorable, as regards the mother, as those of Dr. Simp-
son.
  By the ordinary methods of practice, rather more than half  "
the children are  lost; and Dr. Simpson  attempts to show that
the mortality is scarcely more than this when the  placenta was
extracted before  the child.  He gives a table of 141 cases: of
these the child was saved in 33 cases ; in 79 cases it was born
dead ; in 1 the  child was  anencephalous, and died shortly after
birth  ; in 28 cases, the result,  as regards  the child,  was not
stated.  But such a state of mortality cannot be hoped for from
artificial extraction.  In many of  the  cases of spontaneous ex-
pulsion, the foetus,  membranes, and  placenta are  expelled  by
the same pain.   Dr. Simpson, as  Dr.  Fleetwood Churchill  .
observes, has only  recorded one case of the child  being born
alive  when the  interval after  the removal of the placenta was  t
more  than ten minutes.  Dr. West collected 17 cases; but in 16
of them the children were  lost.  If this  frightful rate of foetal
mortality should be preserved, it must go  far to prevent the
adoption of extraction in any but the most unpromising cases.
  In 1S47, Dr.  Barnes enunciated the principle, that a partial
separation of the  placenta might, in certain cases, be sufficient
to arrest the haemorrhage, and at the same time afford a chance
of safety to the child.  In a recent paper on this important sub-
ject, an  abstract of which was published in The  Lancet in
January 1858, Dr. Barnes recommends a partial detachment of
the placenta in  cases where it is partially attached to the cervix,
or  where  it is implanted  in  its  whole  circumference.  His
method is to detach that portion of the placenta attached to the  -
cervix,  after which he believes that  no further separation  is
produced by the uterine  pains, and the haemorrhage  entirely
ceases.  The portion of the placenta attached above the cervix
is left, and  remains as a  medium for  the supply of the foetus.
Dr. Barnes has  collected a large amount of clinical facts and ex-
perience bearing upon this subject, [which he  has published
since  these lectures  were delivered, and may be found in extenso
in the London  Lancet reprint  for Sept.,  Oct., Nov.  and Dec.
1857.]  Nothing could be more valuable than the establishment
of a mode of practice which should  diminish the danger to the
mother, and increase the chance of safety to the child.   In Ger-
many, several  physicians  have  done Dr.  Barnes  the  honor to 
442             DANGERS OF PLACENTA  PREVIA.

claim and contend for originality in advancing  the
the  partial  separation of the  placenta;  but there
Fi&. 124=.
 Varieties of placental attachment. E, E, Fundal Placenta. D, D, Lateral Placenta. P, F, C, B,
Latero-cervical Placenta.  A, B, B, F, Seat of cervico-orificial, or central Placenta.  A, E, Line of
boundary between normal and previal placental attachment, and consequently of spontaneous
placental detachment, during expansion of cervix.

doubt the  principle was  clearly expressed  by him nearly  ten
years  ago.   The preceding engraving, executed from a drawing
by Dr. Barnes, indicates  the  various positions in  which  the
placenta may be  attached.  (Fig. 124.)
   The danger as regards the mother, in placenta praevia, arises
chiefly from the direct or secondary effects of loss of blood, and
from  injuries done  to the  passages by operative  proceedings.
Dr. Tyler, of Dublin, has related  a case, in which  traumatic   \J
tetanus  followed  upon placenta praevia.   Uterine  phlebitis is
frequently met with  after placenta praevia  in cases where the
patient  survives  delivery.   Out  of sixty-four cases,  Dr.  Lee
records that  phlebitis occurred  in  six   cases.  As  phlebitis 
BARNES  ON PLACENTA PREVIA.
443
occurs in cases where turning has not been performed, or where
the operation gave  little or  no pain,  it is  probable that the
disease of the veins may be caused by their being bathed in the
uterine discharges  as they pass the os  and  cervix uteri.  The
special dangers to the child arise from asphyxia, the result of
the flooding, or pressure on the cord in  turning, etc.

  [The opinions of Dr. Barnes, which are in  the papers already
alluded to, fully enunciated and fortified by cases which tend
to sustain his position, are substantially  as follows.  As they are
so important in their  claims,  they  are here given quite  in
extenso, and as nearly as possible in his own words:
  If we watch attentively a case of labor in which the placenta
presents—I  mean of course such a case as admits of simple watch-
ing, that does not call for obstetric interference—we shall observe
that as soon as the longitudinal muscular fibres of  the womb
have  begun to contract so as to pull back the lower segment
from the central point represented  by the os uteri  internum, a
certain amount  of  detachment  of the  placenta from the  part
nearest to  the os takes place ;  owing to the periodical and
sudden nature of the  uterine contraction, this detachment is
also sudden; the sudden detachment is attended by a sudden
escape of florid blood ; the contraction ceasing, the flow of blood
also, for the most part, ceases  entirely, or subsides greatly ;  with
the returning contraction, there is a fresh detachment of placen-
ta, and another gush of florid  blood ;  the contraction  at an end,
the flow of blood again subsides.  This order of events recurs
in the same succession, perhaps several times.  But, at last, if
the child be not first extruded, a stage of labor arrives when the
recurrent contractions of the womb do not entail any further
flooding J the pains return in their usual course with their usual
strength, and with  their usual effect of further dilating the os
uteri, and forwarding the labor; but there is  no more hemor-
rhage.  The labor is resolved  into a natural  labor, and may be
safely concluded by the natural  powers.
  Now this history, true to nature, is diametrically at variance
with the still received  dogmas, that the haemorrhage is the v-
necessary result of the expansion of the os uteri, and that there
is no safety  but in delivery. 
444       PLACENTAL LIMIT LIABLE  TO DETACHMENT.
  It is not, then, the  separation of the placenta which secures
immunity from flooding, but the contraction of the womb.
 This figure is a diagrammatic view of the progress of detachment of placenta.  It is cast off in •
zones or rings, if the case is one of placenta centralis ; and in segments of rings, if one of cervico-
orificial placenta. At A, A, the dilatation of the os involves no further detachment of placenta.

   There is, then, an anatomical, a physiological limit to the ex-
tent of placenta liable to detachment during the expansion of the
womb.  This is why, after a certain stage of  the labor, no fresh
bleeding surface is exposed.  But how is the bleeding stopped
from  that  part of the  uterus  already bared of placenta ?  By
precisely the same mechanism as that which stops the flooding
after normal  detachment  of  the placenta from its normal seat at
the fundus.  The longitudinal muscular fibres of the lower seg-^
ment must contract to pull open the mouth.  Expansion, dilata-
tion of the mouth, is contraction  of the cervix.  This contrac- v
tion, by shortening  the cervical portion of the' womb, casts off
the placenta, and exposes the ruptured mouths of the  utero-pla-
cental vessels.  The first effect is, bleeding.  The second is, to
stop the bleeding.   The contraction  goes on either actively, or
passively and tonically, in most cases ; and this  further contrac-
tion constricts the  orifices  of the vessels—closes them: it is
haemostatic.   If haemorrhage be renewed, it does  not proceed,
except under  circumstances of excessive muscular relaxation__
the " passive  haemorrhage " of  Dr. Chowne—from  the surface
bared by  the preceding active contraction :  it proceeds from a 
             VARIETIES  OF PLACENTAL ATTACHMENT.        445

 fresh zone  or  arc further from  the os, bared of placenta by
 another contraction.  This zone  or arc is, in its turn, in like
 manner sealed;  and there  is another pause in  the flooding.
 Zone after  zone  is thus  bared by recurring contractions, and
 successively sealed up until that physiological limit, that line of
' demarcation between normal and abnormal placental implanta-
 tion, the boundary-line of placental detachment, which I claim   ,
 to have discovered, has been reached.  This zone attained, the
 labor is a natural labor !
   At this point of our inquiry we  may usefully enumerate the
 the varieties  of seat of placental attachment.  To illus-
 trate this point, I have constructed a diagram. (Fig. 124.) The
 placenta may be  attached to  the fundus or upper  zones  of the
 uterus—fiundal placenta ;  it  may be seated on the middle zones
 —lateral placenta ; it may encroach downwards upon the cer-
 vical zones—latero-cervical placenta;  or  it may grow entirely
 over the inferior  pole, rising  on all sides so as to occupy the cer-
 vical zones—the  cervico-oriflcial or central placenta.  (Fig. 123.)
 The fundal and lateral placentas  are  not, unless under very
 exceptional circumstances, liable to detachment, or to lead  to
 flooding, before the birth of  the child.  The latero-cervical and  ^
 the central placentas are, however, so liable.  The extent  to
 which  this liability goes  is  greatly affected  by the extent  to
 which the encroachment takes place withing the cervical zones.
 In this case there may be little or no haemorrhage;  but  should
 the encroachment proceed further down, the danger of haemor-
 rhage would much increase.   There are cases of flooding before
 the birth of the  child, in which no placenta can  be felt, and  ^
 which  are yet strictly cases of placenta praevia.   How, it may
 be asked, do we  get  evidence of this ?  Nothing  is more sim-
 ple.
   The following  case shows one kind of proof:
   On   the  13th  of May, 1852, my  assistance  was required
 by one of the midwives  of  the Western  General Dispensary.   *
 A poor woman, weakened by poverty and hard  work,  having
 had two children at full term  and of full  size,  wras in labor
 at  nine a.m.   For two days previously she had had haemor-
 rhage,  which was still going on.   The  head was  low  in the
 pelvis  and  lying in  the  first position, and  there appeared to
 be sufficient room; it had, according to  the midwife, been in 
   146       EVIDENCES OF CENTRAL  PLACENTA  PREIVA.

   the same position  for four hours without any advance.  The
   pains had ceased altogether.  Pulse  feeble; face pale ; great
   exhaustion,  anxiety,  and depression  of mind.   Fearing that
   further haemorrhage might be fatal, I determined on delivering
   by forceps.  Whilst waiting for the  instrument, I directed the
   midwife to give an enema.  I  comforted the patient  by assur-
   ance  that  she would do well.   Almost  immediately after,
   effective pains returned, and the head was expelled  in an hour.
   No further haemorrhage.   Child  still-born.
     Lt appeared to me that the uterine contractions were arrested
   in the first instance  under the  influence of anxiety  and terror.
   The midwife, before sending for me had sent for Mr. Cholmeley
   and Dr.  Babington (she  was  a  patient of Queen Charlotte's
   Hospital), and more than two  hours had been thus lost.  My
   arrival and assurances restored her  confidence; and under the
 J beneficial influence of that feeling  the uterine contractions
   returned.   The  decidual surface  of  the  placenta presented
   numerous specks of osseous deposit; the margin of the placenta
   presented large fresh coagula of dark color in the substance, and
   very large fresh  coagula were attached to the very edge,  and
   had evidently proceeded from a rupture of the circular venous
   channel which courses round the  placenta.
     It is this presence of coagula in the  margin of the placenta
   which proves that it had been  detached during labor, and that
   it had encroached upon the  cervical region of the womb.   In
   cases  of this kind it  is often  remarkably  well seen  how
-V dependent the haemorrhage is upon the inactivity of the womb,
   and how completely contraction checks it.
     Another proof is very interesting.  I believe it was first ex-
   plained by Levret:
     "Lorsque le placenta est attache dans le fond  de  la matrice,
   centre  sur centre,  non seulement  le cordon ombilical est an
   centre  du placenta,  mais meme les membranes se dechirent dans
 '  leur  milieu  a une  egale  distance, pour ainsi dire,  de tous ses
   bords ; et lorsque le placenta ee trouve devie" vers les  parois de
   la matrice, outre que le cordon suit et  marque le deo-re" de cette
   deviation, les  membranes se dechirent en meme raison__c'est-a-
   dire, d'autant plus pres de l'un des bords du placenta que cette
   deviation est grand.  Si done le placenta est attache  assez bas
   dans un  endroit des parois de la matrice pour que le cordon se 
RENT  OF TUE MEMBRANES--WHERE.
447
trouve implante* sur le bord, ce sera sur ce meme bord  et  dans
ce meme point que les membranes se dechireront."
  I have made the following sketch to illustrate this position.
Recently this subject has been experimentally examined by Dr.
Yon Ritgen.   He found that  the bag of membranes burst at
the edge of the placenta in 22 cases ; it burst at one inch from
the edge in 8 cases;  between one and two inches in 12 cases;
between two and three inches in 16  cases ;  three  inches in 5
cases ; between three and four inches in 4 cases  ; at four inches
in 6 cases; between four and  five inches in 8 cases; at  five
inches in 3 cases ; at six inches in 6 cases ; and  at eight inches
in 3 cases.  It follows, that since the distance of the edge of the
placenta from the rent is absolutely decisive as to the distance of
the edge of the placenta from the os uteri, that the edge of the
 Drawing showing how the seat of rent in the membranes indicates the seat of attachment of tho
placenta to the uterus.

placenta rested on the os uteri in 22 cases, and was within one
inch in 32 cases, and  so on.   This proves that the placenta 
448         CROSS-BIRTHS WITH  PLACENTA  PREVIA.
has commonly a much lower seat  than has hitherto been be-
lieved.
  This frequent latero-cervical attachment of the placenta has
other important bearings in obstetric  practice.   It was pointed
out by Levret that it was  a  frequent cause of laborious labor
and of post-partum haemorrhage.  The attachment  of the pla-
centa to the lower segment of the uterus so modifies its thick-
ness, vascularity, and capacity for contracting equally with the
other portions of  the uterus situated in the same  zone, that the
labor is rendered  painful, and lingering; and, when the child is
born, the  faulty position of the uterus, added to previous ex-
haustion, disposes to a renewal of haemorrhage.
  There is another fact of practical interest.  The frequent com-
plication of cross-presentation of the  child  with  placenta  prae-
via has often been observed.   The explanation of Levret satis-
factorily  ranges  the  two  facts  in  the relation  of  cause and
effect.
  In describing a case where the head was thrown on one  side,
which he delivered by  the  forceps, he says:   "II n'est  pas
difficile de decider que le placenta  s'ctant fortuitement attache"
du cote droit pres de I'orifice  ; il a du empecher  la matrice  de
se dilater suffisamment de ce  cote, consequemment il l'a oblige
a. prendre  une figure oblique.  Mais ce qui  a totalement deter-
mine" cette mauvaise situation a ete  l'inflexibilite"  de  I'orifice  de
cet organe en cet endroit, lequel j'ai reconnu dur et comme cal-
leux, pendant que son cote oppose etait totalement efface.  II
fallait  done,  par ces raisons,  que I'enfant, se presentant  par la
tete, elle s'engageat dans ce detroit suivant une ligne oblique a
la rectitude du corps."  And at page  125 :   " La clifficulte  de
l'enfantement ne vient pas  seulement dei'obliquite de la matrice,
mais encore de la difficulte que I'orifice a a se dilater dans le
lieu prochain de Pattache du  placenta, par la raison que la paroi
de ce viscere est plus epaisse  dans cet  endroit."
  The following diagram will serve to impress this fact.
  I believe these  considerations  present a rational explanation
of a multitude of cases of prae-partum haemorrhage, lingering
labor, cross-births, and post-partum haemorrhage, the cause  of
which has been altogether overlooked.
  Having considered  the varieties  of seat of the placenta we
are naturally led to examine the relation of  the several parts of 
             RELATIVE SIZE OF  MUSCULAR FD3RES.          449

the muscular structure of the uterus to the placenta in its differ-
ent positions.   The general disposition of the muscular fibres of
  A, The rigid inclined plane formed by the placenta, and hypertrophied placental seat of
uterus, throwing foetal head over to B, The thin yielding portion of uterus.
  C  Thin yielding portion of uterus distended  by hydrostatic pressure.

the  uterus may be taken  to be pretty accurately determined.
There is a general accordance amongst anatomists concerning the
leading points.   The dissections of the Hunters  confirmed, cor-
recting somewhat, the  description of Ruysch, and these in their
turn have  been confirmed by the dissections of Sir Charles Bell,
Professor Owen, and others.   Preparations may be seen in most
museums which exhibit clearly the disposition of the  muscular
fibres in the different regions.  I must, however, recite  to you
the description of Sir Charles Bell, not  only on account of its
graphic beauty, but  also because he has  laid the  anatomical
foundation of those physiological views concerning praevial pla-
centa to which I was led by clinical observation.
  " It has been proved by the sections of the uterus made in
                               29 
450   ACTION  OF THE  UTERUS WITH PLACENTA PREVIA.
different states of its contraction, that the order of the muscular
fibres is calculated so as to close the vessels ; that where Nature
has provided for the attachment of the placenta, there the bro-
ken vessels are guarded by th,e provision of the surrounding mus-
cular texture; but we know also that  during this contraction of
the superior part of the womb, the lower part dilates and relaxes.
Now if the contraction of the womb be essential to the safety of
the mother, what  will be  the effect of the attachment  of the
placenta to a part of the  womb which must  relax during the
labor!  Every one knows the peculiar danger of placenta pre-
via, that each labor-pain as it returns  increases the violence of
the flooding- instead of checking; it.
  " I have been led to conclude that the placenta cannot be par-
tially separated if it be attached in a regular circle to the fun- J
dus of the uterus: it cannot be  partially separated, and cannot
be separated bodily until the uterus is permitted to have a great
degree of contraction by the delivery of the child ; the circular
muscles of the fundus being agents in a double  capacity, that is,
both in expelling the child, and in constringing the uterine ves-
sels, byr the time the child  is expelled, the vessels of the fundus
are greatly diminished in  diameter.   Further, the place and
strength of the  muscles being perfectly regular  and  uniform,
their action must have the  effect of equally drawing the surface
of the uterus, which is in correspondence with the margin of
the placenta; but  no one part of it will be separated until the
general restriction  is nearly completed.   This will not be the
case when the margin  of  the placenta extends irregularly, or
when the placenta is attached to the side of  the uterus.   After
the  delivery of  the child in cases 0/  flooding, it is not uncom-
mon  to find a portion of  the placenta low down in the uterus,
and separated, while the greater portion remains attached to the
fundus.  In examining the inner surface of the uterus by dis-
section, I have  seen  the part corresponding with the placenta
irregular in its form and extending towards the  side and neck of v
the uterus.   In such circumstances  of the  attachment  of the
placenta, the retraction on the lower part of the womb being to
a greater extent than the fundus, will account  for the too early
separation of that margin of  the  placenta  which  stretches
towards the  orifice and also for the haemorrhage which is  a con-
sequence of this partial separation ; but, in progress of the  labor 
ZONES OF PLACENTAL ATTACHMENT.
451
and after the discharge of the waters, the more powerful efforts
of the uterus draw the muscular fibres more closely around the
bloodvessels, and then the flooding ceases."
  The chief points in the  physiology of placental  attachment
are expressed in the following diagram :
                       *fUNDALZONE*
                           SAFE
                  '///^CENTAL SE^T \
                  ^££jft POLAR circle!,
                                          1
                    MERIDIONAL ZONE    I
                 S4/r£  PLACENTAL SEtf 1
                    TEDIOUS  LABOUR    fl

                 t°ST-PARTm FLOODlW


                   ^ERVICALZOW
               DANGER^^LACE^^SEM

 Diagram illustrating the various sites of the placenta, and the relation of these sites to h^mor-
rhage.

  The inner surface of  the  womb may be divided into three
zones or regions by two latitudinal circles.  The upper  circle
may be called the Upper Polar Circle.   Above it is the fundus
of the uterus.  This  is the seat  of fundal placenta: the most
natural position.  It is the zone or region of Safe Attachment.
The lower circle is the Lower Polar Circle.  It divides the cer-
vical zone or region from the meridional  zone.  The space com-
prised between the two circles is the region of lateral placenta.
When attached in this region, the placenta is not liable to pre-
vious detachment.   It  may, however,  cause  obliquity of tne
uterus,  transverse  position of the child, lingering labor, ana
dispose to  retention of the placenta and post-partum haemor-

  Below this circle is the cervical zone : the region of danger-
ous placental attachment.  All placenta fixed here, whether it 
452
EXACT POSITION  OF LOWER CIRCLE.
consist  in  a flap  encroaching downwards from the meridional
zone, or whether it be the entire  placenta, is liable to previous
detachment.  The mouth of the womb must be pulled open to
give passage to the head.  This enormous contraction or retrac-
tion of  the longitudinal cervical fibres is incompatible with the
preservation of the adhesion of the placenta which is within its
scope.  In  every other part of the womb, there is  an easy rela-
tion between the contractile limits of the muscular structure and
that of the cohering placenta.   Within the cervical region this
relation is  lost.   The contraction of  the uterine tissue is  in
excess.
  The lower Polar Circle is, then, the physiological line of demar-
cation between praevial and lateral placenta: it is the boundary-
line below  which  you have spontaneous  placental detachment
and haemorrhage ; above which, spontaneous placental detach-
ment and haemorrhage cease.   If, through the successive active
contractions of  the longitudinal muscle, all that part of the pla-
centa which had been originally adherent within the cervical
zone, be detached; and if, as is the constant tendency of Nature,
these intermitting  active contractions, and the continuous tonic
contraction going on in the intervals, arrest the haemorrhage, a
stage is reached when the labor is free from all praevial placental
complication ; the cervical placenta has become changed into a
lateral placenta ; the labor is, in all respects, a natural labor.
  It is important  to determine the exact position of this lower
Polar Circle or boundary-line between haemorrhage and safety.
The means  exist of defining this with tolerable accuracy.
  In the first place, if we reflect that the  lower segment of the
womb must open to an extent corresponding to the circumfer-
ence of  the  child's head in order to  permit its  extrusion, we
shall, by noting the amount of necessary recession or shortening
of the neck of the womb, in order to reach this extent of expan-
sion, obtain a measure of the original depth of the ceryical zone,
the region of praevial placental attachment.  The following dia-
gram will serve to illustrate this position :
  There is another evidence distinct from, but confirmino- the
preceding.   If, after its expulsion, we  examine a placenta, the
edge of  which,  at the beginning of labor at the full term had
been felt reaching  to the edge of the os uteri internum, we find
that part which had been adherent within the cervical zone and 
BOUNDARY  LINE OF SAFETY.               453
which had  been consequently detached, infiltrated with coagu-
lated blood, its substance perhaps indurated, and altogether pre-
senting an  appearance  quite different from that of the mass of
the organ which had adhered within the meridional zone, and
  Diagram showing a lateral placenta descending to (AA) the boundary line between the meridional
and cervical zones.  In this case the placenta descends to the very point of fullest expansion of the
os, and therefore remains just within the limit of safe attachment. The space between AA and BB
is the necessary range of orificial expansion.

which had only  become detached after the expulsion of the
child, through the general contraction of the womb.  This part
is usually so well defined as to admit of  being measured.   It is
usually found to vary from three to four  inches in length.   This
distance from the  os will bring us  again  to the lower Polar Cir-
cle.
  I believe, however, that  the boundary-line of safety is often
practically reached before the  expansion of the  mouth of the
womb has reached the full diameter of the child's head.  I have
observed that the haemorrhage has completely stopped when the 
454    TREATMENT OF VARIETIES OF PLACENTA PREVIA.
os uteri  had opened to the size of the  rim of a wine-glass, or
even to a lesser size.  In ordinary labor, when the bag of mem-
branes or the child's head is  driven down upon the os by the
pressure from behind—that is,  when expulsive  pains succeed to
the preliminary dilating pains, the  presenting part becomes a
mechanical  distending  or  stretching power.   The os, partly
opened by the active shortening of  the  longitudinal muscular
fibres,  is  fully opened by the distending cone driven through it,
as an india-rubber band is expanded.  Thus it is  that a part of
the opening of the os uteri is gained by a process that does not
involve detachment of placenta.
  These  cases  and  arguments  demonstratively exclude   the
operation of artificial total detachment of the placenta as a, prin-
ciple of treatment of placenta praevia.  These cases in reality
furnish strong presumptive evidence to corroborate the positive
evidence I have adduced, that partial detachment of the placen-
ta—i. e.,  detachment of the portion implanted within the cervi-
cal zone  of the uterus, may be enough—certain favorable  con-
ditions concurring—to control  the haemorrhage.
  Now this  partial detachment is an operation that admits of
being accomplished by the introduction  of  one or two fingers,
and is therefore feasible under the precise circumstances which
preclude  turning or total detachment.
  We  have, then, here a new remedy,  one applicable at the
very juncture where ordinary  means are impossible or danger-
ous.  As contrasted  with the operation of totally detaching the
placenta, it has the further advantage of not  endangering  the
life of the child.
  As contrasted with forced delivery, it has also the advantage
of being less hazardous to the child.
  The  operation which I propose is, to  carry the  detachment
further, so as to separate all that part of the placenta which ad-
heres within the cervical zone  or region of dangerous placental
seat.
  It remains to endeavor to generalize trie varieties of cases of
placenta  praevia;  and  to  endeavor to define the methods of
treatment more particularly applicable to each variety.
  1. We have  those terrible  cases to which we have just ad-
verted, where the  os uteri  is rigid  and undilated, the flooding
profuse, the powers of life ebbing fast;  where to wait  for spon- 
         ERGOT AND GALVANISM  IN PLACENTA PREVIA.     455

taneous arrest of flooding, or the natural dilatation of the os, is
to wait for death.  These are preeminently the cases for  resort
to the  operation referred to.  It must, however, be first stated,
that this class admits of being further subdivided.   There are
cases in which contraction of the uterus is going on ; there are
cases—more  dangerous still—in which  contraction  is absent.
Labor  with relaxation is  dangerous under  almost  every con-
dition : it is eminently  so when complicated with placenta
praevia.
  Where  contraction is present, we  possess one necessary ele-
ment of safety; we may be satisfied with the artificial separa-
tion of the  placenta from its attachment to the cervical zone.
Where contraction is  absent, we must  at the same time use
every available means of rousing the contractile energy of the
womb.  Sometimes the stimulus imparted to the reflex system
by the necessary manipulation  is itself  enough to excite con-
traction.  But not always.  We must then give stimulants in-
ternally ; apply warmth to the surface  if the skin is cold and
there is great depression; rub the abdominal muscles and the
body of the uterus firmly.   This is a case where the ergot of
rye is especially indicated.   If it fail, then we  have galvanism,
which  rarely or never fails—an agent perfectly under control,
which  we can apply and intermit at pleasure, and whose force
we can graduate as we like.
  If the  haemorrhage should continue, or be renewed  with
urgency, I  propose as  the next step, tlie total cervical de-
tachment of the placenta.  The detachment must  be carried
further, by sweeping the finger round between the placenta and
uterus on that side to which the main bulk of the organ adheres.
In this manner the whole of that part which  had been seated
within the cervical zone will have  been detached.   We shall
have imitated the operation represented  in the diagram fig. 124,
as being occasionally—I believe often—effected  by the spon-
taneous efforts of Nature.   Now this detachment will not of
itself stop the haemorrhage.  We may, I think, ^anquillize our
minds  as to the effect on th^ mother of that small portion that
will escape from the detached placental surface.  But the uter-
ine vessels may pour forth  blood until'the haemostatic resources
of Nature or  Art come in to play.   Those I have before des-
cribed  : continued contraction of the muscular structure of the 
456       TOTAL CERVICAL DETACHMENT OF PLACENTA.
womb, the contractile action of the coats of the uterine arteries,
and  the  formation  of coagula in their mouths.  In  the major-
ity of cases, these resources are  sufficient;  the haemostatic  pro-
cess  may, however,  be further assisted by  plugging again.  A
method of plugging is recommended  by high authority, which
appears deserving of attention.   Moreau advises the application
of a  lemon, the end of which has been cut off, to the os uteri,
and  to retain this  in situ by firm pressure through  rags or
sponge.  The acid juice favors coagulation as well as the  pres-
sure, and retention of blood. The soaking of the sponges or rags
used for plugging in vinegar is a common practice ; but it seems
to me reasonable that more powerful styptics should be used.
I suggested some time ago, the  injection of  the sesquichloride
of iron.  Dr. Schreier, of Hamburg, has related some instances
in which  this agent was employed with success.  M. Dupierris,
of Havana, advises  the use of tincture of iodine.  He says that
he has injected a mixture  of one-third tincture of iodine with
two-thirds  water, in one hundred cases of uterine haemorrhage
of various kinds with uniform success.   He relates three cases of
haemorrhage attending labor.  The sesquichloride of iron, how-
ever, appears to me the preferable agent.
  By the  proceedings I have  described, . we may  reasonably
hope that in the vast majority  of  cases the haemorrhage  will
cease.  If  it  should not, time will have  been gained; the os
uteri may have  become soft  and dilated;  and, in the event of
its being felt necessary to  resort to forced  delivery, this opera-
tion  may be performed with comparative ease and safety.
  2.  There is another class  of cases, happily more frequent than
the preceding, where there is less urgency, more scope for tem-
porizing.  We  have seen that the expansion of the os  may.be
effected without necessary  loss of blood to  such an extent as to
constitute flooding.   In the conduct of such  cases we have, in
the physiology which I have enunciated, a guiding principle that
carries a  rational  faith  in the  resources of  Nature.   It is in
these cases that the natural tendency to  restrain the flooding
caused by the successive  detachments of zonular portions of
placenta is most strikingly marked.  A knowledge of this prin-
ciple will give an intelligent confidence in all those measures,
such as the plug, ergot, rupturing  the membranes, which has
been recommended  on  various  physiological  or  empirical 
STYPTICS IN PLACENTA PREVIA.
457
grounds.  Even in these cases the  operation of freeing the
smaller segment of the placenta, so as to allow it to be carried
over to the side of the uterus which holds the main body, will
be of essential service.
  3. There is a third class of cases in which the principle is all-
important.  I mean those cases where, after even alarming loss-
es,  the  haemorrhage  has  ceased spontaneously.   Under the
prevailing dogmas the arrest of haemorrhage inspires no hope in
the breast of the accoucheur.  He is taught to  believe that it
will " unavoidably"  return ;  he hastens to deliver;  and the
poor woman who had  reached the haven of safety  is destroyed
by  the operation, a victim of the " nimia diligentia medici."] 
LECTURE  XXX.
                FUNIS  PRESENTATIONS.

  Gentlemen :—The Funis may present alone at the beginning
of labor, or it may descend with the head, arm, nates, and any
other presentation  of  the  foetus.   Its positive  frequency is
greatest  in head cases, but relatively it is more frequent in arm
and shoulder presentations than in other varieties.   This serious
complication may occur  at  any time during labor.   It  may
happen before  the  evacuation  of the  liquor  amnii, when  the
head  or  presenting part  is passing the os uteri, or when it is
emerging from  the perinaeum.
  The Causes  of funis presentations  are various.   In  arm
cases, where the body of the child lies transversely, the  anatom-
ical position of the umbilicus and the funis  favors the descent of
the cord, and this descent is still further promoted by the fact,
that in shoulder cases the circular os uteri  does not at all points
closely embrace the presenting part, on account of its irregu-
larities.  In its contractions, the uterus  cannot  sweep  equably
over the  shoulder as it does  in  cranial presentations during the
pains, so as to carry up the funis when there is any tendency to
prolapse.  Presentations of the feet and breech, or of the hands
and feet, are frequently  complicated with the funis, and from
the same causes.  In  the case of head presentations, length of
the cord, small  size of  the head, the descent of  the hand with
the head, a large quantity of liquor amnii, and its sudden evac-
uation, or a pelvis above the average size, may cause prolapsus
of the cord.  It  happens in twin  cases,  particularly in the de-
livery of the second child.  The position of the placenta is also
influential as a cause of funis presentations.   The  cord is prone
to descend when the  placenta is partially attached to the os
uteri, or when the placenta is fixed to  the lateral walls of the
placenta instead of to  the fundus, or when the placenta being 
          STATISTICS OF PRESENTATION  OF THE FUNIS.        459

seated near the fundus, the cord is inserted into the edge instead
of the centre of its diameter.  Mr. Roberton, of Manchester,
points out that, in cases of contraction  of the brim of the pelvis,
where, on the rupture of the membranes, the head does not de-
scend upon the os uteri, but remains suspended at the brim, the
funis is very apt to float down with  the liquor amnii and  pass
through the os.  An interesting series of cases has been reported
by Mr. Roberton, which fully bears out this view.   When the
head of the foetus remains  above the os uteri, the relations of
the os to the presentation very much resemble those which ob-
tain in shoulder or nates cases.  There is a want of that apposi-
tion between the os uteri and the presenting part which prevents
prolapsus of the cord in perfectly natural cases.
  As regards the frequency of this complication, Dr. Fleetwood
Churchill has collected 128,224  cases of all presentations, which
yielded 579  funis cases, or  about 1  in  221*.   As regards the
mother, labor is not in the least degree rendered more unfavor-
FlG. 125.
          Presentation of the Funis, with the head in the first position.

able than usual, but the mortality to the foetus is very great.
Considerably more than 1 in 2 of the children die in cases where
the cord presents.   In arm presentations the mortality is rather 
460
FUNIS PRESENTATION SIMULATED.
more than 1 in 2.   It will be remembered that in breech cases
the mortality  was 1 in 34-, and in footling  cases, 1 in 24.  In
turning, the foetal mortality is rather more than 1 in 3.   Thus
the preseutaXioix-of the funis is more dangerous to the child than
any other variety of labor.
  The  symptoms of  funis presentations  are  sufficiently
Fig. 126.
Presentation of the funis, with a hand and foot.
well marked to make their diagnosis easy.   Sometimes a loop
of cord, several  inches  in length, hangs from the vagina.   It
may be pulsating, or  it may be cold and flaccid.  But in one
case the umbilical pulse, and in the other the twisted arrange-
ment of the cord, or an ocular inspection, will remove all doubt.
In cases where the cord comes down with the advancing part of
the child, or presents with it at the os uteri, the only part of the
full-grown foetus which can be mistaken for it is the closed hand
or the toes.  The knuckles, when only part of the  hand is felt,
or the row of toes, may feel somewhat like the end of a loop of
cord.  But the presence or absence of pulsation, and the exam-
ination of a few inches of the cord, or enough of  the extremities
to reach  the  wrist or the ankle, will  make the matter  clear.
There is one complication of labor which it is necessary to men-
tion, in which a mistake respecting the cord may lead to the
most serious results.   In cases of ruptured uterus, a coil of the 
            FUNIS VERSUS BREECH AND FOOTLING CASES.       461

 small intestine  may  pass through the laceration, and present
 in the os uteri or the  passage.  This has, in rare instances, been
 mistaken for the cord of a dead child, and pulled  down or even
 cut off by ignorant or incautious persons.  A case of this kind
 occurred in London, and another in Ireland, incredible as it may
 appear, within  the last  ten or twelve years.  In cases of this
 kind happening to a  midwife, in  which a medical man  might
 be called after the rupture of  the uterus and prolapse of the in-
 testine, some little caution would be necessary to avoid mischief.
 An inexperienced accoucheur  might pull at  the supposed  cord,
 and do the  gravest injury, particularly if the previous history
 of the case had been kept from him.
   Of course, the cause of the Mortality in  funis cases is the
 pressure exerted upon the cord, between the  presenting parts of
 the child and the hard and soft parts of the mother.   The child
 dies of asphyxia, the fcetal circulation being, in severe cases, en-
 tirely cut off from the respiratory functions of the placenta. We
 may compare the child under the circumstances of funis presen-
 tation, to cases  of turning, to cases in which the placenta is
 separated, or  the contractions of the uterus are so intense and
 continuous  as to prevent the circulation of the  blood in the
 maternal side of the  placenta.  The comparison  between the
 presentation of  the funis, and the descent of the  nates or feet
 foremost, is very obvious.  Wherever the order of labor is such
 that  the funis, or any portion of it, precedes  the descent of the
 more bulky portions of the foetus, the case  is essentially one of
 funis presentation. Thus, in footling, breech, and turning cases,
 as soon as the umbilicus  engages in  the pelvis, pressure is ex-
 erted on the cord, and the cases are identical with funis presen-
 tation.   The mortality depends on the length of time to which
 the funis is  subject  to pressure, and  the degree of the pressure
 during the exit of the foetus.   Thus it is greatest in funis  cases
 proper, in which the cord comes before or with the presenting
 part, and is thus subjected to pressure during the whole of
 labor.  Next to  this, footling  cases  are the  most fatal to tlje
 child, as here the pressure on the cord  commences as the umbi-
licus descends through the soft parts, and  these  have been but
little distended by the  descent of the feet and breech in succes-
sion.  In breech cases, the mortality is less than in footling cases,
because the soft parts have been distended by the passage of the 
462
DANGERS  OF FUNIS PRESENTATIONS.
nates with the feet doubled up towards the abdomen.   In cases
of the descent of the cord with the head, in cranial or face pre-
sentations, the pressure exerted on  the cord  is greater than
under any other circumstances ; but it is of short duration, since
as soon as air can reach the mouth of the foetus, pressure on the
cord becomes of little  consequence.   No comparison can be
made between  the  mortality in cases of  turning  and funis pre-
sentations, because  the  great mortality to the foetus in turning
depends on other causes as well as upon the pressure upon the
cord.  Certain circumstances  besides the presentation exert an
influence upon the mortality in funis cases.  The younger the
foetus, for instance, the  more  safely pressure is borne, and the
longer  it may be continued without a fatal result.  The risks of
a fatal  result to the child, when the  funis presents in a first
labor, are very great, whatever the part presenting with the
cord.  They are much less in the case of patients who have had
many and easy labors.   The danger is greater when the foetus is
male than female.   The least dangerous cases of  cord presenta-
tion are  those in which it happens to the second child in twin
cases, especially when, as is frequently the case, the second child
is smaller than the first.  The  danger  is increased when the
pains are very  frequent and prolonged, but when the pains are
moderate, and with a fair  interval, the child recovers from the
effects  of the pressure  of one pain before  another comes on.
Care should always be taken to inform the friends of the patient
of the danger in which the child is placed by the descent of the
funis.
  The  principle of Treatment in funis presentation  is the
removal  of the cord from  pressure, or subjecting it to compres-
sion for as short a time as possible.   These objects may be car-
ried out  by  the Reposition  of the Cord within the  uterus; by
placing it in such a situation in the pelvis as to escape pressure
as far as is practicable;  or by artificial delivery, as by turning,
or the  use of the forceps.  No one method can  be advised for
fye  treatment of  such cases.  The principle of management
being held in view, the  means adopted in individual cases must
depend upon the exigencies which attend them.  As the mother
is not in danger from this casualty, no steps should be  taken  to
secure the  child which are likely  to bring the mother into
danger, as this would be substituting a greater for a lesser evil. 
           VARIOUS  METHODS OF REPOSING  THE CORD.       463

  A primary rule in the management of these cases is, the pre-
servation  of the liquor amnii.  As  long  as the  membranes
remain  unbroken, it is hardly possible  for the child  to  be
destroyed bj compression  of the cord, and  not until they are
broken should any attempt be  made  to replace the funis.  It
cannot be done effectually ; the child is as  yet  in  little  or  no
danger; and attempts at manipulation must  hazard  the rupture
of the membranes.  The more  labor progresses before the evac-
uation  of the amnion,  the shorter will be the time of serious
compression, and the less the amount of compression will  be
from the  gradual dilatation of the soft parts under fluid pres-
sure.
  The  Reposition  of the cord within  the uterus  is the
most satisfactory method  of treatment we  can  adopt, but un-
fortunately it is not always practicable, or  else  the pains cause
the renewed descent of the cord after its  temporary replace-
ment.  The degree to which the cord should be returned is a
matter of some  difference  of opinion.    Sir  Richard  Croft
recommended that the cord should be carried up into the  uterus
so as to hang it upon the limbs of the child.   Others, as Arneth
of Vienna, advise that it should be  returned above the  head,
and allowed to remain in the hollow formed by  the  neck.  No
doubt, the latter answers every purpose,  if  the  cord will keep
there,  since children are frequently born with the  cord  coiled
once or twice round the neck without  injury, and the introduc-
tion of the hand into the uterus during labor is  necessarily
attended  with some risk to  the  mother, except in the most
favorable cases.  Various  methods  of  procedure have been
advised for the reposition of the cord.  The most simple  instru-
mental method is by the use of a whalebone needle, or bodkin,
and a loop of tape.   This, as Dr. Ramsbotham remarks, has the
advantage of being made extemporaneously  in a few minutes in
the lying-in room.  A flat piece of moderately flexible  whale-
bone, about half an inch in breadth and a foot in length,  and a
yard of tape, are all that is necessary for its construction.  An
eye or  hole should be made near  one  extremity of the  whale-
bone, large enough to allow the tape to run in  it readily.  In
using it, a loop of the tape  should be passed  through  the eye,
and the end of the loop of funis should be included in the loop
of the tape, when the ends of the tape should be drawn so as to 
464
INSTRUMENTS FOR REPOSING THE CORD.
bring the loop of funis towards the eye of the  instrument, and
to retain it there without exerting pressure enough on the cord
to interfere with the placenta-foetal circulation.  The whalebone
should now be passed  into the uterus by the side of the present-
ing part, in an interval between the pains, and after having been
kept there during a pain, the tape may be brought away by
drawing at one of the strings, and the slip of whalebone  after-
wards removed.  If this noose be relaxed a little, so as to avoid
strangulation of the cord, there can be no harm in  leaving  the
instrument in the utero-vaginal canal, as it offers no impediment
to the progress of labor.   Michaelis, of Kiel, recommended that
a large sized, male, gum-elastic, stiletted catheter should be used
for  the same purpose.  He advised that the ligature should be
passed through the loop  of funis, when, being drawn loosely to
the eye of the catheter,  and  the stilette being introduced only
so as to avoid the possibility of  doing  injury, the instrument is
to be passed above the head  or presenting part, and left there,
the stilette  being withdrawn,  until the completion of labor.
But at the present time, Michaelis has, I believe, abandoned his
ingenious instrument for the use of the fingers.
  [A very ingenious instrument called a portecordon is made by
Luer from whalebone or hard rubber, as shown in the annexed
cut. It is made in two portions, one sliding over the other.   In

                   g=       a---        qgja^
a sharp bend at one extremity the cord is seized and  may then
be pushed up to the fundus uteri if desired when the passage is
not blocked.  Then, by withdrawing the slide, the cord may be
disengaged and the instrument withdrawn;  or, if desired, the
instrument may remain, its smallness preventing its causing any
obstruction or being in the way, while its retention  may more
effectually prevent the subsequent descent of  the cord.]
  I see no reason why  the  cord  should not, when  it is suffi-
ciently low to admit of manipulation, and when it  returns after
reposition, be pierced with a needle and thread or worsted, in
 
            NO DESPAIR WHILE THE CORD PULSATES.        465

such a way as to escape the vessels, and be tied to the end of a
slip of whalebone, which might  then  be returned, and kept in
situ until the completion of labor.  But in ordinary cases, the
accoucheur can do more with the hand and fingers than with the
most ingenious instruments. In returning the cord with the hand,
two or three  fingers of the right or left hand, as may be most
convenient, should be introduced by the side of the head or pre-
senting part,  and with the tips of the fingers the prolapsed por-
tion of the cord, being gathered  together, should be pressed up-
wards, during an interval of freedom  from pain, and retained
above the presenting part until the next pain comes on.  When
the uterine contraction of the uterus  reaches the fingers, they
should be withdrawn, so as, if possible, to leave the funis within
the grasp of  the uterus.  The contraction of the uterus will, if
the operation be successful, sweep the cord  upwards, instead of
expelling it.   It  may, however, come down  again  when the
uterus is  relaxed, or it may be extruded by the succeeding pains,
and require other  attempts of the same kind to keep it above
the presenting part.  Drs.  M'Clintock  and Hardy, whose  direc-
tions for  the  reposition of the  cord are very excellent, advise
that in attempting its  reduction by the hand, the woman should
lie upon the side opposite to that on which the cord protrudes;
that is, if the  cord be felt on the right side of the pelvis, the
woman should lie  on her left side, and vice versa.  They also
recommend that before its return it should be drawn, if possible,
towards the pubes, as the shallowness of the pelvis in this situa-
tion renders  the return of the procident cord more easy than
when it lies towards the sacrum.  As  long as  the  pulsation of
the cord  is vigorous, we should not be deterred by difficulties in
attempting its reposition, as this is sometimes effected only after
repeated  trials.
  When, in spite of our endeavors, the cord slips down again at
every pain, means are recommended for keeping the funis above
the presenting part.   This may sometimes be done by passing a
wedge  of sponge up  after the  cord,  as recommended by Dr.
Collins, so that when the pains come on,  the  sponge is  com-
pressed between the presentation and the walls of the  canal, and
the further descent of the funis  prevented.  Sometimes, where
the extent of  funis prolapsed is considerable, and the cord thin,
so as easily to slip down, some  authorities have recommended
                            30 
466
OPERATIONS IN CORD PRESENTATIONS.
 that  it should be gathered together, and put in a  soft leather
 pouch or bag, the  mouth  of which should be drawn  together
 sufficiently to keep the mass in the bag, but not to constrict the      »
-Cord-.- The -bag is then to  be  passed up within the os  uteri by
 the fingers.  This manoeuvre substitutes a considerable mass for
 the thin lubricious cord, and is less likely to be protruded after
 its reposition.   The bag remains, when the proceeding is  suc-
 cessful, until the child is expelled.  This  operation is, however,
 difficult, and one now rarely, if ever, attempted.
   When the  cord  cannot  be returned or retained within the
 uterus, it becomes necessary to place the prolapsed cord in such
 a position  in the pelvis that it may be compressed as little as
 possible during the passage of the child. It should be brought,
 as recommended by Dr. S. Merriman, into the oblique diameter
 of  the pelvis, opposite to  that which  is occupied by the child.
 In  a vertex case in the first position, with the head in the right
 oblique diameter, the funis should be kept as  closely as possible
 to the left  sacro-iliac synchondrosis, in the second position, with
 the head in the left oblique diameter, and in both cases the rec-
 tum should be emptied, but particularly in the first, as the cord
 then lies between the side of the child's head and the rectum of
 the mother.  In other presentations, when  no other assistance
 can be rendered or seems  necessary, the cord should be shifted
 as far as possible into that part of the pelvis which is least occu-
 pied by the child.  It should rarely, if ever, be brought towards
 the pubic  arch, as in this position  the effects of pressure are
 generally very great.  In  cases of large pelvis in multiparous
 women, when the pains are moderately strong, and occurring at
 proper intervals, the passages being well relaxed, and labor com-
 pleted in a short time, the  arrangement of the position of the
 cord will often be sufficient to secure the safety of the foetus.   In
 primiparous women, or where  there is rigidity of the soft parts
 and a small pelvis, such measures are of little or no  avail in
 arresting the long effects of pressure.
  The propriety of Turning in cases of funis presentation,
 combined with any other part of the child than its pelvic extrem-
 ity, is one  of the vexed questions of obstetrics.  Many eminent
 authorities  have  commended, and others condemned, this prac-
 tice.  The  truth is,  that the fitness of turning for any particular
 case requires great tact and judgment, and admits of no reduc- 
               TURNING IN FUNIS PRESENTATIONS.           467

 tion to rule.  Mauriceau performed it in a number of cases with
 great success in saving the child.  So  did Boivin and Lachapelle,
 and so  have  many contemporary  accoucheurs.   The  strong
 point in the operation is, that it enables us to complete delivery
 in a shorter time than would otherwise be the case, and in this
 way the chances of safety to the child are increased.  The weak
 points are, that the operation is not perfect, considered in relation
 to the object we have in view.   It  does  not deliver the child
 from danger,  but  substitutes the risk of  pressure  from the
 shoulders and head upon the cord after the  passages have been
 distended by the breech, for the primary  pressure of the cord
 by the head without any  previous distension of the parturient
 canal.   Of course, in arm cases in which  the  funis presents,
 version is  performed, but with reference rather to the arm than
 the funis complication.  It would be very interesting  to have a
 statistical  comparison between the results to the child in those
 cases in which the funis presents in combination with the pelvic
 extremity and  those in which it presents with the cephalic  end
 of the foetus.  But I believe no such statistics exist, and, in their
 absence, we must consider the question of turning upon other
 grounds.   In this country, the tendency,  in recent /ears,  has
 been to consider, with Dr. Robert Lee, that  turning should rarely
 be practised.  I believe the cases in  which version is in proper
 operation, simply on account of funis  presentation, are rare; but
 there are  other contingencies, such as moderate contraction of
 the  pelvis, cases where the pelvis is  capacious, where other
 means have been tried in vain, and where  turning can be easily
 performed, but there is evidence that the child is passing into a
 dangerous state, in which the operation  of turning will save
 fcetal life without more than very slight hazard to the mother.
  In cases where the labor has sufficiently  advanced, the  use of
 the forceps or the vectis, the administration  of the ergot of rye
 or a stimulating  enema,  are of  great  value in  completing
 delivery.   These means are to be reserved  for those cases in
 which  prolapsus occurs, or continues, when  the  head is low in
the pelvis, and the os uteri is fully dilated.   In cases where the
funis is complicated with  breech or  footling presentation,  the
means described when speaking  of breech cases, for hastening
delivery and preserving the child, should be practised.
  When the cord remains  pulseless and flaccid for a considera- 
468      POSTURAL TREATMENT IN FUNIS PRESENTATIONS.

ble time, the child is already dead, and we may save ourselves
from anxiety or  attempts at delivery.  We must not, however,
be in too great a hurry  to consider the child beyond  hope.
Cases are on record in which the cord being pressed upon from
above, the loop hanging down is pulseless from pressure on the
arteries, but  the heart may beat  for a considerable time, and
the child ultimately be born alive.   Sometimes in the  conduct
of these  cases, the cord will cease to pulsate and  the  heart of
the child will fail, but nevertheless, from some alteration of posi-
tion, the  heart rallies and  the pulsation of the cord is restored.
Those cases in which the cord comes down with the head, most
easily admit of the reposition of the cord, where,  as in breech
cases, the cord has a great tendency to come down after its re-
placement.  Although when the cord comes down before the rup-
ture of the liquor amnii, the child is in no danger as long as the
membranes remain intact, such  cases are very dangerous to the
child  from the length of time during which it is generally sub-
j ected to pressure.  On the contrary, when the cord descends
towards  the completion of labor, the risks of the child  are less,
because vje  generally have it in our power to complete  delivery
within a  given time in such cases.   The length of time  the cord
may prolapse in some cases without destroying the child, is ex-
traordinary.  I once knew a case where it was  prolapsed three
whole days, but was afterwards  reposited,  and the child was
born alive.
  [In a recent paper read by Dr. T. Gaillard Thomas, to the N. Y.
Academy of Medicine, a new and very ingenious method was
proposed, which  he calls postural  treatment, by which to re-
turn the cord into  the cavity of the abdomen.  The causes of
prolapsus of the funis  he enumerated are, 1st, the  slippery na-
ture of the cord itself, and 2d, the inclined direction of the uter-
ine axis,  which being a line running from the umbilicus, or a lit-
tle above it, to the coccyx, favors very much  the  tendency of
the slippery part to roll outwards.
  These  conditions can be overcome, and also are themselves
rendered serviceable  in effecting reduction, by  inverting the
uterine axis, to  be effected by placing  the woman upon her
hands and knees.
  Dr. Thomas's rules of treatment are thus given by him—
  1st. If the cord is detected  before the  waters have  broken 
RULES OF POSTURAL TREATMENT.
469
let no manual  assistance be  offered, but place the woman at
once in position and trust to this for its return to the uterus.
2d. Should the waters have flowed away, and left  the cord 
470           thomas's postural treatment.

below the head,  place the woman in position, and push it up
with the hand if practicable, or with a portecordon, if not so.
—3d. Lei n<Tmanipulations be commenced until the woman be
placed in position.
  4th. In returning the cord into the uterus, the whole hand
should be  introduced into the vagina—this is essential to  suc-
cess—the fingers alone will fail.] 
LECTURE XXXI.
                 DEFORMITIES OF THE PELVIS.

   Gentlemen :—Distortions of the Pelvis are  amongst  the
 most serious dangers which await the  parturient female and her
 unborn offspring.  The severer forms  of deformity are compara-
 tively rare, but slighter deviations come under our observation
 pretty frequently, especially in highly-civilized, over-crowded,
 and ill-fed  populations.  In  the  case of minor deformities, or
 alterations of dimension, it is, in most instances, the child only
 which suffers.  As obstetricians have gradually perfected them-
 selves in  the diagnosis of  pelvic deviations, it has become cus-
 tomary to resort to operative procedures at an earlier stage of
 labor than formerly, and thus much unnecessary pain and risk
 have been saved to mothers.  Graver forms  of distortion of
 course involve operations attended with much risk to the parent.
 Hysterotomy, in this country at least, has had  a very fatal  his-
 tory ; and when  the pelvis is  greatly contracted, evisceration
 and piecemeal extraction of the foetus is a protracted and ex-
 tremely dangerous  operation.  The best safeguard against er-
 rors of practice,  whether they consist of premature  efforts to
 deliver; or of timorous delays, is to be found in an exact know-
 ledge  of what deviations may present  themselves; how they
 may be recognized; how their extent may be determined  ap-
 proximately ; and  what influence they are likely to exert upon
 the progress of labor.
  The conventional phrase,  " deformities of the pelvis," must be
 held to imply something more than its etymology contains.  By
it we understand all deviations from the standard size and form,
of whatever nature  they may be, and however they may have
been  effected.  Many  attempts have  been made to  treat  the
subject of pelvic deviations systematically.  Some writers have
classified them according to the degree of distortion, and others
                                                     471 
472
RACHITIS VERSUS MALACOSTEON.
according to the  kind of distortion; but it is impossible to ar-
range them together  in  the same satisfactory manner  as a na-
turalist  groups plants and animals.  It is  better to  dispose of
the different  deformities met with one by one, to indicate their
pathological  and mechanical  relations, to  point out how they
may be  recognized, and afterwards to  subjoin  such practical
conclusions as may seem most warranted  by the accumulated
experience of the past.  An immense variety of deviations from
the natural size  and  form of the pelvis have been  met with :
contractions  of the brim, cavity, and outlet, in various direc-
tions, caused either by disease, tumors,  or  fractures; arrest of
development, which  gives  us a pelvis of  the infantile type;
equable  enlargement and  equable contraction; the masculine
type  of  pelvis; funnel-shaped pelvis; flatness of the sacrum;
and oblique distortion of the pelvis.
   The most important pelvic deformities, perhaps, with which
we are acquainted, are those which arise from rachitis, or from
Malacosteon.  In the first of these diseases, distortion is  pro-
duced during infancy,  or at least some  period  anterior  to
puberty; malacosteon,  or  osteo-malakia, on  the contrary, is  a
disease of adult  life.  The effects produced by each of these
diseases  are,  of course, somewhat different,  although  in both
cases there is softening and distortion of bone.   The mechanical
relations of the adult and infantile pelvis are somewhat different
—the width of the infantile  pelvis is less  in proportion to the
height  of the individual  than after puberty;  the  obliquity of
the pelvis is much greater, and the heads of the thigh bones are
thus in every way brought nearer to the line of gravity.  The
softening which takes place in malacosteon is more  equable
than that of rachitis—that is to say, the  whole structure  of a
bone is  similarly invaded  by it, while in rickets the alteration
of intimate structure affects particular  portions of a bone ;  and,
 except in extreme cases, leaves comparatively solid osseous dis-
 tricts, which take little or no  share in the torsion produced.   In
 accordance with  these facts,  it will be found that rickety pelves
 affect one kind of distortion, and malacosteon pelves another.
 In the  first case, the  deformity produced is  generally of the
 elliptical  variety, the sacro-pubic diameter being  decreased,
 and  the lateral very much increased, relatively, and sometimes
 absolutely.  In malacosteon, on the other  hand, a  reverse con- 
            malacosteon  deformities are angular.        473

dition obtains—the deformity is angular, the pelvis is rostrated
or beaked, the sacro-pubic  diameter is  increased relatively to
the transverse, and the transverse diameter diminished abso-
lutely.  This  statement,  however, must only  be taken as  a
general one ; for  there are several  cases on record, which show
incontestably  that  the  angular variety of  distortion may take
place as a result of rickets.  A most remarkable case is recorded
by Naegele', in which all the characters of the osteo-malacious
pelvis obtained;  but there was not the slightest doubt that the
disease which  produced the deformity was rickets.  The same
authority had  observed two other cases, which contradicted the
established belief that  rachitis was not productive of  angular
deformity of the pelvis; and he refers to  several other cases
collected by competent observers.   Stoltz communicated to  him
the case of two children, of  the ages of  one and eight years  res-
pectively, in whom, although rickets had  been undoubtedly the
disease, yet the pelves were alogether of the form generally sup-
posed to be peculiar to osteo-malakia.  Otto, Wallach, and Von
Krumbholz, mention exactly similar cases; and Burns admits-
the existence of angular deformity in connection with  rickets.
An oblong deformity of the pelvis is sometimes met with where
there is a backward  curvature of the spine.   In this case, the
sacro-pubic  diameter of the brim is very much increased ;  the
antero-posterior diameter of the outlet is  proportionately  de-
creased, but not always.
  The accompanying engravings are illustrations of characteris-
tic specimens of rickety and malacosteon pelves respectively:

                           Fig. 127.
Pelvis deformed by Rachitis.
Fig. 127 is a representation of a rickety pelvis affected with 
474
CHARACTER OF THE RICKETY PELVIS.
the usual ovate deformity.   The sacrum in such cases is placed
more horizontally than natural; the promontory projects  for-
wards and  sinks, as it were, into the cavity of  the  pelvis, so as
to bring the fourth or fifth lumbar vertebra into  the  position
naturally occupied by itself.  The sacrum is somewhat dimin-
ished in depth, though not so much so as in the case of malacos-
teon distortion;  its vertical  and  lateral  curvatures  are both
diminished, and  the bone is consequently very much flattened.
The apex of the  sacrum  and  the coccyx  are bent acutely  for-
wards and inwards.  The wings of the iliac bones are somewhat
flattened and everted, and  carried bodily forwards towards the
anterior part of  the pelvis.  The symphysis pubis is sometimes
projected inwards, so as to  give the inlet of the pelvis an hour-
glass shape.  The tuberosities of the ischia are separated so as
to increase both  the transverse  diameter of the outlet and  the
width of the sub-pubic arch.
Ft* 128.
           Rostrated variety of Malacosteon Pelvis, seen from the brim.

  Figs. 128—31 are  malacosteon pelves.   They are specimens
of the oblong rostrated variety.  Figs. 130 and 131, are represen-
tations of the pelvis  of Isabella Redman, seen from above and
below.  The  general effects produced in malacosteon are  nar-
rowing of all the diameters of  the pelvis, but especially of  the
transverse, whether of  the brim, cavity, or  outlet.   The antero-
posterior diameter of the brim, or rather the distance from the 
PELVIS OF ISABELLA  REDMAN.
475
promontory of the sacrum to the symphysis pubis, is relatively
to the transverse diameter, very much increased;  absolutely, it

                           Fio. 129.
Rostrated Malacosteon Pelvis, as seen from the outlet.
is somewhat less than natural.  The pubic arch  is  very much
narrowed.  The tuberosities of the ischia are approximated. The

                           Fi& 130.
Malacosteon Pelvis in extreme deformity, seen from tho brim.
sacrum is  very much incurvated, and  the acetabula are much
closer together than in the normal pelvis.  The ilia, instead of
being carried  bodily forwards as  in  the rickety  pelvis,  are 
476     DUNCAN ON MALACOSTEON  AND RICKETY PELVIS.

folded up, and the iliac fossa is  made  to resemble an oblique
furrow running from above downwards.
Fig-. 131-
The same Malacosteon Pelvis, seen from the outlet.
  Dr.  Matthews  Duncan,  of  Edinburgh, has  elucidated the
difference between rickety and malacosteon pelves, most admir-
ably, in a brief but very able paper in the Edinburgh Medical
Journal for April of the present year.   Numerous diagrams are
given by him, which  convey  more distinctly to the mind the
nature of the deformities they are intended to  illustrate than can
be done by  any  mere written description.   Some  of  these
diagrams are  copied below, and others are modified with a view
to their  simplification.  In  the first place, Dr. Duncan  gives
profile sections of  the pelvis, or rather of that part of the true
pelvis  which is  above the  middle of the third piece of the
sacrum.  The superior plane of the  pelvis is considered as di-
visible into two parts, one posterior and  another anterior, sepa-
rated  from each other by a line drawn across  the pelvis from
one ileo-pectineal eminence to another.
  The same letters apply to  each figure, except that Nis a sec-
tion of the normal pelvis, R of  the rickety pelvis, and M of the
malacosteon pelvis. K is a line drawn from the promontory of
the sacrum (P) to  the middle of the third piece of the sacrum
(W).   C is the sacro-pubic diameter of the brim; S is the upper
part of the symphysis pubis ; D is a diagonal diameter joining
S  and  W;  T is  the  point in the  vertical  plane {P  W S)
traversed by the horizontal  line, which joins  the ileo-pectineal
eminences: in the malacosteon pelvis, this point is  however 
                    DR. DUNCAN S DIAGRAMS;                 477

without the plane.   The dotted lines, T P,  T S, show the rela-

                             FlS, 132.
Profile Section of Natural Pelvis.
tions of the two halves of  the plane of the brim to each other;
and the line  T W shows the relation of the middle of the ileo-
Profile Section of Rickety Pelvis.
pectineal line to third piece of the sacrum.   The  distance be-
tween T and C in each case helps to illustrate the nature of the
Fig. 134,
p,________■;..
w^£
Profile Section of Malacosteon Pelvis.
ilio-pubic angle.   The following table will show the measure-
ments in each case, and develop their essential differences : 
478             duncan's vartetees of pelvis.

                   NOBMAL PELVIS.     BICKETT PELVIS.
                    Millimetres.       millimetres.
 Length of  the line  G  118.....74   . .
            «     K   68.....66   . .
            "     D  112.....104   . .
            "   T P   IS.....50  . .
            "   T 8   40.....28  . •
            "   T W  Nearly the same in each variety
 The distance of T below 0 3.....11.5  . .
 The distance of T above (7 0......0  . .

  "From these measurements," Dr. Matthews Duncan observes,
" it is evident that the  two halves of the plane of the brim,
which,  in  the  normal pelvis, are  almost directly  continuous,
form with one another,  in the rickety pelvis,  an  angle open
above, and in the malacosteon pelvis, an angle  open below—in
both cases of about 141°."
  The three varieties of pelvis  are still  further compared by
studying transverse  or  horizontal  sections.   The two halves of
the plane of the  brim are now regarded as continuous.   As be-
fore, N is the normal, R  the rickety, and M the malacosteon

                             Fro.  135.
Transveree Section of Normal Pelvis.
pelvis; P is the promontory of the sacrum in each case; S is the
symphysis pubis; / I are the ileo-pectineal eminences, joined
MALACOSTEON PELVIS.
  millimetres.
 .  104
 .   38
 .  134
 .   49
 .   62

     0
 .   18 
DIAGRAMS OF DEFORMED PELVES.
479
by the line which  cuts the vertical plane (P WS) in the first
series of figures, at the point T\ and P //are triangles, con-
structed upon this  line.  Comparing these  triangles, it will  be

                           Fia 136.
Transverse Sections of Rachitic Pelvis.
seen at once that the base is very much the same, whether the
pelvis be normal or rickety, but that in the latter the apex has

                           Fia. 137.         i
Transverse Section of Malacostoon Pelvis'.
approached the base to a considerable  extent.   In  the mala-
costeon pelvis, the points P //have all approached each other 
480
PATHOLOGY OF RACHITIS.
very much, and the triangle included by the lines which join    •
these points is much smaller than in either of the other pelves.
These sections  illustrate also the rostrated form of the  anterior
half of the pelvis, and the folding of the iliac wings in malacos-
teon; they also indicate the sinking forward, en masse, of the ilia,
which  was spoken of before as taking place in rickets.  It is
almost unnecessary to add anything more in the  way of illustra-
tion ; the diagrams almost explain themselves.
  The  pathology of the  diseases which result in  the two fore-
going species of deformity  is of considerable interest.  There
are many points of analogy between  the intimate conditions of
the bones in  each case, but there are variations in the details
which  affect  the progress,  terminations,  and alliances of  the
morbid  conditions.   As  a  general  statement, however, it may
be said, that both in the  case of rachitis and osteo-malakia  the
morbid processes partake very much of the nature of inflamma-
tion.
  Rachitis may be divided into three distinct periods. The first
is one of rarefaction, as it is called  by French pathologists ; or
in other words, the structure of the bone  opens up.  In  the
second period, there is something deposited, and hence  this  has
been called the period of organization.  If the disease tends
towards recovery, the third  stage, or period of consolidation, is
established; if,  on the other  hand, the morbid processes  are
pushed  on to their final developments, destruction of  osseous
tissue is in a great measure consummated, and the subject of the
disease perishes either by hectic fever, marasmus, or some inter-
current  disease, such  as  pneumonia or diarrhoea; there  is
generally tubercular deposit in the organ affected.   In  the first
stage of  the disease, the  bones preserve their normal form and
direction, but their consistence is  somewhat diminished, and
they are  more  elastic.   The periosteum  becomes much more
vascular,  is thickened, and adheres to the  bone  more closely
than natural.   On stripping off the periosteum, the bone will
be found moist, uneven, and destitute of its usual smooth aspect.
Between the surface of the bone and  the periosteum, there  is a
deposit of gelatinous, pinkish  matter.  Upon  examining  the
exterior  of the bone  with a glass of small  magnifying power,
after this matter has been washed off, the Haversian canals will
be seen to be much more distinct  and of greater  calibre than 
PROGRESS OF RACHITIS.
4S1
natural, and they are filled with the gelatinous material.  "When
first effused, this is more fluid, and it only assumes the gela-
tinous condition after a certain time.  M. Guerin has examined
this deposit microscopically, and  says that after the exudation
in  question has become  gelatinized, organization  takes place,
somewhat  after the  manner of  false membranes,  and  that
myriads of small  vessels may be  distinguished crossing each
other, and  forming an inextricable web.  The changes  which
occur  in the  bones are more pronounced in  long than in  flat
bones, and  are still  more remarkable in  the epiphyses than
in the shafts.  In all bones, however, and throughout the whole
structure of each bone, the areoles are widened, the structure is
loosened, and a slight increase  of volume takes  place.   The
medullary  canal, as well as  the interspaces  between the solid
elements of the  bones, are filled with the sanguinolent, greasy
matter  referred to  above ;  the  color  has been compared  to
that of currant-jelly.   The  precise spot  at  which  the histo-
logical changes referred to are most prominently developed is,
however, just  where  the  shaft and epiphysis of the  bones
join, or in  that portion of cartilage which is undergoing osse-
ous transformation.  The flat bones become  somewhat  swol-
len.
  Thus the phenomena of this period are—first, vascularization
of the  bone and periosteum ; secondly, slight swelling of  the
epiphyses and flat bones; thirdly, openiug up  of the osseous  tis-
sue, due to effusion of the sanguinolent matter, and absorption of
the calcareous particles of the bones ; and fourthly, softening of
the bone, diminution of specific  gravity, acquisition of unnatu-
ral  elasticity,  and the first indications of yielding to pressure.
The second stage of the disease is marked  hy a still greater in-
crease  of volume, especially towards the extremities in long
bones ; this is  more apparent than real, but nevertheless  it will
not do  to attribute the whole of the apparent increment of  the
epiphyses to atrophy of the muscles, above and below the artic-
ulations.  The bones now begin to curve and yield to pressure
in a very  marked  manner.  Some of the curvatures are  the
result of the weight of the body itself; others are the result of
muscular action, and  the habitual posture  of the child will
materially  affect the  character of  the  distortions, especially
about the pelvis. The vascularity  and softening of the bones,
                             31 
482                 RACHITIC CONSUMPTION.
 and the opening up of the lamellae, keep pace with  the con-
 tinued  effusion which obtains as the disease advances.  The
 effused matter, wherever it is  poured out, becomes adherent to
 the  surfaces with which it  is  in  contact, and is transformed,
 especially towards the extremities of the bones, into a reticular,
 elastic, reddish tissue, like a fine sponge.   It is curious to  ob-
 serve that the convex  aspect of the  bones differs very much
 from the concave ; and that it is somewhat  granulated, and is
 sonorous when struck.  The concave surface, on the contrary, is
 of the consistence of cartilage, or of a bone softened  in acid.
 The touch, as well as inspection,  reveals  a totally  different
 composition, and  a  dense  but  soft and elastic  tissue  may be
 recognized adhering intimately to the under surface of  the peri-
 osteum ; this tissue is thick on  the concave surface of the bone,
 but is insensibly lost on the lateral aspects.   The calibre of the
 medullary canal is considerably diminished. If the disease tends
 towards recovery, absorption of the calcareous portions  of the
 bones is reduced within natural limits, and solidification takes
 place.   The reticular tissue becomes dense, and spiculse of bone
 are found in it; the  lamellae thicken, and ossification is carried
 on with great  vigor.   Towards the extremities of long bones the
 adventitious reticular tissue is in a great measure re-absorbed.
 Now, the curvatures of the bones diminish to a certain extent,
 but this depends upon their degree, intensity, and  the  develop-
 ment of the subject  of the disease ; if the curves have not been
 very great, and reparation occurs early, very little trace may
 be left of the  disease, but opposite  conditions can hardly  fail to
 result in permanent deformity.  Should the  disease pass on to
 its most untoward termination, osseous structure is almost en-
 tirely destroyed, and the intimate  condition of the skeleton is
 very similar to that which obtains in osteo-malakia.  M. Guerin
 has named  this condition  "rachitic consumption."   A  most
 elaborate account of  the pathology both of rickets and osteo-ma-
 lakia is  to be found in M. Beylard's work on these subjects,
recently published, of some parts of which the foregoing details
 are an abridgment.
  The following rough analysis of  the  constituents of  bones in
rachitis, as  compared with the normal state,  will indicate as
 clearly as possible the nature of the organic defect which results
 in torsion and fracture:
4 
MOLLITIES  OSSIUM.
483
                        Organic matter.      Inorganic matter.       TotaL
Rachitis—Rokitansky.....81.....19.....100
        Davy......74.....26.....100
        Bostock......80.....20  .  .    .  .  100
Normal bone in the child—
        Schreger.....50.....50  .....  100
   Osteo-malakia would appear to occur in two forms.    In one,
 fragility of the bones is most apparent; in the. other softening.
 In the  first variety numerous  and repeated fractures occur  in
 nearly  all the long  bones;  in the  second, distortion  is the
 characteristic result.   Syphilis, cancer, and a rheumatic diathe-
 sis, have each and all been claimed by various writers as allied
 diseases to the one  in question.  There is no doubt that  great
 fragility of the bones  occurs in  the advanced stages of  cancer,
 and sometimes also in syphilis when it  has become constitu-
 tional, but it can hardly be said that mollities ossium, properly
 so called,  has any special relations  with other  constitutional
 diseases; if any one  condition is more constantly related to it
 than another,  it is perhaps that  of utero-gestation frequently re-
 peated.  In every gestation the  system of the mother has to part
 with a large quantity of osseous matter for the development of
 the foetus.   The simple mollities ossium appears  to be more like
 advanced infantile rickets, and  fragilitas ossium  is, according to
 Mr. Paget, a true fatty degeneration of bone.   The. worst cases
 of the disease are ushered in by acute pains all  over the body ;
 the urine  is loaded with a whitish deposit (phosphatic), and a
 general cachexia appears to have invaded and taken possession
 of the system.  As  a general rule, the disease is fatal after re-
 peated fractures of  the bones have taken place, or the skeleton
 has become  strangely distorted.   The familiar engraving of
 Madame Supiot illustrates  the  extent to which the bones will
 yield in extreme cases.  The rule as to fatality, however, is not
 an absolute one; for Naegele" relates a most remarkable case of
 a woman who  had six healthy living children at the full period;
between  her sixth and seventh labors she became the subject of
malacosteon, and such distortion of the pelvis took place that
 delivery  had  to be effected  by the  Caesarian  operation; the
patient died.  The most remarkable point in the case was that
the pelvis had regained its natural density.  Thus death was the
result of the operation  for delivery, and there is  no reason to 
4S4      ANALYSIS OF DISEASED AND HEALTHY BOXES.

doubt that the woman would have entirely recovered had preg-
nancy not taken place, or the operation been  rendered necessary
by the previous distortion.   When the disease occurs in women
who are breeding, it is  frequently progressive, increasing with
each pregnancy.  In a case reported by Dr. Cooper  in  the fifth
volume of "Medical Observations and Enquiries," the deformity
increased in such a manner as to reduce the sacro-pubic diame-
ter of the pelvis to an inch and a quarter in the last  pregnancy ;
the Caesarian operation was performed, and the patient died.
Barlow reports eight analogous cases in his Essays.  The effects
produced upon the bones in the form of disease under consider-
ation  are, alterations of form, weight, and consistence, and to
these  may be added fractures and alterations of the  intimate
structure of the bone.  A brief sketch of these particulars must
suffice.  The alterations in form are infinitely various according
to the intensity of the malady, the action of the various muscles
attached to the bones, the use made of the limbs by  the sufferer,
the positions habitually assumed, and  sometimes modifications
are produced by their  supporting apparatuses.   Long bones
curve at first in the direction of the normal flexures  and at their
weakest points ; in a more advanced stage they assume S- or Z-
shaped  irregularities of form.   Flat bones fold up, as it were,
and are also compressed by superincumbent weight.  Fractures
take place generally  in a transverse direction in long bones, and,
as the force applied is comparatively feeble, the periosteum does
not necessarily rupture.  M.  Buisson met with a case  in which
there was an immense number of  fractures,  sixty-three ;  nearly
all were more or less undergoing reunion.  Wilson has observed
that in the  same subject fractures unite, while others take on
hardly any reparative action; false joints sometimes result from
these ununited fractures.  The specific gravity of bone is very
much diminished in this disease, not only by the removal of a
large quantity of earthy matter, but by the superaddition of a
quantity of fat, amongst which are the ordinary fat of the human
body and crystals of margarine separately aggregated  together.
Healthy adult bone  has a specific gravity of from  1.97 to 1.87.
Rokitansky  gives .721 as  the  specific gravity of  bone in a case
of mollities.  Chemical analysis shows an enormous diminution
of earthy matter.  The two following analyses are by Berzelius
and Rokitansky respectively: 
              EARTHY MATTER OF THE SKELETON.           485

                       Animal matter.      Inorganic matter.        Total.
Healthy adult bone.....33.30.....66.70.....100
Bone affected with mollities  .  .  76.20.....23.80.....100

  In Mr. Wood's articles on the Pelvis, in the " Cyclopaedia of
Anatomy and Physiology," there is a table of the  respective
amounts of earthy matter in various parts of the skeleton ;  and
he has pointed out a fact which is very interesting—viz. that of
the bones of the pelvis, the  pubes is that which loses most of
its earthy constituents in malacosteon.  This accounts, he says,
for the rostrated form of the pelvis in certain  cases.   The  inti-
mate  changes which take place are very analogous to the more
advanced stages  of infantile  rachitis.  Some  variation occurs
according to  the kind of mollities. In general, it may be stated,
that the periosteum  is preternatural^ vascular, thickened, and
easily detached ;  it draws its prolongations  into the Haversian
canals along with it when detached, and sometimes spiculoe, or
granules of bone, adhere to it.    At  other times, the periosteum
is very adherent;  and, again,  it  is incrusted, as it were, on its
inner surface, with a thin  lamina of bone, and constitutes all
that remains  of a skeleton.   In the  celebrated case of Madame
Supiot it was quite  natural, notwithstanding the extremity to
which the disease had advanced.   The variable accounts given
of the state of the periosteum may perhaps depend upon the
different stages of the disease attained in the different specimens
reported  upon.   The bone itself undergoes  various changes,
which  consist of an effusion of gelatinous matter, like  that
poured out in rachitis.  This occupies the Haversian canals, and
the medullary canal also; and as  the lamellar structure is opened
up, occupies the spaces between the laminae.   The  areoles of
cancellated tissue are also filled with this matter;  and the par-
titions between them are absorbed as the disease advances.  A
large quantity of fat is to be found in the grumous contents of
the bony cylinder; and Mr. Paget is of  opinion, that in a great
majority  of  cases this quasi-gelatinous  matter is  indeed   only
disguised fat.  Before- the bones are reduced to  this extreme
point of degeneration, they may be cut with a knife, and  may
be even indented by the finger nail.  The laminse, or bone cor-
puscles, would appear to be generally enlarged and  the canal-
iculi  either  shortened or altogether absent.  Thus  there  is  a
general opening up of the structure of the bone, a vascularization 
4S6            NAEGELE ON DISTORTED PELVIS.

and  thickening of  periosteum, and an  effusion of  adventitious
matter, as in rachitis. The differences would appear to be in the
occasional absence of anything  abnormal in the periosteum, in
the extremely fatty  nature of the effusion, the  absence of that
fibroid organization  by which the bone is supplemented, as  it
were, in rachitis, in the disease  attacking all parts  of  a bone at
once, and, finally, in there  being, in  a great many cases, some
constitutional cachexia,  or cause of debilitation.
  A most interesting and important variety of pelvic deformity, is
the " obliquely distorted pelvis," first described by Naegele\

                           FiG»  138.
Pelvis obliquely distorted to a moderate degree.
  This eminent observer published a  most laborious  memoir
upon the obliquely distorted pelvis, in which he described most
accurately and minutely no less than thirty-seven pelves affected
with  this  malformation.   Those  who  desire  to study  the
deformity will find an excellent translation of the original work
by Dr. Christie of Aberdeen.   It will of course  be impossible
to follow Naegele throughout  his  laborious  dissertation.  We
must be  contented with reviewing the general characters of the
obliquely distorted pelvis, pointing out  the diagnosis of it in the
living  subject, and  considering  what  influence  it may have
upon  labor, and what are  the  pathological or other  conditions
out of which  it arises.   The following characters, then, are
general: 1. Anchylosis, or rather  fusion, of  the sacrum, with
one  or  other of the  iliac bones.   2.  Imperfect  development
of that lateral half of the  sacrum which is fused with  the ad-
joining  iliac bone.  3. Narrowing of the os  innominatum, and
diminished width of the great sacro-sciatic notch  on that  side 
RESUME OF NAEGELE'S VIEWS.
487
on wlrjch the anchylosis of fusion  exists.   4. Deflexion of the
whole sacrum towards the anchylosed side, and  turning of the
anterior surface of this bone in the same direction.  5. Displace-
ment of  the symphysis pubis towards the opposite side to that
on which the sacro-iliac fusion obtains.  6.  Diminished excava-
tion, or  greater pianeness, of the inner surface  of that lateral
half of the pelvis which is on the same  side as the anchylosis.
7. Diminished curvature of the posterior half of the linea ileo-pec-
tinea on the side opposite to the anchylosis, and increased  curv-
ature of  its anterior half.   8.  Increase of that oblique diameter
which extends from the anchylosis to the acetabulum of the  other
side, and diminution of the remaining oblique diameter.  9. The
distance  of the promontory of the sacrum from the acetabulum,
on the anchylosed side, is much less than the same measurement
on the opposite side; and the same  is true of lines drawn from
the promontory of the sacrum to either ischial spine.   10.  Con-
vergence of the walls of the pelvis  inferiorly, approximation of
the spines of the  ischia, and narrowing  of the sub-pubic  arch.
11.  A  vertical plane, coinciding with  the sacro-pubic diameter
of the pelvis, does not correspond with the  mesial plane of the
body, but is  deflected so as to  make an angle, with a vertical
transverse  joining it  posteriorly, greater than a right  angle  on
the anchylosed side, and less than a  right angle on the opposite
side.
                            Fick 139.
Pelvis obliquely distorted to a great extent.
The diagnosis of an obliquely distorted pelvis is not par- 
488
DIAGNOSIS  OF  DEFORMED  PELVES.
ticularly difficult, now that we are in possession of such exact
information as to the nature of the deviation.  Notwithstanding
this circumstance, such a distortion, unless very much exagger-
ated, is extremely liable to be overlooked.   The subjects of this
deformity are, generally speaking, well shaped in other respects;
there is no very striking diminution of their breadth across the
pelvis; they are as active as other people; and there is, in fact,
nothing to call attention to them, until obstructed labor reveals
the condition of their pelves;  always provided, as before men-
tioned, that the deformity is not extreme.   The gait is affected
when much distortion obtains.   Should any suspicion of this dis-
tortion arise, we may seek for  information in three ways: first,
by  vaginal  examination;  secondly, by  external measurements
with Baudclocque's " compas  d'epaisseur;" and thirdly, by let-
ting fall certain vertical lines  from points of the surface of the
body, whilst it is in an erect posture.   Vaginal examination will,
perhaps, yield less information than either of the other means of
exploration.  The promontory of the sacrum is generally pretty
well out of reach ; the cavity appears roomy enough; and the
narrowing of the sub-pubic arch and convergence of the parietes
of the pelvis  inferiorly, are not sufficiently pronounced  to be
readily  appreciated  by the toucher.   More  reliance may be
placed on  external  measurements,  taken from  certain  easily
recognized osseous points, to other similar ones, generally on the
other side of the pelvis.  From the description given before of
the general characters of the kind of pelvis under consideration,
it will be seen at once that the following rules are merely corol-
laries of the statements made them.
  The following distances should be taken and compared:
  1. From the tuberosity of the ischium  on one side, to the pos-
terior superior spinous process of the ilium on the other side.
  2. From the anterior superior spinous process of one side, to
the posterior superior spinous process of the other side.
  3. From the spinous process  of the last  lumbar vertebra, to
the anterior superior spinous process of each ilium.
  4. .From the trochanter major of one side, to the superior pos-
terior spinous process of the ilium on the other side.
  5. From the symphysis pubis, to the superior posterior spinous
process of each ilium.
  It is quite unnecessary to state what are the normal measure- 
CAUSES OF DEFORMED PELVES.
489
 ments of each of these distances; the significant  fact is  their
 relative length.  If there is any very marked difference between
 the  corresponding  measurements—say, on an  average, half an
 inch to an inch—there is reason to suspect oblique distortion;
 and the side on which the anchylosis is may be determined by
 bearing in mind the following short rule—viz., that in measure-
 ments 1, 2, 4, and 5, the posterior extremity of that measurement
 which exceeds its fellow is on the  side of the anchylosis; and in
 measurement 3, the anterior extremity of the  shorter measure-
 ment is on the same side as the anchylosis.  The last method of
 examination is, to  let a plummet line fall from the symphysis
 pubis in front, and  another from the spinous process of the last
 lumbar vertebra behind, the body being erect.   If the pelvis be
 obliquely distorted, these lines will not both fall in the  mesial
 plane  of  the  body,  and the anchylosis will be found on the
 opposite side to that towards which the anterior line tends.
  The causes of oblique distortion have been stated to be,
 arrest of development, and fusion of the sacrum with  the ilium,
 and  anchylosis, in consequence of inflammation  of the sacro-iliac
joint.  Naegele* leans to that view of the case  which  considers
 the deformity as the result  of an  original anomaly of develop-
 ment, and for the following reasons: 1. Because the fusion of
 the  sacrum with  the ilium  is  complete, as well in  reference to
 the internal structure of the bones  as to their external condition.
 2. The breadth of the " os innominatum " of the affected side is
 affected, as well  as its  length.   3.  Synostoses of  other bones
 occur, as original anomalies of development,  and  are usually
 accompanied by  deformity.  4.  Tlie obliquely  distorted  pelves
 are all very much like  each other; and 5. Because no history
 of disease has ever yet  been traced in a case of oblique  distor-
 tion.  Dr. Rigby rather  inclines  to the inflammatory theory;
but  anchylosis has  occurred without  producing the deformity;
so that it is obvious that whether anchylosis from disorganization,
etc., of the  sacro-iliac joint plays  a part in bringing about the
deformity in question or not, it must at any rate be supplemented
by some other hitherto undiscovered condition.
  The influence exerted by oblique distortion on the progress of
 labor will depend upon its degree, and in part also upon the
presentation of the foetus.  The most favorable presentation will
be the apposition of the long diameter of the presenting part to 
490          DIMINUTION OF THE SUB-PUBIC ARCH.

the longest oblique diameter of the brim.   Supposing the head,
in a vertex case, to have entered the cavity of the pelvis, an
obstacle will now be opposed both to its descent  and rotation,
by the approximation of the spines of the ischia to each other ;
and the want of space anteriorly, in that direction towards which
the  occiput  rotates, would  be  a   still  further  impediment.
Emergence of the head would be  opposed by the  narrowing of
the transverse diameter of the outlet, and  by diminution of the
sub-pubic arch.  Naegele considers this distortion as important
as any other, because there are no circumstances  indicative of
deformity sufficient to arouse suspicion beforehand, because it is
frequent, occurs, in  healthy, well-formed women, has never yet
been recognized in a living female, and so far as is  known, has
always proved fatal  to both mother and child. 
LECTURE XXXII.
           deformities of the pelvis.—{Continued.)

   Gentlemen :—We were engaged in the last Lecture with  the
 study of the three most important abnormalities of the pelvis,
 whether considered from a mechanical or a pathological  point
 of view.  In passing on to the more subordinate deviations from
 the " standard pelvis," it must be  borne  in mind, that though
 they  may  be possessed  of less  theoretical interest,  they  are
 equally important  in relation  to the practice of the obstetric
 art; that the same  questions will be raised as to operative pro-
 cedures as  in the case of  the deformities already described, and
 that they will have  to be decided upon the same principles.
  Exostoses  and Osteo-Sarcomatous tumors, arising gen-
 erally from the internal surface of the pelvis, occasionally pre-
 sent an insuperable  obstacle to delivery per vias naturales.  The
 frequency of these growths, according to some, would  appear to
 have  been very much overrated.   Many  cases have  been put
 upon  record as exostoses, which have not  been proved to be so
 by a sectio cadaveris ; and the histories of others have  contained
 particulars which mark them out as being in reality something
 very  different to what  they were conceived to be  by  their
 authors.  Amongst  the cases of  doubtful authenticity may be
 mentioned  one which was reported  as an exostosis of the upper
 part of the sacrum: and, in order  to effect  delivery,  a red-hot
iron was passed up to the  quasi  tumor,  through an earthen
tube introduced  into the  vagina.  Delivery was effected in this
case, but the diagnosis was probably as incorrect as  the treat-
ment was barbarous.  Projection forwards of the promontory of
the sacrum has usually been the condition, without doubt, mis-
taken for osseous tumor of the bone.  In order to establish the
diagnosis of an  exostosis, or  other growth from the internal
surface of the pelvis, it is necessary not merely  to explore the
                                                     491 
492
BONY GROWTHS WITHIN  THE PELVIS.
cavity of the pelvis, but to compare the results of such exploration
with external admeasurements, and at the same time to inquire
into the previous history  and collateral circumstances of the pa-
tient.   The consistence of bony growths in this situation is not
so markedly different from that of the bone itself, as to furnish
discriminatory evidence of any value.  With regard to the na-
ture  of these growths, it may be stated  that  they are for  the
most part cancellated internally, communicating with the can-
cellated structure  of the bone from  whence they spring; and
externally they have a laminar wall more or less dense.  Some
exostoses of a denser nature, more like the ivory exostoses found
on the  cranial  bones,  have been mentioned as occurring  espe-
cially  in  connection with  the  anterior  walls  of  the pelvis.
Spiculae of bone, too, would appear to be occasionally developed
in some of those modifications  of the fasciae which constitute the
ligaments of the various pelvic  viscera.   A connection would
appear  to exist between osseous growths about the  pelvis and
the gouty or rheumatic diathesis.  In some cases a blow has ap-
parently been the origin  of the tumor.  The sacro-sciatic liga-
ments  are  sometimes partially ossified,  and fibro-sarcomatous
tumors at other times spring from them; the  first of these ab-
normalities produces a pelvis like that of the  Ai, or the Mylodon
Robustus.  The sacro-sciatic joints are the seats of some osseous
projections, and, in fact, almost any joint of the inner aspect of
Fia. 140.
Bony growth from the Sacrum.
the pelvis may be occupied  by tumors of various kinds; but
the upper half of the sacrum is the locus in quo of the great ma- 
             OSSEOUS  DEPOSITS WITHIN THE  PELVIS.         493

jority.  The influence exerted upon labor  by these tumors is ol
course proportionate to the  diminution they produce of the
various diameters of  the inlet, cavity, and  outlet of the pelvis.
Being in most cases  incompressible, any operative  procedures
instituted for delivery will be the same as in the case of diminu-
tion of the bony passages arising from distortion.  In some few
instances, tumors may be, and indeed have been, removed from
the pelvis in the  course of  labor, and with  perfect success; but
these have been fibroid growths, situated  near the outlet.  In
calculating the probable effect of a tumor within the  pelvis
upon labor, regard must be  had not merely to the degree in
which it encroaches upon the  cavity, but upon the  impediment
it may offer to the rotation of the fcetal  head.  Occasionally it
happens, in some cases of genuine exostosis, that the bony struc-
ture is so loose as to admit  of being broken down during labor,
either by the  foetal  head or  the  manipulations  of the  ac-
coucheur.
                         ■ Fig. Ml.
Sacral exostosis filling the Pelvis.
  The  Pelvis .JSquibiliter Justo Minor  is the next  devia-
tion from  the normal standard which we have to investigate.
As its name implies, this is a  symmetrical pelvis  smaller than
natural.  Three  distinct varieties are met with: first, where the
subject is  rickety and affected  with distortion  of the spinal 
494
UNUSUALLY SMALL PELVES.
 column or limbs, the  pelvis being unaffected, except as regards
 diminution  of size;  secondly, the  true dwarf has generally  a
 pelvis small even in proportion to the rest of the skeleton ;  and,
 thirdly, there are numerous cases of ever-varying degrees of sym-
 metrical contraction,  which are wholly disconnected  with any
 deformity or constitutional vice whatever.  The last category of
 cases must be looked upon simply as parallel to those freaks of
 development which produce small heads, small hands, or small
 feet; probably such deviations are all hereditary.  When  this
 departure from the normal standard coexists with rachitic dis-
 tortion in other parts  of the body, the diminution in the diame-
 ter of the pelvis is generally about one-fourth; thus the conju-
 gate diameter of the  brim would measure three instead of  four
 inches, and other diameters would be reduced in the same ratio.
 Various opinions have been pronounced as to the frequency of
 equable contraction of the pelvis.  Dr. Fleetwood Churchill be-
 lieves equable enlargement to be more common.  However this
 may be, it is pretty certain that  diminished  size of  the pelvis is
 much oftener met with than systematic writers would have us
 believe.   Dr.  Robert Lee  says, "About one-sixth of all  the
 cases of difficult parturition which  I have observed in London,
 depended upon narrowness of the pelvis, from  arrest of develop-
ment and distortion."  If we eliminate from this  estimate the
comparatively rare cases of actual distortion, how large a num-
ber will remain to be accounted for as mere arrests of develop-
ment?  The experience of every practical obstetrician who is not
 determined to find a special distortion in every case of impact-
ment of the foetal head, must point to this conclusion—namely,
that  of those cases which  require the use of  the forceps for  the
 remedy of impaction  within the cavity of the pelvis, a large
majority are simply instances of pelves rather  smaller than na-
tural.  Many  serious considerations attach  to the subject  of
 " equably contracted pelves;"  the chances are very much in fa-
vor  of its not being recognized until labor  has  come  on, or,
indeed, has made considerable progress ;  and even when recog-
nized, it is extremely difficult to determine the deo-ree of diminu-
tion, or  predicate the  nature  of the assistance likely to be
necessary.  When there is an obvious distortion, these difficul-
ties are eliminated from the question, and the special  deviation
stands out in bold  relief, as something not  to be  overlooked. 
EQUABLY CONTRACTED PELVES.              495
The nature of the impediment to delivery offered  by the reduc-
tion of the size of the pelvis, is of a double character: there is
an obstacle to descent, and an obstacle to rotation.  Bearing in
mind what has been said upon former occasions as to the resem-
blance of the internal surface of the pelvis to a female screw, it
will readily be understood that a comparatively slight contrac-

                            Fig. 142.
           Skeleton of a rachitic Dwarf with equably-contracted pelvis.

tion is  sufficient to derange the intra-pelvic  rotations of the
foetal head ; and a slight impediment to rotation is tantamount 
496
HYPER-OSSIFIED INFANTILE PELVIS.
 to a vastly greater impediment to direct descent, upon  obvious
 mechanical principles.
   Allied to the  Pelvis  JEquabiliter Justo Minor, are certain
 other forms of diminution, such as the " Infantile Pelvis " and
 the " Masculine Pelvis."  These abnormalities differ from the
 one  just considered in possessing a special character.  The in-
 fantile form of pelvis, besides being decreased as regards size, is
 more oblique in  position;  the antero-posterior diameter of the
 outlet is as  great, if not greater, than the transverse ; the arch
 of the pubes is narrower, the  tuberosities of the ischia are ap-
 proximated, and  the whole pelvis is  shallow.  Such pelves as
 these are not always completely ossified; thus the several pieces
 of which the innominate bone is composed may still remain dis-
 crete, and the segments of the sacrum may not have coalesced.
 It occasionally happens that this type of abnormality co-exists
 with size equal to the adult pelvis.   Dr. Murphy has described
 a pelvis of the infantile type, which was absolutely larger than
 the normal  adult pelvis ; the  antero-posterior diameter in this
 case was five inches and a half, and  the whole pelvis was per-
 fectly ossified.  The  " masculine pelvis " is, as its name implies,
 one which approximates very much in dimensions and character
 to the pelvis of the male.  Such conformations are met with
 in the persons of robust laboring  women, in  whom there  is a
 general resemblance to the opposite  sex, not only in this one
 particular, but in nearly all those marks which pertain to sex. It
 is not uncommon to see women of the lower orders, whose bones
 are very large, voice harsh and loud, and face coarse and hairy.
 The  pelvis  which affects the masculine  type of  development
 is rounder and smaller at the brim ; the cavity is deeper, and is
 convergent inferiorly or funnel-shaped ; the spines of the ischia
 project into  the cavity of the pelvis; the tuberosities of the same
 bones are  approximated : and all the eminences, processes, and
 ridges, are more pronounced than in the standard female pelvis.
 An hypothesis has  been put  forward  to  the effect that  this
 variety of formation  is a hyper-ossified infantile  pelvis.   I  am,
 however, rather inclined to accept it simply as  one of those
 occasional instances  of convergence of the sexes with which
 every observing  person must be  familiar. Parturition will be
affected much in the same  way as in the infantile  pelvis • if
there is anchylosis of the coccyx with the  sacrum or any other 
UNUSUALLY LARGE PELVES.
497
pelvic joints, as is sometimes the case, additional difficulty will
be encountered.
  The Pelvis JEquabiliter Justo Major is one in which  the
measurements  are absolutely increased,  their relative  pro-
portions being  observed.   Recorded instances are not very
numerous, and  this is obviously because women affected with
this deviation are not generally  the  subjects of protracted or
dangerous labors.  It must not, however, be  assumed that a
very roomy pelvis is  necessarily  associated with very rapid or
easy  delivery,  for it would  appear that the effect upon  the
mechanism of labor of a too large pelvis is, to a certain extent,
accidental.  It  may happen that, from a want of approximation
between certain  correlated diameters of the pelvis and foetal
head, those rotatory movements which conduce  to natural  de-
livery do not take place; and this applies to cases in which the
pelvis is too large, as well as to  cases in which it is too small.
The idea of the screw may be made subservient here to a  cor-
rect  appreciation of  what would appear,  at first sight, para-
doxical, if it is remembered, that  unless  those points of  the
foetal head and  the pelvis of the mother which represent respec-
tively the flange and worm  of a male and female screw, are
brought into apposition, the movement of the head through the
pelvis will be one of advance simply, without any rotation ;  and
this movement  of advance  may very well take place in such a
manner as to bring the longest diameter of the foetal head  into
relation with the shortest diameter of the outlet of the pelvis.
The  mechanism, then, of labor, where the pelvis is wider than
natural, must be looked upon as something indeterminate  and
fortuitous.   Should the fcetal head have the proper rotations
accidently impressed upon it, or should it gravitate into  the
proper position, labor will be easy and rapid,  but it may in
some  cases be otherwise.  It is very probable that those  cases of
unconscious or  sudden delivery which are quoted  in works on
medical jurisprudence were, to a certain extent, connected with
abnormal width of the pelvis.  Narcotism arising from drugs or
disease may abrogate consciousness during labor;  but where
neither of these circumstances obtains, diminished resistance on
the part of the soft or  bony passages must be looked to in expla-
nation of the phenomena in question.   The works of Dr. Taylor
and Dr. Beck  abound in cases of sudden  and almost  painless
                             32 
498
INCREASED CURVATURE OF SACRUM.
delivery, which  can hardly be accounted for, except  upon the
supposition of there having been an enormously wide pelvis.
Amongst the other effects of increased capacity of the pelvis
upon the process of labor  is, descent of the uterus while  the
fcetal head is still within the os uteri.   Instances of this have
been recorded, in which the foetus has passed the external geni-
tal opening as far as the shoulders, the  head being still closely
invested by the uterus.  Such a condition as this is obvioushy
favorable to the occurrence of inversion of the uterus ;  and this
latter may, in  fact, be enumerated as one of the untoward  cir-
cumstances  to  be  apprehended  in  connection with  enlarged
pelvis.  Prolapse of the various  viscera within the pelvis, and
retroversion of  the uterus, are conditions favored, or  likely to
be  induced,  by the  abnormality under consideration.    The
largest pelvis of this kind, whose dimensions have been recorded,
is one described by Giles de la Tournette.   The most important
diameters were—
                                                  Total.
       Antero-posterior of brim    ...........5.5
       Transverse of brim..............6.5
       Antero-posterior of outlet...........5.5
       Transverse of outlet.............5.5

  Dr. Barnes and  Dr. Murphy have described pelves of nearly
equal size.   As regards the relation of increased capacity of the
pelvis to the general conformation and stature of the individual,
it  may be stated as a general rule, that tall women are by no
means likely to be the subjects of such  increment; it has rather
been observed that women of low stature, and with large heads,
have the most capacious pelves.  Some persons profess to dis-
cover a relation between the length of the phalanges of the fin-
gers and the capacity of the pelvis, maintaining  that women
with curb fingers have small pelves, and vice versa.
  Flatness of the sacrum, with or without an  alteration of
the angle made by the sacrum  with the vertebral column, is
occasionally met with.  The obvious consequences of this abnor-
mality  are,  diminution of the antero-posterior diameter of the
cavity of the pelvis, and obstruction to the  intra-pelvic rotation
of the fcetal head.   Increased curvature of  the sacrum is gene-
rally connected with some morbid condition of the bones but as
a deformity, per se, it is not  of  great  interest.  In some  rare 
CAUSES OF PELVIC DEFORMITIES.
499
cases of spinal deformity, the curve of the spine is so considera-
ble that the lower lumbar vertebrae descend into the pelvis, and
occasion a deformity equal in extent to a large exostosis, or the
deformity of osteo-malacia.  At the present time, these cases are
attracting considerable attention in Germany.
  Fractures  and dislocations  of  the pelvis occasionally
result in a diminution of its diameters.   Such cases, however,
must be very rare, as women are not generally exposed to those
violent  mechanical  injuries  which produce displacements, of
any kind, of the various segments of  the pelvis.   Mr. Barlow,
however, performed one of  his successful  cases  of  Caesarian
section in consequence of distortion, resulting from the fracture
of an innominate  bone.  The rarity of fractures of the pelvis in
women is compensated for, if the expression may be allowed, by
the fact that they are generally attended with permanent dis-
placement, or other results which tend to diminish the capacity
of the pelvis.   The deposit of callus which  takes  place would
appear to be very erratic, and  to  have a tendency to encroach
upon the cavity of the pelvis. Dr.  Lever  met with  a case where
there was a bony  projection of more than an inch into  the pel-
vic cavity, in consequence of a fracture of the acetabulum; and
Burns relates a case where a similar  ossific formation resulted
from a similar injury, the projection being two inches long.
  Miscellaneous deviations from a normal condition of the pel-
vis will include, in addition  to those already mentioned, projec-
tions of various points of its  osseous anatomy inwards,  without
any general vice  of conformation;  and the results of dislocations
of the hip-joint, arising from morbus coxarius.
  The study of  the  causes of those  pelvic  deformities which
depend  on irregularity of development or growth, is a subject
of great interest, and one which has  occupied the attention of
many great obstetric authorities.   These deformities have been
explained in various ways,  all  having relation to the  real or
supposed laws  under  which the  normal pelvis  is developed.
The latest hypotheses have been those  advanced by MM. Dubois
and  Gavarret  in  France, and Dr. Matthews Duncan  in  this
country.   Dubois and Gavarret suppose the  development of the
sides of the pelvis to depend on the wedge-like pressure of the
sacrum between the innominata. When anchylosis exists in one
or  both  of  the  sacro-iliac  synchondroses,  they  suppose the 
500
RATIONALE OF THE OBLIQUE PELVIS.
wedge-like pressure to be destroyed, and in place of the natural
curve of the  sides of the pelvis, the line becomes straightened.
When the anchylosis affects one side only, the development of
the affected  side is interfered with, while the other half of the
pelvis is developed in a normal manner, and oblique distortion
is the result..   When there is a  double anchylosis, both sides of
the pelvis are straightened, and the deformity, instead of being
oblique,  is symmetrical.   Dr.  Matthews Duncan controverts
these views very forcibly.   He  believes  that the  lateral curve
of the pelvis is produced by the pressure of the  trunk above,
and  inferior  extremities below, upon the sacral  and  cotyloid
ends of the beams formed by  the ilia.  I believe the mechanical
relations pointed out by Dubois and by Dr. Matthews Duncan
really exist;  that the sacrum acts  as a wedge, and that the ilia
acquire  a tendency to  curve from  the pressure  exerted by the
sacrum from above, and the femora from below; but other con-
siderations besides  those of mere mechanical weight and pres-
sure enter into the problem.
   At the time of puberty we have  the three  permanent articu-
lations of the true pelvis—namely, the two sacro-iliac synchon-
droses and the  symphysis pubis.  We have also the Y-shaped
triple articulation  between the ilium, ischium, and pubes on
each side.  These make in all nine articulations, and seven sepa-
rate  bones for the  true pelvis.   These  bones all grow from
the centre to the circumference ; and it is to their circumferen-
tial increase,  taken  collectively, that the expansion of the pelvis
at puberty is attributable.   It is not a little remarkable, that the
division  between the  ischium, ilium, and pubes, should remain
until after the completion of the development of puberty.  The
capacity of the pelvis must very much depend on the period at
which the junction of these bones takes place.   When anchylosis
takes place between the sacrum and ilium, before the period of
puberty, the  circumferential increase  of the  aspects of the
sacrum  and  ilium  engaged  in the articulation is impossible.
Hence the arrest of growth on the anchylosed side of the pelvis
upon  which oblique deformity depends.   This appears  to me to
be the chief  element  in the  rationale of  the oblique pelvis of
Naegele\  The medium of union between the sacrum  and  ilia
and the  pubic bones at  the symphysis, is very much more  conso-
lidated after than before the development of puberty.   It is pro- 
DIAGNOSIS  OF THE OBLIQUE PELVIS.
501
bable that when  this consolidation and the obliteration of the
Y-shaped articulation takes place early, we have, in some cases,
the infantile, or equably-contracted pelvis.   When it occurs late,
we have, I would suggest, equably-enlarged pelvis.
   In the case of early anchylosis of some of the cranial bones,
we have flattening and diminution of the size of the head in the
vicinity of the anchylosis.  It appears to me, then, that the sim-
pler explanation  of the dependence of certain  pelvic  deformi-
ties upon the conditions of growth and development is much to
be preferred to the recondite influence of mechanical and mathe-
matical causes.   Passing from the circumferential increase of
the pelvic bones themselves at puberty to the cause of  this
increase, we  come to the  action  of the ovaria.   It  is to the
development and activity of the ovaria  at  puberty  that the
development of the  pelvis at this  epoch  is due.   Where the
ovaria are wanting, the  pelvis  is not developed, just as  in the
case of the removal  or  absence of the  testes  the  bones of the
larynx do not undergo their usual development at puberty in the
male.
   Instruments for obtaining the internal and external admeasure-
ments of the pelvis were  formerly much used in  the diagnosis
of pelvic deformities, and in forming an estimate of the proper
treatment to be  pursued.  They have, however ingenious, gra-
dually given way, particularly in this country, to the use of the
educated finger as the best of all pelvimeters.   Before the com-
ing on of labor, deformities of the  pelvic  brim may sometimes
be measured by introducing the two first fingers and separating
them so as to touch  the promontory of the sacrum and of the
symphysis pubis, and then altering their position so  as to measure
the  transverse diameter.  Where the deformity is   high up,
this manipulation fails, and it becomes necessary  to  introduce
the whole hand into  the vagina, when a satisfactory exploration
can be made.  Deformities of the  outlet may be  diagnosed by
the finger alone,  with sufficient readiness by the practised accou-
cheur.   Before the  coming on  of labor, we have, in cases of
deformity, to compare the diminished pelvis with  the pelvis of
average size.   In actual parturition, we  have to compare the
deformed canal  with the size of the foetal head which  has to
descend through it.   A given amount of deformity may of
course be very formidable or of little import, according as the 
502         AIDS TO  LABOR WITH DEFORMED PELVIS.

child is mature or premature, living or dead, or according as the
head is large and ossification  more or less perfect.  In labor, it
is more difficult to introduce the whole hand, but this is some-
times necessary and proper when the head, or presenting part, is
arrested high up in the  pelvis.   The single finger passed in to
its utmost length and rotated within the pelvis will seldom fail
to inform  us of the existence of deformity or  diseased growths
in the pelvis.  This information having been acquired, we can
introduce two  or three fingers, or  the whole hand, as may be
necessary, to make out the special condition of the pelvis.
  The Treatment of Labor, complicated  with Deformed
Pelvis, varies according to the amount of impediment presented,
and according to the risk in which the mother is placed by the
energetic action of the expelling powers when the foetus cannot
pass through the pelvis in the  ordinary manner.  The aids to
delivery, under these  circumstances, are the Yectis, the short or
long Forceps, according as  the head may be arrested at the out-
let or brim of the pelvis; Turning, in cases of shoulder presen-
tion, and also in certain cases where the deformity is such as to
warrant the belief that  the head may be extracted, but where
the forceps are inapplicable ; Craniotomy, in cases where the
head of the living child cannot  pass, or where the continuance '
of labor, without assistance, endangers the life of the mother;
and lastly, the Caesarian Section, in cases where the  delivery of
the child by perforation and the crotchet is impossible.   But
before and  beyond all these means, except  in cases where the
action  of the Lever, or the compression and  extraction exerted
by the Forceps, is  sufficient to give birth to the child alive, the
remedy, or rather the preventive of danger is to be found in the
Induction of Premature Labor.  A great and beneficent exten-
sion of the operation for the  induction of  premature labor  may
be made in these cases, and it is questionable—nay, almost cer-
tain, that  the  fatal  operation of hysterotomy would  rarely, if
ever, be called  for, if this  operation were always performed in
cases of distortion, and at the proper time.
  The cases and circumstances under which these several proce-
dures become necessary, in  the management of  labor compli-
cated with deformity, will  be entered  into fully  when treating
of these operations themselves in a subsequent part of the pre-
sent course. 
PELVIC DEFORMITY FROM BONY GROWTH.       • 503
  Addenda.—Dr. H. F. Kilian, of Bonn, has with great ability
and minuteness investigated  the deformity produced by the
development of spiculse and crests of bone on the edges of the
Cancerous growths from the bones of the pelvis,   Pelvic deformity, from anchylosis of the
          causing deformity.                     hip-joint.
different symphyses, the superior margin of the pubis, along the
linea-ilio-pectinea.  These thorns or  crests are simply a hyper-
trophy of the natural condition of the bones, but by projecting
Minor degree of deformity from exostosis of the pubis. 
 504 •  ABNORMAL SHARPNESS TO THE EDGE OF THE BONES.

 inwards they interfere with the progress  of labor, and lead  to
 rupture of the uterus by pressing upon and wounding the organ
 during the course of labor.   Cancerous  disease of the bones
 of the pelvis sometimes produces serious  pelvic deformity.   [I
 have especially seen cases where the edge of  a bone, as the
 promontory of the sacrum—in a case similar to that referred  to
 by me on page 515—or the symphysis pubis, being pushed out
 of its normal position,  by distortion remote from this point, and
 accidentally  happening to be  sharper than  usual,  had cut
 through, as with a knife, the uterine walls  pressed upon it.]
  Dr. H. F. Kilian  describes very  minutely  a form  of pelvic
 deformity depending on disease and displacement of the lumbar
 vertebrae to such an extent as to encroach on the pelvic  area.
 He believes  that by a disease of the cartilages of the lower
lumbar  vertebrae occurring  after  puberty,  the cartilaginous
structures are so softened as to allow the vertebrae to sink tosre-
ther, one upon the  other, and thus produce a high degree of
deformity at the  brim. 
LECTURE   XXXIII.
                     OBSTRUCTED LABOR.

  Gentlemen :—Having considered the subject of Pelvic Defor-
mities in the  two preceding  lectures, I wish, before directing
your attention to impediments  connected with the Soft Parts, to
say a few words respecting those morbid states of the Coccyx
which interfere with  labor.   The joint between the first bone
of the coccyx  and the  extremity of the  sacrum may become
anchylosed, or  the mobility of the  separate bones  upon each
other may be   destroyed by bony deposit.  Anchylosis of  the
coccyx may depend on inflammation, the result of blows or vio-
lence ; scrofulous disease of the sacrum  and coccyx;  injuries
occurring during difficult labors ; or it may exist in women who
become pregnant for the first time late in life. The coccyx may
from these causes become fixed in its natural position, it may be
curved  forwards, or it  may be bent at right angles with  the
extremity of the sacrum.  In either case  it may interfere with
the progress of labor, but particularly when the bone  is bent
forwards to a  considerable  extent.   Sometimes, as  in  a case
which recently fell under my observation, the coccyx is not only
incurvated forwards, but it is  considerably enlarged by scrofu-
lous disease. Encroachment of the coccyx upon the diameter
of the pelvis to such an  extent as to interfere with labor, is  not
a very  common event,  but in  the accumulated  records  of
obstetric practice many  cases are met with in which an anchy-
losed  coccyx has interfered with the course of labor  to such an
extent as to destroy the child.  In other cases, fracture of  the
coccyx  has  occurred  from pressure  of the head, and in some
instances this operation has been performed by the accoucheur.
The diagnosis of coccygeal anchylosis is not very difficult. The
immovable bone can be  felt by the finger in making an exam-
ination, and the extent of the impediment to the escape of  the
foetus readily appreciated.  The treatment in such cases must be 
506
MORBID STATES OF THE COCCYX.
either the application of the forceps, fracture of the anchylosed
bone, or  the induction of premature labor, in  cases where the
amount of impediment is great, and particularly where it has  in
previous  labors led to the  loss of the child.   No serious injury
has resulted from the  breaking down of the anchylosis, either
artificially  or  when  this has occurred in the course of labor•
but in  some cases the bony union is so firm as to render this
impossible, under the disadvantages  at which the accoucheur is
obliged to act.   In many  cases of otherwise  natural labor, the
coccyx is bent back to  such a degree as to leave a painful condi-
tion of the bone for months, or even years, after the occurrence
of labor.  This state is generally relieved by counter-irritation
over the  sacrum.
  Mechanical  obstructions to the progress of labor, depending
on  the state of the Soft Parts of the Mother, may occur at any
point of  the parturient canal, between the uterus itself, and the
external  parts  of generation.   In managing such cases, we have
to remove or diminish  the  obstructions to such an extent as to
admit of the passage of the child ; or we have to evade them by
inducing premature labor,  at a time when the  size of the foetus
is such  as to allow of its transit.   In many of these  cases,
other considerations  besides  those relating   to the mechanical
obstruction to  labor have to be taken into account.  The obstruc-
tions themselves may depend upon constitutional states, or they
may excite other disturbances apart from the impediments  to
labor.
  When speaking of the management of ordinary labor, I have
referred  to those cases  of rigidity of the uterus which  admit of
relief  without operative means.  Occasionally, cases are met
with where the rigidity is excessively unyielding, or  in which
the matter passes beyond  rigidity, and  there  is agglutination,
occlusion, or entire  obliteration of the os.   This may exist  to
such an  extent that labor becomes impossible, unless rupture  of
the cervix takes place, or  artificial assistance can be rendered.
In  cases  of this kind it has been known for the  whole of the
lower segment of the uterus to be  separated  in the form of a
muscular ring, and detached from the rest of the  uterus by the
strength of the pains  acting  against  an occluded os.   Other
patients  have  died undelivered, where rupture has not occurred
and where no operation has been performed. 
ENTIRE OCCLUSION OF THE OS UTERI.
507
  Excessive rigidity can be readily understood, but entire occlu-
sion of the os uteri is difficult of comprehension.  The causes of
this  extraordinary state  of  things are, it must  be confessed,
involved in obscurity.  It has been supposed by some authori-
ties that the marginal surfaces of the os uteri adhere together as
a consequence of inflammation or ulceration.   Others believe
that a  fa^se membrane is thrown out, which entirely  seals the
cavity  of the uterus.   Naegele-, the  younger, describes a  thin
membrane as being the medium of occlusion in certain cases.
Many  observers have declared their disbelief in the possibility
of entire obliteration of the os, and have believed that in  cases
where  it has been supposed to exist, the os uteri was only raised
so high towards the sacrum by anteversion as to render it impos-
sible to  reach  the  aperture.   So much  concurrent testimony
exists,  however, in proof  of the real occurrence of what appears
to be entire obliteration, that the reality of its  existence cannot
be doubted.  Dr. Ashwell relates a case in which incision was
required in four successive labors in the same woman, attended
by different practitioners.  The os uteri could not be detected.
Smellie,  Hamilton, Naegele,  Gooch,  Dubois, and others, have
also related cases in which there was entire or partial oblitera-
tion at the time of labor.
  It is evident that even in the worst cases there must have been
an os uteri to render conception possible.  But in  some women
the os  and cervix are  very imperfectly developed  in  the unim-
pregnated state, the aperture remaining so small as not to admit
a probe without difficulty.  The degree to which the os and cer-
vix develop during pregnancy is very different in  different
individuals, and 1 suspect that some at least of the cases of sup-
posed  occlusion of the os are in reality cases in which the fun-
dus uteri has become  developed to a normal extent under the
influence of gestation ;  but the os, originally small, has remained
altogether  undeveloped, or nearly so.  This explanation seems
to me more in accordance with the known physiological history
of the uterus than adhesion of the sides of the os, or the organiza-
tion of a false membrane in the aperture.  It can readily be
understood that when the os has remained throughout pregnancy
of the small size natural  to some women  in the unimpregnated
state, it cannot be detected by the finger in the large surface
presented by the  expanded inferior segment of the uterus.  In 
508
TREATMENT OF RIGIDITY OF THE OS.
some of the cases in which incision has  been practised, the  os
uteri has been examined a considerable time after labor, and the
os and cervix have been found small and imperfect.  Some cases
of simple rigidity, no doubt depend on the undeveloped  state of
the  os uteri, the  unyielding os of the  unimpregnated state
being,  as  it were, affixed to  the gravid  uterus.  No doubt,  in
other cases the rigidity depends on morbid conditions, of the  os
uteri existing before the commencement  of gestation,  or the
result of injuries inflicted in former labors. It is now known
that slight laceration of the os uteri very frequently occurs dur-
ing the passage of the head, and the cicatrizations resulting from
such injuries may well give rise to subsequent rigidity of the  os
during labor.   Adhesion of the  openings of any of the orifices
of the mucous canals of the body are, it is well  known, exceed-
ingly rare.  In the most perfect cases of occluded os, it is found,
moreover, that  no signs  of  inflammation have existed during
pregnancy.  It is quite possible  and probable that some of the
cases of occlusion have been cases in which the os uteri was too
high and  directed too much  backwards to be reached in an
ordinary examination.  In a supposed case of this  kind,  it  is
very important to arrive at  a correct diagnosis.  Anteversion
should be suspected, and the position of  the  uterus rectified
when this state exists, before arriving  at a positive conclusion.
In making an examination in such a case, the finger should not
be' trusted to alone, since it cannot reach the os uteri, but the
whole  hand should be introduced into the vagina, and  the pos-
terior part of the lower segment of the uterus carefully explored.
It has been found that,  however  small the os,  if  it can  be
detected, and the disposition to dilate imparted to it, the full
dilatation is frequently expected.  When other means fail, there-
fore, the lower segment of the uterus should be  explored by the
aid  of the speculum, as an  aperture so  small as to escape the
finger may become visible to the eye.
   The treatment of such cases is a matter of very great import-
ance.  When the continuance of the  pains of labor for some
hours, and the use of venesection, opium, emetic tartar, or chloro-
form, have failed to cause dilatation, and when the patient is
threatened with serious symptoms, it is necessary to use mechani-
cal  means for the dilatation of the os  uteri.   The choice lies
between dilatation of the os with the finger, or with sponge tents 
SPONGE TENTS, HOW MADE.
509
or the incision of the uterus at its thinnest portion.  Of course,
dilatation is only applicable to  those cases in which the os can
be found, but is so minute as to render delivery impossible with-
out assistance.   When dilatation can be effected  without  vio-
lence, no doubt it is to be preferred to the making of an artificial
os.  Hitherto, the finger  or the bougie  has been used for the
purpose of dilating the os uteri, but I have no doubt the sponge
tent will prove a more efficacious  means of dilatation.   When
dilatation cannot be effected, and labor makes no progress what-
ever,  incisions  should be  practised, the  proper time for the
operation being at that period when natural or artificial  dilata-
tion is shown to be impossible, and when the woman has, never-
theless, not as yet passed into a state of danger.  The fatal cases
which have occurred after incision are  generally cases in which
the operation has been too long delayed.   As to  the mode of
operating, some have recommended numerous incisions round
the real or supposed site of the os; others have recommended
one incision,  from  before  backwards, with  a blunt-pointed
bistoury.  The reason for making an antero-posterior incision is,
that the  uterine arteries may not be wounded; but the bladder
in front, and the rectum behind, must be carefully avoided.  The
incision need not be of any considerable length, as  it is enlarged
subsequently to a sufficient extent by the pains.  This operation,
although never  to be performed but on just grounds, is not so
formidable as it would appear to  be.   I have already referred
to the case of a woman in whom it was necessary, in four conse-
cutive labors, after all of which she recovered favorably.
   [Sponge tents, as represented in the preceding cut, are easily
made.   Select firm pieces of elastic fine sponge, soak them in a
solution of gum Acaciae,  then commencing  at one  extremity 
510       FIBROUS  POLYPI DEGENERATE AFTER LABOR.
wind them as tightly as possible with a strong cord.  After dry-
ing for a week, remove the  cord and smear them with wax or
mutton suet—they are then fit for  use.  When wound upon a
wire, they are introduced with much ease by a stylet as seen in
the following cut.]
  In cases of Fibrous Tumor growing from or on the walls of
the uterus, near the os and cervix, the tumor or tumors may
descend in the pelvis before the head or presenting part of the
child, and cause a very serious obstacle to the progress of labor.
The diagnosis of such  tumors from ovarian tumors is very diffi-
cult, unless made before the coming on  of labor.  The fibrous
tumor is commonly more dense and irregular in shape  than the
ovarian.   Wedged into the pelvis, these tumors not only obstruct
labor, but are  themselves injured  and contused by long-con-
tinued compression  between the fcetal head and the pelvis.  In
some of the fatal cases of this kind, the tumors have been found
in a state of pulpy softening and disorganization.
  [Fibrous polypi connected with the uterus  are very apt to
degenerate after labor.  In the case of a woman that I delivered,
in which the Caesarian operation was advised as giving the patient
the  only chance for life, where two immense tumors existed—one
arising from the fundus of the uterus  and the other developed
from the uterine walls inferiorly and filling up the vagina so as to
push the os uteri entirely out of reach and so obstructing the pas-
sage as  to compel  instrumental delivery-both tumors  broke
down  and softened.   The  lower one had been injured by the
delivery, and a grumous, fetid substance flowed from it; the other
uninjured by the labor, was found after the patient's death to be
filled with the same fluid, showing that the want  of nutriment,
cut  off by the  cessation of blood going to the  uterus, was the
cause  of its death  and disorganization,  and not the  violence
ottered by the difficulties of the delivery.]
  The secondary  disease of the tumors has  evidently in such
cases,  contributed largely to the death of the patient.  Cases 
CICATRIZATIONS OF THE VAGINA.
511
 have occurred in which, during labor, these tumors  have been
 pushed by the hand of the accoucheur above the brim of the
 pelvis, so as to be removed from danger and  the  possibility of
 acting as an obstruction.  In others, it has been necessary to use
 the forceps, or, in  the worst cases, to  perform  craniotomy.   Dr.
 Montgomery relates one in which the obstruction was so great
 that the Caesarian  section had to be performed.  These serious
 results show very conclusively, that in all cases of fibrous tumors
 encroaching largely upon the pelvic brim, the induction of pre-
 mature labor, as  recommended by  Dr. Ash well,  should be
 resorted to.
   Carcinoma of the Os and Cervix Uteri, when the os is dis-
 eased  to a great extent,  sometimes presents an  insuperable
 obstacle to the completion of delivery.  Cases  of this kind have
 occurred in which labor apparently did not come on at the usual
 time, but the  foetus remained for months  after the full term in
 the  uterus.   When allowed  to proceed without  interruption,
 mangling of the os uteri, excessive haemorrhage, and death, are
 almost inevitable.  When the disease is detected early in preg-
 nancy, premature labor should be induced.   When  pregnancy
 has passed to the full term, Professor Simpson has recommended
 vaginal hysterotomy, or the lateral incision of  the os and  cervix
 so as to admit of delivery with the aid of the forceps.  In some
 cases of this  kind, craniotomy is required.  In one  celebrated
 case, Dr. Oldham  performed the Caesarian section, the mother
 and child living for some time afterwards.  In the worst cases
 of this kind, when the mother has but a short  time to live, and
 when the child is healthy, the reasons for the performance of
 craniotomy and the Caesarian section are more evenly balanced
 than  in most  others; but I incline to the former, since,  in my
 opinion, the  value of a brief space  of  existence  to an  adult
mother, whose immortal  interests are  at stake, should outweigh
the precarious life of the unconscious foetus.
  Contraction and Rigidity of the  Vagina may depend
upon the age of the patient, the former existence of abscess, can-
cerous induration, cicatrizations following injuries occurring dur-
ing instrumental or difficult delivery in former labors, the cicatriz-
ations of pelvic abscess, recto-vaginal fistula, etc., and may con-
sist of simple  diminution of the  calibre of the canal, puckering
of its walls, the existence of bands or septa, and almost complete 
512
TUMORS IN THE VAGINA.
closure of the vagina, or Atresia.   These contractions,  which
often become of cartilaginous hardness, are readily distinguished
by the finger from any other form of impediment.   It is remark-
able what  an  amount of contraction may be reduced or drawn
out by the pressure of  the membranes and the advancing head,
or presenting part, when the secretions are  abundant, the  pro-
gress of the labor moderate, and no inflammatory action is set
up.  There is in the vagina not merely the power of distension
under  pressure,  but an active tendency to dilatation, similar to
that possessed by the os uteri.   In the management of these
cases, it is important that the labor, particularly in the propul-
sive or  expulsive stages, should be gradual; with this view, as
well as  the supply of fluid pressure, the  membranes should be
preserved as long as possible.  Yenesection, nauseating doses of
tartar  emetic, warm  bathing, vaginal  fomentations, and   the
relaxing effects of chloroform are useful in severe  cases ; and in
those that do not yield to these measures, careful division of the
constricted portions with  the knife are necessary.  When  the
deformity of the  vagina is excessive, and cannot be remedied by
these means, and when thedife of the mother is threatened by
the continuance of labor, craniotomy may  become necessary.
After delivery,  these  cases  require  careful management  by
fomentations  and  the  use  of antiphlogistic  means to prevent
inflammation and further contraction.  When the patient is con-
valescent, bougies should  be used with a view to prevent the
interference of contraction with succeeding labors.   Unless these
precautions are used, it may happen that  complete atresia, with
retention of the  catamenia, may follow.  Dr. Meigs has related
such an instance, and hot long since a similar case was seen in
this hospital.   Besides contraction of the  passage, the vagina is,
in rare  cases, blocked up by Polypoid tumors growing from its
walls.   Several  cases  of vaginal polypi are  figured by  M.
Huguier.   In labor occurring under such circumstances,  it
would be necessary to puncture these tumors when they contain
fluid, or to remove them, when of a fibrous structure, by the
scissors  or polypus hook.
  The area of the vagina may be  intruded on by other tumors
foreign to the vagina itself.  Of these, Ovarian tumors, Polypoid
tumors springing from the os or cervix uteri, Rectocele or Yesico- 
            TREATMENT OF TUMORS IN THE UTERUS.         513

cele, Faecal collections, and Stone in the bladder are the most
important.
  The existence of Uterine Polypi commonly prevents impreg-
nation, but cases occasionally occur in which gestation proceeds,
notwithstanding their presence,  or they  are  developed during
pregnancy, and at the commencement of labor they emerge from
the uterus,  and prevent  the  progress  of the foetus.   These
growths arise from the  labia uteri, the interior of the cervix, or
the cavity of the uterus.   When they arise from the lips of the
uterus, they are frequently, as observed by Dr. Heming, hollow
and contain fluid; but when attached to the neck or body of the
organ, are of fibrous character and of larger size.   Their attach-
ment to the os uteri, or emergence from within the orifice, can
be made out without great difficulty.  Polypi have sometimes
been detached from the uterus by the force of the pains.   Where
they are of  such large size as to interfere with labor, the fluid
tumors should be punctured, when they  at once collapse; and
the solid polypi  should be removed  either by ligature, torsion,
or excision.   (Fig. 143.)
  In cases of Ovarian Tumor, the  important point is to  dis-
tinguish between cysts containing fluid and solid tumors.  The
former have been safely  punctured, as  advised by  Merriman
and others.  In the case of solid tumors,  so large as to impede
delivery, nothing  can  be done  with  the tumors  themselves
beyond attempting to lift the mass above the  pelvic brim.   [It
may be well to puncture a tumor, the character  of  which is
doubtful, with a fine trochar.  If it be fibrous, this puncture will
do little injury, and that  of little  moment compared with the
injuries effected by the pressure upon them, if left  to them-
selves ; if the contents are  fluid, the advantage of the operation is
                            33 
514
TREATMENT OF  VAGINAL  TUMORS.
Fig. 143.
                    Labor impeded by uterine polypus.

evident.]   When this is  impracticable, it  only remains  to  be
Fie, 144.
Labor impeded by ovarian tumor.
considered whether the child can be delivered by the forceps, or
whether craniotomy may become necessary.   (Fig. 144.) 
             AFFECTIONS OF RECTUM  AND BLADDER.         515

   In the  case of Cystocele, the bladder, as described by the
 late Mr. Crosse, is prolapsed, and descends behind the pubes and
 before the head of the child.  When full of urine, it offers con-
 siderable resistance to delivery, and may itself become ruptured.
 This state does not, as is  commonly supposed, depend on any
 neglect of the patient or accoucheur in  evacuating the bladder,
 but arises from prolapsus of the bladder existing  before and
 independent of pregnancy.  It is remedied by catheterism, but
 is is necessary to pass the catheter downwards and backwards in
 such a case.  Care is required in the diagnosis of this affection,
 as it has happened that the distended bladder has been mistaken
 for the amnion, and punctured under such misapprehension.
   Impaction  of Faeces in the Rectum may offer consider-
 able impediment to labor.  This may depend on simple consti-
 pation, or on the accumulation of magnesian deposits in patients
 accustomed to take this alkali  freely for the relief of heartburn,
 or as an  aperient.   At first, some of these cases give  one the
 impression of exostosis, but a careful examination  detects the
 real nature of such tumors.   The remedy of course consists in the
 removal  of the indurated  mass by  enemata, or, in the worst
 cases, by a process of excavation.   It sometimes happens that
 the posterior wall of the vagina  is prolapsed, giving rise to rec-
 tocele.  In the bag thus formed, faecal accumulations may take
 place and encroach upon the  vagina, but this state of things is
 readily removed by enemata.
   Cases have been recorded by Guillimeau, Smellie, Dubois, and
 others, in which pregnancy has occurred coincidently with Cal-
 culus in the Bladder.   When the stone is  large, and des-
 cends  before the  fcetal  head, delivery  is sometimes rendered
 impossible.  When it is small, the bladder may be lacerated,
 and vesico-vaginal  fistula  be  the result.   Some time ago,  a
 patient was under the care  of Mr. Brown in this hospital, whose
 bladder had been lacerated  some years  previously  by  a stone
 during labor, which had remained undetected  in the bladder.
The presence of stone cannot "well be mistaken for any other con-
 tingency of labor, from its situation and  movable character.
 When the stone is detected early, it can generally be passed
 above the pubes, and little or no mischief results.  When, on the
other hand, the descent of the head and the size of the stone ren-
 ders this impossible, the rule is to perform the operation of lith- 
51G
VARIOUS OBSTRUCTIONS TO  LABOR.
otomy  through the vagina.  Probably lithotrity would be the
preferable operation in some of these cases;  but I am not aware
that it has ever been tried.
  Labor  may be obstructed, as  pointed out by Hamilton and
others,  by diffuse swelling of  the soft parts of the parturient
canal.  This is very apt to complicate labor  depending upon
obstruction of any special  kind.  In cases of deformed pelvis,
for instance, there is commonly considerable swelling of the soft
parts, the result of pressure.  In other cases,  the tumefaction
depends  upon plethora,  or excitement of  the passage under the
influence of the normal pressure incidental to labor.  The treat-
ment  of  such  cases, as far as the tumefaction is  concerned,
depends on antimonials,  venesection, and  careful evacuation of
the bladder and rectum.
  Numerous cases are on record, and I have myself met with
instances, in which women with a cribriform  Hymen, or with
the hymen in a state  of almost  cartilaginous  hardness,
and an aperture of small size, have  become pregnant,  and the
structure has remained undisturbed until it came to be  an impe-
diment to labor.  The pains of expulsion would, no doubt, in
all such cases tear through this obstruction, but it  is much less
painful to make a crucial incision before the parts have become
distended ; still better, this operation should be performed, when
the nature of the  case is known, during pregnancy, and such
cases generally are known, because women in whom intercourse
has been  imperfect, mistake the  signs of pregnancy for a tumor
or suppression of some kind, and apply for advice.
  The  obstructions limited to the Yulva  consist of a Varicose
state of  the labia, (Edema of the labia or nymphae, and
Encysted or Fibrous tumors of  the labia.   The enlarge-
ments mentioned are generally connected with hyperaesthesia of
these sensitive parts, and the suffering they occasion is usually
of greater consequence than their mechanical interference with
parturition.   In the case of extensive  oedema from the pressure
of the  gravid uterus in the latter  part  of  labor, or from  the
existence of albuminuria, it may be necessary to puncture the
skin in several places with a fine needle, as recommended by the
late Mr. Ingledue, in order to let off the  effused  fluid, particu-
larly when this state of things occurs  in a primiparous woman.
Occasionally the swelling in these cases is enormous,  and it  is 
INCISION OF RIGID PERINEUM.
517
difficult or impossible to make  an examination.  Sometimes
fomentations will relieve the pain,  and promote the relaxation
of the skin to such  a degree, that, with patience the fcetal head
passes.  The  ergot  of rye is useful  in  some of these cases, and
is to be preferred to the forceps, as causing less  risk of lacera-
tion.  It is only with great difficulty that the forceps can be
used  in considerable swellings of  the external parts,  and the
risk of lacerating the vulva or perinaeum with the instrument is
very  great.    When oedematous swellings of  the vulva are
neglected, serious consequences may ensue.   Cases  are recorded
in which sloughing has occurred from this condition, to such an
extent as to destroy the patient.  In Thrombus or in varicose
states of the vulva, pressure should be exerted on  the parts, or
cold  applied  during the pains,  so as, if  possible, to prevent
excessive  dilatation and bursting and effusion into the cellular
structure  of the labia.  It  is generally at the moment when the
head passes that the varicose tumor bursts from excessive disten-
sion.  In  cases where the effusion takes place before the termi-
nation of labor, little  can  be done beyond  the use of pressure
and cold, as the blood rapidly coagulates  in the cellular tissue,
and  cannot be evacuated  by puncture.   Obstruction  of the
vulva from large encysted tumors (unless the contents are fluid),
or fibrous tumors of the vagina,  the latter of which sometimes
grow to'an  immense size, can  only be dealt with efficiently
before the coming on  of labor,  or before the  advent of preg-
nancy itself.   When the encysted tumors contain fluid, as in the
case described  by M. Huguier, puncture by a  fine trocar will
produce immediate relief.   In rare cases, the perinaeum is so
rigid and unyielding as to offer an  obstacle to the advance of the
head.  Under  these  circumstances, when  fomentations, tartar
emetic, venesection, and chloroform, have been inefficient, it has
been recommended that the perinaeum should be incised.^  Inci-
sion is believed to  prevent extensive laceration, and the incised
wound heals readily after labor.  The force of the uterus would,
in almost all cases, overcome or  break through the impediment
offered by a rigid perinaeum, so that we must look on incision of
the perinaeum as a  preventive of laceration rather than a means
 of removing obstruction. 
[LECTURE  XXXIY.
     OBSTRUCTED LABOR FROM RIGIDITY  OF THE  OS UTERI.

  [The following was  read before the N. Y. Academy of Medicine, March 3d,
1858, and is published by the permission of that body. It is here inserted in
full, omitting only the introductory portion, the facts of which may be found at the
close of Lecture XVI. of this work. I have thought it best to preserve the integrity
of the paper, although it may somewhat repeat what elsewhere is probably better
stated by the author.]

   Gentlemen :—Scientific research  has now,  as it appears to
me, demonstrated incontestably, the  anatomical division of the
hollow organ so long known as the uterus, into two portions, the
neck and  the body.   Henceforth, we must recognize two dis-
tinct organs—the  one the cervix, composed of firm but elastic
structure, scantily provided with blood-vessels and in which but
a small trace of nerve tissue is found.   The body of the uterus
is composed of  a  coarser  fibre,  a muscular tissue capable of
much hypertrophy, abundantly supplied with both arteries  and
veins, also with nerves, concerning which  no little research has
been undertaken and some controversy has resulted, especially
between Drs. Lee  and Snow Beck.
  Without this  anatomical demonstration, the  nervous sympa-
thies between the  cervix and the body of the uterus, especially
when the sensibility  is exalted  by the chronic inflammation
to which  the  former  is  subject, is evident  to accoucheurs
and uterine pathologists,  whose  daily observations evince the
fact.
  This anatomical distinction of  one  apparent organ into two
bodies,  is  not  without its  correspondences  in  the  human
economy.   The  brain is divided into the cerebrum and cerebel-
lum ; the testis  into  the testis proper and the epididymis: the
kidney, according to  the  research of our learned Isaacs  has
been demonstrated in this  Academy, as divisible into the true
kidney and the supra-renal capsules.
     518 
SPASMODIC RIGIDITY OF THE OS UTERI.         519
   These  anatomical  distinctions  have  led  to  pathological
divisions and correlative treatment.  I purpose now to make
similar distinctions and to ask your attention to some practical
suggestions respecting the treatment of various  forms of diffi-
cult parturition, arising from morbid  conditions  of the  os  and
cervix uteri.
   Rigidity of the  ©s uteri  is probably the  most frequent
cause of dystochia, perhaps more common, if not so serious in its
nature and results, than  all other causes combined.  One need
attend but a few labors to find instances where everything seems
to encourage the hope  of a speedy and favorable  termination,
but a firm and unyielding os resists severe and prolonged pains.
wears down the strength of the patient, the spirits of attending
and anxious friends, and the patience of the physician.  For
such cases I offer no  new relief.  The benefits  of tartar  emetic,
opium, venesection are familiar to all; injections per anum of
antispasmodics, as assafcetida, etc., and inunction of the os uteri
with  the  extract of  belladonna, have been fruitlessly tried by
others;  but there are some other methods of treatment  less
common, which I will venture to enlarge upon.
  The case is before us of a  healthy woman of abundant mus-
cularity,  young  and vigorous, or old and inelastic, perhaps
feeble and suffering  from organic disease,  such as  to make the
repeated efforts of straining not only exhausting but dangerous
to life from the rupture in a tuberculous lung  or of a diseased
heart.  The waters have long since flowed away, the os  is  dry
and  hot,  hard  and  unyielding to the head, pressing strongly
upon it, even while the  general strength seems  giving way,
chloroform is the great remedy, given not niggardly, although
gradually and with great care, watching both pulse and respira-
tion, even to full anaesthesia.  In  such cases, I have seen,  and
many around me I know have also, the heat depart from the os;
the dryness  disappear with the recurrence  of  the  natural
mucous exhalations, the rigidity vanish and dilatation result,  and
with the renewed pains upon " letting up " the anaesthesia, a
speedy delivery crowning the work.   It is in these cases where
chloroform is indeed a boon from heaven, of which too much
can scarcely be said.
  But there are instances where the rigidity does not appear to
be of this apparently spasmodic description, but where perhaps, 
520
FIBRINOUS RIGIDITY OF THE OS UTERI.
from a chronic inflammation, there seems to be an infusion of
fibrinous matter into the tissue of the cervix, and which is not
amenable to the passive powers of anaesthetics.  These require
more potent remedies, and not unfrequently I have found rigidi-
ties relieved by the employment of the douche as first  recom-
mended  by Kiwisch and  adopted  by many  others.   This is
simply the throwing of pure water with any ordinary self-inject-
ing india-rubber (Mattson's or  Davidson's) syringe against the
os uteri and base of the  bladder and uterus.  This in itself  will,
either by its nervous shock or by destroying the integrity of the
ovum, produce premature delivery, where we are compelled to
do this serious operation for the preservation  of the life of the
mother.  Warm water seems to have the best relaxing effect
when labor has fairly commenced and where only relaxation of
the os  uteri seems requisite  to complete the delivery.   Cold
water seems to act more  efficiently in stimulating  the tardy
uterus  to action, where labor has  commenced but has halted or
delayed  in  its  progress.  Sometimes the alternation  of the
douche  at different temperatures will effect the relaxation of
the os,  and at the same time  by the shock, stimulate the perhaps
flagging uterine action.  A gallon or two of water  should be
thrown  against the os in dystochia from rigidity, every half hour
or hour,  till relief is attained if possible.  As an  incentive to
uterine  action in the case of  attempted miscarriage, the douche
need not be repeated more than three or four times a day, and
in a day or two labor  pains  will  gradually commence  and
increase in strength. To  effect this purpose, the douche, although
not always effectual, is the safest and pleasantest operation, the
labor ensuing is more natural,  and  no possible injury can be
done to the organs by the operation.
  But sometimes the nature of the os uteri is so changed  by dis-
ease or inflammation from friction, etc., that it is cartilaginous in
its consistence and in the character  of its internal  or external
tissues.   Some positive force must take the place of the passive
treatment just recommended.  If the pains are not violent, or
if they can be  temporarily suspended by an  opiate, or in con-
junction with  anaesthetics, especially if  it be  an  abortion or
prernature delivery, accompanied by haemorrhage, then plug-
ging the os uteri with a  sponge tent  will,  with   some
efficiency, if there be time for this delay, dilate the mouth of 
           CARTILAGINOUS RIGIDITY OF THE  OS  UTERI.       521

the uterus, and in the latter cases act as a tampon and prevent
haemorrhage, save in the cases of abortion  (to produce which it
was first recommended by Kluge) or miscarriage. I cannot say
that I place much reliance upon this surgical appliance.
  But there are cases that resist all such moderate attempts at
overcoming the rigidity; the os seems to be converted into car-
tilage ;  it has stretched out till it is an inch or two in diameter,
and then, firm, thick, hard, dry, hot perhaps, it does not, possibly
cannot, dilate.  With the extreme violence of the pain the head
has descended into the cavity of the pelvis, bringing its surround-
ing os with it.  Sometimes the os, by a violent pain, is torn off
and forms  a perfect ring, as lately  shown at the Pathological
Society in this city.  What is to be done,?  There is  no alterna-
tive.  Incision of the os, is imperative, and it is a perfectly safe
operation.   I have done it three times with perfect success.   We
all know, too, that the os tears; we have felt it give  way under
our finger, we have felt it after the labor; we often see, with the
aid of the  speculum,  the os torn and ragged and ulcerated on
these torn edges, the sequelae of difficult labors.  Cut it then with
long scissors or with probe-pointed bistoury—cut it anywhere.
Writers theoretically advise who have never done this operation,
and one cautions  against  dividing  on the  sides lest it tear up
and so divide the uterine  sinuses; and another, not to divide ante- 
522
INCISION OF THE OS UTERI.
riorly and posteriorly, lest the bladder or rectum be injured.  I
have  divided  the  os both  anteriorly and laterally, and always
without any haemorrhage, subsequent  inflammation or apparent
ill consequences.  It is unattended with pain, the patient noticing
only a sudden feeling of power to assist the uterine  action by
voluntary muscular effort.   There is  no difficulty in  the opera-
tion, the bistoury being guided upon the finger and the incision
being made outward, and the edge guarded by the finger, lest it
wound the vagina after having divided the os  and cervix.
  Division of the os uteri has really little danger, although occa-
sionally followed by some  bad results.  August 11th, 1846, I
attended a woman in her fourth confinement,  who  previous to
this had a  prolapsus of the uterus to such an extent as to pro-
trude from the vulva to the length of two or  three inches, and
impregnation had  taken place by the insertion of the  penis into
the os uteri!  She had strong labor pains when I arrived, and on
making an examination, I found a large mass,  the os uteri, pro-
jecting some inches from the centre of the vulva, which I supposed
were cedematous labia, with edges hard, swollen and everted, bear-
ing a strong eimilarity to the nose of a demijohn.  The orifice easily
admitted two fingers, above which the head was presenting in
the position of the vertex.   After delaying till symptoms of con-
vulsions appeared, the  os remaining undilated, hard and dry, I
applied the  short forceps through  this os.  Traction but brought
down the head with the enveloping os, to the full extent of the
everted vagina.  At this period the parts were in a most extraor-
dinary state.  The projecting tumor, which exteriorly the vagina
and interiorly the uterus,  was a cone, eight inches in length, five
inches in diameter at the base, where it united with  the body,
and three inches at its apex.   In the apex was the opening, two
and a half inches in diameter, through which the hairy scalp of
the foetus, in rugae with the pressure,  was  slightly projecting.
Dr. Cheeseman  was now called; I  proposed dividing the os,
and, with his assent, I made an incision superiorly, to the length
of 21 inches ; the uterine pains tore up this incision l£ inches fur-
ther, and a healthy girl was speedily delivered.  The haemor-
rhage was very slight and arose  principally from  its  congested
state.   The os, along its whole border for the width of an  inch,
was indurated, and the integument thickened, and on its inner
surface  was changed in its  character, so that it resembled carti- 
UTERINE PROLAPSUS DURING LABOR.
523
lage.   The uterus never returned to its normal position, notwith-
standing that pessaries, astringent injections, etc, were used, but
came down when she walked. After a few weeks I lost sight of
her.   The cut surface speedily  cicatrized,  but did not unite.
Case reported in full in American Journal of Medical Sciences,
Oct. 1846, in which are quoted two or three corroborative cases,
all that exist upon the records of  obstetric surgery.
  In the same journal for July,  1852, I report the first case on
record, on this side of the Atlantic  certainly, of division of the
os uteri when internal, for rigidity.   The patient was  a large,
muscular woman, thirty years of age, in labor with her first child.
She had been in active labor, when I first saw her, twenty-four
hours.  The os was  rigid, notwithstanding she had been bled
a pint and had taken tartar emetic in nauseating doses and seve-
ral grains of opium.  On examination, I found the vertex present-
ing in first position, pressing hard upon the os, dilated to the size
of a tea-cup  top, exceedingly firm and hard.   At my sugges-
tion, venesection  was again resorted to, and §xvj further taken,
producing some dizziness but no more dilatation.  Twenty-four
hours  elapsed without the slightest change.   She  took  eight
grains of  opium  in divided  doses before receiving  any relief,
and slept some, and the pains soon resumed with full force, but
now diminished, the os not perceptibly dilated, vulva dry and
hotter than yesterday.   The friends urge some measures  for
relief.  The  only reason apparently why the labor does not
advance is the rigidity  of the os,  and if that could  be  over-
come, it appears  that the labor would go on to a speedy termi-
nation.  But how to effect this  desired result? All the usual
modes had been fruitlessly exhausted, mechanical dilatation by
the fingers was impossible.  A vigorous pain may perhaps lace-
rate the os.   Lacerations of the  os uteri are frequent.  May it
not  then, be  cut?   The attending physicians advise cranio-
tomy.   She had felt no life during the day.  Remembering the
former case, I determined to divide the os: with a pair of curved
uterine scissors, I  made an incision upon one side three quarters
of an inch, and on the other a  quarter inch in length.   The pains
were revived by an infusion of ergot and a large putrid child was
delivered.  The labor was  delayed  after the operation, by the
head remaining nearly an hour on the perinaeum, after passing
through the divided os, and the body not being delivered without 
524
AUTHORITIES  ON RIGIDITY  OF THE OS.
strenuous assistance.   The occiput was to the right iliac anterior.
Operations subsequently upon the os uteri have but strengthened
my belief in the utility of division of the os for protracted rigid-
ity.   Instead of using the  scissors I would prefer a long probe-
pointed bistoury, as  more convenient and  less objectionable
from the character of  the wound made.
  The patient speedily recovered, but for a prolonged period sub-
sequently had profuse leucorrhoea, and was for a long time after
childless.   Had she been of a less impracticable character and
had submitted to the treatment appropriate to the lacerations and
fissures of the cervix uteri,  she  might  have  so far recovered
as to have again become impregnated.
  While I counsel this operation in  all appropriate cases where
other means have failed, I am aware of its  contradiction to the
teachings of others, some of whose opinions I will quote.
  " I believe we shall rarely, if ever, fail in softening the cervix
by some of the remedies I have recommended, and I must beg
leave to enter  my protest  against  more active interference."
—ChurchiWs Theory and Practice of Midwifery, page 397.
  " Under all  circumstances, if you  must  have recourse  to
instruments at all, you had better at once have recourse to the
perforator."—Blundell.
  Baudelocque says: " After a convenient delay, to ascertain that
the efforts of nature cannot overcome the resistance, and the
administration of proper methods to relax it, it must be cut  in
several places, as some practitioners have done.  These incisions
are preferable to rents,  which might  take  place in it, and have
never been attended with the same consequences."
   Dr. Dewees, quoting the above, thus remarks:  " The success of
this plan has been verified, in this country, as the case of Dr.
Thomas  Archer most satisfactorily  proves,  where the uterus,
loaded with its contents, was pushed through the os externum
.   .   .   he  accordingly   made  three  cuts   in  the uterine
circle,  .  .  .  each   about  two  inches  long;  ...   no
unpleasant  symptom followed."  The  case  is evidently very
similar to the one reported by me above. 
ON DIVIDING A RIGID OS UTERI.
525
  Dr. Dewees also quotes Moschati, who made several incisions
in the circle of the os uteri with success, in 1827.
  Dr. Murphy says: " If these means fail, it becomes a question
whether we  should wait  for  the death of the child, in order to
remove it by the crotchet, or incise the unyielding cervix.   The
former practice involves a sacrifice of life, but generally secures
the mother from  the injurious  effects which may follow.   The
latter may be  the means of preserving the child, but if the in-
cision lead to a laceration of  the uterus, the mother is at once
placed in the most imminent danger of her life.  The  fear of
such a consequence, it appears to me has prevented any attempt
being made  thus to  cut  though this  Gordian  knot of difficult
labor in its first stage: but whether this, like  other operations, is
only surrounded  by chimeras of the imagination, which  some
bold spirit will dissipate, remains yet  to be proved.   Incision
has been  performed without  accident; the  same may happen
again ;  and I confess, in a case such as I have described to you,
I should be  more disposed  to adopt the shorter course, in the
hope of saving the child, than  to wait until its death enabled
me to remove it.  This, however, is but an  individual opinion
and needs support."
  My  old instructors, Chailly and  Cazeaux  have written with
more fullness upon this subject.  Chailly says: " Aussi si cet 6"tat
a re'siste aux bains, a  la saignee, a. la belladonne, ce qui arrivera
le plus ordinairement, on devra pratiquer des  incisions sur les
parties laterales de I'orifice, a l'aide du bistouri en croissant on
du  bistouri droit boutonne, et mieux encore a l'aide  des ciseaux,
courbes sur leur tranchant, et  conduit sur le doigt jusque dans le
col uterin.  II est utile, dans ce cas, de multiplier les incisions,
pour qu'elles fournissent une assez grande dilatation, sans qu'on
ait  a craindre qu'elles ne se prolongent trop haut.   C'est aussi
pour eviter les consequences  de ce prolongement, qu'il ne faut
pas les faire a. la partie anterieure et post&'ieure de I'orifice. En
effet, prolonge'es  dans  cette  direction, ces incisions pourraient
iuteresser la vessie ou le rectum.
  " J'ai vuce debridement de I'orifice suivi du meilleur effet, soit
sur des femmes  oil la rigidite  pure et simple du  col etait le
seul obstacle, soit sur  d'autres chez  lesquelles les parties etaient
plus ou moins altereesl
  " Chez une jeune fille agee de dix-sept ans  qui vint accoucher 
526
SCARIFICATION OF THE CERVIX UTEKI.
 a la clinique, le col a l'etat sain d'ailleurs, etait tellement rigide,
 qu'il ne ceda qn'aux incisions.   L'enfant fut expulse en position
 occipito-posterieure non reduite.
   " Les  incisions furent encore  le seul moyen de rendre  l'ac-
 couchement possible, chez une femme agee, mere de dix enfans;
 le col  etait tellement degenere que, de prime abord, il fut pris
 pour le placenta implante sur I'orifice."
   Cazeaux writes from less experience:  " Si I'orifice  externe
 retracte- est seule cause de la difficult^, on aura recours aux  inci-
 sions multiples pratiqu^es sur le pourtour du col."
   Dr.  Lever  {Guy's Hospital Reports) says such an  incision is
 unattended with danger, unaccompanied  by pain and free  from
 copious or dangerous haemorrhages.
.  Rigby says, where the structure of the os uteri has  been much
 injured the resistance wul  probably  be  so great as to require
 artificial dilatation with the knife.
   Professor Braun of Yienna thus writes respecting the treat-
 ment exclusively of eclampsia: " Scarification of the cervix uteri,
 at a more or less advanced  period of the stage of dilatation, for
 the purpose of facilitating labor, has been recommended by Pare*,
 Mesnard, Contouly,  Lauverjat, Dubois, Kiwisch, Killian, Crede
 and others, and it is done either with a probe-pointed bisteury,
 a  utero-stomatome (two scarificator  blades) or  long, bent  scis-
 sors.  In the hands of a practised operator, the making of these
 incisions, under the  above-mentioned conditions, does not in-
 volve  any danger and contributes greatly to  rapid  dilatation
 when the cervix is peculiarly rigid and undilatable.  But when
 we  consider the question of  the necessity  of this proceeding,
 it is, indeed in very rare  cases only to be justified, inasmuch
 as in the literature of  the  subject only very  few observations
 are  recorded in which the performance of hysterostomatomia
 was found to be indispensable, and  that more on theoretical than
 practical grounds."   And again:
   " The dilatation of the soft parts by incision which has  been
 recommended by Baudelocque, is without danger  only when
 merely the external os uteri or the vaginal portion of the cervix
 are incised a few lines deep ; it is very dangerous if the os  uteri
 be very thick, or if  the undilated part of the cervix  still form a
 canal  from \ to 1 inch (Paris) long, because then the incisions
 can no longer be exactly controlled, but  penetrate too deeply ; 
          VALUE OF THE INTEGRITY OF THE OS UTERI.       527

and the subsequent introduction of the hand or extraction of the
foetns may produce uterine  lesions dangerous to life, and under
which the patient may sink, after she has recovered from the
eclampsia.  ....
  " Our opinion therefore, is, that forced delivery, with bloody
or bloodless dilatation of the cervix, is never to  be resorted to
when any injury from it is to be feared; and we  think the wise
consideration of the success, from the above described methods
of increasing the pains (colpeurysis, the introduction and reten-
tion of an elastic catheter between the  chorion and the walls of
the body and fundus uteri, tepid  uterine douche,  rupturing the
membranes, secale cornutum, etc.) affords sufficient  reason to
induce  us to  abstain from doing  harm either by rash ofncious-
ness or  irresolute passiveness."
   It is a question worth considering and deciding, of how much
Importance is it to  preserve the Integrity of the Os Uteri,
or rather should the danger of lacerating it be  considered as an
objection of  any serious moment to an obstetric operation, hav-
ing for its end the preservation of the life of the child ?
   I am free to confess that, after much thought and some experi-
ence  upon these  questions, my  mind is made up.  The first
duty of an accoucheur is to save the life of the mother, the second
to save the life of  the child', the  mother is  to be saved at any
cost, the child may be mutilated, destroyed, to effect this end.
The child  must be  saved  at any cost short of the life of the
mother.
   The  mother's safety being secured, the child's must  be
sought for with the least possible injury to the mother.  The
physician who delays delivering a child  till  it dies  from pres-
sure, or asphyxiated, rather than risk injury—not danger to the
life of the mother—errs greatly.  It is a poor parent that would
not hazard  even life  to save a child in danger; the physician in
a conscientious discharge of his duty  should hazard not the life,
but any injury to the mother, be it  immediate pain or subse-
quent disease or imperfection.
  The older writers  have taught that for all obstetric operations
we should  wait for the dilatation of the os  uteri, and  English 
528
FORCEPS YlTH UNDDLATED OS.
obstetricans have even insisted, that, in addition to this, the head
should have so far descendedas that the ear may be felt before
the forceps may be applied,   litill, in cases of arm presentation,
it was allowed that turning might be performed as soon as  the
os was sufficiently dilated to adnit the hand through  it.
  When death was considered 10 be the  invariable result of
rupture of  the uterus, and the body of the uterus and the  cer-
vix uteri were supposed to be but parts of the same organ, such
teaching was proper, but the anatcmical discoveries of the nine-
teenth century makes such teachings effete  and  new directions
proper to be substituted.  Injuries  to  the  uterus may be fol-
lowed by metritis, while injuries to  the os and cervix rarely if
ever.    We see this  organ shockingly  mangled by unprin-
cipled abortionists, but unless the body of the uterus is injured,
death never following ; inflammation, of the os and cervix rarely
if ever spreading to the uterus proper.
  If, therefore, there be immediate necessity for any obstetric
operation, do it irrespective of the local condition; apply  the
Forceps through  an  undilated Os; perform craniotomy
through a but partially dilated os ; atnd even, if necessary, incise
the os, in order to render an operati on  practicable.
  Not to occupy too much time, I wvill quote but two cases from,
my own practice  to substantiate th e feasibility, of the position
laid down.                        *
  June 15th, 1855.—Mrs. G------, J3j)ast Eighteenth street, was
taken in labor with her second child.  /For several weeks she had
experienced severe  uterine  haemorrhageV  under the care  of a
homoeopathic. With the commencementofN uterine action, Dr. J.
W. Francis was called, and noting the profi jse flow, sent for Dr.
R. S.  Kissam.  The  existence  of placenta 7 praevia  was recog-
nized, and  they remained with her all night a\ad gave such relief
as was possible.   At their request, I saw her aU  4 a.m. ; she was
blanched, covered with a cold sweat, complaini 'ng of ringing in
her ears, swimming in head, etc.  She then tot ok the aqueous
extract  of  ergot 3j.  every quarter  of an hour,  t She was  tam-
poned, waters not evacuated.  I recommended tht^ removal  of
the tampon, and rupturing the membranes, which \«vas done and
the os found to be dilated to the size of a tea-cup to' p,  the pla-
centa torn  from the anterior lip and the border loosed the vertex
presenting  high up in first position, little or no expulsOive pains, 
OBSTINATE RIGIDITY OF THE OS.
529
  some flowing with each pain.   The ergot had little effect, and
  after a half-hour's delay, when it was supposed that she could
  scarcely survive an hour longer,  I suggested diminishing the
  head and delivering by crochet and craniotomy forceps, as the
  speediest method of  arresting the haemorrhage, and offering the
  only hope of saving her life; as, independent of the uncertainties
  of the length of time required  for the use  of forceps, the dan-
  ger of recommencing the flow of blood by further disturbance
  of the placenta, probable in these operations, would be avoided
•  by this operation.  I performed this  operation with some  diffi-
  culty,  owing to the small opening of the os, scarcely two inches
  in diameter, and the mobility of the head in the superior strait,
  and  delivered a male child weighing  ten  pounds.   The patient
  got up without experiencing any unpleasant symptoms referring
  to the  uterus, and 16 months subsequently was again confined
  without difficulty.
   January 18th, 1858.  At the request of Dr. John Bishop,  at
 6 a.m., I saw Mrs.  J----, Allen street, in labor with her  first
 child.  She had been taken in labor three days previously, but
 the  day  before,  at 4 p.m., the membranes had  ruptured.  I
 found her a short, muscular young woman, much exhausted, the
 pains excessively strong, and occurring every ten  minutes, the
 os, no more dilated than when  first  seen  by Dr.  Bishop,  now
 about 2£ inches in  diameter, firm but  not rigid, and  the  head
 in the superior strait, movable, and not pressing upon the os
 uteri or base of the uterus ; even  with the extreme pain the os was
 not pressed upon, the head evidently resting upon the promontory
 of the sacrum and the os pubis.  I advised delay and morphine.
 She took a grain  and  a half in three hours,  but at 12 m. there
 was no more dilatation, no rest or cessation  of the tremendous
pains.
  More morphine was advised, and at 4| o'clock she had taken
two grains more with no  evident effect, the head  only being
now immovable, the os still undilated ;  craniotomy was thought
of, but as the child  was  evidently living I was inclined to apply
the long forceps upon the head, still above the brim of the  pel-
vis, although  immovable.   This through the  still  undilated os
was  done without great difficulty, and by strong traction  the
head was brought, down into the  pelvic cavity and so as to press
upon  the os.   Chloroform was now given as a relaxant  of the
                            34 
530
FORCEPS WITH RIGID OS UTERI.
firm os, and by continued traction a large but asphyxiated male
child was delivered, which after a half hour's labor breathed with
some regularity and lived till 9 p.m.   Upon the prominence of
the left frontal bone was a spoon-shaped depression, where the
pressure upon the promontory of the sacrum had been exerted.
The mother made a speedy " getting up." Present—Drs. Bishop,
Tuthill, Wilson, and Saunders.
  I am fully aware that the opinions here expressed are opposed
to the teachings of the authorities.  Yelpeau says it is not allow-
able to introduce the forceps into the womb, until the orifice is
sufficiently dilated and the head ceases to be movable and loose
above the superior strait.
  Ramsbotham, like all the older English practitioners who prefer
craniotomy to the long forceps, says: " When the head is placed
in any one of these situations and the  symptoms require it, we
feel  ourselves warranted in  attempting to deliver by the short
forceps—provided the  os  uteri be fully dilated—if we can feel
an  ear  distinctly—if  there  is  sufficient space in the  bony
passages for the  head to emerge—and if the soft parts are suffi-
ciently  dilated  to admit  of its  exit without suffering serious
injury."   And again : "If there exists a well-grounded fear that
the uterus may injure itself by the violence of its own expulsive
efforts, in  such a case,  provided the os uteri is completely, or
almost fully opened, with  the vagina and perinaeum  sufficiently
distensible, delivery  may often  be accomplished  by the  long
forceps."  Dr. Keating, the editor of  the Am.  edition,  says:
" Under no circumstances should the forceps be inserted within the
os uteri; their application should be delayed until the circle of the
os has risen above the parietal protuberances."  Churchill says:
" I do not speak of the difficulty of the forceps when the  os is
rigid, because it should  never be attempted."
   Blundell, enumerating a horrible catalogue of errors to guard
against, says: " You may try to use it when the parts are rigid,
and the os not fully expanded."
   Rigby fairly gives  reasons for his opinions, insufficient as they
seem to be.  He  says :  " In applying the forceps  there are two
indications which, coeteris paribus, are requisite in every case;
first, that  the os uteri shall  be fully dilated;  ... as it will be
very difficult and frequently quite impossible to pass the blades
between the head and os uteri when only partly dilated ; it will 
IRRITATION OF THE  OS UTERI.
531
 be very difficult to avoid injuring its edge more  or less, and if
 we do succeed in applying and locking the forceps, on making
 an extractive effort we shall find  that the uterus  descends with
 the head as we draw it down."
   I dare to oppose these teachings because they are theoretical,
 established upon no  successful practice; secondly, because the
 theory is founded upon the belief that the corpus uteri and the
 cervix uteri are the  same organ; thirdly, I know from actual,
 personal, practical experience that  the  rules laid down by the
' magnates are not without exceptions.  I therefore, while assert-
 ing that the occasions for operations within an undilated os uteri
 are rarely—very rarely required, yet claim that  they be  con-
 sidered as feasible and worthy of confident resort in  times of
 great emergency.
   In the  haemorrhages of abortion,  operations have been con-
 sidered proper, Dewees having proposed a hook for the removal
 of the embryo and placenta.   I have several  times removed a
 three or  four months' placenta by twisting it off with polypus
 forceps (See  cut,  page 196) from its uterine  attachment  and
 delivering it through  a rigid os, which had barely  allowed, with
 great pressure, the small embryo to pass through it.  ISTo injury
 has ever resulted from this operation, and I am confident that
 life has been saved by thus stopping an apparently fatal haemor-
 rhage.
   When the head has descended  into  the  pelvic cavity, so that
 the finger may pass into the os, it may be somewhat dilated by
 sweeping the finger around and within with some steady pres-
sure upon it.   This irritation will also excite  flagging uterine
pains, particularly if the finger be passed as high up as possible,
so as to reach beyond the  cervix, where the nerves are sparsely
distributed, to the base of the uterus proper.  This mode of proce-
dure I have practised  for many yearsrand supposed it a personal
experience of my own, as it is not generally counselled in  the
writings of obstetricians, although  recommended by Puzos and
indorsed   by  Yelpeau, Burns, Hamilton  of Edinburgh, etc.
Within the last few months, Professor Miller  of Louisville, in
his recent work, advises such procedure.
  This is of more evident value in  those  cases characterized by
a long anterior lip, where the head has come well down into the
sacral cavity, but its flexion  and further progress is impeded by 
532
IRRITATION VS. ERGOT.
this extended anterior  lip, which is so thin as not unfrequently
to be  supposed to be the membranes applied closely over  the
head,  or even the scalp itself, when I have known  propositions
for the application of forceps to have been made by practitioners
of forty years' experience.
  Irritation of the os and cervix uteri as a  provocative of
uterine action, I therefore would strongly urge upon practitioners
of midwifery  as  a proper and feasible  operation, and particu-
larly upon those  who  are in the  habit of giving  ergot under
such circumstances.  I am confident that I cannot recommend a
practice so deleterious as ergot giving.
  Gentlemen, I thank  you for the attention which  you have
given to me.   The practice of midwifery has so long been con-
sidered merely as an art, that its scientific aspects have been
overlooked.  May I trust that a learned  Academy will not pass,
without careful  examination, any  conscientiously  made state-
ment, although it may  conflict with the prejudices or even care-
fully-formed opinions of the learned and  the wise.] 
LECTURE XXXY.
               TARDY AND  PRECIPITATE LABORS.

   Gentlemen :—In a great number of the difficult cases of mid-
wifery, we  have to deal either with  Excessive or Deficient
action of the Uterus and of those organs which are associated
with the womb in childbirth.  Sometimes this excess or  defi-
ciency depends upon other causes than the uterus itself; but in a
great number of cases, inertia or excessive activity of the organ
play important parts, and it will  be very useful, in a practical
point of view, to consider the nature and tendencies of the  two
great and opposite  classes  of difficult  labor thus produced.
They throw  mutual light upon each other, when we study atten-
tively their  nature  and causes, and the  several accidents  and
complications they tend to produce.                      .
  Twenty-four hours is the time which has been accepted with
nearly common  consent  amongst  accoucheurs,  as the limit
beyond which a strictly natural labor should not pass.  It is,
however, equally agreed that little or no mischief can be caused
by any ordinary extension of time in the early stage of labor,
before the os uteri has dilated widely, and before the membranes
have  broken.  The vast majority  of labors are finished much
within the time mentioned, especially in multiparous  women,
but individual cases are met with in which labor extends beyond
twenty-four  hours without any other morbid element saving that
of simple protraction.  Still, the statistical inquiries of Dr. Simp-
son and others have proved to a demonstration that the great
proportion of fatal and dangerous  results, both to mother  and
child, is met with in cases in which labor is prolonged over the
natural time, and the extent of this mortality increases accord-
ing to the time to which the protraction of the  labor extends.
On the other hand, excessively rapid labors have their peculiar
risks to the  mother and  child,  though this class of  dangerous
• 
 534      POWER OF THE UTERUS  IN YOUNG AND  OLD.

 labors is much less numerous  than that depending upon pro-
 tracted labor.  In both protracted and precipitate labors, other
 matters play important parts, besides the activity and  excessive
 action of the uterus ; but the state of the  uterus and expelling
 powers, in these  cases, is  sufficiently important to merit our
 special study.
  In  the lecture on the Nervi-Motor Actions of the  Uterus, I
 have  entered pretty  fully upon  the  nature of the  expelling
 powers which accomplish  the  act of parturition.   The  causes
 which interfere with these powers, so as to produce parturient
 inertia or excess, are very numerous  and varied.  Upon their
 proper comprehension, our means of relieving the inactivity or
 violence of the organ will very  much depend.   Let us, then, in
 the first instance consider the subject Tardy Labor, from In-
 ertia of the Uterus and other parturient powers.
  In  some constitutions, particularly those of lymphatic  habit,
 the action and development of the uterus  is naturally feeble.
 General debility during pregnancy, or at the time of labor, from
 Avhatever  cause  arising,  produces inactivity of the uterus and
 the abdominal muscles.  The uterus acts more feebly in hot than
 in  cold climates, in the heat of summer than in winter; and
 some  of the  most distinct cases of uterine inertia to be met with
 in this country occur in  women who  have been enervated by
 long residence in. the tropics.   Age is another source of defi-
 cient uterine action.  When a woman  becomes pregnant for the
 first time towards the close of the  child-bearing epoch, the pains
 of labor are  less powerful than in  the case of a younger female.
 In the cases I have  seen of precocious  pregnancy, when very
 young girls  have become mothers, the labors have been  tardy,
 and the pains less powerful than natural.  It is also found, that
 in women who have borne many children in rapid succession,
 the powers of the uterus decline during the later labors.   This
 is contrary to what occurs in the history of any other muscle of
 the human economy, and many observers of the fact have been
 puzzled to explain it.  If, however, we take into account the
gradual development of  the nuclear muscular structure in the
 virgin, its gradual decline  towards and after the end of the
child-bearing epoch, and the  circumstance  that  a new set of
fibres have to be produced in the  gravid uterus in each succes-
sive pregnancy, we shall  readily understand why the organ of
• 
         TARDY LABOR FROM POSITION OF THE UTERUS.      535

the very young  gravid woman, of the patient  becoming  preg-
nant for the first time late in life, or of the multiparous woman,
whose uterus has been developed and redeveloped a great many
times in the space of a few years, should not be  according to the
most perfect type.   The state of the mind in controlling uterine
action is also very remarkable.   The Protean infiuence of emo-
tion may act as a powerful oxytocic, or it  may  entirely suspend
the uterine action.  The unexpected entrance of the accoucheur,
the receipt of some sudden  intelligence, a  thunder-storm, or, in
fact, any emotional disturbance whatever, may arrest labor in
mid-career, and it  may be  some hours before the action of the
uterus is resumed.   I have seen, on more than one occasion,
chloroform produce tardy labor,  by weakening, or for the time
arresting, the action of the uterus.
   Yarious matters relating to the position of the uterus, and the
condition of the parts which, are indirectly concerned  in the
uterine efforts, have a tendency  to prevent their  full develop-
ment.   The effects of the position of the womb are so remark-
able as to have attracted the attention of the best  obstetricians.
In the ordinary uterine  position, at the  commencement and
during the  progress of labor, the axis  of the  uterus coincides
with the axis of the inlet of the pelvis.  In anteversion from  a
pendulous state of  the abdomen, this correspondence between
the axis of the uterus and  the upper part of the canal is des-
troyed, and the organ acts at a great disadvantage.  The force
exercised by the uterus is  in the direction of its own axis, and,
in anteversion, this urges the presenting  part of the  child, not
,into and through the pelvis, but against the promontory of the
sacrum  or  last  lumbar   vertebra.   Under these  circum-
stances, the action of the  uterus  is inefficient,  and it is, more-
over, less powerful  than ordinary.  In those  rare cases of par-
tial retroversion which continue up to the time of childbirth, the
uterus also  acts at  a great mechanical disadvantage.  Such is
also the case when, from rigidity of the abdominal parietes, the
use of tight stays  or bandages, or other causes, the position  of
the gravid uterus is more vertical than it ought to be.  In both
retroversion and in  the more common vertical  derangement  of
the uterine axis, the imperfect pains urge the head  or presenting
part of the  child, not into the pelvis, but against the pubic arch.
Wigand has beautifully described and figured these displace- 
536
LABOR TARDY IN DOUBLE UTERUS.
ments as a  cause of tardy labor.   He shows  that part of the
difficulty in the case of dwarfs arises from  anteversion of the
gravid uterus.  These results are also increased or diminished
by the position assumed by the patient during labor.
  In the erect position, or when  the patient lies on her back,
any tendency to  retroversion or a vertical position is increased.
When the axis of the uterus approaches  the vertical  direction,
the woman will often instinctively  lie on  her side, and bend her
body forwards ; or, if in the upright position, she will stoop, so
as to bring the axis of the uterus into  correspondence with the
axis of the pelvic inlet.  It is the province of the accoucheur, in
all cases, t' bear these facts in mind, and  to act upon them, so as
to produce the proper physiological  coincidence  between the
axis of the  expelling  organ and the bony canal  which the foetus
has to enter and pass.  That  common form of obstructed labor
in which the anterior lip of the uterus descends before the head
and is squeezed for hours between the pubes and the head of the
child, is, in the  majority of cases,  connected with anteversion,
and the direction of  the aperture  of the  os  towards the upper
part of the sacrum.  The  remedy  for  this state of things  con-
sists more in rectifying the anteversion in the early part of labor
than in any pressure  or manipulation of the os uteri itself.   In
cases of anteversion, when the head or presenting part is driving
against the upper part of the sacrum, placing the patient on her
back, or supporting the uterus with an abdominal bandage, will
bring the uterus and  pelvis into harmony with each other, and a
foetus which no power could move onwards, while the mal-posi-
tion of the uterus  continued, now  enters the pelvis with ease.
The  anteversion of the uterus is  sometimes  caused,  not by a
mere relaxation  of the abdominal muscles, but by  a positive
breach in their structure, as in cases of large umbilical  hernia,
in which condition the inertia of anteversion, and the want of
the normal support  of the uterus  by  the  abdominal muscles,
should always be foreseen.
  Labor is  observed to be slow and tardy in  cases of  double or
bicorned uterus.    This, as "formerly shown, is  an approach to
that which obtains in the lower animals as the normal condition
of the  organ.   In this anatomical state of  the  womb, it  is
found to be thinner than  in the  perfect uterus of the  human
female.   With the lower animals, the thin, bicorned  uterus has 
UTERINE DISEASE RETARDS LABOR.
537
 no powerful action during parturition.  Its function  is to bring
 the foetuses to the os uteri, where they are successively grasped
 by the powerful muscular structure of the vagina, and delivery
 is gradually effected.   When  the human female has the uterus
 after the imperfect duplex type, the  vagina being with  her an
 organ of little parturient value, and the obstructions incident to
 the human pelvis being in full force, labor is performed under
 great disadvantages; the action of the uterus especially is liable
 to be imperfect, and easily exhausted.
   Inflammation of the uterus, rheumatism, gout  and neuralgia
 affecting the organ, sometimes retard labor to a considerable
 extent.   The excessive suffering produced by the pains prevents
 their full development.  Besides the positive  feebleness or iner-
 tia of the uterus produced by the various causes which have
 been enumerated,  labor is often retarded  by partial contractions
 of the uterus.   The uterus contracts under such circumstances
 in a spasmodic and irregular manner, or, instead of  the uterus,
 the abdominal  muscles, or the muscles of the inferior  extremi-
 ties, are thrown into a state of spasmodic or cramp-like contrac-
 tion at each pain.  The  great cause of  this state of things, as
 formerly shown by Dr. Power and other obstetricians, is intes-
 tinal irritation.
  The course of labor should run in a certain definite and regu-
 lar manner.   At  first the actions are simple, and  the  uterus
 alone is concerned.  As it proceeds it becomes more compli-
 cated, and the nervi-motor actions are more intense.  The uterus,
 under the stimulus of labor, becomes more and more powerful
 until it accomplishes delivery.  But if  baulked in  its natural
 course, the uterus  and associated organs are very apt to fall into
 a state of partial inertia.  Thus, a dose of opium, or too early
rupture of the membranes, occurring either spontaneously or by
the act of the accoucheur, will  often impede labor for  many
hours.  The same  thing happens when the membranes remain
too long unruptured.   The uterus now refuses, as it were, to go
beyond the stage of dilatation, while the liquor amnii is retained.
Although, as a general  rule, the early  rupture of the membranes
retards labor, cases occur in which the evacuation of the  waters
increases the uterine efforts.  These cases occur in women when
 the quantity of liquor amnii is very small, and when the punc-
 ture  of the membranes at once brings-the solid parts  of the 
538
PHENOMENA OF TARDY LABOR.
child in full contact with the uterine parietes ; or in cases of dis-
tension of the uterus by excess of the amniotic fluid, where the
action of the uterus is simply impeded by over-distension.
  In some patients, labor is  retarded  in  the propulsive and
expulsive stages, not only by the withdrawal of any  effort of
volition which could aid the process, but by a perverted volun-
tary interference with the  natural course of the pains.   If, in
the stage of dilatation, women are permitted to make voluntary
efforts, they  become  fatigued when  the voluntary efforts are
really required.  In the stages  of  dilatation,  the reflex and
voluntary efforts should partially  or entirely close the glottis, so
that the distended thorax may act as a fixed point for the efforts
of the  voluntary muscles; but  some women delay labor by
excessive timidity, opening the glottis during the whole of the
pains, refusing all voluntary effort, and causing  lingering,  or
comparatively powerless labors.
  Uterine inertia may supervene  in  the course of a  labor
which has commenced in a natural manner, and proceeded to a
certain extent in the ordinary course.  The uterus is apparently
not strong  enough to continue its contractions, grows more and
and more feeble, and at length comes, as it were, to a dead stop.
After an  interval of rest, it acquires a new  supply of  nervi-
motor power, and the  pains return in some cases, but  in others
they are not resuscitated, and the patient, if left to herself, would
pass through  the symptoms of  arrested labor, and die  unde-
livered.  Entire and persistent failure of uterine action is always
a sign of a state of considerable  danger to the lying-in woman.
The pains have acted in  the nature of shocks to the system, and
when labor is uncompleted, the foetus remains in the  passages,
pressing on the hard and soft parts of the mother, and constituting
a grave source of irritation and peril.  Although the child no lon-
ger irritates the nervi-motor apparatus of the uterus and. the rest
of the parturient canal, it is a powerful irritant to the vascular and
other tissues with which  it  is in contact.  The  natural secretions
are arrested,  the parts  become  hot  and dry, tumefaction of
the soft structures occurs, sanious and foetid discharges are set
up, sloughing occurs,  and, unless rescued  from this state, the
woman  perishes from the combined effect of the  shock to the
nervous system incident to  labor, and the irritation  and exhaus-
tion produced  by the . presence of the foetus  in the parturient 
          VARIOUS DISEASES THE  CAUSE OF TARDY LABOR.      539

 canal.  In these cases, shock is felt more than in cases of healthy
 labor, and there is something peculiarly noxious to the system
 in the presence of the foetus  in the passages in a half-delivered
 state.  This state of things belongs to the past, and to the  age
 of the ignorant midwife, rather than to the present day, and we
 may congratulate ourselves that such cases  are now  only seen
 as rare exceptions.  We may hope and expect that, in the pro-
 gress of obstetric knowledge, the death of women from exhaus-
 tion   consequent upon  lingering  labor, where the muscular
 powers are  at fault, but where no  insurmountable mechanical
 difficulty exists,  will become  impossible.
   One class of tardy labors depends on faulty action of the expel-
 ling powers which act in harmony with the uterus.  A variety
 of causes interfere with the voluntary and reflex action of the
 respiratory muscles.   In cases of labor occurring  in phthisical
 patients, and the various diseases of the lungs, such as bronchi-
 tis, pneumonia, and pleuritis, the distension of the chest, closure
 of the glottis, and powerful expiratory actions of respiratory
 muscles, are all impeded.   Sometimes labor comes  on  at the
 natural term in chronic pulmonary disease; in others, the lungs
 are the  subject  of acute disorder, and labor is  excited  by the
 local  disease.  In both, particularly the latter, labor is impeded,
 painful, and most distressing to the patient.   In paraplegia, the
 parturient woman is cut  off from the aid of voluntary and reflex
 respiratory action.  In the various forms of cardiac disease, and
 in abdominal maladies,  the   auxiliary powers which aid the
 uterus in  the propulsive  or expulsive stages, can only be brought
 into operation in a very imperfect manner.  In a former lecture
 I have spoken of ovarian and  fibrous tumors as offering mechan-
 ical impediments to the  passage of the child. In  cases  where
 these  tumors are above the pelvic brim, the action of  the  uterus
 and of the abdominal muscles are interfered with by the press-
 ure and bulk of  the tumors.   The respiratory actions of labor
 are necessarily  imperfect in ascites  and  in ovarian dropsy.
 General plethora, and in  particular a fatty state of the omentum
 and abdominal parietes,  frequently interfere  with  uterine  and
 respiratory action.
   The prevention of tardy labor will  be  best insured by pre-
serving the course of parturition in as  natural a track as  possi-
ble.   With this end, we should attend  to the time at which  the 
540
TREATMENT OF TARDY LABOR.
liquor  amnii escapes, aim at a  proper harmony between  the
axes of the uterus and the pelvic inlet, encourage the voluntary
efforts  at the proper stages, and discourage them before the full
dilatation of the os uteri;  avoid opiates or sedatives of uterine
action  when there is any apprehension of feeble labor; remove
intestinal or gastric irritation  by an aperient or enemata, and
encouraging  vomiting;  preserve the  confidence  and mental
tone of  the patient; and give moderate and  sustained sup-
port and  stimulus  during  labor,  particularly  in the  early
stages.
  In tardy labor, the  pains are more  powerful in  the upright
than  in  the  recumbent  position,  and  the  patient may  be
encouraged to walk about and to stand up, leaning on a chair
or supported by the nurse, during the pains. An abdominal ban-
dage will often have the best  effect,  apart from any influence in
correcting anteversion, by supporting the abdominal muscles
and exerting the stimulus of pressure  upon the uterus.  Yomit-
ing, sneezing, coughing,  the  action of the bowels, all tend to
excite  the uterus; and the administration  of a brisk purgative
enema is often most effective  in rousing the uterus  from a state
of atony or torpor.  I have formerly mentioned that the exami-
nations of the accoucheur have a tendency to excite uterine con-
traction.   In  powerless  labors, digitation should  be  more
freely resorted to than in  other cases, and when making examin-
ations  firm  pressure  should  be made  on the perinaeum, this
being  the seat of a considerable number of excito-motor nerves
in relation with the uterus.
   When labor is arrested in mid-course, or towards its termina-
tion, the uterus and its associated  muscles often begin  to  act
again  after a short interval of rest.  In cases of this kind great
good is  frequently done by  a full  opiate, particularly in cases
where the preliminary part of labor has been tedious, and  the
patient has long been without sleep.   After a few hours' rest,
the uterus will resume its work with  energy, and the patient,
refreshed by repose, will go  on favorably to the termination of
labor.   Such cases  must,  however, be carefully distinguished
from those  in which  exhaustion of  the body generally, and of
the uterus in particular, has been induced to such  aa  extent as
to be beyond the power cf  restoration by temporary rest, and
which rest from the pains, before the  completion of delivery, is 
OXYTOCICS IN TARDY LABOR.
541
a deceitful truce, and in itself an exhausting and dangerous con-
dition of the patient.
  Cases of retarded labor from the disease of other organs, par-
ticularly the lungs and heart, require to be treated with  refer-
ence to the extra-uterine disorder. I shall have to discuss, when
treating  of the induction of premature labor, the propriety of
artificial delivery in cases of the occurrence of acute pulmonary
disease in the latter  part of pregnancy, and also  in cases  of
chronic heart disease. During the occurrence of actual  labor,
under these circumstances, all we can do is to avoid every unne-
cessary exertion or excitement.   I have already mentioned, that
in cases of inflammatory disease occurring to  the gravid woman,
the symptoms are preternaturally acute, and generally require
decisive  treatment.   When  the uterus is inactive from inflam-
matory, rheumatic, or gouty disorder, bleeding and antimonials
are required.
  In entire arrest of labor from failure of uterine action, when
nothing is hoped from rest, we have to resort to oxytoxic  reme-
dies, and to  instrumental delivery.  Ergot of rye,  galvanism,
borax,  and  cinnamon, are the chief agents  by  which we  can
act  upon the uterus, and I propose hereafter  to devote a lecture
to the special properties of oxytoxic remedies.  The ergot is, of
all, the most powerful and certain, and  in  half drachm doses
of the  powder infused  in boiling water, and taken every ten
minutes, to the extent of three or  four doses,  it will generally
excite  the  uterus, unless the  tone  of  the   organ is  entirely
exhausted.   On  account of the  spastic contractions of  the
uterus, caused by this medicine, which interferes  with the utero-
placental and perhaps also  from some  specific influence upon
the circulation of the foetus, the state of the child should always
be watched while the mother is  under  the influence of ergot,
and  delivery  completed  by the  forceps,  if the action of the
fcetal heart is quickened to any great extent.   In  uterine inertia,
as in all  other  cases, the  os uteri  must be  dilated,  or readily
dilatable, before the  ergot  can be given with safety, and there
should be no extra-uterine impediment to delivery.   Tlie ergot
is especially suited for those cases of uterine  inertia in which
rapid delivery is not called for, and when the head of the child
is not  low  down enough   to render  the application of  the
forceps easy.   Dr. Yernon, the very able obstetric  resident of 
542
OPERATIONS IN TARDY LABOR.
this hospital, has recently given small doses of  strychnia in
cases of labor marked by pure uterine atony with good  effect.
  Where the symptoms are urgent, as regards either the mother
or the child, particularly the former, the long forceps, when the
head  is at  the  brim, or the short forceps  or  vectis, when
the head is sufficiently low, are called for, and in extreme cases
of danger to the mother, craniotomy becomes  necessary.  In
cases where the child is already dead, and  cannot  be delivered
immediately by the forceps, the  operation of craniotomy and
extraction by the  crochet  should  be performed.   A train of
serious  symptoms often  follows  upon deliveries marked  by
uterine  inertia.  These will have to  be  considered  separately,
the most important  of them being non-detachment, or non-ex-
pulsion, of the placenta and post-partum haemorrhage.
  We have next to consider  the  opposite state  of things, or
precipitate  labor, from  violent or excessive action  of the
uterus and its associated muscles.
  The great majority of  precipitate  labors depend upon the
constitution and temperament of the mother.  As  some women
and some families always have slow and lingering labors, so
others invariably complete the process in a rapid and powerful
manner.  Nothing  can  be more  in  contrast than  the  strong
parturient  action of the well-fed, hard-worked,  and exposed
woman  in agricultural districts, and the more feeble powers of
the denizen of large towns  of the  same rank.  Fortunately,
with the diminished power, there is also  diminished resistance,
from relaxation of the tissues, otherwise difficult labor would be
far more frequent than it is in such cases.  In the robust coun-
trywoman the  resistance  to  be overcome increases, to some
degree,  in proportion to  the  strength and excitability of the
nerve and muscular fibre.  In women of powerful nervous and
muscular endowment, under any circumstances, labor sometimes
becomes almost tetanoid in character.
  It is observed that women wdio  have been the subjects of
dysmenorrhoea, suffer from painful  and violent labors probably
from the persistence of ovarian excitement up  to and  during
the process of parturition. Some women, particularly hysterical
subjects, increase the pains of labor to a dangerous extent by pas-
sionate  and  uncontrollable voluntary efforts during the stages of
propulsion and  expulsion.  Dystocia of this kind  may depend on 
CAUSE8 OF PRECIPITATE LABOR.
543
a small quantity of liquor amnii, when the uterus is well devel-
oped, and the nervi-motor powers of the mother active.  This is
because the body and limbs of the foetus are  from the first in
contact with the uterus, and because solid, rather  than  fluid
pressure is directed against  the  os uteri during the stage of
dilatation.   The  early rupture of the membranes, occasionally
instead of retarding labor, brings on a perfect storm of uterine
action.  Fear,  terror,  and mental emotion  of any kind  will
sometimes render labor acute to an extraordinary degree.   The
most  rapid  action of the uterus, we  can conceive,  is that in
which the child is expelled partly through the influence of ter-
ror, in cases  of sudden death, as  in  drowning or suffocation.
Under such circumstances, the whole process of delivery, at,
the full term, has been completed in a few minutes.  Here the
oxytocic effects of the carbonic acid retained in the blood  con-
cur with  mortal anguish and  the act  of dissolution  itself, in
evacuating the  womb.   In the febrile condition, and blood-poi-
soping, which obtains in  small-pox, and scarlet fever, and  albu-
minuria, labor is usually rapid from excessive uterine action. It
is scarcely necessary to refer  to  the injudicious  administration
of the ergot  of rye as a  cause of precipitate labor.  Cases of
rapid labor from the great size of the pelvis  belong  alto-
gether to a different category from that we have now been con-
sidering.
  The management of precipitate labor  consists  in  the avoid-
ance and removal of its causes, and the employment of pallia-
tives of uterine action.
  The position  of the patient in cases  of acute and violent labor
should be the recumbent from the first.  Mental and  physical
stimulus of all kinds should be  avoided as  much  as  possible.
No examinations beyond those  actually necessary to ascertain
the presentation of the course of labor and to aid the passage
of the foetus through the external  parts, should be  made.  In
cases  of constipation and faecal accumulation in the rectum, the
bowels should be cleared by mild enemata.   When the uterine
action is increased, and aided by the uncontrollable volition of
the patient,  the  remedy consists  in encouraging her to cry
out lustily, during which all voluntary action is impossible.  It
was a pious fraud recommended by Denman, to tell  the woman
in the latter part of labor, the child was already born, when she 
544
TREATMENT OF PRECIPITATE LABOR.
was in danger of laceration, and thus  to make  her  cease from
the expulsion.  Yenesection, nauseating doses of tartar emetic,
a full opiate, or chloroform, are the most powerful sedatives  of
uterine action which we possess.
  The train of evils produced by precipitate  labor  is scarcely
less  dangerous than that following in the wake  of tardy labor.
Amongst the accidents produced by excessive uterine action,  we
have rupture of  the uterus, laceration  of the  perinaeum, reten-
tion of the placenta from closure of the os uteri,  hour-glass con-
traction, inversion of the uterus, and prolapsus, and procidentia.
In rare cases,  when the pelvis is  large or  the child small, the
violent uterine and abdominal action brings down the uterus,
and  we have procidentia,  during  the  act  of labor.   Such
cases require careful support of the uterus  by  the  hand or a
bandage, to keep the mischief as limited  as possible.  It  has
also been observed that puerperal mania has a tendency to fol-
low precipitate labors.  In some cases, apoplexy or convulsions
are caused  during the violence of  the pains.  In  precipitate
labor, the  state of the child must be attended to.   The incessant
uterine action sometimes destroys it by asphyxia, from arrest of
the  utero-placental  circulation.    The foetus is  occasionally
extruded with such violence as  to snap the  umbilical cord; this
is  particularly the case when  the mother  is  allowed  to  be
delivered  in the upright position.  Under  the same  circum-
stances, the child  may be seriously injured by  being  shot  out
wTith violence upon the floor. I once knew  a case of precipitate
labor in which the patient, not  supposing delivery to  be  near,
insisted upon going  to the water-closet, and the child  being
suddenly discharged into the pan, had to be  rescued from  the
peril of death from drowning,  as  well as  mechanical injury.
On a former occasion this patient had  dropped or expelled  the
child upon the floor, while standing at the  bottom of  the  bed.
Cases of this kind have a medico-legal bearing.  It is, of course,
of the highest importance to distinguish between cases  of acci-
dental birth of the child while  the  mother  is at  the closet, and
premeditated infanticide. 
LECTURE  XXXYI.
   DIFFICULT  LABORS DEPENDING ON THE  STATE  OF  THE OVUM.

  Gentlemen :—Jhis form of Dystocia may depend upon dropsy
of the different serous cavities of the foetus; tumors or disten-
sions of other parts of the body:  colossal size of the foetus, with-
out relative disproportion; morbid ossification of the joints of
the body generally, and especially of the cranium; the various
teratological monsters and errors of development;  twins ; short-
ness of the  funis umbilicalis,  and  excessive  rigidity  of  the
membranes.   Of all these impediments to  natural delivery
Hydrocephalus  occurring in the  foetus is  the most impor-
tant, and to this complication I shall first direct your attention.
  Hydrocephalus may occur to  the foetus in utero to such an
extent as to interfere with labor, or render it altogether impos-
sible.   The size which the head sometimes attains  in these cases
is enormous.  Several pints of fluid have been known to escape
after perforation,  and Merriman mentions a case in which the
head, the circumference of which measured  twenty-two inches,
was born alive by the natural efforts,  the average circumference
of the head measuring  about fourteen inches.  In these cases,
the bones  are  generally  thin,  the  fontanelles large, and the
sutures membraneous and gaping.  Hydrocephalic children may
present with the head;  but, as  formerly mentioned, there is in
these cases a great  tendency to the  presentation of the pelvic
extremity  of the child.   When  the head presents in hydro-
cephalic cases,  the  symptoms are, arrest of the head above the
brim of the pelvis, there  being  no deficiency of  the expulsory
action, and no pelvic or other impediment to the descent of the
head on the part of the mother.  When examined", the  area of
the cranial surface, which may be reached by the finger, is flat-
ter than usual, conveying the impression of belonging to a larger
spheroid than the natural fcetal head.  The bones are usually thin,
                             35                       545 
54:6         MECHANISM OF  A HYDROCEPHALIC HEAD.
and the fontanelles, when they can be explored, are  beyond the
natural size.   Under the  influence of strong pains, and when
labor has been of long duration, the rounded shape of the head
is altered, the edges of the cranial bones can be felt through the
fontanelles or sutures ; fluid can be detected, somewhat like the
fluid when the  amnion is  unruptured and  the membranes are
more dense than usual.  In the irregularity and  projection of
the edges of  the bones, the hydrocephalic  head resembles the
head of the premature  foetus, or of the foetus at the full time
with the  head  imperfectly ossified,  only that in the case of
hydrocephalus the  size is greatly increased.   When the foetus is
dead, the flaccidity of  the hydrocephalic head  is  commonly
greater than  usual.  When the pains relax, this  sense of fluid
disappears.  In breech or footling cases complicated with hydro-
cephalus the diagnosis is more difficult.   There is  in such  cases
a natural descent of the pelvic extremity of the body of the child
until the head comes to engage  in the pelvis, when  a sudden
arrest  takes place, notwithstanding the  continuance  of strong
and  regular pains,  and the  portion of the head of the child  which
can be reached gives the  impression of a large, loosely ossified
cranium.  The limbs of the child are  generally shrunken or
wasted.
  It might be supposed that in a case of hydrocephalic head,
when the  bones are thin, and readily compressible, labor  would
take place easily and without bad results.  Such is  not, how-
ever, the  case.  As just mentioned,  cases do occur  in  which
hydrocephalic heads  considerably above the average circum-
ference pass through the pelvis without assistance, but these are
exceptions, and a favorable result by the natural powers should
not be  depended on when the  amount  of  fluid  is large.   The
cause of the difficulty depends not only on the large size of the
head, and in  some cases upon its extensive ossification, but on
the loss of the proper cranial shape under pressure, and the con-
sequent want of due mechanical relation between the head and
the  screw-like  arrangement  of  the pelvis.   The head  passes
through as a matter of brute force, instead of in the rotatory man-
ner natural to  the well-formed fcetal head.  There  is not only
difficulty  as regards the actual  passage of the head, but danger
to the  mother, in  these cases.   Left  to  themselves, such cases
are almost sure to be attended by serious results.  The uterus 
             RUPTURE WITH HYDROCEPHALIC HEAD.         547

may be ruptured, or the vagina lacerated, by the force of the
pains; or exhaustion may be produced.  The head of the child,
instead of preserving any definite relation to the pelvis, is jam-
med into the cavity, as insisted upon by Dr. Ramsbotham, so
as to fill it equally in all directions.   The irregular edges of the
bones are liable to damage the  soft parts, and numerous cases
are on record  in  which inflammatory action, sloughing, and
death have  been  thus  caused.  Occasionally,  a spontaneous
resolution of the difficulty occurs by the rupture of the head,
and escape of the contained fluid, under the pressure of the pains.
This happens more frequently when the foetus is dead, and par-
tially decomposed, than under other circumstances.  Dr. Robert
Lee, Dr. Simpson, and  others have pointed out that in some
cases there is not merely expansion  of the head, but the cranial
bones  are greatly developed, and  the  sutures  comparatively
closed.  Of course, under these circumstances the difficulties of
delivery are greatly increased.   Out of seventy cases collected
Tt& 115.
by Dr. Thomas Keith, he remarks  the  significant fact that the
uterus was ruptured in sixteen.  The mixture of solid and  fluid
pressure brought to bear on the os  uteri and the vagina in cage
of hydrocephalic births, is perhaps greater than under any other 
548
TREATMENT OF HYDROCEPHALIC HEAD CASE.
circumstances whatever.  In five cases  to  which Dr. Lee was
called in  consultation, and which are related in his " Clinical
Midwifery," the mothers  all died, either from inflammation or
rupture of the uterus; but he observes that,  had perforation
been performed sufficiently early, some or all of them might
have been saved.   In hardly  any of the emergencies of mid-
wifery is  an  early diagnosis and prompt action more impera-
tively called  for.
   The treatment of these cases is sufficiently simple, when an
accurate diagnosis has once been made.   We must evacuate the
fluid when the size of the head is so great and  the progress of
the labor so slow, notwithstanding effective  pains, as to lead to
the conclusion that the case cannot  be  safely left  to  a natural
termination.  In many of these cases, the child is already dead,
or dies during labor, in which case all scruple respecting crani-
otomy will of course disappear.  When the life of the mother is
in imminent danger, the  perforation of the  head may be more
cheerfully  performed  than in  almost any other cases, as  the
chances of living after birth are so slight, even when most favor-
able, that we cannot compare them with  the life  of the mother,
to the extent we are sometimes warranted  in doing when  the
foetus  is strong and healthy.   Every care  should be  taken to
make  out such cases  with accuracy, as it would be a  grievous
mistake to perforate  the  head of  a  healthy foetus, instead  of a
hydrocephalic child.  Time should  also  be given to make  the
case clear, but without waiting so long as  to endanger the serious
injury of  the mother. After  the  perforation of the head,  the
escape  of fluid generally diminishes the size of the head  to a
greater extent than occurs in  craniotomy under any other  cir-
cumstances, and delivery is generally easy.  Sometimes, the head
is perforated  for arrest, when hydrocephalus has not been sus-
pected, when the sudden escape of the fluid gives the first indi-
cation of the  nature of the case.  Dr. Simpson suggests that the
perforation of the head by a small trocar may be preferable to
the use of the perforator and scissors, as  by  this means the fluid
can be evacuated  and the head diminished so as to render
delivery possible, without necessarily destroying the child.   He
also throws out the hint, that in pelvic presentations, in  hydro-
cephalic cases, the fluid may be drawn off by opening the ver-
tebral canal in any part of the spine. 
TARDY LABOR FROM ASCITES.
549
   Ascites is another form of dropsy to which the foetus is liable,
 and which  sometimes exists to such  an  extent as to interfere
 with labor.  This may be confounded with tympanitis occurring
 in a dead child ; but, as Dr. Fleetwood  Churchill remarks, in
 tympanitic  distension there is  generally  crepitation  from  the
 presence of air in the cellular tissue of the face and chest, when
 the  head  presents and has been delivered first, in such  cases.
 Ascites may also be  mistaken for excessive secretion of  urine,
 and its retention  in the foetal bladder, as pointed out by Depaul.
 The proper treatment in  cases of ascites is, to puncture  the
 abdomen of the foetus and evacuate the  liquid.  This paracentesis
 should be performed by means of a  long fine trocar.   While
 speaking of ascites, it may be mentioned that, from adhesion or
 stricture of the urethra, the fcetal bladder  may be distended to
 such an extent as to reach the scrobiculus cordis.   Such a case
 could hardly be distinguished from ascites; and if this were pos-
 sible, the  treatment—that  of puncture of the accumulation by
 the trocar, when it interferes with labor—is the same.
  In connection  with these forms of  dropsy, we  must discuss
 those cases of accumulation of serum in the serous  cavities, par-
 ticularly of the brain and spinal marrow, attended by deficiency
 of the bones, muscles, and integuments, forming Spina Bifida
 and  which are sometimes  so large as  to interfere with the pro-
 gress of labor.   Dr.  Meigs describes  a case of dropsy of the
 head, combined with fissure  in the  posterior walls of the cra-
 nium, where the  extra-cranial tumor was in its greatest length
 nine inches long.   Ruysch relates one in  which the tumor was
 as large as the head itself.   I have seen a case in which the tu-
 mor was considerably larger than  the  head, and the subject of
 it lived until after the time of puberty, the  cerebral  development
 being  very  small.   The  head was carried  forward,  and  the
 tumor rested on the shoulders in standing or walking.   Similar
 tumors may form at any part of the spinal column, but they are
more frequent in the cranial and  sacral regions than in  other
parts.  When not of large size, they impede labor but little. In
 the case referred to by Dr.  Meigs (Fig. 146), the head was born
 first, when, the tumor remaining above  the pubes, the rest of
 the body was  born by spontaneous evolution.  After this, Dr.
 Rohner, the attendant, was able, by powerful traction, to bring
 down the watery  tumor without injury. 
550              PROGNOSIS OF SPINA BIFIDA.
  When speaking of the development of the serous amnion, and
of the serous cavities of the body generally, by the processes of
Fib. 146.
inclusion and separation of  the various parts of the serous layer
of the  early ovum, I have  mentioned that,  in some cases, the
same secretion of serum which is physiological in the amnion is
apt to take place  in the serous membranes of the young foetus,
when it becomes pathological, constituting the first forms of
dropsy in the animal economy.  All the serous  accumulations
we have now been discussing, in the brain, spinal marrow, and
peritonaeum, arise in this way, as the result of inflammation or
erratic development, and are frequently found to exist in com-
bination with dropsy of the  amnion itself. In the case of serous
tumors of the head and spine  and other tumors  in which the
serous membranes are protruded externally, there is,  in addition
to excessive serous secretion, deficiency of the development of
the bones, muscles, and integuments, all of which are developed
from the primary serous layer.   When there is malformation as
well as serous tumor, the case is probably dependent on an error
of development;  where there is no malformation, inflammation
of the serous membranes has generally existed, and the evidence
of this is  frequently found  in post-mortem  examination.  [The
attending physician should give a very guarded prognosis to the
anxious friends as to  the future condition of the child, as it is
extremely rare for children with these malformations, either
with or without any operation, to survive more than a year or
 r'-o^or, months, fatal inflammation sooner or later ensuing.] 
MECHANISM  OF  LABOR IN MONSTERS.          551
  Teratology presents us with a number of monstrous combi-
nations of twin children in which  either two foetuses are
fused together to a greater  or  less extent, or in which they are
joined  together without any  great  extent of organic  union.
There  may be two heads with  only two arms and two legs, the
bodies being  fused from  the neck to the sacrum, or there may
be the same extent of union with four arms and four legs; there
may be one head and a large  trunk composed of the fusion of
two  bodies, possessing four  legs and four arms.  In the case of
two children  perfectly formed or nearly so, but  united at one
point, the union may occur at  different parts of the body. The
forehead or vertex of  two children may be united.   The union
may be at the side, or at the sternum, or by means of the intes-
tine  only, at  the umbilicus.   The sacrum  is another point at
which union takes place in  these cases.   The union or fusion is
always symmetrical.   In accordance  with that plan of develop-
ment in twin cases, alluded  to in the embryological portion of
the present Course, it is only the same parts in opposite children
that  admit of union—that is, it  is head to head, side to side,
sacrum  to sacrum, and never  any heterogeneous union which
occurs.
  These cases are happily rare, and they present  unusual diffi-
culties to the completion of labor. It might seem impossible that,
in such as that figured on page 537, natural delivery should be
effected, did we not know that these monsters are not only born,
but, as in the case of the Siamese twin, the African twin recently
exhibited, and a number of  other well-known cases, the double
monsters have lived,  and have  even reached maturity.   Favor-
able  circumstances must concur to enable double monsters to be
born alive.   The children must be small or premature, and the
pelvis full-sized.  But little  is  known of the mechanism  of par-
turition in monsters.   In  the case figured, which  is  related by
Dr.  Meigs, spontaneous  evolution occured.   One head  came
down first;  this was  delivered, and became fixed against the
pubic arch, when the body came down in the manner described
when speaking  of  the process of evolution  in  arm cases, the
second head being delivered last.   Dr.  Meigs points out that it
can only be by this method  that double monsters are generally
delivered.  Even when the  feet present, and the union is at the
sacrum or any part of the trunk after the delivery of the but-
tocks, the upper part of the  body and head must descend by a 
552
INSTRUMENTAL  ASSISTANCE WITH  MONSTERS.
process of evolution.  We do, however, know that, in twin cases,
it happens at rare conjunctures, that the two heads, or the head
Fig. 147.
of one child and the pelvis of another, engages in  the  pelvis
simultaneously.  In such a case as the  Siamese twin, it  is im-
possible to conceive but that if a  head presented in the first in-
stance, one child  must have been delivered down the point of
union, when the rest of the same foetus must have been delivered
by  a  method similar  to that of  spontaneous evolution.   Such
cases  afford the proof that, in some instances, both children may
be born living, and viable.  But in many cases on record, it has
been necessary to diminish the child by  amputation of the head
and evisceration.   Such cases are puzzling to the accoucheur in
the first instance, and no  rule of diagnosis  can be given  for
them.  The obstetrican must  depend upon  his general  know-
ledge and resources for the detection and management of such
cases.  At first  they  must prove exceedingly perplexing, but
they gradually reveal their true  nature as the course of  labor
proceeds.   The same principle must be followed in these as in
other cases where, from disproportion, the living  child cannot 
CAUSE OF UNUSUALLY LARGE F03TUSES.
553
pass with safety—namely, delivery,  destruction, evisceration,
and  mechanical delivery of the remnants of the twin monster.
The  law takes the same  cognizance  of monsters as of normal
children.   In destroying  the foetus we must not at all take the
fact of the monstrous birth into consideration, save in so far that
it becomes an additional  difficulty in delivery, and a greater
probability than usual that natural delivery cannot possibly be
effected.  When women have been delivered naturally in such
cases, great suffering, and subsequent  inflammatory disorder,
have been recorded.   The possibility of using the forceps, as an
aid to delivery in such cases, can only  be decided on by individ-
ual peculiarities; certainly no rule can be laid down.
  The different forms of Ectopy, in which, from faulty develop-
ment of the parietes of the body at the mesial line, organs that
should be internal are external, in the rare cases in which they
occur, sometimes complicate  labor.  In cases of Exomphalos,
when the liver  or intestines  have  protruded through the um-
bilicus,  the  tumors  have been  met  with of  very  large size.
Large  bulk  of the child, without  disproportion, is a common
cause of difficulty.  The average weight of the mature foetus is,
as remarked  by Dr. Rigby, from six  to seven  pounds; but he
refers to cases occurring  in the practice of Dr. Merriman,  Sir
Richard Croft, and others, in  which the foetus weighed fourteen,
fifteen,  and nearly eighteen  pounds  at the  time of delivery.
When, in these cases, the  bones of  the head are ossified as much
as usual, the difficulty is often very great.  The largest children
I have met with in practice have been in cases  where, from
pendulous abdomen, the foetus had been retained  beyond the
full term, and where  the difficulty of  labor had been increased
by weakness of the abdominal action during labor.  The obstruc-
tion produced by increased bulk may  be in some degree estima-
ted by the fact that the slight difference between the size of the
male and female at the time of birth  greatly increases the rate
of mortality, in the case of males, both to the mother and child.
In  extremely rare cases, the whole  of the  articulations have
been ossified  to such an extent as  to  interfere with the passage
of the child.   Sometimes the  cranial bones are prematurely ossi-
fied, so that the bones are as firm and the sutures as  consoli-
dated at the time of birth, as they should be  at four or five years
of age.  From cases of this kind which have fallen under  my 
 554        TARDY LABOR FROM SHORTNESS OF CORD.

 observation, I suspect that this may be one cause of idiocy, by
 mechanically preventing the development of the brain.
  In twins there is generally considerable difficulty and delay
 in  the birth of the first child.  The presence of  the  second
 foetus causes the uterus to act upon the first at a great mechani-
 cal disadvantage.  Labor in twins and  triplets in  the human
 female, is  somewhat similar  to  delivery in cases in which
 animals bring forth several young at a  birth ; but, as I have
 formerly remarked, there is not in the uterus and vagina of the
 human subject the same facilities for the  descent and expulsion
 of successive children.  In some cases, shortness of the funis, or
 twisting  of the  cord  round  the  foetus,  forms an impediment
 to labor.   JSTaegele" and some other  authorities have doubted
 that shortness of the cord can act in this way.  Plenty  of cases
 are on record, however, in which difficult  labor occurred in con-
 nection with shortness of the funis.  If the cord, as is sometimes
 the case, is only so long as to suspend the foetus in utero,
 there  must  be a difficulty in  expelling the foetus, even if the
 fundus uteri follows the child, since  the foetus is curved and
 bent in utero, but is  extended during  its way  through  the
 maternal passages.  Dr. Rigby relates a case in which the cord
 was little more than two inches long, and in which  it was rup-
 tured during the birth of the child.   Probably shortness of the
 cord is a predisposing cause of inversion of the uterus. Rigidity
 of the membranes is a common but easily remediable source of
 delay in  labor.  They  are, however, sometimes so  tough, that
no efforts of the uterus  can rupture them, and they require arti-
ficial puncture.  We are in want of  some efficient  instrument
 for  puncturing the membranes, as the  finger-nail  is  a very
clumsy and sometimes embarrassing method, besides that  the
scalp of the child sometimes gets damaged by its use. Probably
an  instrument constructed on the principle of  that used for
puncturing  the membrana tympani  would  be the  best  that
could be devised for this purpose.
  Dr. Simpson mentions a condition of the child depending on
 accidental misplacement of the arm, which offers a considerable
 impediment to labor, and which he  supposes  may  not be an
 uncommon  cause of obstructed  labor.   In  the  displacement
 referred to, the arm of  the child, instead of resting on the ster- 
ACCCIDENTAL MISPLACEMENT OF THE ARM.
555
num, is turned round the  back of the neck.  It would  be well
if accoucheurs meeting with such  cases  should put them ou
record.
Accidental displacement of the arm. 
LECTURE  XXXVII.
            POST-PARTUM  HEMORRHAGE.

  Gentlemen :—There is  scarcely an occurrence in the whole
range of obstetric practice  more alarming  or  dangerous than
Flooding after the Birth of the Child.  This tragic compli-
cation of labor often happens, too, when the patient is supposed
to be free from danger, and when the accoucheur, fatigued by a
long attendance, is  congratulating himself upon the completion
of his duties.  There can be  no contingency in which the life of
the  patient depends so completely on the coolness, decision, and
promptitude of the  attendant.   Nothing, indeed can more thor-
oughly tax  his highest skill, and the  whole of his resources, than
the  spectacle of a woman in imminent danger of death from this
form of haemorrhage.
  Let us, in the first instance, consider the circumstances  under
which  patients  are predisposed  to  this accident.  The  Chief
Sources of Flooding—namely, the open mouths  of the veins
on the internal surface of the uterus, from which the placenta
has been separated, have already been pointed out.   It has also
been shown that the great natural defence against haemorrhage
lies in the efficient contraction of the  uterus after delivery.
Whatever tends  to enlarge the  venous  openings or to prevent
the contraction of the whole  organ, necessarily tends to the pro-
duction of haemorrhage.  Thus, a large placenta, from the greater
size of the utero-placental vessels, gives the tendency to flooding.
For the same reason, post-partum flooding, after delivery  at the
full term, is far more dangerous than haemorrhage occurring after
premature  labor.  The circumstances which  interfere  with effi-
cient uterine contraction after  delivery, or produce inertia, are
many of  them the same as those which lead to powerless  labor.
Post-partum haemorrhage is, in fact, one of the sequelae of uter-
ine inertia.  Amongst'these circumstances are, a general relaxed
    556 
            CAUSES OF POST-PARTUM HEMORRHAGE.         557

habit of body, weakness of the abdominial muscles, and umbili-
cal hernia.   Such conditions are frequently found in the great-
est degree, in women  who have  resided  in  tropical  climates.
They occur also in women who have borne  large families, as
explained when  treating of uterine inertia.   The uterus often
flags when labor has been long  delayed from any cause, whether
the womb be simply inert,  or  worn out by  prolonged  action.
Thus the organ  frequently refuses to contract after labors  in
which the forceps or craniotomy have been required.  The same
result may spring from exactly  opposite  causes.  After a very
rapid labor, or after the  extraction  of  the body immediately
upon the birth of the  head, the uterus  may  suddenly fall.   It
has not been fully and  gradually roused to that powerful state
of contraction which  insures the safety  of  the  mother after
delivery ; or, too suddenly becoming empty,  it refuses to con-
tract, just as we sometimes witness to be the case after the sud-
den evacuation of the liquor amnii.   I have pointed out that in
labors occurring in women suffering from albuminuria the womb
often remains flaccid after delivery to such an  extent as to cause
dangerous haemorrhage.
  The  Symptoms of Post-partuin  Haemorrhage  are those
which  belong to  the uterus itself, and  those  arising from the
effects  of loss of blood.   The haemorrhage may occur before the
expulsion of the placenta, and immediately after the birth of the
child,  the placenta being detached, but remaining in utero, or
in the vagina; or it may take place  only when the after-birth
has  been expelled.  The most sudden  and profuse  losses are
those which occur when the placenta, having  separated without
being expelled, distends the uterus, and enlarges the area from
which  the blood  escapes.  The first sign we have of haemorrhage
may be a gush from the uterus,  and the  accoucheur first learns
the contingency he has to deal with, by hearing the plashing  of
the blood upon the floor.  I may  here mention a  circumstance
which  sometimes alarms us unnecessarily.  In cases where the
head of the child has so accurately fitted  the passage as to act as
a ball-valve, the principal part of  the liquor amnii remains, and
gushes out after delivery, mixed with the blood effused from the
separation of the placenta by the pains which  have expelled the
child.  When the hot stream comes upon his hand the accouch-
eur may  suppose it to be haemorrhage, but the eye soon distin- 
558        HEMORRHAGE WITH UTERINE CONTRACTION.

guishes the real state  of things.   Where the gush  of blood is
enormous, and occurs immediately after delivery, the uterus and
vagina are dilated, and there  being no impediment to the free
escape of blood externally, the clothes of the patient and the bed
are drenched with blood.  Sometimes the mischief is hidden,
and an immense quantity of blood may escape from the uterine
vessels  without  any  discharge externally.   The body  of the
uterus is dilated, but the os is contracted, or  plugged with coag-
ula, and the blood accumulates in the uterine cavity.   Under
these  circumstances,  the organ  remains  in a state  of  persis-
tent atony, not the slightest effort at  contraction is made, and as
a muscular organ it is in a  perfect state of  paralysis or death.
When the  abdomen is examined  by  the hand, the womb is felt
to be large, soft, and  flaccid, and altogether unlike the dense
organ in  a state of normal  contraction.  In other  cases, the
haemorrhage may be intermittent.  There is  marked  relaxation
of the uterus, followed by intervals of contraction.  During the
state  of dilatation, little or  no blood  appears externally, but
gushes  of blood or coagula take place  every time the  uterus
contracts.  In such cases, the uterus is felt externally to be in a
state  of alternate relaxation and  contraction, the contractions,
especially, being attended by severe pain.  Sometimes great
agony, without efficient muscular contractions, is  felt while the
uterus is being distended by coagula.  There are yet other  cases
in which the uterus contracts moderately,  but in which there is
a constant and dangerous oozing of blood.   It has been said by
some authorities, paticularly by Gooch, that haemorrhage may co-
exist with powerful contraction of the uterus.  But this is not to
be received without reservation.   In such cases there is generally
a retention of some portion of the placenta.  With the cavity of
the uterus free and uninjured, and continuous contraction present,
dangerous haemorrhage from the venous sinuses is  a  mechanical
impossibility ; and it weakens our faith in the great  means of
arresting haemorrhage, to believe  that contraction and  haemor-
rhage may occur  together,  save under exceptional circum-
stances.  Fullness of the circulation  was supposed to be a cause
of haemorrhage, the blood escaping in large quantities from the
exposed extremities of the uterine arteries, after  the entire or
partial separation of the placenta  ; and bleeding  from the arm
was  advised  and  practised as a remedy,  under the idea of 
             HEMORRHAGE FROM  LOSS OF DECIDUA.          559

diminishing the momentum of the current from the heart.  Such
cases  rarely, if  ever, happen to such  an  extent as to cause
uneasiness, at the present day, and few persons would now dream
of venesection in post-partum flooding.  If such a remedy could
be necessary, it is too surely in operation, from the haemorrhage
itself.   Minor haemorrhages may occur fro'm  limited lacerations
of the os uteri, the vagina, and the perinaeum, but these  are
seldom,  if ever, attended  by  danger.   Occasionally, flooding
occurs to a considerable  extent some hours of several days after
the completion of delivery.  When  this occurs,  it  is probably
similar to the losses which occur in monorrhagia.  After labor,
as formerly shown, the whole of the decidua  is thrown off from
the internal surface of the uterus, leaving a large surface from
which the blood constituting the lochial discharge exudes.  We
can  easily understand that  profuse lochial flooding may occur,
when we consider the larger superficies of the uterus after par-
turition,  and  that its internal surface is in much  the same state
as that which  obtains during  menstruation.  The  tendency to
loss of this kind  is necessarily increased by  flaccidity, or large
size of the uterus.  This condition, or the detachment of portions
of placenta which have remained  in utero, gives rise  to the flood-
ings under consideration.  In the cases where the lochial dis-
charge  has continued for several weeks after  delivery, I have
found the loss to depend on laceration or abrasion of the os uteri,
and the blood exudes chiefly from the surface of the os and cer-
vix, as in the majority of cases where the spurious menstruation
of pregnancy exists.
  The Effects of Eoss of Blood  are most appalling to witness,
and would require a dramatic pen to do  full justice to their por-
traiture.  In the most formidable cases, the great mass of the blood
may be withdrawn from the body in the space of a few minutes.
The woman may suddenly fall into a mortal syncope, from which
she  never recovers.  When the effects  are more  gradually
induced, the pulse fails, or  is not  to  be  detected in the limbs;
the respiration becomes gasping and diaphragmatic, the patient
crying wildly  for air; she loses  her sight, and  complains that
everything about her is dark.  Sometimes jactitation is present,
and she tosses her arms and limbs about wildly, and with such
violence, as to  exhaust her remaining strength; at others, she
manifests an  almost  irrepressible  desire to sleep, w)ien, if per- 
560
PUERPERAL  PALLOR FROM FLOODING.
 mitted, her repose would be the sleep of death.   Vomiting fre-
 quently occurs; sometimes convulsions  are produced ;  the  sur-
 face  of the  body, especially  the  extremities,  are cold,  and
 bedewed with sweat, and a pallor which exceeds all others, and
 which  may be termed  the Puerperal Pallor, almost represents
 death itself.  The symptoms I have mentioned, if permitted to
 continue, are the sure evidences of a state of the utmost peril,
 or the harbingers of dissolution itself.   When the patient per-
 ishes, it is either from successive syncopes during the course or
 after the arrest of the haemorrhage, or she dies by the process of
 gradual sinking some hours after  labor.  The  danger of the
 patient must be estimated from the symptoms as  much  as  from
 the amount of blood  actually lost.  Some women  die  after a
 very moderate loss, while others bear an immense flooding, and
 recover with great rapidity.
  The first point in the management of post-partum haemorrhage
 relates  to iis Prevention,  Where there have been, any cir-
 cumstances connected with  the labor, which leads us  to fear
 haemorrhage, one or two doses of ergot should be given during
 the last pains which expel the child, or immediately after  its
 expulsion, and before the extraction of the placenta.  This plan
 should always be followed in cases where women have  suffered
 from  flooding  in several successive labors.   Immediately after
 delivery in suspicious cases, the hand should be placed upon the
 abdomen, and kept there until efficient contraction is felt  to have
 taken place.  An abdominal bandage should be  placed lightly
 round the body, before the completion of labor, so as to have it
 ready if necessary without disturbing the patient.  The horizon-
 tal position should of course be strictly preserved.  Sleep imme-
 diately after labor, should not be permitted, and the vulva should
 from time to time be examined, to learn the amount of discharge.
 As soon as the uterus is found to have contracted, the abdomi-
 nal bandage, with a compress  of two or three folded napkins,
 should be applied.  I have known cases where I  have been
 obliged to  attribute a  fatal  result from  haemorrhage  to the
 neglect of bandaging after delivery.
  In the Treatment of Post-partum Floodings, we have two
things requiring instant attention, one being the arrest of haemor-
rhage  by  uterine  contraction—the other, the sustentation  of
the patient under the immediate effects of loss of blood.  As I 
                  COLD DOUCHE IN FLOODING.              561

have pointed out in my work on  Parturition, we have  a good
many  powers to appeal to for  inducing uterine  contraction.
There is the reflex contraction of the uterus, as when we dash
cold water upon the vulva or abdomen.   There is the direct
spinal excitation of the uterus, when we act not upon the exci-
tor nerves of the surface of the body, but upon the  spinal mar-
row  itself—as when we give  ergot.   There is the peristaltic
action  of  the uterus and  the  contraction  depending on mus-
cular irritability of  the  uterus itself which we  call  into  opera-
tion when we manipulate the uterus, or excite it by galvanism.
We can also imitate contraction of the  uterus,  to some extent,
by mechanical  compression;  and we  can exert pressure upon
the great vessels through which  the blood  is poured into the
uterus  before it escapes from this organ.
  In practice, and in the worst cases, the uterus should be grasped
and held firmly by the hands, through the abdominal parietes.
This excites the peristaltic and reflex action of  the  uterus, and
compresses the  organ mechanically.  When the uterus is got
well under control in  this  manner, flooding to any extent  is
impossible.  Several doses of the  ergot should be administered
in quick  succession,  and cold—or, if  in  summer, iced water
should be  dashed upon the vulva and abdomen.  Douching with
a wet towel, or a stream of water from a height,  upon  these
parts, is very effectual in rousing the uterus to contraction. The
time during which it is necessary  to  grasp the uterus is often
very considerable.   When these means fail of entirely arresting
the haemorrhage, the hand should be introduced into the uterus,
and the internal surface excited by the  knuckles of the  closed
hand.  I have not the same dread as many accoucheurs  have  of
introducing the hand  into the uterus, and, as  I have once  or
twice insisted on in these lectures, I  believe, in the present day,
more mischief is caused from a kind of fear of  the  uterus, and
of interfering with it, than from bold  and intelligent efforts  to
control  it.  The hand should always, if possible, be  wrashed
before its introduction.  With the hand in  the uterus, it becomes
more easy to grasp and compress the organ.  As an addition  to
the introduction of the hand, where the uterus  is felt to  be in a
state of atony or paralysis, I have injected cold or  iced water,
in a full stream, into the cavity of the organ, and in this way I
have several times rescued women from an apparently hopeless
                              36 
562
TRANSFUSION IN FLOODING.
condition. I have had no experience of the effects of galvanism
in post-partum flooding, but where there was time to bring it
into  operation,  I should have no doubt of its  power.   With
respect  to  the  modes of using reflex  action for  the arrest of
haemorrhage, it should be mentioned that cold and heat, alter-
nately, are  more efficacious than  cold  continuously used, even
when we inject into the uterus itself.  It should  also be  borne
in mind that cold is a powerfully depressing  agent, and  should
not be used to such an extent as to weaken the patient.   When
one reflex surface is exhausted, we may often appeal to another
with great effect.   Thus, when cold to the vulva  and abdomen
has been used so long as to lose its effect, cold sprinkled on  the
face, swallowing  a gulp of  cold  water, giving  the  patient a
piece of ice to hold in her hands,  an enema  to the rectum, will
excite reflex uterine contraction.   Whenever coagula  collect in
the vagina  or in the uterus, they should be turned out by the
hand.  Clots are a source of great irritation,  and  their presence
tends to keep up haemorrhage. Their removal alone often sud-
denly relieves the patient of severe spasmodic pain, and stops
all loss of blood.   In cases of haemorrhage, where the placenta
is only partially separated, or where  it is  detached from  the
uterus, but retained in its cavity,  the  placenta should always
be  separated and removed, as  early  as  possible.    Some
practitioners have recommended,  under such  circumstances,
that  we should wait a little when the patient is much exhausted
before  removing  the  placenta, on the  ground that the  opera-
tion  itself,  and  the removal  of the mass of  the  placenta, tend
to produce syncope.   We may wait an instant, while we pour
some brandy down the patient's throat, but I have seen  much
mischief from delay beyond this, and never any harm from  im-
mediate action.  We  can  make  up for the  removal of mere
mass by external pressure, and every inch by which we reduce
the size of the womb increases the patient's  safety.  Pressure
upon the aorta and  inferior  cava has been recommended by
many authors.  In extreme cases,  transfusion has  been advised,
and, when  other means fail, I should have no  hesitation  in
recommending and performing it.  Some time ago, a lady was
under my care in whom transfusion was performed successfully
by Mr. Soden of Bath, and from the nature of the case, I have
no hesitation in stating my belief that  the operation saved her
life.  This measure seems particularly suited  to cases in  which 
              HEMORRHAGE FROM MALPRACTICE.           563

patients are slowly dying by the process of syncope, some hours
after haemorrhage has ceased.
  [Haemorrhage occurring after the Birth of the Child, I
divide into two classes, the first ending with the delivery of the
placenta, and the second embracing the floodings after the pla-
centa has been expelled.  In these two classes are included the
haemorrhages most commonly found in practice.
  There are a small  number of females who are peculiarly lia-
ble to uterine haemorrhage, and who always commence to flood
as soon as the child is born.  There seems to be with them some
peculiar nervous distribution to the uterus, which prevents this
organ from immediately responding  to  its new condition.  The
pains have been powerful and effectual, for a longer or a shorter
time, till the child  has been expelled.  Up to this period there
seems to be no want  of contractibility in the organ, and  as the
head advances, and the child is expelled from  the cavity of the
womb, the womb contracts upon it, and is gradually diminished
in size.   How is the case usually conducted in practice ?   As
soon as the head is expelled,  the anxious attendant begins to fear
that every moment the haemorrhage will commence, and impetu-
ously seizes upon the expelled  portion and pulls  away for  dear
life, although without much regard for the life of the child,  from
the danger of rupturing the ligaments of the  cervical vertebrae
and the  spinal cord.   In  great haste, therefore,  the  child is
extracted, and sure enough the haemorrhage commences  just as
was expected, and  the physician congratulates himself that the
child is  out of the way.   But the placenta is still there, and
this he also forcibly delivers.   Still the haemorrhage continues,
and the  case  soon becomes one of great peril to the mother,
anxiety to the physician, and horror to the surrounding friends.
  The cause of all this, is the bad practice of the attending phy^
sician, in very many  cases.
  The labor went on well enough as long as it was left to itself.
Then why not continue ?   " Meddlesome midwifery " does not
mean solely in applying  forceps, using the vectis and Smellie's
scissors.  On the contrary, there is  more " meddlesome midwi-
fery" in the  practice of many gentlemen who never touch an
instrument.   It is especially  illustrated in the case just narrated,
not solely from imagination;  for such practice I have myself
seen and heard of. 
564
NATURE  IN PUERPERAL HEMORRHAGE.
  The contractions of the uterus and its diminution in volume, as
I have before stated, goes on  regularly so long as the child ad-
vances towards birth, and as the head passes through the superior,
middle, and inferior straits.  While it rests upon the perinaeum, and
even when entirely expelled, we have no flooding.  How then
shall  we  proceed to continue  this  desirable state of things?
And this  is the great point to be especially noted  in the treat-
ment of these cases.  Imitate nature, as she has already mani-
fested herself, or  rather let nature alone.   Instead of franti-
cally seizing hold of the head and pulling  like a  madman, sit
down quietly and wait for nature to  finish a work  she  is abun-
dantly able to  perform, and  which she has  so far ably  and
effectually accomplished.   From some  idiosyncrasy the uterus
is unable to effect a speedy contraction, and time is necessary.
Let it take its own time,  and yours likewise.  Patiently wait,
not only till nature has expelled  the shoulders, but the hips also,
and do not think  of lending a fingers strength towards  comple-
ting the delivery, so long as any portion of the child  remains
within the uterus. Every one knows that it has long been recom-
mended to introduce the hand into the  uterus to  arrest flooding,
by the stimulus of its presence. Does not the body or legs of the
child do this work as effectually  as the hand of the  accoucheur ?
  In this  method I have treated very  many cases: one, a lady
several times confined in England, and  once by the late Dr. J.
Kearney Rodgers.  In  every  confinement she  had bled pro-
fusely.  At this labor everything  was prepared for a similar scene
of doubt and danger.  I administered a half ounce of the tinct.
of ergot as soon as the head pressed upon the perinaeum.  It was
soon expelled.  I then repeated the dose, and in from ten to fif-
teen minutes the uterus itself, by  repeated contractions, expelled
.the child in safety, and not a gill of blood was lost.
  A case  very similar to  this occurred, where in  several pre-
vious labors the  haemorrhage  had been profuse, the attending
physician  was arrested in his desire  to deliver the  child imme-
diately, and forty minutes suffered to elapse after the head  was
delivered  before  the child  was  wholly taken away from  the
mother.  The child was purple in color from the influx of blood
into the head producing temporary asphyxia, but subsequently did
well, while the mother had no flooding of any account—the peri-
naeum only showing a slight flow,  not amounting to a haemorrhage. 
                 HEMORRHAGE AFTER LABOR.              565

  Sometimes,  however, the energetic, spasmodic  action of the
uterus does not permit the delay, giving no time for the uterus to
contract firmly upon itself.   In the case of the wife of  a member
of the Academy, who flooded after every labor to a really fright-
ful extent,  the uterus violently contracted until the  child was
completely expelled, and then relapsed  into a state  of inertia,
accompanied by most profuse haemorrhage.
  It is the  duty, therefore, in  all such cases, to do as  little as
possible to assist the delivery in this last stage, and particularly
when subsequent flooding is to be expected.
  In cases of Abortion, when the means already proposed in
such cases  do  not arrest the abortive action, if the flow of blood
be great, it is  advisable to give large and repeated doses of the
secale cornutum, in order not only to stimulate the uterus to a more
speedy discharge of  its contents, but also to press the foetal head,
or presenting  portion, strongly against the opening os  uteri, and
thus to act as  an internal plug.  Should, however, the flow be
excessive, in addition to this treatment it may be advisable to
tampon the vagina.   The best means of doing this,  is by the col-
peurynter as described on page 180.  This may the more appro-
priately be done early in the flow,  when  the firm and slightly
dilated os  uteri  evinces that some time must elapse  before the
contents can be expelled.  In these cases it may frequently be
well to pass a piece of alum into the vagina  before using the
tampon, to assist in the coagulation.
   It should be remembered that the bleeding in  these cases is
especially  efficient  in relaxing the  cervix, often  a tedious and
painful process, and that the haemorrhage  to be particularly
dreaded, arises in an after period from the retained placenta, of
which I shall  speak in its proper connection.
   I, not unfrequently, as the head  passes the vulva, and parti-
cularly when  there is any fear of flooding, give a  half ounce of
the tinct. secale cornutum, as a precaution against flooding, and
not as an adjuvant  to the labor.  The alcohol  acts as a general
stimulant,  and the  ergot tends to  insure a permanent contrac-
tion of the uterus.
   When the child is  delivered, then,  not unfrequently,  a
flow  commences from the uterine surface to which the placenta
was  attached.  The first aim  is to  secure uterine contractions.
It is  worse than useless  to  deliver the placenta,  if  this  is not 
566
ADHERENT PLACENTAS IN FLOODING.
effected; for if this is done, instead of a few sinuses  left open
and bleeding, there remain those of the whole placental surface,
and the flow is thereby very much increased.
  The uterine action should be excited by the administration of
ergot in full doses; (I have, not unfrequently, given gvj. of the
tincture in the course  of an hour, and from which no injurious
effect can be expiected); by firmly grasping the uterus through
the parietes of  the  abdomen ; abdominal frictions ; ice to the
abdomen, alternated with cloths wrung out of hot water or the
cold and hot douche alternated :  these, one or all, will soon pro-
duce a  temporary, if  not permanent, contraction.  During this
period the placenta should be delivered.  If requisite, the hand
should  be introduced,  and the placenta seized,.and, with as little
force as possible, removed.   The uterus should be suffered to do
this action by its own expulsive force.
  There is much said about Placentas being Attached to the
Uterus, adherent placentas, etc.   While I am far from doubting
this condition of things to sometimes occur (as in the  case of a
woman  kicked in the side, by name Conretty, which came under
my personal knowledge at the  Boston poor-house, in .1844), I
am inclined to think it a rare occurrence.   Every placenta is
adhesive, and I defy any one, in  a uterus at its full distension,
to peel  one  off from the uterine walls.  The placenta is always
adherent until the uterine  contraction slides the uterus away
from its surface, leaving it free.   When, therefore, the hand is
introduced and  an "adherent placenta" is discovered, it is but
another method of stating that the uterus is found but  partially,
or not sufficiently, contracted to have detached the placenta.
  The texture of the placenta is  of various characters.  Some-
times we have one firm and tough.  These can be torn off, with
sufficient force, provided a border or an edge be found detached
upon which to lay hold, or  the uterus may be excited.  Some-
times they are soft and pliable, when they are easily torn in pieces.
Occasionally a small portion remains  attached to the sinuses of
the uterus, too small for the uterus to act upon as a foreign body.
Great injury has, not unfrequently, been done, by attempting to
detach this insignificant portion, under the idea of present haemor-
rhage and future inflammation to ensue from its presence.   The
fact is,  that in such  a case no blood flowrs through the  pla-
centa, for the  character  is  so  changed  as not  to  be able to 
       DANGER FROM PORTIONS OF RETAINED  PLACENTA.      567

perform this office.   Indeed, I  do not think there are many
except Dr. Simpson, who imagine that a haemorrhage from the
placenta ever occurs but from the uterine walls, from which the
placenta has been removed : no  blood can flow from the uterine
sinuses, for they are firmly plugged by this  remaining piece of
placenta, so firmly that the plug cannot be easily removed; no
haemorrhage can, therefore, ensue, unless it be from the neighbor-
ing sinuses left patulous by the removed portions of the placenta.
But if the remaining piece is small, it cannot interfere with the
contraction, which will close  up the open mouthed  vessels, and
thus there will no bleeding ensue from the presence of this small
portion remaining.
  The only ill result that can therefore occur will be the subse-
quent inflammation.   In general this small portion will speedily
be  detached and discharged by the after-pains—at any rate it
cannot be considered to be so  fruitful a cause of subsequent
inflammation as the forcible attempts to remove it.
  It is frequently very difficult to know whether or not the whole
placenta is  delivered.  From the  irregular  contraction of the
uterus there frequently appears to be a portion remaining, when
in reality the suspected part is the internal surface of the uterus,
somewhat rough where the placenta had been attached.  In the
case  of a lady, to whom I was called at the request of the
attending physician, a few months since, confined with a prema-
ture five months child, the os was rigid five minutes before the
child was expelled.   It suddenly opened, expelled the foetus, and
as suddenly closed, retaining the placenta within.  "When I saw
her, the after-birth was partially delivered, in a mangled state,
and when I removed the remainder (with  much difficulty pass-
ing my hand  within the cavity of  the uterus), it was impossible
to say whether it was all  delivered or not.   Interiorly the sensa-
tion  to the hand  indicated that a portion  remained, but con-
cluding  that  it was  but  a part of the uterine  surface, I let  it
alone ; the haemorrhage ceased, and no inflammation  occurred,
 as  undoubtedly there would, had I attempted to remove this real
 or  supposed portion.
   This state of things is  of not unfrequent occurrence in abor-
 tion  and miscarriages.  The uterine efforts force  through the
 firm and imperfectly dilated os, the yielding foetus, adapted  by
 its shape to make an easy exit.  When this occurs, the placenta 
568         THE TAMPON IN UTERINE HEMORRHAGE.

is very generally left behind.  Its broad, flaccid mass, resists the
attempts of nature, not only to dislodge it, but to force it through
the rigid and narrow opening.   It, however, not unfrequently
succeeds, so far as to separate a portion  from its uterine surface,
and thus to cause a continued  haemorrhage.   The feeble cord is,
in the vain attempt to remove it,  broken off, and the protruding
membranes offer but a feeble hold by which  to extract the bulky
placenta.
   In these cases, it is generally recommended to securely tam-
pon the vagina, and to trust to time for  the  result.   The action
is the formation of a clot, thus arresting further haemorrhage,
and the  leaving the placenta, either to be expelled from  the
uterus by the further softening and enlargement of  the os uteri,
assisted by the normal contractions of the uterus, or stimulated
by ergot; or to be  decomposed, and  thus flow away, or be
absorbed.
   It may readily be seen that there are many risks to which
the patient is  exposed,  from this  treatment.   First, the  clot
intended to restrain further flow, will not be formed until  the
cavity of the vagina (which  is  always,  no matter how thor-
oughly plugged, capable of containing more  or less  blood, per-
haps an ounce or two only, but still enough  to be often worthy
of serious consideration), is filled.   Next,  the  cavity  of  the
uterus will not unfrequently, continue to receive blood, and often
to a very great amount—the uterus may be  considered capable
of expanding to the size to which  it had attained when the labor
commenced.  In an abortion at two or three months, this quan-
tity will not be very large ; but if the  patient  has previously
lost any  considerable amount, this is deserving of special atten-
tion.
   The tampon, therefore, is to be considered a very valuable
means of arresting haemorrhage, in cases of  abortion when  the
patient has not previously flooded, but one of  doubtful utility if
the haemorrhage has been profuse, and rarely if ever to be used
in any form of haemorrhage at or near  the full  time, after  the
child has been  delivered.  From the very fact  of  the tampon
shutting the  vagina, we are prevented  from ascertaining  the
actual condition of things from time to time, and the result is
an entire ignorance whether the continued prostration, the occa-
sional faint feeling-5, dizziness in the head, tinnitus aurium, etc., be 
HOW To REMOVE THE PLACENTA.
569
 caused by a continued haemorrhage, or be but the results of the
 derangement of the circulation, from the previous great loss of
 blood, or nervous irritability.
   The subsequent ill results from the use of the tampon  need
 not here be enlarged upon.  It is only necessary to allude to the
 uncertainty attending its final removal, and the fear of irritation
 or inflammation attending its  too long use;  the  danger  of
 renewed haemorrhage from its too speedy removal;  the  liability
 of uterine inflammation  from the presence of a foreign body,
 the placenta and clot in the uterus; the chance of phlebitis  from
 the absorption of pus, etc.
   It is on this account  that writers and practical  men of late
 years have urged the immediate removal of the placenta.  In
 abortions and miscarriages at an early  period, generally there
 is little fear of a want of uterine contraction following.   It is not
 the danger arising from this plan, but the difficulty of effecting
 it, that has prevented its general adoption.
   How shall the  small  and fragile placenta be seized  hold of
 and withdrawn ?  Some have recommended  the  introduction of
 one finger into the uterus, and bringing  down one edge of the
 placenta,  and  twisting it round  and round, not only  thus to
 detach the entire mass, but to  also so shape it that  it may the
 more easily pass through the os.  Where this can be done, by
 all means do it!   But it should be remembered that in the great
 mass of cases, it  is impossible to reach the os so  as to pass  one
 finger  into its cavity, far less to effect  any good result,  if it
 arrive there, to say nothing of the utter  impossibility of aiding
 the finger with the thumb of the same hand.
   I have, however, effected the desired result, as already reported
 {American Medical Monthly, September, 1854),  in one case, by
 passing a small pair of polypus forceps (cut, page 196) through
 the os, and thus  seizing the placenta, twisting it round, and by
one or more operations of this sort completely detaching it  and
bringing  it  away.   This operation I conceive  to be the  true
method of treating these cases, particularly those in which a few
more ounces of blood are to be feared as liable to be fatal.  The
tampon may be used if early applied, and where the pregnancy
had not advanced more than three or four  months, but never
afterwards, unless  as  a temporary resort, while fitting  instru-
ments were obtained.
• 
570       MINOR TREATMENT  OF  UTERINE HEMORRHAGE.

  In cases of Flooding at or near full time, when the  after-
birth is retained, I have said that after uterine contractions are
obtained,  the placenta should be  speedily delivered,  and  if
necessary, by introducing the  hand.  When the  hand is  intro-
duced,  especially if cold, uterine  action will  take place, very
generally.  But it  should be  especially remembered that  the
placenta is not to be violently torn from the uterus, and removed,
unless  there  be uterine action  sufficient to indicate to the ope-
rator that the uterus does and will fully contract, lest by so  doing
new sinuses be laid open, and fresh and increased bleeding be
the result.   Neither  should the hand be  removed until  the
uterus  contracts down upon it as it recedes.
  Some operators have recommended that a fresh  lemon be
introduced with the hand, and crushed within  the cavity of the
utSrus,  that  its acid  might act as a  local  stimulant.  Others
advise  the injection of a large quantity of cold water.  I have
never  personally used either of them, but while I  may  allow
them merit as adjuvants, they cannot  be used  to the  neglect of
the plans  and treatment I have already stated.  I give it with
the more  confidence, from the fact that, although having had
some experience in  troubles of this character, I have  never had
a patient die, either from the immediate or subsequent effects of
haemorrhage  from the uterus, accompanying labor.
  Whether, therefore, the haemorrhage proceeds  from the pla-
centa—as a  very  few state—or from the  uterine walls,  from
which  it has  been torn—as is the general opinion—the facts
observed by Dr. Mackenzie and others, in their experience, and
in experimentation upon the lower animals, all unite  in the pro-
priety, aye, the absolute necessity, of removing  the placenta.
To this  I  have added  some important points, as  they seem to
me, to  guide  in performing this serious operation.
  But  the haemorrhage is not  always arrested by this delivery
of the placenta, and sometimes, when  this is  effected  naturally,
the haemorrhage commences for the first time—how is  this to
occur, and how shall we meet its exigencies ?
  It occurs either from a want  of or an irregularity in the  char-
acter of, the uterine contraction, in the first place,  and secondly,
from a  mechanical impediment to the  closing of the uterus and
a consequent  haemorrhage from the patent mouths of the uterine
vessels..
• 
         HEMORRHAGE FROM IRREGULAR CONTRACTION.      571

  The uterus, not unfrequently, seems to have lost its power and
is unable at once to contract  persistently and effectually.  Its
nervous energy is wanting.  One seizes it with the hand through
the abdominal walls, and it is hard and  like a ball under the
grasp, but in a few moments it is felt getting softer and softer,
and finally the firm mass is not to be found.   It seems to have
eluded the grasp, but it has only dilated again, again by more
external irritation to recontract.  But with  every dilatation its
cavity is filled with blood, and with  every contraction  the gush
is perceptible externally !  Whence is this ?  And what is to be
done?
  Sometimes a firm contraction is felt, and yet the haemorrhage
continues.  This may arise from the hourglass contraction, which
occurs alike after the placenta  is delivered as before.
  This  irregularity of  contraction is developed  in  different
localities;  more  frequently,  indeed,  does  it  occur  from  the
abnormal  action  of the circular fibres of the uterus, which, by
their exclusive operation, cause  that form known as the hour-
glass ;  but this same  irregularity is  manifested  also  upon the
portion below and upon the neck, and thus causing a concealed
internal haemorrhage, by the flow of blood being thus prevented
from escaping externally and  being perceptible.   This form is
particularly dangerous, on account of its subtile progress—not
unfrequently the patient is dead before anything is known of it.
  In December, 1852, I delivered Mrs. Mason with forceps of a
living child, and she was safely put to bed, and I remained with
her about an hour.  Happening to pass by about an hour after-
wards, I found that she wras  complaining of a disturbance of
vision, and of hearing water boiling.  I wras informed that she
had not had the least bloody discharge, and that these symptoms
had  come on  after a  slight vomiting.    On examining the
abdomen, the  uterus was found  much  distended, as was after-
wards known, with clots of blood.   This was properly attended
to, and she subsequently had no further haemorrhage.   Many
similar cases might be mentioned, for they are sufficiently com-
mon to have been noted by every practitioner.
  It remains now for  me to mention the remaining species of
uterine haemorrhage, and that is where it  is kept up from
the presence of a mechanical impediment to the  contrac-
tion of the uterus.  This occurs in the following manner: 
572           HAND LN THE  UTERUS IN FLOODING.

  When the placenta is expelled from the uterus, some  small
clots remain, and the uterus, not being immediately contracted,
the flow continues until a considerable clot fills the cavity of the
uterus.  When once this occurs, it is almost impossible for any
amount of uterine contraction  to  expel it.  It is not a plain,
round, smooth mass, but  its surface  is closely adherent to  the
uterine parietes.  Every one has seen with how much force the
blood drawn into a bowl adheres to it, so that the  vessel may be
everted without  disturbing its contents.   This adherence is
equally strong to the  uterine parietes, and far  more  extensive.
In addition  to this, upon the surface to which the placenta was
attached, the clot is prolonged into  the uterine sinuses, consti-
tuting so many firm bonds of adhesion.  The strength of  these
clots is only fully appreciated  by those who have attempted to
remove them.
  Now  in all these forms of  haemorrhage,  occurring after  the
delivery of the placenta, but one course of treatment is called
for.  The hand should be passed  into the uterus.  In the first
place its introduction will overcome  any irregular  contraction,
for it should be  passed  through  the hourglass, or  any  other
irregular contraction, until it  arrives at the fundus.  Next, its
presence as  a foreign body will stimulate the uterus to expel it,
and  by so   doing effect  the desired  result.  Finally, with  the
hand we should  break up the clots, and sweep  them  all out of
the uterus and vagina.  The uterus will then contract down to
its proper size.   It is then to be retained in that position, b}' the
hand external to the abdomen, by the administration of ergot,  etc.
  The importance of  this method  of treatment is not generally
acknowledged by practitioners, especially in the last form of
haemorrhage mentioned.  Many hesitate upon breaking up these
clots, which must be done again and again, as fast as  they may
form.  It appears to many that a clot always serves  to arrest a
haemorrhage, and so it does in perhaps every instance  except in
the haemorrhage from  the uterus after the delivery of the pla-
centa.  In this case, as I have attempted already to  show,  the
bulk distends the uterus, and thereby forces open  the  uterine
vessels which are closed, by withdrawing the clot, and the con-
sequent  contraction.   It should  be  remembered,  and  it is
generally lost sight  of by the physician in his anxiety, that  the
patient is as thoroughly bled, whether the blood be drawn into 
STIMULANTS IN HEMORRHAGE.
573
a bowl, is received into the bed-clothes around her, or is clotted
in the cavity of the uterus.
  A most marked  instance of the  great  importance  of  this
method of treatment, occurred in a  case in which I had been
called in consultation, in consequence of some difficulty occurring
in a breech presentation at a first delivery.   The patient, a young
woman, had been long  ill, with  intermittent  fever, had an
enlarged spleen, etc., and was delivered of twins, both breech
presentations.  Some ten minutes after the labor was finished,
and she had been carefully bandaged, etc., our  attention  was
particularly  drawn by  a sudden  vomiting, almost  coincident
with which a gush of blood from the vagina was heard.  Ergot
was given, cold applied to the abdomen, and contractions brought
on to such a degree that the uterus was hard and firm under the
hand, but larger than when it had contained the placenta.  The
contraction  continued  persistent;  still she was faint, almost
pulseless,  covered with  a cold sweat, and at intervals much
worse.   It was  evident that the haemorrhage was continuing
internally, although none escaped.   But  one duty remained.
Introducing the  hand, I  swept out every clot, the uterus  con-
tracted to a proper size, no further haemorrhage ensued, and the
patient was saved, who, by any other mode of  treatment, would
have been lost.
  Compression of the Aorta, as a means of arresting  uterine
haemorrhage, is a form of treatment often more theoretical than
practical,  and where, from the thin habit of body, it is practical,
it is of less value than  would be supposed.  In the cases where
I attempted  to put  this suggestion  in practice,  I have found
little benefit  from it.]
  During the continuance of uterine haemorrhage of any kind,
no stimulus is so  useful  as brandy.  In post-partum floodings,
especially, immense quantities  may be  taken with the utmost
benefit.  It is a misfortune that in some cases  there is such an
amount of gastric irritability that  all stimulus and  support is
rejected by vomiting.   This sometimes happens in hysterical
subjects, the hysterical  element persisting  even in the  act of
death itself.  In such cases, small quantities of brandy or beef-
tea should be given.   The patient should  be kept with the
pelvis raised  and the head depressed, the object being to retard
flooding, and supply the circulation of the  brain.   I have found 
574          AFTER SYMPTOMS FROM HEMORRHAGE.
          /
from experience, that less tendency to syncope is present when
the patient  lies on her left side than in other positions.  Fresh
air should be  supplied, as by fanning and  open windows, and
the patient kept with as little movement  of the  limbs as  pos-
sible.    After  the  cessation of haemorrhage, when the  effects
have been severe, the patient should not  be moved at all for
some hours after labor, and she should not be allowed  to stand
or to sit up during defecation or micturition, for  many  days, or
even two or three weeks, after labor.  Many patients have  died
suddenly from exertion of this kind taken  before they had suffi-
ciently recovered from the loss of blood.   When patients have
been very much reduced by haemorrhage, considerable discre-
tion is called for in the introduction of food and support into the
system.  We must not, on the one hand, push too much nourish-
ment  rapidly, otherwise we distend  the weakened vessels,  and
may incur the risk of apoplexy; or, on the  other hand, starve
the patient, or we  perpetuate the state of anaemia.
  There is an after-train of symptoms arising from loss  of blood,
consisting of reaction,  particularly affecting the heart and brain,
which to some extent  imitates active disease.  There is violent
palpitation, acute pain in the head, violent throbbing of the caro-
tids, and intolerance of light and sound.   Great care   must be
taken not to treat such symptoms by local or general blood-let-
ting, as  has sometimes happened.  A good  diet, stimulants,
steel and tonics, are required in such cases. 
LECTURE  XXXVIII.
              RUPTURE  OF  THE  UTERUS.

  Gentlemen :—This is  the most fatal  of  all  the  accidents
which attend the processes of gestation or delivery, but fortu-
nately it  is of rare  occurrence.   Dr. Fleetwood Churchill has
collated 113,138 cases of  labor,  out of which number it occurred
in S5, or about 1 in 1,331.
  Any part of the uterus  may be the seat of laceration.  It
occurs far more frequently at the junction of the  os and  cervix
with the vagina than at any other part, and it is more common
at the anterior or posterior surfaces of the  lower segment  of the
uterus than at the  sides  of the  organ.  It may  occur  at any
part of the fundus or body of the uterus, or extend throughout
its whole length.   Sometimes a rent is made in the cervix with-
out extending  to the rim  of the  os.  In rare instances, the lace-
ration extends to the bladder.  Several cases are on record,  in
which the laceration has  been  circular  in form, and has com-
pletely  separated  the os and a discous  portion  of the  cervix
from the rest  of the organ.  Occasionally, the lacerations are
incisiform  and numerous, being found  immediately under the
peritonaeal surface ;  and it has occurred that  all the symptoms
of ruptured uterus have been caused by separation of the peri-
tonaeum from  the uterus, and sub-peritonaeal effusion of  blood,
without actual laceration of the fibres of the uterus.   In other
cases the muscular structure  has been  torn, the peritonaeum
remaining uninjured.  The reason  of the great comparative fre-
quency  of the lacerations at the os and cervix is readily  under-
stood.   It is in  this situation  that  the  great amount  of the
extending forces of the uterus,  and the distending forces  of the
foetus, are brought to bear in  parturition.  The  reason  of the
sub-peritonaeal lacerations will  also be understood, if we bear in
mind the anatomical insertion of the fibres of the external layer
                                                       575 
 576          STATISTICS OF RUPTURE OF THE UTERUS.

 of the uterus into its peritonaeal coat.  The shape and the exact
 direction  of the laceration  may vary  almost infinitely.  The
 edges of the rupture are generally ragged and  uneven, and in
 some cases softened, or even putrid.
   Rupture  of the Uterus  occurs  in cases  where  labor
 has been rapid, and also in cases where it has  been protracted.
 The  majority of cases occur, however,  in  labors which have
 been under twenty-four hours, and which could not, on  account
 of their length, be classed  as preternatural  labors.    It  may
 happen at any  age,  but in the majority of cases on record,
 women who were the subjects of  it have  been  upwards of
 thirty years of age.   It may, I think, be  doubted whether this
 circumstance arises from increased power, or diminished devel-
 opment, of the uterus in women who are advanced in the child-
 bearing epoch.  The presentation of the  child has  a  consider-
 able influence upon the occurrence of the rupture.   Out of 303
 cases of  all presentations  collated by  Dr.  Trask, of  White
 Plains, N. Y., 16 were arm presentations, or about 1 in 16.   As
 the proportional frequency of arm presentations,  compared with
 other presentations, is only about 1  in 230, we  must consider
that  rupture of the uterus occurs relatively, in  a much larger
proportion of arm  than  of other presentations.  On the other
hand, 2 of the 303 cases, or 1 in 151, were breech presentations.
As breech cases occur in about the proportion of 1 to 59 of all
presentations, we must conclude  that the tendency to rupture
of the uterus is less in breech than in other presentations.
  It  has been stated again and again by  obstetric authors  that
women are less liable  to rupture of the uterus in first than in
subsequent labors;  and by many it is  accepted as a  proved
position in obstetrics, that this accident seldom occurs to primi-
parous women.  Thus, two  of the latest and  best authorities,
Dr.  Fleetwood Churchill and  Dr. M'Clintock,  state  that  " it
rarely occurs with first children," and " it is  a well-established
fact,  that women in their first pregnancies are very rarely the
subjects of  ruptured  uterus."   An appeal  to  statistics  will
modify this opinion very considerably.   Dr. Churchill gives 75
cases, ranging from the first to the eleventh pregnancies, 9 of
 which were in primiparous women.  The particular distribution
of these cases was as follows:   As already mentioned, 9 were
cases of first pregnancy, 14 occurred in  the second, 13  in the 
             RUPTURE OF UTERUS  IN FIRST LABORS.          577

third, 11 in the fourth, 2 in  the fifth, 9 in the sixth, and 8 in
the seventh,  the remaining 9  cases  being divided in smaller
numbers  amongst  other  pregnancies.   Dr. Trask has  col-
lected 303 cases ranging  from  the  first to  the seventeenth
pregnancies,  in which 24  occurred  in the first  pregnancy
and labor, 18 in the second, 17 in the third, 21 in  the fourth,
18  in the fifth, 16 in the  sixth, and a smaller proportional
number in successive gestations.  Thus, out of 75 cases given
by Dr. Churchill, it occurred in first pregnancies in 9 cases ; and
out of 303 collected, by Dr. Trask, 24  happened in primiparous
women.   If,  on the one hand, we take first labors, and compare
them with subsequent labors, all grouped together, no doubt the
primiparous is less liable to the accident than the multiparous
woman.   But if, as is the fair way of  putting the  case, we com-
pare first labors with second, third, fourth labors, etc., separately,
we shall find that the primiparous woman is  hardly, if  at all,
more  exempt  than  women in  second   or  third  labors,  etc.
Instead, therefore, of  saying there is anything like an exemption
in favor of the  primiparous woman, all which  the facts warrant
us in stating is, that the uterus developed for the first  time  is
not more likely to become ruptured  than in subsequent preg-
nancies.
  The causes of uterine rupture  are, some of them, those  cir
cumstances which produce  precipitate labor, while others are
connected with tardy labor, or depend upon particular condi-
tions of the uterus.   Violent uterine action alone, after the rup-
ture of the membranes, when the pelvis and foetus are  of the
normal size, may rupture the organ.   Before  the evacuation of
the liquor amnii there is seldom any risk of laceration.  The
danger of  this accident is very much  increased where the foetus
is of  large size, or where the pelvis is below the  natural dimen-
sions.   It is  liable to happen in quick labors, where the uterine
contractions  are very powerful, where the child is a little above
the usual size, and where the pelvis is only slightly contracted,
or where  both  these  conditions meet together.  In such cases,
the violent contractions tend to tear the os and cervix uteri; the
fcetal head contributes to its laceration  by distension, and the
walls of the  organ are at the same time weakened by compres-
sion between the foetal head and the pelvic walls.   The sex of
the child has a material influence as a cause of rupture.   Of 54
                             37 
 578     RUPTURE OF THE UTERUS WITH  BOYS AND GIRLS.

 cases described  by Dr. Collins  and Dr. M'Keever, the  births
 were 38 bo}Ts and 16 girls.   The accident also occurs in tardy
 labors, when the uterus acts strongly,  and when the head  is
 large, as in  hydrocephalus, or when the pelvis is deformed to a
 great extent.   In these cases, the most  violent and long-contin-
 ued contractions of the uterus are exerted to overcome the diffi-
 culty, and the organ is necessarily bruised by the distorted pel-
 vis and the  head of the child.  Very much  the same state of
 things is produced by certain malpresentations, as, for instance,
 when an arm case is left to nature,,and the child gets jammed
 into the  pelvis without hope of escape, with a powerfully con-
 tracting uterus behind it.  The same kind of danger of rupture
 as that which arises from deformed pelvis is sometimes met with
 in cases of  anteversion, when the  head is driven against the
 promontory  of  the sacrum.   Numerous circumstances predis-
 pose the uterus to rupture, such  as the occurrence of inflamma-
 tion in any part of the organ,  either during  pregnancy or at
 the time of  labor.  In  the unhappy cases  in which pregnaucy
 happens  during  the  existence of cancer uteri, and where the
 patients go  to the full term, lacerations  almost inevitably occur
 during labor.  It is  also caused  by excessive rigidity or  occlu-
 sion of the os uteri, unconnected  with malignant disease.  Long
 continued compressions of the organ between the head and the
 pelvis, in difficult labors, tend to this catastrophe, by producing
 softening of  the muscular structure.   A considerable number of
 the lacerations  met with in practice depend, in all  probability,
 to some extent, upon feeble  development of the uterus  gene-
 rally, or upon some local weakness of the organ.   We must not
 think of the  gravid uterus as an organ which is pretty much the
 same in all  women.  The uterus of  every woman, and it may
 almost be said of every pregnancy,  differs to a considerable ex-
 tent.  Nothing  can be  more dissimilar  than the thin parietes
 met with in one  organ, and  the strong development found in
 another.  Cases are also met with in  which some particular part
 of the uterus is thinner than in others, or in which  the os and
 cervix have not been properly developed.   I give here a repre-
sentation of a very interesting specimen from the Museum of
 Guy's  Hospital, in which the cervix was  not developed to  a
 normal extent, and in which a hole was torn in the neck during
labor.  These cases of preternatural thinness,  or of local  de- 
        THINNESS OF Till-: UTERUS  A CAUSE OF RUPTURE.     579

ficieucy, account for those instances of rupture which occur from
the contractions or movements of pregnancy alone, or in which

                          Tie.  L48.
laceration takes place in labors not at  all remarkable for the
violence of the pains, and where the head and pelvis are of nor-
mal size.  There can be no doubt that in cases where the uterus
is  feebly  developed,  or weakened by disease and exhausted
action, the contractions of the abdominal muscles must  contri-
bute to the rupture of the organ, by urging the head or present-
ing part of the child through the os uteri.  The incautious use
of instruments,  or their most  careful  application when  the
uterus is  predisposed to the  accident, may  cause  rupture.
Wherever the ergot of rye is given incautiously or improperly,
the risk of ruptured uterus is incurred.  When given  in too
large quantities, or when the os  uteri is not  well dilated, or 
580
UTERINE RUPTURE FROM INJURIES.
when the head is larger or the pelvis smaller than natural, there
is always danger of laceration.  It may even be produced by
improper digitation, during the course of precipitate labors.
Numerous  cases are on record in  which the uterus has been
lacerated during an examination made at the acme of a strong
pain.   There can be no doubt that such irritation of the vagina
and os uteri, and the  consequent increase in the force of the
pains  excited in the form of reflex  action, have  contributed in
such cases to the disaster.  The attempt to turn, when the uterus
is in a state of violent contraction, and when the waters  have
been long discharged, or the attempt to introduce the blades of
the forceps  before the proper dilatation of the os  uteri, [?] have
been  known to  rupture the organ.  Various conformations of
the pelvis, apart from mere diminution of size, may lead to rup-
ture, such as exostoses presenting rugged  or sharp outlines to
the uterus,  a  keen  linea-ilio-pectinea, or an acutely pointed
ischial spine. Lastly, external mechanical injuries may produce
sudden laceration of the gravid uterus, particularly in the latter
months of pregnancy. It has happened from falls, kicks, wounds
made with sharp instruments, the goring of bulls, etc.   Any
form  of  mechanical violence,  apart from  labor, may  either
puncture or incise  the organ, or rend its  walls asunder.   In
pregnancy, rupture  of the uterus may be caused  by mechanical
injuries,  by spasmodic contractions of the uterus (referred by
the older authors to movements of the foetus), and inflammatory
disease or  imperfect development  of  the  organ.  It may also
occur from interstitial gestation, when the ovum is lodged in the
uterine parietes.  All cases of rupture of the Fallopian tube, or
of the cyst containing the foetus, in extra-uterine gestation may
be compared,  to some extent, to rupture of the  uterus  during
normal gestation or parturition.
  The Symptoms which sometimes warn us of Impending
laceration, are incessant and tetanic contractions of the uterus,
under circumstances where the organ cannot be relieved by the
descent of the  head  or presenting part.   Whenever obstruction
and  violent uterine efforts concur, we must be on our guard
against this form of danger.   Cramp-like  pain  in  the uterus,
especially opposite  the promontory of the  sacrum or the sym-
physis pubis, or distressing cramps  in  the lower extremities,
occasionally precede rupture.  A constant  pain  in some region 
            3YMPT0MS OF RUPTURE OF THE UTERUS.         581

of the uterus during the progress of labor, or in the latter part
of pregnancy, is indicative of danger.  This kind of pain during
gestation, may be  indicative  of partial metritis, and  during
labor, of a similar affection, or of severe local pressure.   In the
majority of  cases, however, there are no premonitory signs of
the accident which  can be depended upon.  We must rely for
warnings, not so much upon symptoms, as upon a knowledge of
the causes which lead to this accident.
  The Symptoms which denote the actual Occurrence of
Rupture of the Uterus, are  generally very  marked,  though
cases sometimes occur in  which the evidences of the accident
are so uncertain  that it cannot be positively known until  after
death.  There is  usually a sudden, sharp, and excruciating pain,
sometimes accompanied by a  snap, audible  to  the patient, and
even to the bystanders.  With  this there is recession of the  head
or presenting part of the child, and a sudden arrest of the pains.
If the  laceration  be extensive, the child commonly passes
through it into the abdominal  cavity, and can  be felt distinctly
through  the abdominal walls.   A  coil of intestine sometimes
passes through  the  fissure, and is felt in  the vagina.  There
quickly ensues upon  the rupture, the symtoms of collapse, and
the matter ejected from the stomach is of coffee-ground color,
consisting of epithelium  and  blood  exuded from  the  gastric
lining membrane, or bile which has been acted on by the acids
of the stomach.   There is a sudden gush of blood from the  va-
gina, and blood  escapes in considerable quantity into the  peri-
tonaeal cavity. Another sign of very great significance, pointed
out by Dr. M'Clintock, is the  sudden death of the foetus.   The
action of the foetal heart ceases suddenly, almost immediately,
after the accident; so that, in  suspicious cases, the stethoscope
should always be used.  There are various circumstances, it
must be mentioned, which complicate the diagnosis.   In some
cases, there is no immediate pain of a violent character, but, the
dangerous symptoms come on some hours, or even days, after  the
accident.   Occasionall v, and particularly when the lacerations
are sub-peritonaeal only, the pains  do not cease.   Sometimes,
when the rent is considerable, the  pains are not arrested, and
the foetus does not pass into the perinaeum; but cases occur when
the rupture only takes place as the foetus is passing through the
external parts.   Sometimes the recession of the head is caused 
5S2          PREVENTIVE TREATMENT  OF RUPTURE.

by a sudden  discharge of liquor amnii, or the head of the first
child  may  suddenly recede in  twin cases.   As already  men-
tioned, the  great  majority of cases end fatally.   Patients may
die of shock,  or haemorrhage, a few minutes after the accident,
or they may die after days, or even weeks, of suffering.  When
the result is protracted, death ensues from  peritonitis, or  from
pelvic  or uterine abcess.  In some  cases, the loop of intestine
protruding  through the vagina has  been strangulated  by the
contracting uterus, and sloughing of  the intestine, or the symp-
toms of strangulated hernia, ensue.   In rare cases, women have
recovered, and have borne children  subsequently;  and one or
two instances are on record, in which  women have  lived with
the foetus in the abdomen, as occasionally occurs in  the abdo-
minal variety of extra-uterine gestation.
  The most important part of the Treatment is that which may
be termed the Preventive.   This consists in the  subdual, as far
as possible, of local metritis during gestation or parturition ; the
induction of  premature labor in cases  of pelvic deformity; the
moderation of excessive  uterine action ; the promotion of the
dilatation of the os uteri; and the relief of the patient by cranio-
tomy when the pains cannot be moderated, and the proportions
between the  head and  the pelvis  are such as to render the
delivery of a living child impossible, before  the risk  of rupture
has been incurred by protracted labor.  As regards the means
of diminishing excessive uterine action  and rigidity of the os
uteri, the effects of venesection, tartar  emetic, and  chloroform,
have already been remarked upon.
  The Treatment of Rupture of the  uterus when it has posi-
tively occurred, demands every attention, both  on  account of
the child, and because occasionally women recover, under such
circumstances, from the  utmost extremity  of  danger.  The
greatest chance of safety is given to the woman by immediate
delivery.  If the child has passed entirely or partially into the
abdomen, the hand should be  introduced, and the  feet drawn
down, and  delivery effected as promptly as possible, care being
taken not to injure any of the abdominal viscera, or to draw them
down through the opening.  When  the disproportion of size is
such as to render the extraction of the head difficult, it should
be perforated 'behind the ear, particularly if the child be already
dead.  When the head has not receded after rupture, and when 
           TREATMENT OF RUPTURE  OF THE UTERUS.         583

the pelvis is full-sized, the forceps may be used ;  but cases
admitting of their application in this contingency are very sel-
dom met with.   The general rule is to deliver, under such cir-
cumstances, by  the  perforator and crotchet.   This operation
requires, however, greater  care  than usual, on account of the
tendency of the head to recede under the use of the instrument.
When the child can be delivered  promptly by  any of these
means, the amount of shock and  subsequent peritonitis is to
some extent moderated.  Cases, however, occur  in which deli-
very per vias naturales is impossible, either from rigidity of the
os uteri, or from contraction of the uterus, and especially of the
aperture through which the child has escaped into the abdomen.
Under  such circumstances, if the woman is  in a state to admit
of it, and especially if  the suffering be great, it is probable that
chloroform may be of great use in these cases, by relaxing the
uterus,  and thus averting  the  alternatives  of  abandoning all
attempts at relief, or performing gastrotomy.  Incisions into the
os uteri have  been recommended  with a similar intention.
Under these desperate circumstances, when chance, or  gastro-
tomy, alone  remain, what is to be done?  Some have said the
best practice is to leave the case entirely to Nature, pointing to
the extraordinarily rare cases in which the child  has been dis-
charged by  abscess through the  abdominal  walls, and the
mother has  recovered.   Others advise the performance of gas-
trotomy, and the removal  of the child, especially if the foetus
be alive.  This is, of  course, a  desperate  remedy.   It  is very
questionable which of these two  modes of procedure is to bo
preferred.  In cases of great collapse, and when  death is immi-
nent, the performance  of gastrotomy is not to be commended ;
but when the patient is strong,  and delivery by other means is
found to be utterly impossible, without even greater danger than
this  operation holds  out, I think it  should be performed.   We
must, however, be sure of our diagnosis before venturing on so
grave a step, particularly as not long since, gastrotomy was per-
formed with  this intention in this metropolis, in a  case where,
on opening the abdomen, no rupture of the uterus was found !
   Immediately after  the extraction of the child, full doses of
opium  are  required.   During the state  of  collapse,  stimuli
should be administered, bearing in mind, however, the peritoni- 
584        TREATMENT OF RUPTURE OF THE UTERUS.
tis which ensues if the patient  recovers.  With respect to the
general plan of treatment, it may be said that it should be very
nearly the same as  that recommended in cases of extra-uterine
gestation after the  rupture of the  cyst.   Particular  points of
difference in individual  cases  will have to be  met as  they
arise. 
LECTURE  XXXIX.
               INVERSION OF THE UTERUS, ETC.

  This accident,has  sometimes  been attributed  to  irregular
action of the uterus, but more generally to mechanical traction
of the cord, and to injudicious attempts at removing the retained
or adherent placenta.   When  Inversion of the Uterus is re-
ferred to traction of the umbilical cord, whether in consequence of
a short funis, the  sudden birth of the foetus while the mother is
in the upright position, or the attempts of the obstetrician to
remove the placenta, it is always believed to depend  on the
merely mechanical force which is in operation.  It is considered
that the fundus uteri is dragged down mechanically through the
os uteri and  vagina,  the uterus being supposed to be  passive
during the occurrence of the inversion.  I have always been of
opinion that, in the great majority of cases, the accident happens
in consequence of irregular but active contractions  of the uterus
itself.  No doubt, cases may occur in which inversion is pro-
duced  by great tension upon the cord,  while the placenta is
firmly adherent to the fundus, and that all violent traction of the
cord while the placenta is  attached  to the fundus is  reprehen-
sible.  But when inversion is thus produced, there must be a
consenting action  of the uterus.   The accident has sometimes
happened when the hand has been  introduced to peel off the
•placenta from the fundus, when the hand, placenta, and uterus
have all been forced out by the violence of the abnormal uterine
action.  All the facts connected with this catastrophe  show that
it generally depends, not upon a passive, but an active, condi-
tion of the organ.  There are numerous points which prove that
it may happen spontaneously, and apart from all interference on
the part of the accoucheur.  It may occur after the death of the
mother, as the result  of post-mortem contraction of the uterus.
Numerous cases  are  on record in which the uterus was found
                                                      535 
536        SYMPTOMS OF INVERSION OF THE UTERUS.

inverted before any attempt whatever had been made to remove
the placenta, and  while the  patient was lying quietly in bed.
It has even been known to occur in the unimpregnated uterus.
I have  elsewhere  insisted  that the unimpregnated  and virgin
uterus, particularly under irritation, possesses more motor power
than is  generally  attributed  to it.  The nulliparous organ has
been known to invert  itself, as the result of spasmodic action,
in long-continued monorrhagia, or as the result of a small poly-
pus or fibrous  tumor in the cavity, or upon the peritonaeal  sur-
face, of the fundus.  The more this subject  is studied, the  less
will it be referred  to merely mechanical derangements.
  Let us observe the steps  by which complete inversion is  pro-
duced.   There is,  first, cup-like  depression of the fundus uteri;
coincident with, or immediately following upon, this depression,
there  is hour-glass  contraction of the body or lower portion of
the uterus.   The annular contraction of  the body of the uterus
grasps the introcedent fundus as it would a foreign body,  and
carries it downwards fur expulsion through  the os uteri, the os
uteri being at this time either in a state of inertia, or actively
dilated, just as at the end of the  second stage of labor.   After
the inverted uterus has  passed through the dilated os uteri,  this
part  of  the organ becomes contracted, preventing  re-inversion
from taking place.  Thus, there is, first, depression of the fundus
uteri,  with annular or hour-glass contraction of the body of the
uterus, and dilatation of the  os uteri.  Next, there is  intussus-
ception  of the fundus by the body of the uterus.  Lastly, com-
plete inversion occurs,  with contraction of the os uteri upon the
inverted organ.  If we wished to  describe this accident in three
words,  they  would be—introcession—intussusception—inver-
sion.  The displacement may not be complete ;  it  may in some
cases stop at introcession ; in others, at intussusception, and then
return to the natural state ; or it may remain intussuscepted, or
in a state of partial inversion.  We  may compare perfect inver-
sion of the uterus to intussusception of the intestinal canal, only
that  the intussuscepted  portion  of intestine  is not protruded
externally.
  Inversion produces violent disturbance of the nervous system,
and is frequently attended  by alarming haemorrhage.  But the
symptoms of the intussuscepted uterus are equally violent.  The
strangulation of the fundus is almost as severe a shock to the 
DIAGNOSIS OF INVERSION OF THE  UTERUS.
587
system  as actual rupture.   In  inversion, the haemorrhage is
somewhat arrested by the os uteri acting as a tourniquet to the

                           Tic, 149.
  Commencing inversion of the uterus, from a preparation in the Museum of Guy's Hospital.
       i
uterus.   In  either case the shock to the system may be so great
as to cause death within a short time after the  accident.  The
shock is so severe that a  fatal  result has ensued, when little
blood was lost, and when, after a short time, the re-inversion of
the uterus was effected.   The diagnosis of this affection is suffi-
ciently  easy when  the  placenta is  adherent to  the inverted
uterus, but there are  circumstances which complicate the diag-
nosis, when  a  tumor appears in the vagina after the separation
and expulsion of the placenta.   In true  inversion, the globular
ball of the uterus is entirely absent from the hypogastrium, and
a bleeding mass is found  in the vagina, or protruding externally
This mass may, however, be stimulated to some extent by  a 
588
MALPRACTICE A CAUSE OF INVERSION.
prolapsus or procidentia, occurring immediately after labor, or
by the extrusion of a polypoid tumor after the expulsion of the
placenta.   In the case of the prolapsed or procident uterus, the
diagnosis is easy, from the  presence of the os uteri in  the  most
depending part of  the tumor.  The distinction between polypus
and inversion is not so easy, particularly when the polypus is ot
a fibrous character, and of the same density and structure as the
walls of the uterus itself.   In the case of polypus, there is the
sensation  of a  solid mass;  and in inversion, that of a hollow
organ is  conveyed to  the finger.  When punctured or pricked,
the uterus is said to be  much more sensitive to  pain  than the
polypoid tumor.  In complete inversion the fossa round the base
of the tumor is  limited  in extent, while  in  polypus the finger
may be passed into the cavity of the organ, the pedicle can gen-
erally be felt, and  there is the uterine tumor in the lower part
of the abdomen.  Great care is required in the diagnosis, as
cases have occurred  in  which a polypus  has been mistaken for
an inverted uterus, and, in some instances, inversion has occurred
without the accident  having been  recognized at aU, until  long
after the time of labor.
  Inversion generally occurs quickly after the delivery  of the
foetus, between  the expulsion of the child and the expulsion of
the placenta.  I have known it to take place after the  death of
the mother, and after rupture of the  uterus  had occurred.  In
the latter case, the foetus was passed into the peritonaeal cavity,
while the uterus became inverted,  and  protruded through the
vagina.  The predisposing causes of the accident are the causes
of acute labor,  and excessive or irregular action of the uterus.
It is of very great importance to understand clearly the real
nature of inversion, as it is one of those accidents which is most
confidently referred to mal-practice.  The less it is considered a
mechanical displacement,  the less disposition will there be to
attribute its occurrence  to the accoucheur;  owing to  the  pre-
valence of the  mechanical idea, obstetricians have sometimes
been blamed most  unjustly in cases of post-partum inversion.
  The treatment of inversion  consists  in  the mechanical
reposition of the uterus. Immediate  steps should  be taken to
reduce the inversion, because of the rapidly-increasing contrac-
tion  of the os uteri, which, by impeding the  circulation, causes
an increase in the size  of the tumor.   The size of the  uterus 
           TREATMENT OF INVERSION OF THE UTERUS.       589

should be reduced as far as possible by pressure, and by detach-
ing the placenta in cases where it  still adheres.  By moderate
but sustained force the uterus is then to be passed up through
the vagina and os uteri.  After the organ has been partly passed
through the  os uteri, the muscular action  of the uterus  itself
assists  in restoring  it to the proper position.  It is reinstated
with a sudden jerk, causing a considerable report at the moment
of its restoration.   In cases where intussusception exists,  the
hand must be passed through the os uteri, so as to overcome the
annular contraction, and to restore the intussuscepted portion to
its  proper position.   Cases  of intussusception and  inversion
require careful watching until the uterus has permanently con-
tracted.   Although it may justly be said  that inversion may
occur when  the accoucheur is entirely blameless, I do not think
the same can be said  when the case is  allowed to remain unre-
duced, and the patient lives on in a state of extreme misery and
danger.  It  would  be extremely culpable  if such  an  accident
either  passed unrecognized, or if the first few hours after  labor
were allowed to  pass without the re-inversion of the uterus.   I
cannot suppose that with  proper and prompt management any
case could be considered irreducible, within a reasonable time
after the  accident.  Suppose  the  os uteri  to be in a state of
spasmodic contraction, we have in chloroform a powerful means
of rendering it dilatable, and of allaying pain when the tender
state of the uterus is such as to prevent the necessary manipula-
tions.  In these  cases promptitude in  action is of the greatest
consequence.  Every hour that elapses after the accident before
the reduction of the inversion is effected increases the difficulties
in the way of its accomplishment.  Very  rare cases  are met
with, in which menstruation has been normally performed with
an  inverted  uterus, and  when  the  presence of a tumor in  the
vagina and a considerable leucorrhoeal discharge have been the
only symptoms ; and cases are recorded in which the uterus has
spontaneously re-inverted  itself   a  considerable  time  after
delivery.  Usually, however, the patient is subject to an almost
constant drain of blood and muco-purulent  discharge from  the
inverted mucous surface, and she perishes after  a longer or
shorter interval.   The alternative, when reposition is considered
impossible, is the extirpation  of  the  inverted organ  by  the
dangerous operations of the ligature or excision. 
590
TREATMENT OF ENCYSTED PLACENTA.
  There are some other abnormal actions of the uterus, allied in
some  respects to inversion, to which I must now direct  your
attention.
  Encysted Placenta is a term sometimes applied  to cases in
which a sphincteric contraction of the os uteri comes on rapidly
after  parturition, before the placenta has  been expelled.  The

                          Fra, 150.
Hour-glass contraction.
placenta, in these cases, may either be attached to the uterus, or
it  may  have been  thrown  oft', and  be lying close within the
contracted os uteri.  This complication is most common  after
acute labors, or in prolonged labors, where the pains have  been
excessive, up to the time of delivery.  Excepting that it occurs
after delivery, instead of in the early stage of parturition, it is
comparable to that  form of rigidity, in which  sphincteric con-
traction of the os  uteri is predominant.  Owing to the increased
mobility which the os uteri acquires during the progress of labor,
its post-partum contractions are sometimes more forcible  than
any active contraction  which occurs before delivery ;  and the
rigidity is never mechanical,  because  of the  great dilatation
which has occurred during the progress of the labor.
   In treatment, it is of considerable importance to deal promptly
with these cases.   The  longer the os uteri remains contracted,
the more  difficult will its dilatation, so  as to admit of the  ex-
traction of  the placenta, become.  If the placenta can be felt 
RESULTS OF ENCYSTED PLACENTA.
591
close to the os uteri, gentle but firm traction of the cord, held as
near as possible to its root in the placenta, should be used, so as
to convert the placental  mass into a dilator.  We  can often
beneficially assist the effects of traction of the umbilical cord in
dilating  the  os uteri, by  gentle  pressure   exerted  externally
upon the abdominal surface, at each  recurrence of the uterine
contractions, sweeping the placenta, as it were, into  the  pelvis
and towards the os uteri, by the hand, while  steady traction of
the cord is being kept up.  If these methods should not be suc-
cessful, the os uteri must be slowly dilated by the fingers, so as
to admit the hand or fingers, according as the placenta may be
required to be detached from the uterus, or merely withdrawn
from the  cavity.    The utmost gentleness consistent with  the
necessary force should be  employed; and, if necessary, any
threatening of convulsion or laceration should  be prepared for
by  bloodletting.   If the patient's  mind should be excitable,
or the dilatation of the os  uteri should be painful, an opiate is
of great use; but it acts rather by soothing  mental emotion
and allaying pain, than by reducing  the spasm of the os uteri.
When the case is misunderstood or neglected, and  the woman
survives the shock and the effect of loss of blood, her life is gen-
erally one of danger and misery.  I have met with several cases
of encysted placenta, where  the secundines had been allowed to
remain a considerable time, and where the os uteri was in a state
of the most perfect contraction, where chloroform  was of the
greatest use in relaxing  the  os uteri, and allowing  the accou-
cheur to perforin  the manipulations  necessary  for the removal
of the placental mass. 
592       TRUE AND FALSE HOUR-GLASS CONTRACTION.

  The foregoing remarks apply to cases in which the placenta is
either wholly adherent to the uterus, or the whole  uterus  is so
firmly contracted upon the separated placenta, as to  prevent
internal uterine haemorrhage.   Cases, however, occur in which
spasmodic closure of the os uteri is attended with separation of
the retained placenta, and inertia of the body and fundus.  In
such cases, dangerous internal haemorrhage is inevitable, and the
removal of the contraction of the os uteri becomes  quite secon-
dary in importance to the arrest of  the haemorrhage.  Our  first
object here must be to excite such an amount of uterine  contrac-
tion as to stay the loss of blood.  In all  cases  where  the  first
steps taken for the dilatation of the  os uteri, which of themselves
tend to produce uterine contraction, are ineffectual, the uterine
inertia should be  treated most energetically, without any refer-
ence to the state of the os uteri.
  In some cases of retained  placenta the uterine spasm is not
situated at the os  uteri, but  at the junction of the  cervix  uteri
with  the body of the  organ ; in the same situation, in fact, as
the narrow portion of the organ in the unimpregnated state, and
at which  the  greatest resistance  is met with in  the  intro-
duction of the uterine sound.  This state of the uterus is called
Hour-Glass Contraction.
  [According  to  this view, Fig. 152 represents  hour-glass  con-
trction, as first described by Guillemot, but such I do not think
is the generally received opinion.   Such contractions of the os
uteri do exist and may be mistaken by the careless or ignorant
for hour-glass contraction, but this  is in or near the middle of
the uterus, dividing into two portions  from whence comes its
name, represented by cut 150, and referred to in the following
sections as " simple hour-glass contractions."]
  In other cases the constriction is still higher up, involving the
body of the uterus, being similar in its nature to those band-like
spasmodic contractions, which  are sometimes observed in the
large intestine.  In the lower animals, where the uterus in- its
anatomy resembles an  intestine, there can be  no difficulty in
understanding this form of annular  contraction.
  In  other cases  the  hour-glass contraction occurs after the
separation of the placenta, when it may be the cause of  internal
haemorrhage, because of the inertia of that portion of the uterus
which is above the stricture.  After the expulsion of the foetus, 
TREATMENT OF HOUR-GLASS CONTRACTION.
593
the contractions of the uterus ought to be uniform in the entire
organ, so that in hour-glass contraction there is always a double
Tic. 151.
               Contraction, of the upper portion of the uterus.

departure from the physiological condition of the uterus ; there
is both spasm and inertia.  The treatment of these cases must be
conducted on the same principles as cases of sphincteric contrac-
tion of the os uteri; but we have an additional remedy, of con-
siderable efficiency, in frictions applied to the abdomen over the
uterus.   True and complete hour-glass  contraction is a rare
affection ; but in very many cases of post-partum haemorrhage,
portions of the uterus are spasmodically contracted, while others
are so relaxed as to admit of the flow of blood from the mouths
of the vessels on its internal surface.  Occasionally it happens
that one lateral half of the uterus will be  contracted while the
other half is relaxed.  In cases of haemorrhage, with hour-glass
contraction, there may be no escape of blood per vaginam, the
effused fluid being confined in the upper chamber of the uterus
by the stricture.
  The causes of hour-glass contraction may be any of the causes
of acute, irregular, or tardy labor; but it most generally occurs
after rapid parturition, particularly the rapid transit of the child
through the external parts.  Coagula in the uterus, the retained
placenta, or improper traction of the  cord, and mental emotion,
are all exciting causes of the accident
                               38 
594     ENCYSTED PLACENTA VERSUS SPASM OF OS UTERI.

   [An elaborate paper upon  this subject was recently read to
the New York Academy of Medicine by Dr. Martin.  It declared
that hour-glass contraction never occurred without an adherent
placenta, although there was frequently adherent placenta with-
out this form of uterine contraction].
  It will be useful to compare the different forms of irregular
action of the uterus with each other.  The resemblance between
the spasmodic form of Rigidity of the os uteri during labor, and
the most simple form of Encysted Placenta—namely, sphincteric
closure of the os uteri with retention of the placenta—is at once
obvious.  The same contracted state of the os uteri is present in
Inversion, after the  uterus has descended through  the os  uteri.
In the form of encysted placenta, or irregular  action of  the
uterus, constituting  Hour-glass Contraction, we have precisely
the same condition of the middle portion of the uterus  as that
which obtains in the second stage of inversio-uteri.  In simple
hour-glass contraction, the cavity of the uterus is divided into two
parts by the contraction of the middle portion of the organ ; but
when, owing to irregular action  of the  fundus, this part of  the
organ descends into the cavity of the uterus, and the hour-glass
contraction  then occurs, the  fundus uteri is seized by the con-
tracting ring of the uterus, borne down through the os uteri and
FlCr. 152.
           Contraction of the os uteri and the whole of the uterine cavity,

vagina, and inversion  is thus  rendered  complete.   After the
inversion, the os uteri, which dilates to allow the inverted uterus
to pass, becomes firmly contracted.   Again : all these abnormal
actions, occurring after delivery, are but modifications of exces- 
VARIOUS FORMS OF AFTER PAINS.
595
sive After-Pains.  In severe after-pains, it is easy to feel with
the hand that the uterus becomes hard and prominent at partic-
ular points, and soft and depressed at others.  From these irreg-
ular contractions the more  serious irregularities of the uterine
action arise.   Sphincteric and premature closure of the os uteri
is the most  simple derangement; next comes the annular contrac-
tion of the upper part of the cervix, or  the body of the uterus,
in hour-glass contraction; and lastly, the phenomena  of inver-
sion, which is  the most compound of all these disordered actions.
Thus rigidity  of the os uteri, encysted placenta, inversion of the
uterus, hour-glass contractions, and excessive after-pains,  are
merely modifications of irregular uterine action, and they are all
convertible one into the other.   These views materially simplify
our comprehension of these post-partum accidents.  It may be
said, however, that hitherto  they have generally been treated of
in an  isolated  manner, and with little reference to uterine physi-
ology, or to their evident relationship with  each  other. 
LECTURE  XL.
                PUERPERAL  MANIA.

   Gentlemen :—The specific forms of mania incidental to child-
bearing, may occur either during pregnancy,  at the time of
labor, in the puerperal period,  or in the course of lactation.   Of
these, the Puerperal Mania is the most frequent and formid-
able.
   In pregnancy, we sometimes have the nervous phenomena of
gestation in such an  aggravated  form, that the balance of the
patient's mind is lost, and her reason and moral faculties totter
and fall for a time.  This state  of things is brought about by the
hysterical temperament, when in a state of intense development;
by improper moral management on the part of friends and rela-
tions, or depending on the patient herself, by neglect of  the
excretory functions; by hereditary predisposition to insanity,
and by sudden shocks,  etc.   Its treatment has  already been
referred to, when speaking of the diseases of pregnancy, and in
the last  resort, the only remedy we can depend upon is the induc-
tion of premature labor.
  In the course of Labor, a nervous, excitable subject may, at
any time, suffer a transient loss of reason during the height of a
powerful pain attended by almost unbearable anguish.  This
happens most frequently, however, and for a longer time, at the
moment  when the head passes through  the os uteri, or the os
externum, and particularly the  latter.  I have known it to occur
at the moment of birth,  when the forceps  has been used.  It is
more apt to take  place in first labors than  in multiparae, and
when the head of the child is of larger size than usual.  Women
sometimes lose their self-consciousness, or  self-control, and com-
mit, if allowed,  extravagant acts, in  these brief  intervals of
insanity.  When the attack occurs at the time of the passage of
the head through the external parts,  patients  will attempt  to
   59$ 
CAUSES OF PUERPERAL  MANIA.
597
injure the attendants or the infant; and there can be no doubt
that in some cases of Infanticide, where the cliild is destroyed
immediately  after labor, the crime  is  committed  while the
mother is in a state of  temporary  and  irresponsible  frenzy.
Such cases should, however, only be received with great cau-
tion.  This form of mania is  so  transient that it generally only
requires the necessary  amount of restraint, and the removal of
means of mischief, for a very short  period.   I have no doubt
whatever, that this form  of insanity might  be prevented by the
use of chloroform during the pains of labor, before the suffer-
ing has reached such a height as  to make the patient frantic.
  Genuine Puerperal Mania,  or  that which  cecums shortly after
parturition, appears to me to depend, in the great majority of
cases, upon the shock of  labor;  the general and local irritation
incident to delivery, and  its immediate consequences ; and upon
the exhaustion produced  by the accumulated effects of gestation
and parturition.   Except in the few cases in which inflammation
of the brain dbcurs, when it is removed from ordinary insanity,
the disease  is, I  believe,  always attended by  constitutional
exhaustion.
  Various circumstances  predispose to the occurrence of insanity
in puerperal women.  It  sometimes occurs  in combination with
uterine inflammation, or  suppression of the lochia, the metritic
irritation exciting the cerebrum in a reflex form.  Occasionally,
mania alternates  with inflammatory disorder  of the  uterine
organs or the peritonaeum, the one disease completely receding
as  the other becomes  prominent.  The existence of puerperal
mania will sometimes completely mask inflammation of the pel-
vic organs, and even phthisis.   In other cases, intestinal irrita-
tion,  or the use  of  improper and unwholesome  food, is the
exciting  cause  of tl\e  disease, as proved  by its sudden  disap-
pearance when the stomach  and bowels have been efficiently
relieved.  Cases are met with, in which the retention of viscid
and morbid secretions in the  breasts has excited the brain to the
pitch of mania.   This disease is often met with  in  women in
whom hysteria has been very  pronounced during pregnancy.
Hereditary predisposition to  insanity, morbid  fear of labor and
its results during pregnancy,  frights in the course of pregnancy,
or labor, or in the puerperal  period, are important predisposing
elements.  The hereditary tendencies of puerperal insanity have 
598
PREDISPOSITION TO PUERPERAL MANIA.
 been made  out  by  Gooch, Burrows,  Esquirol,  and others.
 Women belonging to families in which insanity manifests itself
 are liable  to puerperal attacks.   Several  women  in the same
 family, or  two or three generations, have been known to  suffer
 from puerperal mania,  and  the  same  woman  is sometimes
 attacked in successive pregnancies. It is found that in times of
 great public  excitement or calamity, puerperal mania is render-
 ed more common.   I saw a case during the late war, in which
 puerperal  mania was caused  by the intelligence  of the sudden
 death of & near  relative.  It has a tendency to occur in women
 who have children very rapidly, and who nurse one  cliild during
 pregnancy with another; or in women who have twins or trip-
 lets, as sometimes happens, several times in succession.  I had,
 some time  ago, a maniacal case in this  Hospital, in which the
 patient had  had twins three  times out of  seven  deliveries.  I
 have seen cases where it had apparently depended on the use of
 large quantities of chloroform during labor.  It has been caused
 by profuse haemorrhage, occurring during  delivery or  after
 labor ; or as the result of profuse  bleedings in puerperal convul-
 sions or post-partum  inflammations.  It also sometimes appears
 as the sequelae of convulsions, in albuminuria, and the  other
 forms of convulsive disorder met  with during labor.   In  some
 cases, sleeplessness, prolonged through several days  and nights,
 appears to  be a powerful exciting  cause of  the disease, but the
 insomnia is both a  cause, and  a symptom, of the  disorder, and
 it is difficult to say to which category the pervigilium frequently
 preceding insanity should be most distinctly assigned.
  Puerperal mania must be distinguished, not only from phreni-
 tis, but from  pure delirium  occurring at the fever  incident in
 some cases to the first secretion  of milk,  or met  with in the
 course of phlebitis or puerperal fever.   The pathological lesions
 found after death from puerperal mania do  not throw any great
 light upon the essential nature of the disease.  No constant
 morbid changes are found within the head,  and most frequently
 the only  condition found in the brain is that of unusual paleness
 and exsanguinity.  Many pathologists have also remarked upon
the extremely empty condition of the  bloodvessels, particularly
the veins.
  The attack  generally comes on within a week or ten days after
delivery.   Sometimes it is sudden, the patient at  once start- 
PREMONITIONS OF PUERPERAL MANIA.
599
ing off from a state of coherence into the realm of mania; but
more frequently there are  some days of  premonitory  warning.
In the latter cases, the patients are either  unnaturally loquacious
or taciturn;  talking incessantly, and upon the most trivial and
irrelevant subjects ; or refusing to speak  even when spoken to.
There is a tendency to complain of the  husband, the nurse, or
to express dislike of the child, and a wish to injure it, with  other
signs of moral perversion.  The pulse is not much accelerated ;
the face pale, or occasionally flushed; the  eyes are preternatu-
rally bright;  there is intolerance, of  light, noise, or of move-
ment in the room.  There is either unbroken sleeplessness, or, if
the patient  sleeps, she is troubled with  dreams, which render
sleep unrefreshing.  The bowels are often confined.  When this
state of things passes on to actual  mania, there  is  the  same
uncontrollable and incoherent loquacity.  If an attempt be made
to take down the words uttered by a patient suffering from  puer-
peral mania, they yield, in  the  worst cases, not  the slightest
thread of coherent thought.  The words or  subjects of rambling
talk are suggested by the objects coming before the senses, but
the mind does not dwell more than an instant upon the same sub-
ject, or the words  uttered by the patient  herself  start succes-
sively the subjects of raving; but  the  prevenient words and
their suggestions are as irregular as  the changing  figures of  a
kaleidoscope, and at times the raving is an unmeaning jabber of
fragments of words, or of sounds which  hardly represent  sylla-
bles.  Sometimes amidst  an amount of  incongruous raving,
certain ideas are constantly recurred to, such as the birth of the
child.  Very  frequently the language of such patients is  most
obscene, and constantly turns upon sexual matters, the move-
ments of the body and actions being such  as to indicate a nym-
phomaniacal condition. Delicate ladies will use language  which
it would  be thought  impossible they could  ever  have had the
opportunity  of hearing.    Sometimes .events  long  forgotten,
and even language  learned in childhood, will be remembered,
 which the  patient would have no knowledge of subsequently.
There is almost always the  inclination to commit violence upon
 herself or others, and particularly upon the  infant.   Many
 patients are at times  conscious of the suicidal or homicidal ten-
 dency, and implore  those around them to defend them against
 their evil inclinations.  When the disease becomes chronic, the 
600
SYMPTOMS OF PUERPERAL MANIA.
 tendency is generally to melancholic, rather than to other forms
 of derangement.
  Sometimes patients refuse food altogether, or accuse those
 about  them of administering poison, or they declare they are
 being  starved even while they are eating  ravenously.   These
 symptoms, or groups of them, in various modes of combination,
 may exist  for a  few  days, or they may continue for weeks or
 even months, the patient being reduced, in protracted cases, to
 the utmost degree of weakness  and  debility\   Nothing  can
 exceed the marasmus of some of  the cases  of puerperal mania
 which spread over a long time.   The  state  of the nervous sys-
 tem interferes in the gravest manner with the functions of nutri-
 tion, and the patient is worn  out  by incessant talking, locomo-
 tion, or such movement as is  permitted, and want of  sleep.   In
 the early stages of puerperal  insanity, the pulse is  often quick,
 the skin  dry and  hot, the head throbbing and heated, and  the
 tongue dry ; the milk  and lochia are commonly suppressed.  As
 the disease becomes chronic, the tongue becomes comparatively
 clean and the pulse natural.   There is a peculiar sour  smell
 about the breath,  and  the  odor of the skin is  very disagreeable.
 The  bowels continue  constipated.  I am not aware that  the
 urine has been examined, but it  is probably loaded wTith phos-
 phates, from the  rapid disintegration or  metamorphosis of the
 material of the brain.
  The  indications of  Treatment in Puerperal Mania  are
 the  subdual of cerebral excitement,  the removal  of  remote
 irritation, the  repair  of  exhaustion,  and the management of
 local disorders complicating the maniacal attack.  The removal
 of the  hair, the application of ice or cooling lotions to the head,
 blistering behind  the  ears, or upon the back of the neck or the
 scalp, and,  in rare cases, a few leeches to the temples, are all
 that we should dare to venture upon in the way of local applica-
 tions.  Subsidiary to these means, but scarcely  of less impor-
 tance in calming nervous excitement, are the avoidance of light,
 of noise, of conversation and  the sight of  persons and  things
having an irritating effect upon the patient.   Every excitement
 of the  senses and of the emotions  should be suspended as far as
possible.   Local irritation should  be removed, by drawing  the
breasts when these are loaded, and by the exhibition of purga-
tives.  Cases are sometimes  met with where the irritation of 
TREATMENT OF PUERPERAL MANIA.
601
 the brain has depended on faecal accumulations, when a smart
 purge has at once and completely recovered the patient.   But
 the cases requiring active purgatives need a nice discrimination,
 otherwise  injury is done by weakening  the patient.   General
 bloodletting is never called for, it is hardly too much to say, in
 ordinary puerperal mania.   There are  few conditions of the
 economy in which bleeding is so ill borne, and in which such
 disastrous results ensue upon its performance.  Many cases are
 on record in which venesection has destroyed  the patient with
 great rapidity.  Within a comparatively short space of time, I
 saw two maniacal cases after delivery in the same district, one
 of which exemplified the danger of bleeding, and the other the
 origin of the disease from exhaustion.   In the first, symptoms of
 mania came on a few days after delivery, and while her medical
 attendant was shut up as a witness in a court of law, another
 practitioner was called in, who, seeing the patient in a state of
 raving excitement, bled  her profusely, when she sank rapidly,
 dying in spite of all attempts to rally her.  In the other  case,
 the patient, partly from principle and partly from poverty, had
 been a teetotaller, and had had children at the rate of about one
 a  year, suckling them upon water and a scanty diet.   When I
 saw her, a week after her confinement, her mind  was  wander-
 ing ; she had scarcely, if at all, fallen asleep, even for a moment,
 during the time  mentioned, and she  had been harassed by the
 constant  application of the child to breasts which refused to
 secrete their nourishment.  The anaemia in this case was extreme.
 Her maniacal disorder increased, and she died, no support or
 stimulus making any impression upon her exhausted system.
   Due  attention  being paid to the cerebral  excitement,  the
 patient should have a full amount of support and stimulus.  It
 often happens that digestion and absorption  are remarkably
 rapid in  these cases, and the patient suffers from  an exacerba-
 tion whenever the stomach is empty, or she is kept long with-
out food.  In many cases, wine, porter, or brandy, can be given
freely, at stated intervals, with the best effect.  Ether, ammonia,
hyoscyamus, and  camphor, are very useful as  supporting  and
soothing  the nervous  system, particularly hyoscyamus in com-
 bination  with ether or ammonia.   Opium is exceedingly useful,
especially in cases  attended by protracted insomnia.  In cases
 most  strongly marked by  excitement,  chloroform has been 
602       HOSPITAL TREATMENT FOR PUERPERAL MANIA.

inhaled with the  best effects.   When  the disease becomes
chronic, the preparations of iron, quinine, and other  tonics are
necessary.   In long-continued cases there is special evidence of
the exhaustion of the reproductive system.   Amenorrhcea gene-
rally exists until the mental  disorder gives way.   Generally,
the mammary secretion is arrested from  an  early period ; but,
beyond relieving the breasts when they are full, no  attempt at
suckling should be made in  these cases.
  Are there any essential  differences between the  Puer-
peral  and  other  forms of  Mania?   Some  authorities
of eminence have believed that no such differences exist, while
others have considered  the varieties of insanity connected with
the reproductive functions,  and particularly the puerperal  dis-
order,  so peculiar as to constitute a distinct  class.  The answer
to the  preceding question will'very much depend upon whether
we  take a large or a circumscribed view of such cases.  If we
look at the patient during the attack alone, the symptoms, it is
true, vary little, if at all, from some other cases of insanity.  If,
however, we  consider the previous and subsequent histories of
cases of this kind we shall come to the conclusion that there are
special features arising out of the facts that the functions whose
disordered conditions produce the insanity are not permanent but
temporary; that patients the subjects of puerperal  attacks are
not so liable as others to renewed invasions of derangerhent, par-
ticularly after the child-bearing epoch has passed, and that they
are not so likely to transmit a hereditary taint to their offspring.
  These points bear practically upon the management of puer-
peral cases.   Those who suppose the puerperal and other forms
of insanity to be identical,  naturally advocate a similarity of
treatment as regards  restraint  and seclusion.  I believe, how-
ever, that great mischief is frequently done by placing puer-
peral  patients in public and private lunatic asylums.  In my
opinion, such cases should rarely, if ever, be placed in asylums.
After their recovery, they frequently retain a life-long sense of
the stigma  of being so treated, the  suspicion of  hereditary
mania is raised against families, and no good is obtained which
could not be derived from a private  seclusion of such patients
from their immediate families and friends.   In no cases do the
blessings of the modern treatment of the insane stand out more
prominently.   I remember, when a student, seeing a patient suf- 
CARE OF THE PUERPERALLY INSANE.
603
 fering from puerperal mania kept for months in a dark pen, with
 only straw to lie upon, and a rug for  a  covering.  No patients
 require more careful watching lest they  should do themselves or
 others mischief.  Every means of injury should be removed or
 prevented, as far as possible, and the patient  should never be
 left for a moment alone,  or especially  with her infant.  It is
 necessary to  gain, by firmness, a  mastery over such patients.
 They recover more quickly when not allowed  to see  their hus-
 bands, infants or immediate relatives, and  they are most easily
 managed by nurses whom they have not previously known ; but
 they often retain for years the keenest sense of any unkindness,
 done to them during the continuance of their disorder. In some
 other  and  more happy  cases, nothing is remembered of the
 birth of the child or  the  subsequent illness.   These are,  how-
 ever,  exceptions,  and  puerperal patients  should always  be
 treated as though they were destined to  a perfect recovery, and
 to remain without any necessary tendency to subsequent mental
 disease.   Dr. Hood dwells  with  great  humanity  upon the
 unhappy position  of some of the  patients confined for life in
 Bethlehem as criminal lunatics, who have killed  their children
 during attacks of puerperal  mania.   Some of  these poor  crea-
 tures having passed the childbearing age, are perfectly clear in
 intellect, conscious of what they have done, and suffer  intense
 misery therefrom, while they have their  desolation  enhanced by
 mixing constantly with  confirmed  lunatics.   Surely  philan-
 thropy should find some remedy for such a state of things.
  The cases of insanity which occur as  the  result  of Undue
 Lactation  are very  similar  to cases  of puerperal insanity,
 only that their symptoms come on in a  more gradual manner.
 When nursing women complain of  loss of sight or  hearing, and
headache,  either  their nourishment  and stimulus should  be
increased, or suckling should be at once discontinued.   Where
there is any predisposition  to  insanity, mothers should  not,  if
possible, be  allowed to suckle their children.  In  all cases  of
this kind the dependence of the mania upon exhaustion is abun-
 dantly evident.  It is  especially likely  to happen when preg-
nancy and lactation are allowed to proceed simultaneously.
  There are in the subjects  of  this  form of disease  the same
suicidal  and homicidal tendencies as in  puerperal  insanity.  I
once met with a  case in which a mother  delivered of twi"« 
604
OVER-LACTATION  A CAUSE OF INSANITY.
became affected in her mind from suckling, and  a wet-nurse
was  procured in the  person of a young girl who had given
birth to an illegitimate child.  She had nursed her  own infant
for some time, and then,  while  being drained by the twins,
again became pregnant.  Signs  of insanity manifested them-
selves, and  she was one day found dead, hanging  behind the
door of her  room.   This form of insanity sometimes comes on
weeks or months after the  close of lactation.   I have no doubt
that the woman Brough, who killed, two  or three  years since,
several of her children at  Esher, and who is now  a confirmed
lunatic  in Bethlehem, had suffered  from over-lactation.  She
had weaned a child not long before the dreadful tragedy, had
complained  of loss  of sight, and severe nervous disorder, and
had suffered in her head in previous lactations. The preventive
treatment of this form of insanity consists, of course, in weaning
as soon as any marked signs of nervous disorder are perceived.
In the management of such  cases,  great  care in guarding the
patient is necessary, and the treatment  of this disease  must be
a supporting and stimulating one, combined with  perfect rest,
and the avoidance, as far as possible, of all moral and  physical
excitement. 
LECTURE  XLI.
             PUERPERAL  CONVULSIONS.

  Gentlemen :—Convulsions, like the other disorders of partu-
rition arising from excessive nervi-motor action, may be divided
into those of Centric and those of Eccentric origin.  This  divi-
sion is the most convenient for an investigation of the  causes of
this formidable disease.
  The Centric  eauses of Convulsion may be either intra-
cranial or intra-vertebral, or both.  I  proceed to speak first of
the intra-cerebral causes.
  Any mechanical or  emotional  stimulus  applied in  excess to
the spinal centre itself, may excite convulsions during the puer-
peral state.  In all women, the excitement  of the nervous  sys-
tem  inseparable from parturition  is  a  predisposing  cause
of the attack,  which  is provoked whenever  any other  suf-
ficient exciting cause  supervenes upon this parturient excita-
bility.
  A clot of blood, or serous effusion, occurring in any part of
the brain, may cause convulsion by mechanical counter-pressure
upon  the medulla oblongata.   In full states of the  circulation,
convulsion may be caused by cerebral  distension alone.  Here
it must be the counter-pressure on the medulla oblongata which,
in part at least, produces  the disease.  Any  disease of the
brain, of the membranes, or of the  skull, capable  of exerting
internal pressure, may cause convulsion in this manner.
  The intra-vertebral causes of convulsion consist chiefly of dis-
orders of the spinal meninges, and upon conditions affecting the
substance of the spinal centre itself.  Probably excessive dis-
tension of this organ with blood excites convulsions ;  it is cer-
tain  that the opposite condition, spinal  anaemia, becomes  a
powerful  exciting cause.   In cases  of irremediable  uterine
haemorrhage, convulsion is  the common form by which death 
606
PHYSICAL CAUSES OF CONVULSION8.
occurs ; or a convulsion may occur from loss of blood before the
patient  is in extremis.   I  shall, moreover,  endeavor to  show
hereafter  that in some cases of convulsion arising from  other
causes, excessive blood-letting comes in at length as a cause of
the fits, the therapeutics of the disease trenching distinctly upon
its pathology.  In  animals killed by blood-letting, either by
experiments or at the shambles, convulsion always occurs  dur-
ing the  act of dying.
  The state of the blood circulating  in  the spinal  marrow, as
regards its constitution,  is an important cause of centric convul-
sion.  All agencies which interfere with the proper depuration
of this fluid during pregnancy, or on  the  approach of parturi-
tion, contribute to render the blood a morbid  stimulant  to the
spinal system.  Such are the constipation and  insufficient secre-
tion from the bowels caused by the mechanical pressure of the
gravid uterus upon the  intestines.  The albuminuria, sometimes
present, and which also appears to be  caused by pressure on
the kidneys, and the renal vessels and nerves, accumulates  nox-
ious elements in the blood.  This condition requires our special
notice, as the most  important  and general of all  the  centric
causes  of puerperal  convulsion.   The  encroachment  of the
abdomen upon the thorax must also render the due oxygenation
of the blood  difficult.  Asphyxia  invariably produces  convul-
sions, and when it occurs during  parturition, must necessarily
produce this disease.  The  act of abortion from asphyxia seems
to be  almost  a part  of  the general convulsion  excited  by the
deprivation of oxygen.   There are various other sources of san-
guineous impurity, all of which contribute their quota towards
rendering the blood morbidly irritating to the nervous  centres.
It deserves to be borne in mind, that  the depuratory functions
ought, in order to preserve health, to be  increased  during ges-
tation, as the debris of the foetal, as well as the maternal system
have to be eliminated by the organs of the mother. Besides these
forms of toxaemia,  the state of the blood which obtains in fevers
or during the excitement  of the first secretion  of milk,  mav
excite convulsive disorder.  In all  these  cases  the  affection of
the nervous system is centric, and not reflex.
  These are  the Physical  causes of disease;  but there is an-
other  and very effective cause of puerperal convulsion which is
Psychical in  its character.   I refer to the influence of emotion. 
PHYSICAL CAUSE OF CONVULSIONS.
607
  Emotion,  then, is a  very important cause of centric  convul-
sion in the  puerperal  state; important both on account of the
severity of the attack when thus induced, the greater absence of
premonitory signs, and the obstinacy of the disease as  regards
treatment.   It is a very old and true observation, that  convul-
sion is often met with  in single women whose minds have been
depressed by the  sense of shame  and misery inseparable from
their condition during  gestation.   But any  violent  emotion of
the mind, whether of joy or sorrow, the  agreeable  or disagree-
able, may excite a convulsive attack.  The return of a husband,
the first sight of the infant  after the hours of intense  expectation,
the pain  and dread of parturition,  or any intelligence whatever,
suddenly communicated, ma}7 hurl the patient  into convulsion.
I myself saw a case  in which a husband, returning from a dis-
tant and  perilous journey a day or two after his wife's delivery,
in the very  act  of greeting him she fell into convulsion ; and
instead of embracing a conscious  mother, he held  in his arms
the rigid form of  an epileptic.  The fit is sometimes produced
by emotional causes of a trivial character.   Mauriceau relates a
very singular case, in  which puerperal convulsion  was  excited
by the disgust caused in the mind of the patient by  the entrance
into her  apartment of  a coxcombical friend, whose  dress was
powerfully scented.
  Such being the principal Centric causes of puerperal  convul-
sions, let us now consider the Eccentric, or  those caused by irri-
tation of incident, excitor nerves, acting through them upon the
true spinal marrow, and its motor  nerves.
  First in importance is, Convulsion from Irritation of the
Uterus itself and the Uterine Passages.
  The  statistics  of labor demonstrate that puerperal convulsions
occur with  greater relative frequency when the head presents,
than in other presentations.  From this it has been  inferred that
its pressure on the os uteri  was a principal cause; but the acute
mind of  Dr. Collins saw that this  coincidence could not be con-
sidered as cause and effect, for convulsions  frequently come  on
when the os uteri is entirely dilated, before the dilatation has com-
menced,  or  after delivery.   Neither this eminent obstetrician
nor any  other has taken the pressure of  the head on the vagina
sufficiently into  consideration, in  connection with the fact, that
 irritation of the vagina  excites more extensive reflex muscular 
 608        CONVULSIONS FROM IRRITATION OF THE  OS.

 actions than irritation of the uterus itself.   This gives a physio-
 logical explanation to the fact  respecting the frequency of con-
 vulsions in head-presentations with  first children, the irritation
 cf  the excitor nerves  of  the os uteri  and the  vagina  being
 undoubtedly greater under such circumstances than  any  other.
 I might adduce  numbers of cases in support of  this view; in
 fact, any case in which all remedies have  been  tried in vain,
 but in  which the convulsions cease immediately after delivery,
 contains its proof.  It must always be borne in mind, when con-
 sidering the causes of excito-motor diseases, that  irritation of
 the peripheral  incident nerves  is  not  dependent on, or to be
 measured by, the mere intensity of pain.   It has been shown
 again and again that the most powerful reflex action of the  vis
 nervosa may be caused without any sensation whatever ; indeed,
 in puerperal convulsions the causes operate  sometimes during a
 state of perfect coma, or they may commence while  the patient
 is in a  profound syncope.  The term irritation, when applied to
 spinal  action, must therefore, as I  have often  observed,  be
 received with its  peculiar signification.
  Convulsions may be brought on by the mere presence of the
 foetus  in utero, there being  no other exciting  cause ; or they
 may occur from the causes of spinal irritation depending on the
first changes which take place in the uterine system preparatory
to labor, before the os uteri has commenced its dilatation.  They
 are sometimes caused by the irritation of a  dead foetus.   The
mere distension of the  uterus  by the  liquor amnii, particularly
in cases where there is a large quantity of this fluid, has appear-
ed to give rise to  convulsions.
  When  a convulsion  has once happened,  the fit may  be
repeated from  causes  of  uterine irritation apparently  trivial
Irritation of the os uteri is one of these.  Denman  relates  the
following of  a case which  occurred to  him :   " When the  os
internum began to dilate,  I  gently assisted during every  pain ;
but being soon  convinced  that this  endeavor brought on, con-
 tinued, or increased the  convulsions, 1 desisted and left the work
to Nature."  A  similar case  was once  related to  me by Dr.
 Ileming.  In other cases, fits have been produced by the hand
 of the  accoucheur in the operation of  turning, or  by the  irrita-
 tion caused by the use of instruments.   Irritation  of the os
 externum is also a powerful excitor of spasmodic action.   Many 
        CONVULSIONS FROM IRRITATION OF THK VAGINA.     609

women die from  the violence of the convulsion  caused by the
passage of the child through the  external parts.  It has even
happened  that successive fits have  been caused by irritation
of the uterus from injudicious  attempts  to apply an abdominal
bandage.
  The following are two interesting cases of puerperal convul-
sions from irritation or excitation of the excitor nerves of the
uterus  and uterine passages, the  irritation being conveyed to
the spinal marrow, and reflected back  on the motor nerves of
the whole spinal system so as to cause the convulsions.  The first
is related by Dr. Ingleby :—
  " A highly esteemed friend  of mine once found it necessary
to pass his hand into the uterus, for the purpose of removing an
adherent placenta,  the ergot of  rye having  been previously
administered.  The introduction was  carefully performed.  The
straining and opposition to his efforts on the part of the woman
were exceedingly great; and at the moment when the operator's
hand had reached the organ, my own hand making counter-pres-
sure  on the abdomen, the patient  became violently convulsed,
and died in less than a  minute."
  The second is from  Dr.  F.  II. Ramsbotham, who relates a
case  of convulsions in which the fits were relieved by bleeding,
and  the woman remained  fifty  hours after the attack before
labor came on.  In  less than five hours she was delivered with-
out any recurrence of the fits ;  but as the placenta did not come
away, Dr. Ramsbotham was summoned, two hours after the
expulsion  of the child.  He remarks  that,  " Under no greater
anxiety than usual when the placenta is retained, I proceeded
in the ordinary way to  remove it.  The  moment I had passed
my hand  completely into the uterine cavity, the  patient turned
upon her abdomen,  and without uttering any expression of pain,
went into  a convulsion."
  Puerperal  Convulsions  may arise from Irritation of Intra-
cranial Excitor Nerves.   It may appear a  nice distinction to
classify  convulsions arising from  cerebral pressure  on the
medulla oblongata,  and convulsions caused by irritation of the
membranes, under different heads.  Yet the one is Centric, the
other Eccentric.   Cerebral pressure affects  the medulla oblon-
gata directly, meningeal irritation reaches it refiexly, so that some
distinction is really demanded.  The known  intracranial causes
                              39 
 610       CONVULSIONS FROM  IRRITATION OF VISCERA.

 of puerperal convulsion of a  reflex  character are, bony projec-
 tions and exostoses, inflammation of  the meninges, the extension
 of red softening of the brain to the membranes, or the extension
 of irritation  from a coagulum in the substance of  the brain.
 Thus, in puerperal convulsion, we have to study the  brain and
 its envelopes under many and very important points of view ; 1,
 as the seat of some of the most important changes which  occur
 during the fit;  2, as the seat of an important  class  of centric
 causes of convulsion; and, 3,  as the source of  irritation acting
 upon the spinal centre  in reflex forms.   As the reflex cause of
 convulsion, we must study7 the brain as we would the uterus,
 the stomach, the intestines, etc.
  Irritation of the bowels, especially of the lower part of the
 intestinal canal, is well known to cause convulsions under other
 circumstances besides those connected with the puerperal state.
 Thus worms, the severe action of purgative medicines, the col-
 lection of indurated faeces in the bowel, have all been  known to
 cause epilepsy,  and  the  convulsions of  children.   It cannot
 therefore  be wondered  at, that  when the  excito-motor system
 is under  the additional  stimulus of either pregnancy, labor, or
 the puerperal state, these and similar sources of excitation should
 cause puerperal convulsions.   Gastric irritation has  long been
 looked on as a cause of  puerperal convulsions, though the true
 rationale has never been given by obstetric writers.   Irritation
 of the Bladder is a less frequent, though undoubted, cause of
 puerperal  convulsions.    Other  causes than those which have
 been given, occasionally operate  on the spinal system, but all act
 in accordance with the  principles   already advanced.   Mr.
 Ingleby suspected that  irritation of  the Mammae might  cause
 convulsions.  Not long since, I saw a case of puerperal convul-
 sion for which no other cause could be assigned than  excessive
 soreness of the nipple, with mammary induration.   The  Skin,
 too,  as an important excito-motor organ,  must  be studied in
 relation to puerperal convulsions.   The same may be said of
 the Liver, and other organs supplied by the pneumogastric nerve.
  Such are the principal causes of puerperal convulsions to the
modus agendi of all of which  the physiology of the true spinal
marrow goes far towards supplying a perfect explanation ; and
it must be remembered that, wanting this mode of solution, the
disease  formed,  confessedly,  one of  the enigmas of modern 
           BLOOD-LETTING IN PUERPERAL CONVULSIONS.       611

 pathology.  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 cen-
 tre, such excitement depending on pregnancy, labor or the
 puerperal state.  While the spinal marrow remains under the
•influence of either of these stimuli, convulsions may arise from
 two series of causes:  those acting primarily on  the  spinal mar-
 row, or centric causes  ; and, secondly those affecting the extremi-
 ties of its  incident nerves, or causes of eccentric or peripheral
 origin.   Though the subject  admits of this  division,  several
 causes may act together, and centric and  eccentric causes may
 be in operation at the same time.  I have made no attempt at a
 division into predisposing and  exciting, proximate and remote
 causes,  because it is evident that a cause which in one case is the
 exciting or proximate, may in  another be  the  predisposing or
 remote cause.   Thus,  irritation of the uterus may be the predis-
 posing,  and irritation  of the stomach the exciting, cause, in one
 instance; while in another, irritation of the uterus is both the
 predisposing  and the  exciting  cause ;  hence, any such division
 must be, to a great extent, arbitrary and devoid of precise mean-
 ing.
   In the Treatment  of Puerperal Convulsions, we have to
 consider remedies which act on the central organ, the spinal
 marrow, and  those which affect  the  extremities  of incident
 spinal nerves.   I  propose,  in the first  instance, to consider the
 remedies of direct or centric action.  Of these, Bloodletting
is  the most important.
   The action of bloodletting on the spinal marrow is  greatly
modified by the condition of the circulation.  In fullness of the
vascular system, it is the most powerful sedative of spinal action
we possess.  Hence,  venesection  is the great remedy in the
simpler form of puerperal convulsion, where the disease chiefly
depends on stimulation of the spinal marrow by excess of blood,
or on the  mechanical pressure  exerted by the blood on that
organ, together with the counter-pressure of the distended brain
on the  medulla oblongata.  In such cases, bleeding  should be
performed,  with a view to its sedative action on the spinal mar-
row, and to avert the mechanical  effects of vascular pressure 
612
VENESECTION IN CONVULSIONS.
from this organ.  Alone, it will frequently be sufficient to sub-
due the disease, particularly when the fits come on before the
beginning of labor or after delivery.   But another most  impor-
tant  intention of bloodletting should never  be lost sight of—
namely, that of preserving  the brain from  injury  during the
convulsion.  Besides the  primary  cerebral  congestion, which
may have been  the cause of the attack by its  counter-pressure
on the medulla, the convulsive actions themselves, exerting great
muscular pressure on  the whole vascular system, and causing,
as they must, the  greatest turgidity of the vessels of the head,
are dangerous sources  of  fatal cerebral congestion, or of serous
or sanguineous effusion.   As in  the case of epileptics, women in
puerperal convulsions  frequently die of apoplexy, produced by
the immense pressure  exerted on the cerebral  column of blood
during the fits.   It is in great measure from the effects of blood-
letting in warding off accident from  the brain  that  bleeding; is
so general in this disease.   The  due recognition of the distinct
operation of bloodletting on the cerebral and spinal systems is
of the utmost consequence.   In plethoric states  of the circula-
tion, it is in  this disease curative in its action on the spinal mar-
row, preventive in  its action  on the brain.
  In  the  absence of  definite  ideas regarding  the  effects of
bloodletting in this  malady, it has  been  sometimes pushed to
excess,  or  practised  where it  should have  been altogether
avoided.  In the numerous cases where, besides vascular excite-
ment of the spinal  marrow,  some  irritation of spinal  excitor
nerves exists as a conjoined  cause of convulsion, repeated bleed-
ings will often fail to subdue  the disease, unless the eccentric
irritation be at the same time removed.  When irritation of the
uterus, the rectum, or  the stomach, is in part excitor of the con-
vulsion, bleeding  alone cannot be relied  on.   It may  at first
diminish the impressibility of the central organ, rendering  it
less susceptible of the  incident irritation ; but  if persisted in to
a large extent without  the removal of the eccentric irritation, it
becomes in  the end positively injurious, by increasing  instead
of diminishing the excitability of the spinal marrow.
   In  vascular plethora, depletion is undoubtedly a  sedative to
the spinal system ; but when the circulation is reduced consider-
ably below par, loss  of blood becomes an actual excitant to this
organ.  Hence  it is that the reports of those who have most 
TRACHEOTOMY IN CONVULSIONS.
613
pertinaciously followed bloodletting, exhibit the loss of a greater
number of patients than those who have been more  cautious in
this respect.  The propriety and  extent of venesection must be
estimated, then, not by the violence of the disease, but by the
state of the circulation in the interval of the fits, and with espe-
cial  reference to the different effects of the vascular  plethora,
and  vacuity upon the spinal centre.  Patients rightly bled in
the first instance,  may  be subjected  to  successive depletion
until loss of blood itself becomes  the cause of the final seizures.
  Similar remarks would apply with almost equal force to the
other parts of the  common antiphlogistic  regimen.   Nearly
allied to the  modus  operandi  of bleeding  are  the effects of
Nauseating Doses of Emetic Tartar, which  have  been found
so serviceable in the treatment of puerperal convulsions  by
Dr. Collins. It is more than probable that this remedy acts as a
sedative on the spinal system through the medium of its effects
on  the  circulation.   In  the convulsion  occurring in delicate
anaemic  women,  bleeding is generally inadmissible, becoming
in fact,  under  such circumstances, an exciting cause of the dis-
ease.  Still, in cases approaching to this state, cautious bleeding
may be sometimes necessary to preserve the brain from injury,
but here venesection requires to be followed promptly by stimu-
lants: such cases  are, however, rare in comparison with those in
which fullness of the circulation exists at the onset of the disease.
  During the  attack of convulsion the  glottis  is partially or
entirely closed.   The  greatest  authority on this  point,  Dr.
Marshall Hall, questions if  true convulsion could  ever occur
without this state of the glottis, and the cerebral and spinal  con-
gestion  which  it occasions.  We know that the epileptic attack is
sometimes worked off by the dash of cold water on the face or
chest, so as to excite a sudden inspiration  and the dilatation of
the glottis.  It is on the same principle, that of exciting a strong
inspiratory act, that  we stimulate the  nostrils or sprinkle the
face with cold water in syncope.   Excitation of the  incident
nerves of inspiration  has in the same way been known  to  pre-
vent the puerperal convulsion.   It is probable that  in  extreme
cases, tracheotomy may afford  relief, and I should not hesitate
about resorting to this operation when the patient was in danger
of dying during the fit.
   Harvey gives an instance in which stimulation of  the trifacial 
  014          WATER SPRINKLING IN CONVULSIONS.

_ nerve within the nostrils recovered a woman who became coma-
  tose during labor.   Denman  also relates an interesting case, in
  which a convulsion was excited  during every labor-pain,  but in
  which he  kept  off the attacks, until  delivery was completed,
  simply by  throwing water  on the face with a bunch of feathers
  at each accession of pain.  It was found that this mode of pro-
  ceeding, from which he augured so favorably  from its  effects in
  this and other cases, did  not prove  equally efficacious  on all
  occasions.  He  observes, that this  is  " a safe remedy,"  which
  cannot be said of  all measures  resorted to in this disease.  It
  must certainly be productive  of benefit in cases where the  glottis
  is not so firmly locked as to render its dilatation  by this means
  impossible.  Even if it does nothing to prevent the accession of
  the  fit,  every time we can dilate the  glottis, and  cause  a  full
  inspiration, we take off a considerable  amount of vascular pres-
  sure from  the nervous centres, and  lessen the  proportion of
  venous blood in the system.
   The application  of Cold is a therapeutic of some importance
  in this disorder.  Cold, applied to the  head in the form of nap-
  kins, lightly  wrung out of cold or iced water,  ice  itself, or a full
  stream  of  cold  water poured from a height, has become an
  approved remedy in puerperal convulsions.  It therefore becomes
  an  interesting question, How does  cold water thus used  act on
  the nervous system ?  It may  act as a sedative on the cerebral por-
  tion of the spinal  marrow, or it may lessen the distended state
  of the cerebral circulation, and thus relieve the counter-pressure
  of the brain on the intra-cranial portions of the  spinal system.
  Probably it acts in both of  these modes.   When used in the
  form of the  continuous  douche, as  sometimes recommended,  it
  would, in addition, tend to excite acts of  inspiration,  and thus
  dilate the  glottis.   The primary sedative action  of cold  on the
  spinal centre would seem to be shown  satisfactorily by the good
  effects of cold applied to the whole length  of  the spinal column
  in tetanus.
   The application  of cold to the spine as  well as to  the head
  may hereafter  be  found  beneficial in puerperal  convulsions.
  Whenever cold in any form is resorted to, its use, except for the
  purpose of exciting the respiration, must be  continuous, as the
  intermittent  application of  cold,  locally  or  generally,  would
  excite, instead of  allay, the  spinal  system.  The  benefit deriv- 
OPIUM AND CHLOROFORM IN CONVULSIONS.
615
able from  cold  appears to  arise from its local action  on the
nervous centres, because in tetanus, the purest form of increased
morbid spinal action, cold  applied  to  the spine is serviceable,
whereas, when applied to  the whole surface of the body, it is
extremely dangerous, and even fatal.
  Some  striking  distinctions  must  be made  respecting  the
administration  of Opium  in Puerperal Convulsions.   If  a
dose of opium be given in  this disease in a full state of the cir-
culation, before  bleeding, there is a dangerous  aggravation of
the disorder ; while if it be  given in puerperal convulsions in an
anaemic subject, or after excessive depletion, it  is of great  ser-
vice.   If, in a case of convulsions, opium be given at the com-
mencement, it is dangerous  in its effects ; but the same medicine
is frequently valuable in the advanced stage of the same case,
when the vascular system has been  powerfully depleted.  Thus
it would appear evident that in convulsions with a full state of
the circulation, opium is a stimulant to the spinal marrow, while
in convulsions with  anaemia, it is distinctly  sedative.  It is cer-
tainly an important point in practice, that the effects of opium
in puerperal convulsion depend on the state of the circulation  ;
that in plethoric or inflammatory conditions it is always danger-
ous, while  in  anaemia  and debility  it may  always  be given
beneficially.
  ^Chloroform  is an  agent of the highest  importance  in  the
relief of puerperal  convulsions when they are dependent upon
spinal  irritability.  The indications for and against its use are
thus summed up by Dr. Barker; " Where the convulsion is the
result  of direct  pressure on the medulla oblongata, or where
the convulsion  produces serous or sanguineous  effusion,  the
chloroform can have no influence in controlling the fits.   Where
then, there is complete coma, and  especially when there is par-
tial paralysis, no  good effect can be anticipated from the use of
chloroform.  No judicious man would think  of using chloroform
in  anaemic convulsions; as  in  allaying the spinal excitability,
there would be great danger  of overwhelming the nerves of
organic life,  and thus  destroying  the life  of the patient.   In
hysterical convulsions, the  chloroform is the sole therapeutic
agent required."]
  The regulation of Emotion is of considerable importance in
preventing the accession of convulsions when they are  threat- 
 616            STATE OF THE CERVICAL REGION.

 ened, and in averting the return of the attacks, in the intervals
 where consciousness is retained.   Mental excitement of every
 kind should be soothed, and avoided as much as possible.   The
 sight of the infant, of alarmed friends or relatives, unpleasant
 intelligence, noises  in  the  sick  chamber, or still  more trifling
 matters, have caused or renewed convulsions.   Perfect  quiet
 and repose within the sick-room, and the absence of all signs of
 excitement on the part of the attendants, are of the utmost con-
 sequence ; the calm  or timid look of the professional man  may
 either excite or prevent a fit.
  During ordinary labors care should be  taken to avoid increas-
 ing the  tendency to contractions of the muscles of the neck; this
 is still more important in labors  with  symptoms of spinal ere-
 thismns, or threatening  convulsion.  Care should be taken that
 during the propulsive and  expulsive stages of labor, the reflex
 contractions about  the neck should not be increased by exces-
 sive voluntary efforts,  or  by violent emotional  disturbance.
 When the neck becomes tumid at  each returning pain, the reflex
 cervical contractions should  be  moderated by  directing the
 patient, not only to withhold voluntary action of this kind, but
 to cry out during the pains, so as to keep the larynx open.  In
 this way sphagiasmus and laryngismus may both be prevented
 by volition, in some cases.  If the cervical symptoms are severe,
 venesection  should be practised before the  accession of convul-
 sion, as  a preventive measure.  Whenever fullness of the  neck
 occurs, either before or after labor, so as  to create an apprehen-
 sion of convulsion,  blood  should be taken from  the head by
 leeches  or by cupping.  There is no point of greater importance
 to the prophylaxis of puerperal convulsion than an attention to
 the state of the cervical region; it is to convulsion what the
 pulse is to inflammation.
  On more than one occasion in the present lectures, I have
spoken of the  great importance of treating Albuminuria dur-
 ing pregnancy.  By the  removal  of the  poisoned  state of the
blood, we may prevent convulsions;  but, unfortunately, when
this state continues up to the time of labor, and  causes the fits,
 we can do little towards the depuration of the blood, or remov-
ing the  renal disorder.   We have no sudden means of relieving
 a patient in  such a condition, except perhaps, to a slight extent,
by puncturing the  skin in situations where the local oedema is 
CATHARTICS IN CONVULSIONS.
617
excessive.   In cases complicated with albuminuria, labor should
be completed as early as possible, due regard being had to the
effects of the irritation which may be necessary to effect delivery.
It often happens that very shortly after the expulsion of the
child,  the  kidneys  secrete  an  immense quantity of urine, and
relieve the patient from the state of blood-poisoning.
  In threatened convulsion, or after the invasion of the  disease,
it is of the  utmost importance to seek out and remove all sources
of reflex irritation.  Remote  causes of irritation should be
sought for, and removed with the greatest care.  The state of
the Stomach, the Intestines, the Breasts, the  Bladder, and other
organs in reflex  relation with the  uterus, should  be examined.
If the fit should have  occurred for the first time after a full meal,
or after indigestible food, an emetic of the sulphate of zinc should
be administered.  If there should be vascular fullness, vene-
section ought to be performed.  The bleeding should precede
the emetic, to diminish the danger to the cerebrum from the
action of vomiting, for emetics given incautiously have occasion-
ally produced sudden death in puerperal convulsion.  However,
when the gastric irritation is undoubted, no  patient should be
suffered to  continue in the fits with the stomach unrelieved.  It
may seem superfluous to urge this, but I have known cases of
convulsion  from gastric irritation, in  which the most sedulous
attention has been  shown  to almost  every other organ  in the
body, except the right one.  Still more important than the  sto-
mach is the state of the bowels.   In convulsions  the  intestines
are very commonly loaded ; it immediately  becomes a question
how to relieve them without producing greater irritation  by the
operation than already exists from  their loaded condition.  The
most violent drastics have been given in such cases without any
ceremony,  as though the  more rudely the materies  morbi were
grasped, the more  effective the remedy.  But it  is of great,
importance to avoid irritating the intestinal canal unnecessarily.
I have known puerperal convulsions produced  by giving  a brisk
cathartic too soon after delivery.   In  fact, there is  little differ-
ence between irritant  drugs  and irritant faecal matter.   There-
fore, whenever the  bowels can be  opened without  purgatives
administered by the mouth, but by aperient enemata, the latter
are greatly to be preferred.   When we give a cathartic, we never
know how  long it may remain to fret the bowels, but an  enema 
618
EN KM AS  IN  CONVULSIONS.
is sure to return almost immediately.  Washing out the bowel
is less irritating than drastic cathartics, and often effective in
removing  faecal accumulations.   A  copious  enema of warm
water, repeated  until free  evacuation has been produced,  has
sometimes  relieved convulsion.   If the warm water  injection
should be insufficient,  castor oil  or turpentine may be  added.
Sometimes the constipation is so obstinate as to refuse to yield
either to enemata or cathartics, and the contents of the  bowels
positively require to be dug out.  I have seen a case of this kind
in which their  excavation was followed by the almost  instant
relief of violent convulsions.   The state  of the bladder  should
always be attended  to in puerperal convulsion, particularly as,
during the insensibility of the intervals, the patient is unable to
inform the attendant of its distended condition.  This may be a
slight thing to mention, but the catheter has sometimes relieved
convulsion when the lancet has failed.
  But the great seat of reflex irritation in puerperal convulsion
is in  the parturient canal.  There is only one direct  mode in
which uterine irritation can be allayed during puerperal convul-
sion, except by the removal  of the foetus.  This is by removal
of the liquor amnii. In cases of puerperal convulsion, punctur-
ing  the membranes  takes off a considerable amount of distension
from  the uterus ; diminishing  the size of the organ, and  the
quantity of blood circulating  through  it.   Hence, though it ren-
ders the uterus  more active, by bringing its parietes into contact
with the foetus,  it renders the organ itself less irritating  to  the
general spinal system.  The evacuation of the liquor amnii is to
the  uterus what the partial action of an emetic or an enema is
to the stomach and intestines.  In convulsion from  uterine irri-
tation, much may be done by the avoidance of all  unnecessary
dilatation and interference with the vagina and os uteri.  Dur-
ing convulsions, all operations upon the parturient canal, whether
they consist of  examinations, dilatation  of the  os uteri and  the
vagina, the artificial removal  of  the foetus, or  the extraction of
the  placenta, should be performed  with the greatest care,  and
with the remembrance of the ease with which renewed fits may
be excited by any irritation of the uterine passages.
  The relation of Artificial  Delivery to puerperal convulsion
is a matter of  deep interest.  Some  obstetricians have  recom-
mended that it should always be performed by turning, crani- 
ARTIFICIAL DELIVERY IN  CONVULSIONS.          619
otomy, or the forceps, when the fits are obstinate and  severe.
In  deciding this point, the particular characters  of individual
cases must be considered.  The general principle which we may
deduce is, that whenever artificial delivery can be effected with
less irritation than would be produced by the continuance of the
child in  the parturient  canal, and its expulsion by the, natural
process, it is advisable that it should be performed, if the situa-
tion of the mother be perilous.   It must be with reference  to
this principle—namely, to the irritation of any particular opera-
tion, and the irritation of labor itself—that turning, craniotomy,
or the forceps, must be decided upon.  All these  operations have
destroyed patients ; and, on the other hand, numbers have died
undelivered, from uterine irritation.  The  question of interfer-
ence is one for which no arbitrary rule  can be laid down, but
which must be decided in each individual case by the particular
circumstance, due reference being had to the excitability of the
uterus under  the stimulus of the foetus,  and  under  artificial
interference.   The point  to aim at should be, never to  produce
more irritation than we remove, and not  to destroy the patient
by an excessive temporary irritation instituted for her permanent
relief,  by the  entire evacuation  of the  parturient canal. Of
course, the  greater  the  operation necessary for delivery, the
greater is the deliberation  necessary before it  is commenced.
In manipulating upon the uterus under such circumstances, we
must never for a moment lose sight of its reflex connection with
the spinal  marrow.   Such appear  to  me to be the principles
upon which we  must attack the uterus in puerperal convul-
sion.
  I now  proceed to the consideration of the form of Puerperal
Convulsion depending on Albuminuria.  Since the present
work has been in the press, an obstetric text-book has been pub-
lished by Dr. Carl Braun, of Vienna, which contains the fullest
account hitherto given  of puerperal  convulsions dependent on
uraemia.   An  excellent  translation of this part  of Dr. Braun's
work has been published by Dr.  Matthews Duncan, and to this
I am much indebted.
  The subject of albuminuria, in  connection with child-bearing,
has already been adverted to in this Lecture and in that on the
disorders of pregnancy.   Puerperal convulsions depending on
uraemia and albuminuria are, without  doubt, the  most important
and frequent convulsive disease of parturition, and require special 
620
CAUSES OF ALBUMINURIA.
notice, as the treatment of such cases is distinct in some respects
from that of puerperal convulsions occurring in the absence of
albuminuria.  Uraemic convulsions, as they  are called, may
happen during pregnancy, in  the course of labor, or after  de-
livery has taken place, but the greatest number of cases occur
during the act of parturition itself.   As already mentioned, this
form of convulsions is centric in its origin, as regards the spinal
marrow, and depends on the circulation of vitiated blood in the
vessels  supplying  the nervous  centres.  The  blood-poisoning
consists chiefly in  the retention of urea in the blood, and the
loss of large quantities of its albuminous  portion.  The symp-
toms of albuminuria during parturition are the same as those of
the disease  in the course of  pregnancy, but  the oedema and
general pallor is more marked, and  towards the end of gesta-
tion, the quantity of albumen in the urine is increased.  During
labor, also, and especially during anaemic convulsions,  there is
an excessive amount of  albumen  in  the urine.  As  women
affected with albuminuria frequently pass through labor  without
convulsions, it is believed  by many authorities  that something
akin to fermentation must occur in the blood, loaded with urea,
and other excrementitious matters, and deteriorated by  the loss
of albumen,  before convulsions can occur.  In this fermentation,
the urea is supposed to be transformed into carbonate of am-
monia, and to this  the convulsions  are  attributed as  their im-
mediate cause.  It is found that the breath, sweat, and the blood
itself, reveal the presence of  ammonia.  In the height of the
disease, the urine is generally acid and small in quantity, or en-
tirely suppressed.   Its  specific  gravity ranges from  1010°  to
1030°.   Before the occurrence of convulsions, the reflex sensi-
bility is increased; but during the fits it  is observed to  be
diminished, and the eye may be irritated  without causino- con-
traction of the lid, while other parts of the  body are observed
to lose much of their susceptibility to reflex stimuli and  impres-
sions.  The actions of the  uterus are sluggish, but continue to a
great extent independently of the fits.
  The  Causes of albuminuria have been adverted to when treat-
ing of the disorder as it  occurs in pregnancy.   Pathological
evidence tends to  show that the condition of the kidney which
is present, closely resembles an acute attack of Bright's  disease.
The urine is dark-colored from the presence of blood corpuscles • 
TREATMENT OF UREMIC CONVULSIONS.
621
and, examined by the microscope, cylindrical clots and cylin-
drical masses of epithelium from the tubuli uriniferi are found.
In fatal cases, the structure of the kidney  is discovered to  be
seriously altered from the normal condition by the presence  of
diffuse inflammation leading to degeneration of the  renal struc-
tures.   It is, however,  remarkable, as  separating  this  form
of albuminuria from others of  similar intensity,  that shortly
after  labor, the urine becomes normal, and  in a few days,  or
at most weeks, all traces of  albumen and of renal disease disap-
pear.  It is  remarkable that in some women, the  albuminuria
reappears in successive pregnancies.
   The attack of convulsions is generally preceded by imperfect
vision, sometimes amounting to total blindness, tinnitus aurium,
irregular action of the heart, intense cephalalgia,  and confusion
of intellect.  The phenomena of the convulsions themselves con-
sist of spasmodic jerking movements of all the voluntary  mus-
cles, attended by complete insensibility.  There is trismus  with
protrusion of the tongue, so that this organ is frequently bitten.
Laryngismus  and spasmodic  contraction of  the  muscles  of
respiration, exist to such an extent as to entirely suspend respi-
ration for some seconds  at a time, and  sometimes cause death
from asphyxia. There is great congestion of the neck, face, and
brain, with strong pulsation of the  carotids and lividity of the
surface.  The pulse is sometimes frequent, at others slow. After
the fit passes off, there is a state of torpor, and then conscious-
ness, more or less complete,  generally returns  after the first fits.
In the worst  cases  there is no return  of consciousness, and as
the fits increase in  number, the state  of torpor or coma  be
tween the  convulsions  becomes more continuous  and  pro-
found.
  As regards the Treatment of the form of puerperal convul-
sions depending on uraemia, the latest experience is against ex-
cessive blood-letting, and, indeed, against bleeding at all, except
in the form of a single venesection at the outset of the disease,
in patients of  full habit.  Chloroform  has been found of great
service in moderating the violence of the fits,  and in rendering
operations, such as  the use of the forceps in turning, compara-
tively easy of performance.   It is also believed that a transient
diabetes mellitus is caused by the inhalation of chloroform, and
that this condition neutralizes  to some extent the saturation  of 
622          CHLOROFORM IN  UREMIC CONVULSIONS.

the blood with urea or carbonate of ammonia, and that chloro-
form  has  thus  a curative  effect in  addition  to its  anaesthetic
influence.   The  remaining indication  is to complete the labor,
when the convulsions occur during the course  of parturition, as
early and with  as  little  irritation as possible.  As the rule,
craniotomy should not be performed, on account of convulsions
alone, unless there  be evidence  of  the death  of  the child.
The forceps should  be used when  the head is within  reach, and
the os uteri sufficiently dilated.  It has been  recommended in
those cases where the head is high in  the pelvis, to use  the for-
ceps after Hatin's method—namely, by introducing one  hand
entirely into the vagina while the blades of the forceps  are
being passed up, so as to direct them to the head.   In cases of
rigidity of the os uteri, labor  should be promoted by  the means
used for the induction of premature labor.  No means are pro-
bably superior to the injection of  two or  three quarts of warm
water into the  uterus itself, by passing a tube up  between the
membranes without rupturing  them.   Professor Braun recom-
mends the introduction of a caoutchouc hag into the vagina, and
its distension with  water, as  a  means of dilating the os uteri,
and also advises incision and cauterization of the os.  Incision
should, however, only be practised in cases  in which it would
be necessary if the labor was  not complicated.with convulsions;
and  the author referred  to, gives no sound reason for the em-
ployment of cauterization.  In this country it  is sometimes the
practice to perform craniotomy when the head is low in the
pelvis, to avoid  injury and sloughing of the perinaeum ;  but the
propriety of this may very well be questioned.  It would  be
better to lacerate the perinaeum by the  use of the  forceps, or
even  to incise it if necessary, than to destroy a living child.
When the patient is sensible between the fits, she should drink
copiously of diluent and diuretic  drinks containing  citric, tar-
taric, or benzoic acid. Cold should be applied to the head in the
form of an ice-bag or a cold douche.  Blisters to the nape of the
neck  are useful in preventing cerebral  effusion.  The bowels
should be moved freely with compound jalap powder or purga-
tive injections.   The bladder should be watched, and the urine
drawn off  by the catheter, if  necessary'.  These points of treat-
ment apply  especially to cases in which the convulsions occur
either before or after delivery. 
            EFFECTS OF CONVULSION ON THE  CUILD.         623

  The fatal effects of convulsion upon the child have long been
known.   A large proportion of the children in  such cases are
born dead.   This result is attributed in part to the influence of
tlie continuous contraction of the uterus in such  cases, in inter-
fering with the placental circulation, but  chiefly to the poison-
ous effects of the blood of the mother upon  the child.  It  is
found that children  born  alive  after convulsions are affected
with uraemia or albuminuria,  and  that this condition lasts in
some cases for a considerable time after birth.  Sometimes child-
ren born  alive  under such circumstances  have themselves died
subsequently  of uraemic convulsions.
  This fact of the blood of the foetus in utero becoming diseased
through the  circulation of the mother, and  producing albumi-
nuria in the child, would render  it  probable that uraemia may
sometimes exist primarily as a disease of the blood, and that the
renal  disorder may be a secondary affection.
  It was also known to the older authors that inflammations of
the serous membranes,  as the pleura and peritonaeum, were fre-
quent after convulsions ; and these  affections are no  doubt due
to the poisoned state of the blood, as  is  also the tendency to
mania observed  in  such cases.  Although  the  renal disorder
disappears so soon after the completion of labor, the anaemia,
hydaemia, and general  depravation of the blood which accom-
panies it, remains for months or even years  before it is entirely
removed.  A tonic regimen, with the liberal  administration of
steel,  will best promote recovery.   Care must be taken not to
confound the symptoms of excitement frequently  attending this
form of debility, with inflammatory disorder. 
LECTURE  XLII.
                     PUERPERAL FEVER.

  About three thousand mothers die in childbed, annually, in
England and Wales.  This is an average of nearly eight deaths
every day from this cause.  The proportion of maternal deaths
to the births, registered in several  years, was found to be 1 in
171.  This mortality, it must be remembered,  occurs  for  the
most part to women in the prime of life, and previously in  the
enjoyment of full and vigorous health.  Amongst the causes of
death during the puerperal period, the disease we are now con-
sidering  is, of all others, the most  important  and fatal.   The
fatality from  child-bed fever is, however, in  the present day,
moderate, when compared with the  epidemics  of former times,
in which, of those  attacked,  positively none recovered;  but
though it is  still little amenable to treatment, when it exists,
there is reason to hope that Preventive Medicine may hereafter
almost, if not entirely, eradicate this formidable disease.
  The histories of  puerperal epidemics  and  outbreaks  show
great diversity in the symptoms and progress of the disorder at
different times.  This disease evidently varies with the constitu-
tion of disease at the time it prevails, being at one time intensely
inflammatory, at another time putrid,  in its form.  In some sea-
sons and places the liver, in others the peritonaeum, in others the
uterus, in others the intestinal canal,  have been attacked ; and
in some of the worst examples, pathology has found no  other
change after death than fluidity and altered color of  the blood.
It may be said, in fact, upon a review of the numerous descrip-
tions of puerperal fever, that there is hardly a  form  of fever or
inflammatory disease which it does not, to some extent, resemble
in character.   The great diversities witnessed in this disease have
led modern observers to assert that  under the term " puerperal
fever " many different and separate  diseases had been described,
   624 
A DISTINCT  PUERPERAL POISON.
625
such as phlebitis, peritonitis, hysterics, enteritis, typhus fever,
remittent fever, erysipelas, toxaemia, and other forms of disease.
The tendency has been, in modern times, to dwell upon the spe-
cial manifestation of the disease, and  to consider  that  all the
various phases of the disease depend on some local disorder, or
upon  some specific combination  of morbid  phenomena.  One
after  another, various  morbid conditions have been thought to
form the chief part of the disease.   At the present day, the doc-
trine  of  uterine phlebitis  may be said to hold this kind  of
preeminence, and there is a general tendency to consider that all
the local and constitutional symptoms and pathological changes
arise  from this source.
  The more puerperal fever  is investigated  and tracked, as it
were, to its elements  or origin, the less satisfactory does any
partial or local explanation of  its nature become.   In the pro-
gress  of such examination, it appears  more and more evident
that there is a puerperal poison to which the lying-in woman is
liable, and which produces all the varied phenomena of puerpe-
ral  fever met with in different epidemics, localities, seasons, and
constitutions.  In one time or person, peritonitis is produced ; in
another, metritis ; in another, phlebitis;  in another, mammary
or other abscesses ;  in  another,  low fever; in another, intestinal
irritation ; in another,  dissolution of the blood,  without a trace
of local inflammatory disorder; and so on throughout the list of
local  or special disorders which have been described by authors
in puerperal fever.   It may be questioned, even, if phlebitis ever
occurs without a poisoned condition of the blood, produced either
as the result of contagion, epidemic influence, or the absorption
of putrid matter from the uterus.
  Thus, in the earliest pathological  arrangements, a great num-
ber of disordered  states were  grouped  together as Puerpe-
ral Fever, without attempt at  discrimination or analysis ;  next
came a laborious separation of  the different forms and manifes-
tations of the disease ;  and the subject seems at the present time
ripe for allying the numerous affections  met with in  puerperal
fever  together, in their origin from a common  cause—namely,
some  Animal Poison, or Zymotic Influence.
   Of the  occasional  Sporadic  appearance  of  Puerperal
Fever, and its  allied disorders, there can be no doubt.   In all
seasons, taking large communities, or large areas, isolated cases
                             40 
(526           SPORADIC VERSUS EPIDEMIC FEVER.

are met with in different localities, and in the practices of differ-
ent medical men, -where single patients are attacked, and where
the disorder is not so severe as to extend itself by contagion or
infection.   In these  cases, when  the poisonous element  is pro-
duced by the patient attacked, it probably originates from  the
state of the blood incidental to  delivery, or depends upon  the
absorption  of irritating or putrid lochial discharges, decomposed
coagula, or portions  of retained placenta.   A  single case pro-
duced in this wa}7, may become  contagious, and cause the  dis-
ease in other patients, through the medium  of nurses or atten-
dants.   It seems to be clearly made out, that in cases of this kind,
and, indeed,  in  all  cases in which  contagion or infection is
concerned in the propagation of puerperal disease, the risk of
the spread  of  the  disorder  is greater in proportion to  the
adynamic type of the cases which first  occur.   In inflammatory
cases, the  risk of the  communication  of  the disease  is  less
than in  the purer forms of fever.   The most convincing proof
of the sporadic origin of some cases of puerperal fever  is found
in those instances in  which single cases occur, and no other cases
happen  either  in  the  neighborhood  or at  about  the  same
time.
   As distinct from the  sporadic appearance of puerperal disease,
we have Epidemic  Puerperal Fever,  or puerperal inflamma-
tion, in  which the disease, in its various  complications, rages in
certain hospitals or districts, being very dangerous at the onset,
attacking the patients of different medical men simultaneously,
prevailing  for a  certain time, and then becoming weaker  and
more manageable in type, until  it  at  length disappears alto-
gether.  Epidemics  of puerperal fever originate in the crowding
of puerperal women  together ; and in  the epidemic prevalence
of erysipelas, hospital fever, typhus,  or other disorders allied in
their nature to the puerperal disease.   In epidemics of this as
well as  other disorders, it is  exceedingly difficult in any given
case to prove whether it arises  from  epidemic  or  contagious
influence.  The best proof we have of the existence of puerperal
fever in an  epidemic  form, is drawn  from those examples in
which  the disease  appears  in certain  towns  or districts  and
affects the  patients of all the medical men alike, but is certainly
not confined to the  practice of  one  or  two accoucheurs.  It is
observed that when puerperal fever prevails epidemically in the 
            CONTAGIOUSNESS OF PUERPERAL FEVER.         627

human subject, the lower animals die in large  numbers of dis-
eases connected with parturition.
  Besides the sporadic and epidemic appearance of this disease,
we have, in my opinion, evidence as  irrefragable as that which
can be advanced in the case of any other malady whatever, that
it sometimes rages as the result of Contagion  and Infection.
Those who deny the influence of contagion, magnify the facts
relating to the sporadic and epidemic  prevalence of this dis-
order, and seek to apply them  to the universal explanation of
cases  in  which contagiousness  appears  most manifest.   It  is
natural, observes Dr. Farr, for any man to shrink with horror
from the supposition that he has communicated so fatal a disease
to his patients, and to be disposed to receive any other explana-
tion than  that which refers  it to contagion.  Nevertheless, the
interests of truth and humanity demand that the evidence of the
contagiousness of puerperal  fever should be put prominently
forward.
  The  following are examples  of the kind of  evidence which
exists in proof of the contagiousness of  puerperal fever, and it
may be necessary to state that facts of a similar  kind to  those
now advanced might be multiplied to almost  any extent:
  A practitioner, for instance, had  been attending cases of
typhus fever.   Within the space of four days he delivered five
women.   All these  women were attacked with puerperal fever,
and all of them died.   This was in a country practice, and the
cases were remote from each other.  Different practices inter-
sected the practice of this medical man at various points, but no
other cases were known to have occurred in  the neighborhood.
Again, a patient suffering from typhus fever was admitted into
a lying-in hospital,  where she remained for a few hours  only.
In the beds on the right hand and the left of this patient were
two lying-in women; both  were attacked almost immediately
with puerperal fever, and  both died.  Take another case :  a
medical man was in constant attendance upon  a patient suffer-
ing from gangrenous erysipelas, and between  the 8th of January
and the 22d of March he attended the labors  of ten women; all
had puerperal fever, and eight of the patients died.  This was
in a town of  moderate size, and no other patients in the  place
were known to have had puerperal fever.  In another recorded
instance, two medical men, brothers  and partners, attended  in 
628
CONTAGION UNQUESTIONABLE.
 the space of five months twenty cases of midwifery.  Of these,
 fourteen were affected with puerperal fever, a fatal result ensu-
 ing in eight cases.  The only other known death from puerperal
 fever, in the same town, within the period named, occurred in
 the case of a patient attended by a medical man who had assisted
 at the post-mortem of one of the  puerperal  patients.  During
 this  disastrous period, the two brothers relinquished all their
 midwifery engagements for  one month, in which time five of
 their cases were attended by other practitioners, and no instance
 of fever occurred  in  the course of that month.  They then re-
 turned, and  several fatal cases again happened.  It is difficult
 to imagine anything more conclusive as regards  the doctrine of
 contagion.  A  curious history in point is related by Dr. Ingleby.
 Two  practitioners  attended a post-mortem where  the  patient
 died from this disease.   One was summoned in one direction to
 a midwifery patient, who was attacked with  puerperal fever;
 the other attended two cases in succession, both of  whom were
 seized with  the same disease.  Dr. Robertson relates perhaps
 one of the most cogent  instances of contagion and fatality on
 record.  In the space of one  calendar month, a certain midwife
 attended twenty cases belongiug to a lying-in  charity ; of these,
 sixteen had puerperal fever and all died.  The other  midwives
 of the same charity, working in the same districts, attended in
 the same time  380  cases, none of whom were affected with puer-
 peral fever.    In a large town containing many thousands  of
 inhabitants,  and numerous medical men,  fifty-three cases of
 puerperal fever occurred.   Of these, no less tfyan forty hap-
 pened in the practice  of one medical man and his assistant.
  In the face of such  facts as these, it does not become us to
 hesitate, or  give out  an uncertain sound respecting the con-
 tagiousness of  puerperal fever.   It is better to know the worst,
 fear the worst, and guard against the  worst, than to harbor un-
 decided opinions.   I have known several instances where medi-
 cal men, believing in the non-contagiousness of  the disease, or
 hesitating between the two  opinions,  had gone on attending
patient after patient with fatal results, until convinced of the
 mistake they had fallen  into  by successive deaths.  No doubt
sporadic and epidemic  seizures are  sometimes mixed up with
those of a contagious origin, in such a manner as to require
 much clearsightedness to penetrate the confusion ; but the facts 
CONTAGION VERSUS DR. MEIGS.
629
of contagion are, as it appears to me, placed beyond all ques-
tion,  and should  never  be lost  sight  of by practical  accou-
cheurs.
  Those who  oppose the view of the contagious nature  of  the
puerperal fever, argue that the cases which seem most conclu-
sively to demonstrate the communicability of the disease from
one  patient to  another  by the  attendants,  really  depend on
epidemic influences.  They point  also to the occasional sporadic
appearance of single cases in different parts of the same  city or
district, in the practice of different medical men.   It  is  also
insisted upon that  in some cases  lying-in women have been  ex-
posed to the influence of  surgical fever, or have been present in
wards containing patients ill of peritonitis, without  contracting
puerperal fever.   The very intensity of the contagious principle
has been used as  an argument against the existence of  conta-
gion.  It has  been  said—How  could any  poison  cling to an
accoucheur for several weeks, as in those instances where medi-
cal men meeting with puerperal  cases have relinquished prac-
tice for awhile, but on returning have brought the disease back
with them?  Great stress has  been laid upon personal experi-
ence, as in the case of  Dr. Meigs, who attended as the consult-
ing physician upon numerous cases in an outbreak of the disease
which occurred to another practitioner,  but Dr. Meigs himself
never took the disease to  any of his own patients. It appears to
me that these difficulties are  much more easy of explanation
than the difficulties attending  those  cases in  which contagion
seems to be most convincingly proved.   Some persons may be
more liable to convey infection than others, just as one individ-
ual is more prone to infection than another.   At  certain  times,
from reasons which we cannot understand, but which we know
must exist, the human organism is in such a state that exposure
to infection  and  contagion does not affect it.   Perhaps one of
the strongest  arguments  in favor of  infection or contagion is
drawn from  the  preventive treatment of the disease.  All the
great reductions  in the mortality have arisen from measures cal-
culated to remove infection and contagion.  In the course of a
few years the mortality in the  great hospital of Vienna was re-
duced from  1  in 10 to 1  in 74  of  the  mothers  delivered, by the
precautions  taken  to prevent  the inoculation and infection of
lying-in women.  In this country the disease is much less form id- 
IDENTITY  OF VARIOUS PUERPERAL DISEASES.
able than it formerly was—a circumstance which  is greatly
owing to the care taken in preventing the spread of the disease
by contagion and infection.
  It is further necessary to insist upon the fact,  that the con-
tagious principle in the case of puerperal fever, is not limited to
the transmission  of puerperal fever, nor to the communication of
infection from  one puerperal patient to another, either directly to
the lying-in  woman or by attendants or nurses, but  that it may
be  conveyed in the  shape  of  several other Animal Poisons.
One of the most remarkable points connected with the puerpe-
ral  poison is the fact, that  setting aside  its sporadic and epi-
demic appearances, it may,  in the first instance, originate from
a variety of causes external to the patient herself.    When once
produced in this manner in single cases, it may be  propagated
amongst puerperal women by infection and contagion. ^ The  ex-
posure of puerperal patients to the influence of Hospital Gan-
grene will  produce  the disease.   Medical men in attendance
upon cases  of Erysipelas  have given  their patients puerperal
fever.   It  has been made out very conclusively by Semelweiss
and others, that  the  miasms derived from the Dissecting-room
will excite puerperal disease. Exposure of the puerperal woman
to the poison of Scarlatina will give rise to puerperal disease in
patients proof against the reception of scarlet fever itself.   The
mortality amongst child-bed women  seized with Small-pox is
well known, and such patients  die with the symptoms of puer-
peral disease, in addition  to the variola.   With respect  to  the
disorders named, and probably others also, such as  putrid sore-
throat and sloughs or abscesses, some law evidently exists by
which they may all be respectively converted into the puerperal
poison.   In some cases, puerperal fever  and  erysipelas have
been observed together  at  the same time,  and in  the same
patient.
   A curious circumstance connected  with the  poison of puer-
peral fever  is, that it may be communicated in other forms to
the nurses, or attendants, and even  to males.   The husbands
of puerperal women may be attacked by sore-throat, erysipelas,
or  typhus fever.  Within  the  last few years an accomplished
physician-accoucheur of this metropolis  was cut off suddenly
by putrid fever, after examining a woman suffering from puer-
peral disease.   In some of  the  cases where the  same medical 
PUERPERAL  POISON IN THE BREATH.
631
man has lost numerous cases  in succession, as many men and
women have died from fever or erysipelas, as those  who have
perished from the puerperal disease.   Thus, we have evidence
that erysipelas, gangrene, fever, etc., in males, or unimpregnated
women, may produce child-bed fever, and we have the converse
proof that this fever may excite other dangerous disorders, as
the result of contagion, in non-puerperal persons.
  How is this  subtle poison conveyed from person to person?
In what media of communication can it lurk ?  Through what
chanuels can it reach the puerperal woman ?   The clothes, hair,
and touch of the person exposed to the poisonous influence have
been supposed to be the chief means of infection and contagion ;
but very remarkable cases are on record, such, for instances, as
when the accoucheur has shaved his head, changed  the whole
of his clothes,  cleaned himself by hot baths and vapor baths,
and soaked his hands in disinfecting  solutions, and yet  he has
taken the malady about with him.  I believe that in such cases
the blood of the person acting as the medium of infection is
affected, and that  by the breath a certain halitus  or  infectious
influence is given out, which acts upon the blood of the puerpe-
ral woman through her  lungs, and  thus conveys to her system
the germs of the disease.  As this point has a practical bearing
of  some importance, I desire in this place to make a few obser-
vations which may explain the position I have assumed.
   If  we attend a post-mortem when the smell is peculiar, if we
spend some time in a lying-in room where the odor of the lochia
 is very strong, or if we  go into any very powerful  smell, the
 taint evidently enters the body by means of the lungs, and can
 be perceived subjectively by the taste or smell, or its odor can
be distinctly  perceived  in  the saliva, in  eructations from the
stomach,  or in the  urinary, cutaneous, and  other  secretions.
Although the party thus affected may have been exposed to the
miasma or  smell but for a short time, his blood gives evidence
of  infection for many hours, or in  some cases for several days
afterwards.   Some habits are more prone  to  receive and retain
this kind of infection than others.  It remains  so long in some
 cases  that the  odor would seem to have a power of sustentation
 or  reproduction, otherwise it is difficult to suppose that an odor
 to  which the lungs have been  exposed, it may be for a few min-
 utes, can infect the blood and all the secretions for twenty-four 
632
DIFFUSION OF ANIMAL POISONS.
 or forty-eight hours.   If we can trace in this way the influence
 of a bad odor, surely we may admit that  the  same thing may
 happen with reference to the wonderfully  subtle poison or germ
 in puerperal fever, or those influences which are evidently con-
 vertible into the puerperal poison, and manifest similar results
 in the lying-in woman. I  believe that the blood of the accou-
 cheur may take up a dose of puerperal poison without manifest-
 ing  any special results in his own system, and  that he may
 communicate it  through the medium of the lungs to his patient.
 In the case of a poison so  subtle, the air  we breathe unites the
 circulations of the accoucheur and patient, and renders them, as
 it were, one.  This is probably one great mode in which animal
 poisons generally are  diffused.   We know that the blood  of
 persons attending patients in scarlatina, measles, and small-pox
 is infected, although they are proof against the disease ; and in
 one remarkable  instance we have the positive  proof that the
 blood is the medium  of infection.   I refer to cases  in which
 pregnant women who have had small pox  in childhood, and are
 proof against infection, but who, on being exposed to the poison,
 convey the disease to the foetus in utero.  Here the blood of the
 mother must be the medium of communication  between the
 patient suffering from small-pox  and the ovum  hidden in the
 womb, and the  lungs of the mother must be the channel  by
 which the  poison enters the circulation.  This illustrates very
 well what I mean by saying that the blood of the accoucheur,
 or attendants, is  one great medium which conveys the poison of
 puerperal fever.   The saturation of the blood of the accoucheur,
 nurse, or midwife, may remain for a considerable  time; for cases
 are   on record in which every case attended by certain  indi-
 viduals for weeks or months has been affected  by the diaease.
 A practical  point deducible from these remarks is, that  in at-
 tending lying-in  patients,  after  the  slightest exposure to  the
 puerperal poison, or  to any miasma which can be converted into
 this poison, or its equivalent, in the lying-in woman, we should
 be especially careful not to go so near as  to establish any com-
 munication between the lungs of  the practitioner and patient.
 In saying this, I  do not mean that other means of conveying the
poison, as  by clothes, hair,  and the  surface of the body, should
not also be guarded against.
  The fiercest outbreaks of this  disorder have occurred  in 
                LYING-IN HOSPITALS  IMPOLITIC.             633

lying-in hospitals, or in hospitals where lying-in  women  are
received with surgical  and medical cases, and where erysip-
elas, gangrene, or fever  have prevailed.   On this account many
have doubted whether  lying-in  hospitals are not mischievous
rather than otherwise, in the present limited state of our know-
ledge of the means of preventing puerperal fever.  Women con-
fined even in misery and squalor  in  their own homes  are less
liable to this disease  than patients collected together in hospitals,
even  when the  greatest care as regards  cleanliness  and ven-
tilation  is observed.  All lying-in women should, as far as pos-
sible, be  removed from the neighborhood of any  contagious
epidemic or  infectious  disease.    It should be a  rule of the
practical accoucheur to  have as little as possible to do with any
of the animal poisons which give  rise to puerperal fever.   He
should avoid autopsies, especially in  cases of death from child-
bed fever, or ordinary inflammation.  The student should not
attend midwifery cases while he is dissecting.   After an attend-
ance upon any suspicious case, the practitioner should change
his clothes, or have  them hung up in a room exposed to  the
fumes of chlorine ; I have no doubt  it would be useful for him
to inhale the  diluted fumes  of chlorine several times a day, and
after touching anything connected with  any source of danger,
to rinse his hands in a solution of chloride of lime or chloride
of zinc.  It is impossible to be too scrupulous, in  a matter of
such moment, and  I have known some accoucheurs  who, on
entering a lying-in room,  always  wash  their hands  before
making an examination.
   In the next lecture I  propose to consider the special charac-
ters  of  puerperal  fever in  its  various  manifestations, and  the
rules of treatment. 
LECTURE  XLIII.
                     PUERPERAL FEVER.

  Gentlemen :—In the last Lecture I stated briefly the evidence
and facts which favor the view that all the different forms and
manifestations of puerperal  fever depend on a specific poison,
arising  in  some  instances sporadically ;  in  others  prevailing
epidemically; sometimes due to the zymotic  influence  present
in erysipelas, typhus, gangrene, surgical fever, and  some  other
diseases ; communicable from patient to patient  by the attend-
ants ; and whose  earliest known effect is a disordered  state of
the blood of the child-bed woman.  I now proceed  to  describe
the different secondary disorders traceable to the puerperal poi-
son.
  In the Adynamic form of Puerperal Fever, the effects of
the poison  are seen in their most terrible and virulent form.
This type of the  puerperal  disease has prevailed in the  most
ravaging epidemics, and also in those  outbreaks in which the
contagious  spread of the disorder has been most  demonstrable.
Occasionally, patients have  been  struck by the  disease during
the course of labor, or within a few hours after  parturition. In
other cases, two or three days have elapsed before the  invasion
of the. disease.   In the worst  cases, patients become  at  once
delirious or lethargic, the  pulse being very rapid, from 120
to 140 in the minute, and feeble.  Occasionally, acute  pain  is
complained of, but more frequently there is in  the  worst  cases
little suffering beyond a feeling of  indescribable anxiety and
depression; sickness and vomiting of coffee-ground matter some-
times distresses  the patient.   The countenance is  commonly
sunken and dusky, or deeply pallid, with the dark circle round
the eyes strongly marked.  Tlie skin is not above the usual tem-
perature, but covered with  clammy perspiration.   Tympanitic
distension  of the abdomen  rapidly  supervenes.    Rigors  or
   634 
SYMPTOMS OF  PUERPERAL FEVER.
635
shiverings  may or may not be present.   There is  little or no
sign of reaction, and in the worst cases  the patients die in a
state of collapse within a short time from the first seizure. Of 88
cases recorded by Dr. Collins, death occurred in 2  cases in 24
hours, in 1  in 27 hours, in 1 in 36 hours ; 9 died  on  the second
day, and 15 on the third, so that 24 perished in less  than 72
hours.  Dr. Ramsbotham states, in the worst cases this disease is
more rapidly fatal than any other disease met with in this coun-
try, except cholera.  Mr.  Iley mentions a case in which death
followed  in less than eighteen hours.
  When, from the less  virulent action  of the  poison, or  the
strength  of the patient, the disease is more protracted, the  same
symptoms are present, but in a  milder  form and degree.   The
invasion  of the disease generally begins on the second  or  third
day, and is commonly ushered in by shivering.   There is in the
earlier stages  increased  heat of skin.    The tongue  is  some-
times coated, at others red ; but as happens with every variety
of puerperal fever, cases are sometimes met with in  which from
the  commencement  to  the termination, the tongue  remains
tolerably clean.   The prostration is less profound, and there is
pain in the abdomen.  Profuse  sweating is a very common and
distressing  accompaniment of the disorder.  In some cases this
is so strongly marked, and constitutes so large a part of the dis-
ease, that Dr. Blundell described it as  a distinct form  of  puer-
peral fever, under the name of Hydrosis.  The  sweat  and  the
breath are  very often accompanied by a sweetish pus-like  odor.
The sweating of puerperal fever does not diminish the secretion
of urine, nor  does it abate the  quickness  of the pulse.    An
intolerable  thirst prevails, and  the patient, drinks immense
quantities of whatever fluid she may be allowed.   Dark  spots
or ecchymoses appear upon the wrists or other parts  of the body.
After two or three days, profuse diarrhoea occurs,  but though
it often appears to be critical iu its nature, it brings  little or no
relief, and the patient is harassed by  frequent  dejections and
vomiting.  The  lochia  are commonly but  not  invariably sup-
pressed.  More frequently, the  breasts  become flaccid and with-
out secretion ; but this  is  not  always  the  case. The pain is
often intermittent, even  in cases where  it is most severe, some-
times giving the attendants and the medical practitioner the hope
that it may be of the nature of after-pain.  In  some  of  these 
G36         MORBID CHANGES  BY TUERPERAL FEVER.

cases the mind is remarkably clear, until towards the termina-
tion  of the disorder.  One of the most constant and distressing
symptoms is tympanitis.   This comes on more rapidly, the more
acute the disease may be,  and soon rises to such a height  as  to
interfere with the action  of the diaphragm and heart.   The
patient may in a few hours become larger than she was before
delivery.  Considerable quantities of flatus may be  discharged,
but no diminution of size is perceptible, the distension appear-
ing to depend on an immense secretion  of air by the mucous
membrane, with paralysis  of  the muscular coat.  In the course
of the disease, obscure  symptoms of uterine inflammation with
enlargement  of the organ, or of peritonitis, pleuritis, or pneu-
monia, are met with.   When the disease proceeds to a fatal ter-
mination, the patient succumbs to exhaustion, the  action of the
heart becoming more frequent and feeble, congestion of the lungs
or effusion into the pleural  or pericardial cavities takes place, and
low delirium or coma is present for sometime before dissolution.
In the rare cases, which terminate favorably, the sweating purg-
ing, or diuresis,  appears to relieve the  patient, and  she slowly
recovers from a state  of great debility, remaining  long  after-
wards in a condition of extreme debility both of mind and body.
In comparatively rare cases, the  chief symptoms of  the  disease
are gastric, bilious,  and enteritic irritation, but these are amongst
the more favorable forms of puerperal disease.
  The  morbid changes met with after death are very various.
In the  most rapidly fatal cases, nothing  has  been met with
beyond non-coagulability,  thinness, and blackness of the blood.
The  blood in these  cases  resembles that of persons killed  by
lightning or hydrocyanic  acid.  There may be no  signs what-
ever of any local inflammation, or disease of the uterus or other
organs.  In the less virulent and more protracted cases, puru-
lent infection of the blood has been detected, and pus has been
found in the veins, and other structures of the uterus.  Conges-
tion of the lungs, gangrenous abcess of their organs,  or effusions
of mixed pus, serum, and  lymph into the pleurae,  have  been
observed.   In some cases, spots  of ulceration  in the stomach
and intestines, or purulent collections in the liver  and kidneys,
are recorded.  Abscesses in the omentum have  been frequently
found,  so have effusions of sanious pus and feebly organized
lymph in  the peritonaeal  cavity, particularly about the uterus 
           CLARK ON LESION IN PUERPERAL FEVER.         637

and its appendages.  The internal surface of the uterus and the
muscular structure have been found  softened and in a state ap-
proaching to gangrene, particularly the posterior part of the organ.
  [In the discussions of the New York Academy of Medicine,
in the spring  of 1857, Professor Alonzo ClaiTc, in denying that
puerperal fever is a fever without  lesion, demonstrated that  at
the extremity of the uterine sinuses are two valves, lapping one
over the other, like  the ileo-caecal valve,  and around each  of
these valves runs a layer of muscular tissue, a part  of the mus-
cular tissue of the uterus.   When the uterus is flaccid or large,
these valves are open; but when it is contracted or reduced  in
size, the  muscular fibre running  through  these valves draws
them together, and thus closing the  sinus, arrests any haemor-
rhage.  In the cases of simple fever  so  called, there is inflam-
mation of these uterine sinuses,  an  exudation lines  the interior
surface of the uterus, which the microscope evinces to  be pus
mingled  with blood,  and  corpuscles ready to be formed  into
fibres.   Cruveilhier calls it " vascular and spongy  vegetation."
But, says  Dr. O, I have examined  it  and find it  to be fibre
formation, and  it is  endo-metritis.   Now I think that this soft,
creamy, brick-dust colored exudation is  to be found in every
case where death has occurred  as  supposed without inflamma-
tion.  Behind the valves in the sinuses, there  is  an ampulla,
a little  sack-like cavity, where, in  these  cases, pus may  be
always found.  There is also pus in the veins of the liver coex-
istent—little greyish spots, easily overlooked, which the  micro-
scope plainly determines to be  pus.]
  It has been mentioned that sporadic  cases of puerperal dis-
ease are sometimes caused by the absorption of sanious lochial
discharges, or  the decomposition of  coagula or  portions  of
retained placenta within  the uterus.  There is also another mode
in which sporadic puerperal fever may occur.   There is some
peculiarity about the state of constitution which obtains  in
pregnancy and parturition, tending to  assimilate  numerous
other affections to the puerperal type.  It may be seen, that  in
the case of a  healthy pregnant  woman attacked with small-pox
or scarlatina, before abortion or premature labor is  produced,
the disease begins to assume the puerperal type.  At any other
time than after parturition, the  presence of  putrid matter in the
uterus does not excite  any great constitutional disturbance,  as 
638    FEVER EXCITED BY INJURIES FROM IXaTRUMKNTd.

witnessed in the case of polypi removed  by ligature.  Any
inflammation of the os or cervix excited by a difficult labor, or
peritonitis caused  in'the first instance  by the violent contrac-
tions of the uterus, has a strong tendency to run into puerperal
fever.
  [I am obliged to enter  my dissent to this assertion, inasmuch
as I have never seen puerperal fever, in but a solitary  case,
where I have operated, and in that with  forceps, and then the
woman had  tumidity and tenderness of the  abdomen for  some
hours before I  saw her.  Even in  those cases where I  have
divided the os and  cervix, not the least symptom of puerperal
fever in any of its  phases was evident. Vide page 528.]
  After the  Caesarian section the patient suffers from an almost
exact likeness of puerperal fever.  Dr. Simpson very ably draws
a comparison between puerperal and surgical inflammations and
fevers, and refers this similarity to the resemblance which exists
between the  uterus after labor  and  a wound after  a surgical
operation.  No doubt this is true to a great extent, particularly
as regards the  occurrence of phlebitis.  But there  is in the
pregnant  and parturient woman a state  of constitution which
predisposes her to the formation of some virus or poison,  capa-
ble of producing the puerperal  type  even before  delivery, or
even before  the commencement of labor.  This is the case after
mechanical  injuries of the gravid uterus.  It is  observed in
cases of peritonitis, pleuritis, or any other visceral inflammation
occurring  during   pregnancy.  Before  the  uterus  has  been
excited to expel its contents, there is an approach to the peculiar
puerperal type of disease.  If a gravid woman be attacked with
erysipelas, she suffers from the symptoms  of puerperal fever or
inflammation before the birth of the child, and the infant  may,
when born, be affected with erysipelas, and die within a few hours
after birth.   Thus, then,  it seems capable  of demonstration that,
apart from the state of the internal surface of the  uterus after
parturition,  and especially that part  of it from which  the pla-
centa has been separated, there is in the habit and constitution
of the gravid woman, some peculiarity which, under numerous
circumstances, produces  the virus or  poison which  gives  their
characteristics to the multiform varieties of puerperal inflamma-
tory and febrile disease.  Amongst the predisposing causes  of
puerperal fever in  any of its forms, anxiety of mind and depress- 
PERITONITIS, PUERPERAL FEVER.
639
ing emotions during pregnancy or at the time  of labor hold  a
very prominent  place.  This is strongly insisted  on by Dr.
Fleetwood Churchill and  many other writers.  Undoubtedly
this cause is a  main  agent in the production of some of the
sporadic cases  of this disease.  Dr. Churchill observes, "Sev-
eral of the worst cases I have seen were mainly attributable to
this cause."
  In many  cases of puerperal fever, Peritonitis ot a more or
less acute form, constitutes the  chief part of the disease.   In
some  epidemics,  inflammation of the peritoneum has been so
universal as to give rise to the opinion that peritonitis formed the
essence of puerperal fever, and puerperal peritonitis and puer-
peral fever came to be used as almost synonymous terms.   This
was very much the state of medical opinion up to the time when
Guthrie, Bouillard and Dr. David Davis initiated the doctrine of
phlebitis and purulent infection of the blood, so ably and labori-
ously worked out by Dr. Robert Lee.   Recent outbreaks of the
disease  have not manifested the peritonitic type so strongly as
previous epidemics, but cases not unfrequently occur,  in which
the peritonaeal  disorder is  the chief local manifestation of dis-
ease.
  In puerperal peritonitis or puerperal fever with peritoneal
inflammation, the disease  usually  commences within two  or
three days  after parturition, and  seldom longer than a week
after labor.   Cases are on record, in which it has Commenced
before the beginning of labor, or during the course of parturi-
tion.   I have already referred to the influence of  contagion and
infection in producing this form of disease.  Patients with easy
labors, and  without a sign of inflammatory disorder may have
puerperal peritonitis as the result of  contagion  or infection,
when exposed  to erysipelas, gangrene, or  any of the  disorders
mentioned in connection with the production of puerperal fever.
It may also arise  from injury  of the  peritoneum during  the
course of  violent labors,  or from exposure  to  cold.   When
caused  in these modes, it is almost universally converted into
the febrile puerperal type.   In some cases it is an extension of
disease from the parietes or internal surface of the uterus, and in
others  it  is a  result of uterine  phlebitis.   The disease  may
involve the whole peritoneal membrane, or it may be localized
in the neighborhood of the uterus, Fallopian tubes, and ovaria. 
610
PULSE IN PUERPERAL FEV1R.
  The symptoms of puerperal peritonitis are generally  in
stronger  relief than the symptoms of any other  form of puer-
peral fever.   Tenderness, pain,  and exquisite sensibility of the
abdomen to  the touch, particularly in the  neighborhood of the
uterus, is generally  observed.   Yet pain is not  always present.
On the contrary, it is entirely wanting in  some of the most
rapidly fatal cases,  and where  post-mortem examinations have
proved peritonitis to exist.   Dr. Ferguson found that out of 173
cases, this symptom was absent in 19.  The pulse is invariably
rapid, remaining throughout the  course of the  disease at from
120 to 110.   This is the symptom  which  in every variety of
puerperal fever never  fails of expressing truly  the condition of
danger.   It  has often  been remarked, that whatever the other
indications may be,  the puerperal woman is never safe whose
pulse rises steadily  above  100.  In  puerperal peritonitis,  the
pulse is quick from  the termination  of labor, and  it has been
observed that where the disease is threatened, the subsidence of
the circulation which is natural after labor does not take  place.
This  rising of the pulse is  the  earliest symptom  of peritoneal
inflammation.  Before the commencement of pain,  rigor or
shivering  almost  invariably occurs.   Sometimes it  does  not
amount to more than a prolonged  creeping over  the surface of
the body; at  others,  it is so  marked  that  the  teeth chatter,
and the patient asks to be held in bed, so violent is the muscu-
lar shuddering.  While the rigor is most distressing, the surface
of the body  is little  if  at all below the  natural standard.  The
state  of  the tongue is variable—sometimes red at the edges,
with a white streak in  the centre, at others coated  or red, and
sometimes without  much decided alteration from  the natural
state.  When the other tissues  of the uterus are  involved, this
organ is swollen, and can be felt distinctly and painfully, until
the rising tympanitis disguises it.  There are  cases in which the
uterus attains a very large size, after ha.ving  contracted  subse-
quent to labor. The tympanitic distension which  ensues is often
very great, and the  swelling of the abdomen is further increased
by eftusion of sero-pus  into the cavity of the peritoneum, when
the surface acquires a peculiar doughy or boggy feel.   Sickness
is very constantly present in this disease, and adds greatly to the
suffering of  the patient, from the compression of  the  abdomen
by the efforts at vomiting.   Dysuria is complained of, and the 
              SUPPURATION  IN PUERPERAL FEVER.          Gil

urine is scanty and high-colored.   As  the  disease progresses.
purging commonly supervenes, the motions becoming dark and
offensive towards the last.   Throughout,  the  breathing  is short
and painful, and cephalalgia is often present.   Beyond  this, the
brain  is  frequently unaffected until  the  close of  the disease
approaches.  The physiognomy is from the first distressing and
pinched, so as to be almost of itself characteristic  of  the dis-
ease.   No one who has ever seen the disease can mistake the
indications  afforded by the countenance and  the pulse.  The
dark areola surrounding the eyes, the dilated  pupil, the glassy
surface and bloodless conjunctiva, give a lustrous and unearthly
appearance to the eyes in all cases of puerperal fever, whatever
the special complication,  when the disease is  fully  formed.
Occasionally in this disease there is an appearance of the sud-
den transferrence of disease to the pleura, and, more rarely, to
the serous membranes of   the brain.    When the peritoneal
inflammation is chiefly limited to the uterus and its appendages,
the symptoms are somewhat less severe, ani the pain more local,
than in  general peritonitis, being felt most distinctly in the iliac
regions, and sometimes on one side  only.   With the local peri-
tonitis,  there is generally inflammation of the  broad ligaments,
the sub-peritoneal  cellular  tissue, the Fallopian tubes,  and  the
ovaria.    Suppuration  and  abscesses sometimes  form  in these
structures, and in the most favorable cases either burst spontane-
ously on  the  surface of the lower part of the  abdomen or into
the vagina or rectum, or they sometimes  admit of  puncture and
artificial evacuation.   A fatal result is almost  invariable when
pus is formed in any considerable quantity upon the peritonaeal
surface.
  The  pathological  changes consist of effusions  of pus or of
lymph,  rarely so highly organized  as after ordinary peritonitis,
sero-purulent effusions  and  abscesses of the surface of the uterus
or its appendages,  or  of the omentum.   In  many cases,  the
uterus  is found diseased,  the   inflammatory  disorder   having
extended from the uterus to the  peritoneum, or, in some cases,
from the peritoneum to  the  uterus.   Softening of the parietes,
patches of gangrene, abscesses in the walls,  and collections of
pus in the veins of the uterus, are met with.
  One of the greatest, if not the greatest,  advances ever made
in the pathology of puerperal  fever consists  in the  knowledge
                             41 
642
SYMPTOMS OF UTERINE  PHLEBITIS.
we  have obtained, in recent years, of the existence of Uterine
Phlebitis  as a very common and destructive form of puerperal
disease.  The  occurrence of uterine phlebitis and suppuration
of the veins in  isolated  cases had  long been  known,  but no
other inquiries, as far as  I am aware, have at all equalled  the
researches of Dr. Robert Lee in this particular department, and
it is  to his extended investigations that we chiefly owe  the
establishment  of the  doctrineof uterine phlebitis as it  occurs
after parturition.  Others have, as I believe, with truth, contro-
verted Dr. Lee's views of the  entire  dependence of  puerperal
fever upon uterine inflammation  and phlebitis, and  it may,  I
think, be shown, that where  phlebitis exists, it is, in almost all
cases, an expression of constitutional disorder, and especially of
a poisoned or diseased state of the blood, rather than  an idiopa-
thic disease.  The researches of Dr. Ferguson and others prove
that puerperal fever may destroy patients before there has been
sufficient time for the occurrence of phlebitic inflammation, and
that in such cases  no  pathological  changes beyond a diseased
state  of the blood are  met with.  Many facts in the history of
puerperal fever prove that before the purulent infection of the
blood, believed by Scanzoni and others to constitute the essence
of the disease, has taken place, changes have  occurred in  the
circulating fluid, which may in some cases destroy the patient
long  before  the suppurating stage  has been  reached.   The
experiments of Dr. Mackenzie, and the cases he has collected,
show that  healthy obstructive inflammation of the  veins,  the
result of simple traumatic  injury,  does not result in purulent
infection of the blood, but that a morbid state of the circulating
fluid is necessary to the production of pyaemia.
   Uterine  phlebitis  generally commences on the second, third,
or fourth day after labor, with shivering  or rigor, and a marked
increase in the thickness of the pulse, which ranges throughout
from  110 to 140 and  150.  There is  usually pain in the hypogas-
tric, or one of the iliac regions, the pain becoming more evident
upon deep pressure.   There is also pain in the back, or in one or
both  hips, extending  downwards to  the thighs.   The pain is
generally intermittent, and is sometimes absent for many hours.
The patient is usually anxious to be quiet,  every movement of
the body greatly increasing the pain when this symptom is pre-
sent.   But in  a considerable number of cases the pain alone is 
LOCHIA IN PUERPERAL FEVER.
643
not so considerable  as to indicate the dangerous state of the
patient, and in some instances it is  absent altogether.  The
lochia may become offensive at the commencement of the dis-
order ; they may be scanty, or they may remain in normal quan-
tity and quality. The mammary secretion is usually suspended;
but in some cases it continues  until the patient is exhausted by
the progress of the disease.   The perspiration is very distressing
and constant, and after three or four days from the commence-
ment of the attack, diarrhoea is generally present.  At intervals
throughout  the course of  the disease, violent rigors are felt,
which may be  supposed  to  mark successive formations of pus,
or the commencement of inflammation in  other organs beside
the uterus.  The state of the tongue is very variable, and it may
be red and glazed, covered by a creamy fur, or scarcely altered
from the natural state. The complexion of the patient is at first
little  altered,  except by the presence of a  hectic spot on each
cheek.  The mind  is clear, but the speech and movements of
the patient are tremulous.    The patient often sleeps  tolerably
well, and frequently expresses  herself as feeling better ; but her
manner is anxious  and trembling, thanking those  about her so
nervously for the slightest attention, that her state in this respect
has often been compared to the incipient  stage of puerperal
mania.   The  tympanitic  distension of the  abdomen is not the
least distressing symptom, giving rise to  hiccup, vomiting, and
greatly interfering with the respiration and the action of the
heart.
  As  the disease progresses,  the  secondary phenomena  of
uterine phlebitis and  the formation of pus within the  veins
become evident.  The patient  complains of pains in some joint
or joints ; swellings appear in the neighborhood of the articula-
tions, and erysipelatous blushes appear on the skin in different
parts of the body.  The hips,  knees, shoulders and elbows are
the joints most commonly attacked.   Large suppurations in the
vicinity of the joints occur, or patches of slough or  gangrene
form  at the sites of the  erysipelatous blushes.   Sometimes the
secondary inflammation attacks the eye, especial!}7 the left, lead-
ing to rapid destruction of the  cornea.  These external suppura-
tions, however painful and exhausting, are considered somewhat
in the nature  of crises,  and  as giving some faint  hopes of
recovery.  Up to this point, up to the time, in fact, when exter- 
644
PYJ3MIA IN PUKRPERAL FEVER.
nal suppuration begins, it is acknowledged by the best authori-
ties that we have no positive signs by which we may be sure of
the existence of phlebitis.  This is stated with great candor by
one of the  latest  and best writers on the subject, Dr. McClin-
tock,  of Dublin.  In other cases, the secondary  inflammations
and suppurations are internal, and attack the  lungs, liver, kid-
neys,  omentum, or other organs.  These complications are more
dangerous than the  external secondary abscesses.  These pheno-
mena cannot exist without the pyaemia of which they are the
results,  indicating its constitutional effects.   When pus is pre-
sent in the  veins, the  inflammatory symptoms subside to a con-
siderable extent, and  adynamic or typhoid symptoms  manifest
themselves.  It is  necessary,  however, to distinguish  between
the low state of system thus produced and the somewhat similar
condition wdiich exists in the first  instance, when the puerperal
virus  is very potent, and before any inflammation or suppuration
has progressed in  the  veins.   When  patients  recover,  they
slowly struggle through the  exhaustion produced by the exten-
sive suppurations,  and may remain  blind or with anchylosed
joints to bear witness to the  terrible ordeal through which  they
have  passed.  When a fatal result  ensues, the patient dies with
symptoms very similar to those described when speaking of the
adynamic form  of  puerperal  fever,  or  exhausted by the  dis-
charges consequent  on the external suppurations.
  The tendency of the puerperal and other forms of pyaemia to
attack the joints, is a very remarkable feature of this aftection.
Large effusions of pus and sero-purulent fluid are poured out in
the joints affected, and the cartilages are often eroded  and des-
troyed to a remarkable extent. No explanation has been given
of the reasons why the joints,  the  eyes, or the serous  mem-
branes should be  especially selected.   I would suggest the pro-
bability, that this selection  may depend  on the nourishment of
parts  of the eye,  cartilages, and serous membranes, by the non-
vascular permeation of the  tissues by the  liquor sanguinis, as
explained  by the  researches  of Mr. Toynbnee.  The  diseased
liquor sanguinis,  or the  liquor  puris, in purulent infection of the
blood, may easily be  supposed to affect especially those  tissues
of the body in which special  provisions  exist for their permea-
tion by the colorless parts of the blood.   One of the earliest, as
well as one of the most graphic descriptions of puerperal affec- 
PREVENTION OF  PUERPERAL FEVER.
645
tions of the joints we owe to Mr.  Coulson, who has described
the dissection of numerous cases of this kind.
  Besides uterine phlebitis, other forms of puerperal inflamma-
tion of the uterus occur.  That which affects  the Lymphatic
vessels does not materially differ in symptoms, progress, and ter-
mination from phlebitis. Inflammation of the  Muscular tissue
and lining membrane of the  uterus is characterized by great dis-
turbance of the nervous sj^stem, distressing cephalalgia; and is
attended by fever of low type.   Occasionally the cerebral symp-
toms are so intense as to entirely mask the uterine disease.  It
is ushered in by the same symptoms as regards  rigors, accelera-
tion of the pulse, and state of tongue as those which attend the
other varieties of puerperal  inflammation.   Its tendency  is to
produce  softening, suppuration, and gangrene of  the substance
of the uterus, and it is one of the most fatal of all the puerpe-
ral  inflammations.
  Before  speaking  of the  Treatment of Puerperal Fever
in its varied forms, it cannot  be  too much  insisted  on that it is a
disease,  almost above all others, open to Prevention rather than
Cure.  The avoidance of injuries of the uterus or vagina in diffi-
cult or instrumental labors, the  entire  removal of  the placenta,
and the  promotion of a free lochial discharge,  with the avoid-
ance of the possibility of inoculating or infecting the puerperal
woman with any of the poisons  which admit of conversion into
the puerperal poison, are of the greatest importance in prevent-
ing the  appearance  or  extension of this terrible  disease.   As
regards the actual treatment, nothing can be more  different than
that which has been  most successful, or best borne in different
epidemics, and at different places and times.
  The  opposite  extremes   of  puerperal fever—namely, the
peritoneal and inflammatory, and the adynamic, are those wdiich
most distinctly admit of positive rules of treatment.  In puer-
peral  peritonitis, copious venesection,  the free use of leeches,
mercurials, opium, fomentations and stupes,  or  wTarm poultices
to the abdomen, counter-irritation, and mild aperients, are the
means upon which we must depend.   The bleeding must,  how-
ever,  be  prompt to  be of service,  and its  extent  must  be
measured by  the powers of the patient and the intensity of the
disease.  A full bleeding to twenty or thirty  ounces at the onset
of the disease will do more to relieve the patient than  any sub- 
646
TREATMENT OF PUERPERAL FEVI-R.
sequent treatment.  She should be bled in the upright position
to incipient syncope, and the bleeding should  be repeated in a
few hours, or  the  abdomen covered with three or four dozen
leeches.   At  the  same time, calomel with opium or Dover's
powder, should be given in  repeated doses at small intervals,
with a view to the production of ptyalism, or mercurial inunction
should be resorted to.   When general arid  local bloodletting
have  been carried as far as the patient will bear, and when the
disease continues,  a large blister over the abdomen is of great
service.  In all cases of puerperal peritonitis, there comes a
time,  unless the patient has been rapidly destroyed, in which
stimulants are required, and this  time  comes much  earlier  in
puerperal than in ordinary peritonitis.   It is only in the most
acute forms cf puerperal peritonitis that such  an active plan  of
treatment as that  now  indicated is admissible.  In peritoneal
disorders  of a lower type,  depletion must be more sparingly
employed, and a tonic plan earlier resorted to.
  In the most  adynamic cases of puerperal fever, a stimulating
treatment must be adopted  from  the first, and  wine, brandy,
ammonia, and quinine  are required.  The only antiphlogistic
remedy that can be resorted to in such cases, is blistering.   In
milder or  more mixed cases, a small bleeding  at the very com-
mencement is sometimes called for, or the application of a few
leeches, but as the patient  passes rapidly into the low stage  of
the disease, support and stimulus become necessary.  The treat-
ment  is little different from that required in  marked cases  of
typhus.
  In phlebitis, the employment of  bleeding is a vexed question.
Some authorities  have  strongly recommended early  bleeding,
and others have opposed it, advocating a tonic  regimen, and
directing all their efforts to  the preservation of as healthy a state
of the blood as  possible.  In one  instance in this  metropolis
bleeding was tried on a  large scale in a lying-in hospital, where
venesection was performed  on the very first approach of the dis-
ease,  and  the mortality was greater than when an opposite plan
was adopted.  In the present state of our experience in this dis-
ease,  bleeding appears  to be called for at its commencement,
when the  pain is acute, and the pulse rapid.   But this disease is
often so insidious,  and its progress attended by such remissions,
that it is difficult, if not impossible, to decide  on  bleeding until 
           OPIUM TREATMENT IN PUERPERAL FEVER.        647

distinct evidences  of pyaemia have appeared, when bleeding
becomes injurious  rather  than  otherwise.  As soon  as  this
becomes evident, cinchona, nitric acid, chlorate of potash, ether,
ammonia, strong animal broths, and wine, are agreed  on by all
authorities as the best line of treatment.  Pain must be allayed
by opiates, and the painful joints bathed with opiate embroca-
tions or a chloroform liniment.  When collections of matter are
evident upon  the  surface, they  should be  opened,  and  it is
believed that the external  discharge of pus adds somewhat  to
the chance of recovery.  Congestion of  the lungs or brain must
be met by sinapisms or blisters, and the meteorismus relieved,
as far as possible, by carminatives, turpentine enemata, or the
introduction of a tube into the intestinal canal.  It is impossible
to do more than lay down  general principles, and indicate the
points of treatment, within the scope of a lecture.   A patient
suffering from the  disease now under  consideration will tax all
the resources and all the vigilance of the most able and pains-
taking practitioner.
  [The treatment by opium in heroic doses, as recommended by
Dr. Alonzo Clark, has  perhaps been the practice of the physi-
cians in and around New York for several  years past; and this
without much other general treatment.   The object being  to
subdue the pulse till its beatings are reduced to or below the
natural number and the respiration to 10 or 15 in a  minute.
The quantity of this drug requisite to subdue the arterial action
is very various.  Given in  the form of morphia, a quarter of a
grain may be taken every hour till narcotism, and, by the conse-
quent diminution of the arterial excitement, the pulse is reduced
to the point desired.  In this condition the patient is kept till the
disease gradually vanishes  away.   Professor Barker, with the
same intent, has substituted the Veratrum Viride for the opium,
and commencing with five or ten drops, gives it in  larger  or
smaller quantities every hour until the pulse and respiration are
brought down  to  the desired point.   With it no  narcotism is
obtained.  An improvement in the percentage of cures is claimed
for  this treatment.] 
LECTURE XLIV.
 PHLEGMASIA DOLENS—PUERPERAL ARTERITIS—SUDDEN DEATH IN
                   THE PUERPERAL STATE.

  Gentlemen :—Phlegmasia Dolens, though generally a dis-
ease of the  puerperal state, is not limited to this period.   It
sometimes occurs during the course of pregnancy, or towards the
end of lactation.  It may also happen independently of child-
bearing, in dysmenorrhoeal patients; in women  suffering from
carcinoma, or the subjects of metritis ; or after the  operation of
tying a polypus.  In still more rare cases, it has been met with
in the male subject, as the result of cold or local  irritation.
  Pathological  researches  show  that the disease essentially
depends on  obstruction of  the veins of the lower extremity.
This is proved  by the dissections of Dr.  D. Davis,  Dr. Lee,
M. Bouillard, Virchow, and numerous other investigators.   The
veins affected are, the crural, iliac, uterine, vaginal,  the saphena,
and sometimes the vena cava.  The obstruction,  in some cases,
consists of fibrinous coagula, and in others of coagulated lymph,
or pus.  The whole of the affected limb, and  frequently the
vulva,  is, as the disease progresses, gorged with serous  effusion,
and in some cases the  lymphatic vessels and  nerves of the ex-
tremity show the existence of inflammation in their structures.
  The  mode in  which  the obstruction of the  veins is  caused is
not at the present time a settled matter.   Dr.  Lee believes it  to
depend on inflammation, extending from the uterine to the iliac
and crural veins.  But cases are met with in which the obstruc-
tion is limited to the veins of the lower part of the leg, or  in
which  it appears in the upper extremities, without symptoms of
local uterine phlebitis. The most recent doctrine—that founded
by  Virchow upon  his numerous dissections—is that  the  first
pathological condition consists of the formation of a coagulum in
the vein ;  and that the inflammation of the vein, effusion of
  643 
CHARACTER  OF PHLEGMASIA DOLENS.
649
lymph and pus, and the breaking-down  of  the  coagulum  and
formation of pus in its substance, are phenomena which result
from the plugging of the veins.   It appears, however, that the
evidence of the extension of irritation or  inflammation from the
uterus to the  veins, in many cases  cannot  be rejected.  This
inflammation of the internal  coat of the vein appears to cause
coagulation of the blood circulating within the vessels.  In other
cases, the presence of vitiated blood in the veins  seems to cause
coagulation and plugging, without the intervention of inflamma-
tion.  When a firm  plug is formed from any cause, patients go
through the phenomena of pure phlegmasia dolens.  When it is
loose, or breaks off,  the circulation  generally becomes vitiated,
and  other symptoms besides  those of phlegmasia  dolens are
manifested.
  The inflammation of the lymphatics and nerves  occasionally
met with is probably of a secondary nature,  and dependent on
the profuse infiltration of the tissue of the limb with serum of a
highly acid and irritating character.  The whole subject is one,
however,  in which pathological  investigations are  not  as yet
definitely agreed.
  The affinity  between phlegmasia dolens and  ordinary puerpe-
ral phlebitis and  fever is strongly marked.  In  some cases of
phlegmasia dolens, the inflammation is not limited to the veins
of the lower extremities, and suppuration occurs in other parts
of the body, and in  the eyes, as in ordinary puerperal phlebitis.
In other cases, inflammations of the serous membranes,  as the
pleura or peritonaeum, are found in combination with the  inflam-
mation of the crural vessels, and the patients  die of precisely the
same symptoms  as  those met with in ordinary puerperal phle-
bitis, or puerperal  fever.  I have also seen cases which tend
strongly to prove that phlegmasia dolens may be produced as the
result of infection.  For instance, a short time ago, a friend of
mine had been in close attendance upon a patient dying of erysi-
pelatous sore-throat with sloughing, and was  himself affected
with  sore-throat.   Under these  circumstances he attended,
within the space of twenty-four hours, three ladies in their  con-
finements, all of whom were attacked with phlegmasia dolens.
  The common period for the invasion of the disease is between
the end of the first and third week after parturition.   For a day
or two before the presence of any  local symptoms in  the extrem 
650
SYMPTOMS  OF PHLEGMASIA  DOLENS.
ities, there is great depression, restlessness, irritability, and fever,
with or without pain  in the  uterine region.   During this time
there is frequently chilliness, or a distinct rigor.   The first pain
in the leg is usually in the calf, and is very intense and distress-
ing ; sometimes the pain is first felt in the ankle, knee, groin, or
hips.   In some cases,  the part first complained of is red, but it is
often perfectly pale.   Within twenty-four hours  from the onset
of pain, the part affected  generally swells and  becomes white,
tense, and shining.  It generally pits on pressure, particularly
at the beginning.  When the swelling commences in the groin
or hips, it commonly extends downwards, but, if  the ankle  be
the first part affected, the swelling ascends, so that in either case
the whole limb usually becomes affected.  Sometimes it is, how-
ever, limited to the parts below the knee.  The femoral vein is
always, when  the disease involves the whole limb, hard and
painful, and rolls under the finger.  The pain  is most intense in
the course of the inflamed  and obstructed vessels.  Sometimes
the track of the vein  is marked by slight redness, but in other
cases, the color of the  skin is not affected. When the lower part
of the limb is the chief seat  of disease, the inflamed and indu-
rated vessels are found in the popliteal space and on the inner
side of the leg and heel.  The lymphatics, as well as the  veins,
are sometimes painful, and the inguinal glands are in such cases
swollen and tender.   The limb becomes of large size from effu-
sion into the cellular tissue, and at the height of the disease, the
tension is such as not  to admit of pitting on pressure. The con-
stitutional symptoms are severe.   The pulse is from 100  to 150,
the tongue generally glazed, the stomach irritable, and the patient
is distressed by profuse sweating.  The debility is  very great,
and the pain often prevents sleep almost entirely.  After a week
or ten  days, or a longer period, according to the severity of the
attack, the disease begins  to decline.   The pain  becomes  less
acute,  the  tension of  the limb  less marked,  and the effusion
slowly disappears.  In other cases, vesication occurs in  certain
parts,  or over the  entire limb.  Sometimes  the  inguinal  and
femoral glands, or the vulva, suppurate; abscesses occur in the
cellular tissue,  or the  knee and  ankle joints inflame  and suppu-
rate.  Generally the left leg is the limb  affected, but  in a certain
proportion  of cases, the disease appears in the right leo- as soon
as it begins to decline in the  left, and in very rare instances a 
CAUSES OF PHLEGMASIA DOLENS.
651
transferrence occurs to the upper extremities.   Even in the most
favorable cases, it is some time before the limb or limbs affected
become of the natural size, or acquire  their usual strength and
freedom from tenderness, and it is remarkable that patients hav-
ing once suffered from this malady are more liable than  others
to the disease, after subsequent labors.   In the worst cases, death
may occur suddenly, or as the result  of exhaustion during the
progress of  the disease, and  the  patient may be worn out by
diarrhoea or by the suppurations which occur in the joints or in
other parts of the affected limb.   When diffuse phlebitis occurs,
in combination with phlegmasia dolens, or  when metritis or
inflammation of the serous  membranes of the pleura or peri-
tonaeum accompanies it, the course of the disease and its dangers
are little different from the other forms of puerperal fever.
   As regards the Causes of the disease, it appears, apart from
the  influences  of contagion or infection, to be brought  on by
early exertion after parturition,  by exposure to cold, and by
unusually severe after-pains.   I  believe, however, that  conta-
gion and infection play a very important part in the production
of the  disease.  I look on a woman  attacked with phlegmasia
dolens as having made a fortunate escape from the greater dan-
gers of diffuse phlebitis  or  puerperal fever.   The plug formed
in the  vein is generally effective in cutting off the affected
extremity from the rest of the circulation, and is so far sanative
 in its influence.  Multiparous women  appear to be more  prone
 to the disease than primipara.
   In the Treatment of  Phlegmasia Dolens, it is necessary, at
 the onset of the disease, to  apply leeches freely  over  the course
 of the  inflamed  vein. This should be followed by poultices to
 encourage  the bleeding, and warm  fomentations, which gene-
 rally relieve the pain more than cold applications.  If necessary,
 the leeches  should  be repeated a second or even a third time,
 but general blood-letting will rarely be required.  Some practi-
 tioners prefer  blisters to leeches, and in the milder cases of the
 disease, they are frequently efficacious.  They should  be applied
 over the seat of pain or the inflamed vessel.  The bowels should
 be relieved by mercurial purgatives, and the administration of
 mercury so as to affect  the mouth, is often useful in the begin-
 ning of the disorder.   Opiates require to  be given freely  to
 obtain relief from pain and to procure sleep.  They are neces- 
 652         TREATMKNT OF PHLEGMASIA DOLENS.

 sary  at  the  commencement of the disease, when the vein is
 acutely inflamed and painful;  and subsequently, when the ten-
 sion  of the limb from  effusion is at its height, or when local
 suppurations occur.   After the first  inflammatory invasion,
 there soon comes a time when  the weakness and depression  are
 so great, that there is no place for an antiphlogistic treatment.
 Patients require strong beef-tea, soup,  broths, milk, arrowroot,
 etc., frequently, according as the stomach will  bear them, and a
 liberal allowance of wine or brandy.  Quinine or bark, with or
 without  the  chlorate of potash or the mineral acids, should at
 the same time  be given.  Much care is required in the local
 management of the  painful parts of  the  limb.   The whole
 extremity should be defended by a cradle from the touch of  the
 bedclothes.  Sometimes the greatest comfort is  derived from
 wrapping the whole limb in a linseed poultice.  When the local
 pain is intense, great relief is afforded by smearing the extract
 of belladonna, mixed with a little water, on  lint, and putting it
 on the painful part as a plaster.  When  the  skin is not broken,
 equal parts of chloroform and  olive oil will  sometimes  allay
 pain.   When vesications occur, poultices, or dredging the limb
 with flour, should be tried  alternately, so as to ascertain which
 is most suitable to the individual case.   Abscesses require to be
 treated as in other parts of the body.  In cases where resolution
 occurs, the disappearance of the swelling may be favored by a
 flannel bandage, the application of an iodine  liniment, or oint-
 ment, or  a camphor and mercurial liniment.  Frequent frictions
 of the limb should be  persevered in.  Change of air, and sea-
 bathing,  if the time of the year  suits, tend greatly to aid
 recovery.
  The subjects of Arterial Obstruction  and Arteritis, occurring
 in connection with  child-bearing and under other  conditions,
 have only recently been investigated, but they already explain
 some  very curious  phenomena  which  had  previously  been
 observed without being  understood.  The  principal  contribu-
 tions to our knowledge of this subject have been  made by Dr.
 Kirkes, Prof.  Simpson, Dr. Lever, Dr. Burrows, Dr. R. Virchow
 and others.  Under a variety  of circumstances solid matters
 may pass into the circulation, and become arrested at various
points, according to the size of the morbid material, and the
vessels in which it circulates.  In cases  of rheumatic or other 
   ARTERIAL OBSTRUCTION THE CAUSE OF PHLEGMASIA DOLENS. 653

disease of the heart, in which vegetations or  excrescences have
formed  upon  the  valves, these bodies may  be detached from
their habitats during the struggles of labor, or in the accelerated
circulation incident to gestation, or the puerperal state, or dur-
ing suckling.  Polypi formed in the cavities of the  heart may
also be propelled into the pulmonaiy arteries or the aorta.  In
diseased states of the blood, and in arteritis, or  laceration of the
arterial coats, it also appears that coagula or effused lymph, may
form impediments in the arterial vessels.   In the case of coagula
detached from the veins, these  bodies  may reach the heart by
the inferior cava, pass through the right side of the heart, and
enter the pulmonary arteries; or pus may enter the general cir-
culation in the same manner in cases of phlebitis, and form the
nucleus of obstructing masses.
  The  symptoms of arterial obstruction vary according  to the
situation in which the obstruction  takes place.    When the
obstruction occurs in the upper or lower extremities, the  symp-
toms bear some resemblance to those observed in  the obstruc-
tions of the arteries  in aged persons  caused  by ossification of
the vessels.  The limb affected becomes pulseless;  sometimes,
but not  invariably, the  temperature falls, the limb is perfectly
useless  and more or less  paralyzed, and  acute  or chronic
gangrene  supervenes.   The pain is intense, and  neuralgic in
character, and the constitutional disturbance great.   In one case
described by Dr. Oke, of Southampton, the gangrene was limited
to the thumb and part of the hand, and the patient  recovered.
When  the obstruction involves the vessels of the  neck, or the
arteries of the brain, abscesses and softening of the brain, with
paralysis, have been observed on dissection.  In cases involving
the pulmonary artery, abscesses of the lungs, or sudden arrest
of the circulation in these organs, have taken place.
  As regards  Treatment, many of the cases  terminate too sud-
denly to admit of any attempt at remedy.   In others, where the
head, lungs, or liver are the organs  affected, the local  disease
caused by mechanical obstruction can only be treated on gene-
ral principles.   In some cases, general arteritis has been proved
to exist by post-mortem examination, the  arterial system  gene-
rally being implicated  to  a great extent, and obstructed by
coagulable lymph.   The symptoms  of such  cases are only
obscurely known, but if the disease could be  detected during 
654
CAUSES OF SUDDEN DEATH.
life, it is probable that the same  treatment as that followed in
phlebitis would be advisable.  When the obstruction falls upon
the extremities, the distressing  pain  should be relieved by
opiates, the temperature  of the  limb preserved by external
warmth, and the patient supported by a generous diet and regi-
men.   In  a well-marked  case  under my care at  St. Mary's
Hospital, the patient very slowly  recovered the use  of the leg,
without the occurrence of gangrene, though  this condition was
threatened for a considerable time.

  The consideration of the Causes of Sudden Death occurring
in the puerperal state is included in the present Lecture, because
some of the most marked cases  of this kind depend  on cardiac,
venous, or arterial obstruction,  and upon  phlebitis and arteritis.
In some cases  of sudden death in connection with gestation,
childbirth, or lactation, but especially during the puerperal
period, the only post-mortem sign has been the presence of firm
coagula in the cavities of  the heart, as pointed out by  Dr.
Meigs.  Others depend on  apoplexy, the result of  obstruction
of the carotids, or the cerebral vessels.  In some cases,  obstruc-
tion of the pulmonary arteries, which have  depended on  the
transfer of coagula from the veins, have caused sudden dissolu-
tion.  This was apparently the cause in the case of the lamented
Duchess De Nemours, as made out by the careful autopsy per-
formed by Dr. Gueneau de  Mussy.  The death in  these cases
generally  occurs during some sudden emotion, or  upon  slight
exertion.   In the cases of  death from coagula formed in the
heart  itself during  life, the coagulation generally  appears to
have occurred during fainting.
  Another cause of sudden death  after labor, consists in the
presence of air in the veins.  This subject has been carefully
elucidated by the researches of Drs. Cormack and  McClintock
and others, and appears to explain some of the lamentable acci-
dents met with after labor.   Numerous  cases of  sudden  death
are on record in which, upon post-mortem examination, no other
cause of death than the presence 'of air  in the heart could be
made out.  Such cases are also illustrated by those  instances in
which death has been caused by the entrance of air  into the
veins of the neck, during  operations on  this  part of the body.
In both classes of  cases the symptoms have  been  found to be 
FATTY DEGENERATION OF THE HEART.
655
closely identical.  The mechanism of this accident in the puer-
peral state seems to be as follows.  The occurrence of physome-
tra  in  the ungravid uterus, and  in  the  uterus  after delivery,
have frequently been noticed.  After labor, it may be caused
by the  secretion of gas from the uterine cavity, or by the decom-
position of intra-uterine matters, such as coagula or a dead child.
If, in such cases, the air does not  escape  from  the  os uteri, but
is shut up in  the uterus, the mechanical arrangements of the
uterine veins favor the entrance of air into the circulation by this
route,  and as soon as it reaches the heart  the most serious symp-
toms are observable.  All the phenomena of  sudden asphyxia
are present; but the chief diagnostic  mark, according to Dr.
Cormack, is  the presence of a "churning" sound in the heart.
  To the list of causes of sudden death occurring in the puerperal
state must be  added Fatty Degeneration  of the Heart.  I have
known several  instances in which  no other cause of death than
a fatty state of the heart  could  be assigned.   In  these  cases
death most commonly occurred  after the patient had taken a
full meal. In  one case, in which  Dr. Arthur Farre showed me
a preparation of the heart, the substance of the ventricle was,
in at least  one-half of its thickness, converted into fat, and at
some  points the muscular  element was scarcely  perceptible.
The arcus senilis was, I believe, observed in this patient during
life.  Other causes of sudden death, such as Syncope shortly
after  haemorrhage,  or following upon the  assumption of the
upright position some time after  extensive loss of blood, have
already been referred to, and need not be dwelt upon further in
this place.
  The  management of these  distressing  cases  is chiefly limited
to  the means  of prevention, and  unfortunately little can be
effected even in this manner. When we  have  said that in cases
of valvular  or other disease of the heart, or in cases of diffuse
phlebitis or phlegmasia dolens—in which at any moment a fatal
plug may be detached and  pass into the circulation—the utmost
quiet of bodjT, and the absence of emotional disturbance, should
be preserved, we have pretty well exhausted all that the history
of such cases teaches us.  In the  case of mere syncope,  every
effort should be made by stimuli  to prevent the long continuance
of this stats, so as to avert  the formation  of coagula in the ven-
tricles.  When the presence of  air in  the veins  is known or 
656       TREATMENT OF FATTY DISEASE OF THE HEART.

suspected,  dift'usible  stimuli and the cold  douche  have been
found  to be most  efficacious modes  of  procedure.   In  fatty
heart, or other  cardiac  disease, great  care should be taken  in
guarding the patient against early muscular  exertion, and espe-
cially against taking indigestive, flatulent, or large quantities of
any kind of food, during the first few days after the completion
of delivery. 
LECTURE  XLV.
            THE INDUCTION OF PREMATURE LABOR.

  Gentlemen :—Under a variety of circumstances of present or
threatened danger, it becomes right and necessary to induce the
premature expulsion of  the  ovum,  by artificial  means, with a
view to the safety of the Mother or Child, or both.
  Cases in which the operation of inducing premature Labor
may be required,  admit of division into three classes:—
  I.  In which the operation  is called for  before the date of the
viability of the foetus, in consequence of diseased  states of the
mother, and  in which the ovum has to be sacrificed in order to
preserve the life of the Mother from great risk.
  II. In which  the operation is required for the preservation of
both Mother and  Child.
  III.  In  which it is performed to save the life of the Child, in
conditions which do  not involve any question of danger to the
mother.
  As one  of the most important principles in obstetrics, it may
be stated, that all  conditions which  render  the death of the
mother imminent, unless the contents of  the uterus are evacu-
ated, call  for the performance of this operation.  At the present
time, the  operation under these circumstances has been extended
to cases of excessive exhaustion from continued and irrepressi-
ble  vomiting;  to cases of  distortion of  pelvis  from  exostosis,
rickets, or mollities ossium,  where the deformity is so excessive
as to render the birth of a living child impossible.   It has been
resorted to  in  cases of  ovarian  and fibrous tumors within the
pelvis, when labor at a later period would hazard inflammation
and softening of the tumors; it has been performed in cases of
cancer of  the uterus; it  has been practised in cases of disease
of the  heart in which urgent and dangerous dyspnoea, or irregu-
larity of the circulation, has supervened; it has been performed
                            42                       «" 
658
INDUCTION OF PREMATURE LABOR.
in cases  of albuminuria  with general  anasarca,  which  has
refused to yield  to  treatment, and brought the patient into a
state of dangerous anaemia and debility ; and in cases of haemor-
rhage from the bowels threatening death. It has been employed
in chorea arising from pregnancy, and also in mania occurring
during gestation ; and it has been used in cases of dropsy of the
amnion, when the fluid has increased to such an extent as to seri-
ously interfere with the circulation and respiration of the mother.
In any other contingency besides those named, in which dan-
ger exists, and in which the peril is materially increased by the
continuance of pregnancy, the induction of premature labor is
justifiable; but, it should be borne in mind, that it ought not to
be performed in any case  before the  time at which the child
becomes  viable, unless there is the certainty of present or future
danger to the mother from the further contiuuance of gestation.
But  in the  cases above mentioned,  in which the  life  of  the
mother is in positive danger, or will  be placed in inevitable dan-
ger, by the continuance of pregnancy up to the time at which
the child becomes viable, it is held right  to sacrifice  the foetus
by  inducing premature labor, and, as a necessary converse,
wrong to neglect the performance of this operation.  Many of
the cases of the  Caesarian operation  in which the lives of the
mothers have been sacrificed, have been cases in which abortion
or premature  labor  might have been induced, and the hazard
of almost certain death avoided.
  Some have maintained that a certain limit should be placed to
the number of times in which  the operation for the induction of
premature  labor should  be performed on the same woman, in
cases where pelvic deformity exists to  such an extent as to'ren-
der the birth of a living child per vias naturales impossible.  It
has been affirmed that women have no right to go on placing
themselves  in the position  to require  the  sacrifice of many
living children in succession, but that they ought  rather them-
selves to  submit to the Caesarian section.  Denman had scruples
on this point, and  in the present day Dr. Radford has distin-
guished himself for his able advocacy of the right of the foetus
afc opposed  to that of the mother, in such cases. My own strong
impression,  I may  say conviction, is,  however,  that we must
deal with the woman pregnant for  the twentieth  time as we
would in her first pregnancy, and that in all cases our clear and 
           MORALITY OF CAUSING PREMATURE LABOR.       659

paramount duty is to save the  woman.   No doubt every right-
minded professional man would urge upon such women the pro-
priety of living apart from  their husbands, or of not marrying
at all; but when pregnancy actually exists, considering that the
mother is the life-giver ; and  that  in the case of the  married
woman pregnancy may be forced  upon  her by her husband;
remembering, too, the immortal interests  of the mother, as com-
pared with the unborn foetus ;  and having in view  the enor-
mous danger to the mother from the Caesarian section, and the
large proportion even  of  children  lost by this  operation—I
am of opinion that the mind  of the accoucheur  should  never
hesitate between  the  induction  of premature labor  and the
Caesarian  section whenever the former operation is practicable,
and that  the question of whether  the  patient is primiparous
or  multiparous should not enter into his  consideration.  This I
believe to be the general opinion amongst medical men, and  it
is that of every English divine I have conversed with on the sub-
ject.
   It is an important element, in reference to this operation, to
decide the Age at which a Fcetus becomes  Viable, or in a
condition to live after its expulsion from the uterus.  The foetus
is not viable—that is, cannot maintain an  independent existence,
until towards the end of the seventh month; and any circum-
stances calling for  the induction of premature labor before this
time,  must  necessarily  involve great risk of sacrificing the life
of the ovum.  Cases occur in which children, born at an earlier
time  than this survive; but these  are rare exceptions.   [Dr.
John  W.  Francis  reports a foetus, born  with membranes
intact in the  twenty-third week  of  pregnancy  that   lived
to maturity.]  Even at the seventh month  they are kept alive
with difficulty.  The state of the heart, as regards development,
the feebleness with which the  foetus sucks before  this time, the
ready failure of  animal  heat, and the inability to bear the move-
ments necessary to  cleansing  and  nursing, render it almost
impossible to rear the fcetus  born at an earlier period.
   In  the second class  of  cases,  the induction of premature
labor is called for between  the seventh  month and the end of
gestation,  and the  operation is performed with a view  to the
safety of both mother  and  child.   The  chief condition  under
which this  occurs  is such an amount of  pelvic  distortion as 
660      NECESSITIES FOR INDUCING PREMATURE LABOR.

would admit of the passage of a child at the end of the seventh
or eighth month, but which at the full term would call for
craniotomy, or, if labor were allowed to go on without assistance,
would endanger the life of  the mother  as well as the  child.
Some of the morbid spates already referred to, as calling in cer-
tain cases for delivery before the end of the seventh month, may
not in others reach a dangerous extent until  after the time when
the child becomes viable.   This is particularly the case  with
respect  to mania, chorea, fibrous and ovarian tumors, disease of
the heart and lungs, albuminuria, dropsy of the amnion, haemor-
rhages,  and other causes of dangerous debility,  which may
admit of waiting until after the  viability of the child, but if
allowed  to proceed after that time would place the woman in
great danger in labor at the full term.   In this second  class of
cases, it sometimes happens that either the mother or the child
may be in the greatest danger of the two, but generally  both
parent and offspring are delivered from  risk by the induction of
artificial delivery.
   In the third class of  cases, the operation is called for entirely
on account of the fcetus, under circumstances attended by dan-
ger to  the  ovum, but which involve  no unusual risk to the
mother. In these cases, of course, the  operation should only be
resorted to after  the commencement of viability to the  child,
and as late in pregnancy as is compatible with the safety of the
foetus.   It is found in practice that some women are delivered
at or near the full term  many times in succession  of still-born
children, there being every evidence that the children have died
during  or  shortly before parturition.   Such children  are fre-
quently thin, and below  the average weight of the fcetus at the
time of birth, but in other cases they are plump and  well formed.
In some cases of this kind, the child is born alive, but is  so feeble
as to survive only a short time.  The cause of  this state of things
depends upon various diseased conditions of the placenta, such as
inflammation, fatty degeneration, syphilitic disease, or calcareous
deposits.   In these circumstances, the changes which naturally
take  place in the placenta as a deciduous organ seem  to  occur
more early, and to a  greater extent than is natural.  As conse-
quences, the nutrition  and respiration of the foetus  is  inter-
' fered with, and  the child either dies  in utero, or survives  its
 birth but a short time.   In other cases, the connection between 
            DIAGNOSIS OF POSITION BY PALPATION.          #61

the uterus  and the placenta is  so slight, that the first pains of
labor separate the two organs,  and haemorrhage during labor,
with the speedy death of the  fcetus, ensues.  The remedy for
such conditions is the induction of premature labor, at a time
prior to  that  at  which  the  death of the  foetus  has  usually
occurred.   Frequently, the mother is aware, by the gradual
diminution of the movement of  the foetus, or by the occasional
occurrence of convulsive movements, of  the approaching death
of the  child.   The diagnosis of such cases is greatly aided by
auscultation.   The  heart of  the child either exceeds  or falls
below the normal standard of frequency in the latter  part of
pregnancy, and auscultation should be resorted to daily in such
cases to ascertain  the condition of the fcetal circulation.  When
premature  delivery is effected, the child  is born alive, and sur-
vives in many cases in which its  preservation  could be effected
in no other manner.   The intra-uterine  marasmus dependent
upon disease of the placenta  generally commences at the latter
part of  pregnancy.   In  cases in which  children are still-born,
without any difficulties connected with the labor itself, the pla-
centa and membranes ought carefully to be examined, as afford-
ing data for treatment in  subsequent pregnancies,  and  for the
performance of this operation.   The  placenta  will, in these
cases, frequently be found  the subject of fatty degeneration, or
the  result of inflammation, or  the  decidual  surface  will be
studded with calcareous matter.
   [It is in cases like this where  assistance is desired  from the
Diagnosis by Palpation, as few would willingly attempt to
bring on premature delivery with the hope of saving the life of
the child if they knew that it presented in any dangerous position.
It is unquestionable  that  the different members  may be dis-
tinctly felt through the abdominal parietes, and by induction the
presentation and position of the child may be clearly established.
To attain to any great certainty in the diagnosis by this method,
the touch must be educated by frequent manipulations upon the
maternal abdomen.  The opportunity is  easily attained, for all
women are more  or less anxious  in regard to the approaching
event of maternity, and when engaged to attend a woman, an
intimation thrown out that by an external  manipulation of the
abdomen, light might be obtained of the position of the child
which would be of importance to both herself and her physician, 
662
ABDOMINAL PALPATION,  HOW  MADE.
 will easily gain her consent to the examination.  There are a
 few requisitions important  to  be observed.  In the first place,
 pregnancy must be advanced to  at least the seventh  month.
 Secondly, the mother  must not be excited  or unwilling, as in
 either of these conditions the  abdominal wralls will be so tense
 or  the muscles  so spasmodically and irregularly contracted as
 to seriously interfere with the exploration.  The  difficulties are
 greatly increased of obtaining a satisfactory result  by the extreme
 firmness or rigidity of  the abdominal walls, as  often obtains in
 first pregnancies, or by the opposite  condition,  which  oftener
 occurs in primiparae when the abdomen is excessively pendulous
 or filled and distended by fat.
  The patient to be examined  should lie upon a bed, the abdo-
 men covered only by a single  thickness of linen,  as a sheet, her
 legs flexed upon the thigh  and the  thighs somewhat upon the
 abdomen, so that being entirely passive there may  be no strain
 upon the abdominal walls.   As may be seen, the position upon
 the  back  will be  found the  most  convenient to  attain these
 results.
  The size and shape of the uterine tumor being obtained by
 percussion, the stethoscope will point out the locality of the pla-
 centa and the fcetal heart.  Thus one point is determined.
  As the head is generally the  presenting part, we first look for
 it in the region of the symphisis pubis.   With the fingers of one
 or both hands, pressure is to be made just above  the symphisis,
 inwards and slightly downwards.  The globe of the fcetal head
 may thus generally be easily recognized.   Running the  fingers
upwards and laterally,  other portions of the fcetus  may be felt.
If the back of the child should be anteriorly, the spinous processes
of the vertebrae may be discovered and numbered.  Then beyond
a slight depression may be felt the projecting nates.   If the
belly of the cliild be anteriorly, its broad and flat surface covered
 by the folded arms and  legs will be perceptible and their various
points, hands, feet, elbows and knees, easily made out.
  If the head is not in the pelvis it is generally still more easily
found, and a spheroid mass in the fundus uteri or laterally will
be discovered.
  We may thus, even without  the stethoscope, determine a ver-
tex presentation if in the first, second, third or fourth positions •
 for if the foetal spine is to the left of the mesial line or navel of 
LAWS OF  ABDOMINAL PALPATION.            QQQ
 the mother, it is a first position; if to the right, it is  a second
 position ; if the prominent knee and elbow be to the right of the
 maternal umbilicus and the sounds of the foetal heart be most dis-
 tinct near the mesial line, it is a third position ;  and if the con-
 trary, it is  a fourth  position.   Twin  pregnancies are  diagnos-
 ticated in the  human female as easily as the number of pups in
 the uterus of a pregnant bitch are counted by the dog fancier.
   A uterine tumor, impacted rectum or distended bladder should
 not be mistaken for the fcetal head.  Peculiar symptoms which
 generally accompany such an abnormal condition of things are
 generally present, but as they  may be  overlooked, it is  best to
 remember that they are  liable to be misunderstood.]
    Many  Methods  of Inducing Premature Labor  have
 been practised.   The earliest plan adopted—that which followed
 the great consultation of accoucheurs in 1756, about a century
 ago—was that of puncturing the membranes with a quill, sharp-
 ened at the  point.  Afterwards, a stilette, or stiletted catheter
 was used.  The  objections  to  this form  of operation are, that
 by the evacuation of the waters at the commencement of labor
 the chances of saving the fcetus  are  considerably diminished.
 It is also dangerous to perform  it  in the  early months of preg-
 nancy, particularly in primiparae, owing to the undeveloped state
 of the os and cervix uteri, and fatal results have followed its adop-
 tion when performed in this way in the latter months.  The dila-
 ation of the os uteri is effected by tents, the  separation of the
 membranes  from  the os and  cervix uteri by a catheter, a large
 bougie, or the uterine sound, the administration of the ergot of
 rye, preferred by Dr. Ramsbotham, the use  of  electricity, the
 application of cupping-glasses to the mammae, as practised by
 Scanzoni, and by other means.   But in all these  applications, a
 considerable time often elapses  before effective uterine contrac-
 tions can be excited, and in some cases the uterus refuses to  obey
 the calls of such  stimuli.
  A method superior to all others, where the safety of the child
 especially is an object, is that  of the  Water-douche, said to
 have been practised in Holland, but introduced in a systematic
 manner into  practice, and  methodized, by the  late Professor
 Kiwisch, of Wurzburg, a man of rare obstetric  genius.  If  a
stream of hot or  cold water  be  directed against, or still  better,
within the os uteri, at intervals of three or four  hours, for the 
664
TIME FOR INDUCING PREMATURE LABOR.
space of ten  minutes or a quarter of an hour  at  each applica-
tion, labor is certainly and  speedily brought  on.  The water
may be made, by means of a syphon and  reservoir, to descend
upon the uterus from a height, or it may be forced into the os
uteri by a common injecting apparatus or  an  O'Beirne's tube.
Kiwisch explained the modus operandi of the douche on the sup-
position that  it caused swelling of  the parts by the imbibition
of fluid, and  separation of the decidua from the uterus.  Proba-
bly the  reflex and  peristaltic  actions  of  the  uterus are also
excited, and  I  have found the  douche more  efficacious when
warm  and cold  water have been injected alternately,  than
when either warm or cold has been applied alone.  The great
superiority of this method consists  in  the  fact  that premature
expulsion, excited through its means, is more certain, and it is a
closer resemblance to natural labor than can be obtained in any
other mode.  There is no risk of any injury to the os uteri and
the membranes remain unruptured, during  the  stage  of dilata-
tion, just as in  ordinary labor.  Hence it  happens that the os
uteri is dilated by the influence  of fluid pressure, and  the fcetus
escapes compression in the early part of labor.  These circum-
stances  are attended by such obvious  advantages, that in  my
opinion no  one would be justified in puncturing the membranes
in a case in which labor was brought on  to save the mother
and the child, or in circumstances where the child alone was in
danger.  The membranes certainly cannot be ruptured as a pre-
liminary to  the  induction of labor without  diminishing the
chances of  saving the child.  I  repeat,  the use of the douche
possesses great advantages in all cases in  which the safety of the
child is an  object.  [For other particulars  see page  520.]  In
cases where there is no possibility  of giving birth to a viable
child, the stiletted catheter or other means may be resorted to, but
even then the douche promises the greatest safety to the mother,
except under  certain circumstances presently to be  mentioned.
  It remains  to say a few words  as to the  Time  at which  the
operation has to be performed, and  as to  the methods of opera-
ting to be preferred in the earlier and later  stages of gestation.
When the premature expulsion of the ovum is  requisite in the
middle months of pregnancy,  or at any time between the fourth
and seventh month, purely with  reference  to the  safety of the 
            METHODS OF INDUCING PREMATURE LABOR.       (565

 mother, the use  of the douche is, I believe, the best method.
 In the early months, while the cervix uteri  is as yet unde-
 veloped, and the ovum is contained in the  cavity of the fundus
 uteri, the douche cannot be relied on.  I have been  consulted
 in one case of marasmus from excessive vomiting during  early
 pregnancy, in which death occurred before the douche could be
 brought to bear.   In these cases, the plan 1 have adopted is, to
 introduce the uterine sound into the uterus, and turn it round
 once or twice, an operation which, according to my experience,
 never fails  to induce the expulsion of the ovum; and  is, I
 believe, attended by little risk, when carefully performed. After
 the third or fourth month, and before  the end of the seventh,
 the membranes may be punctured with the  stiletted catheter.
 At this time there is no expectation of saving the child, and the
 size of the head is not such as  to render the retention of the
 liquor amnii of any consequence.  Before the fifth month it is
 dangerous to use  this instrument.
   For a considerable time, the  operation was not considered
justifiable  in primiparous women.   It was considered  that at
least  the experience of one labor  was necessary in order to
judge of the propriety of  inducing  premature  labor  in  any
 given case.   At present, however, if a woman pregnant for the
 first time passes from any cause into imminent  peril  of death,
 and this peril is increased or caused by the existence  of preg-
 nancy, it is  considered perfectly justifiable to obtain the expul-
 sion of the contents of the uterus.  Again, if a woman in her
 first pregnancy is found  to be so  deformed as to render the
birth of a living child  impossible, it is held to be quite right to
induce premature labor in the early or middle months of preg-
nancy, and not to wait for the danger of her first delivery, and
the performance  of craniotomy.  In cases of  doubtful capacity
of the pelvis, or when the state of the pelvis has not been ascer-
tained before the  time of the first labor,  but in which craniotomy
has been necessary, or  in which children have  been  stillborn,
and the mother  placed in danger from  decided disproportion
between the head and the  pelvis, the practitioner should always
insist upon the necessity of inducing premature labor in future
pregnancies.  In  this way the  lives of multitudes  of children
and  of many mothers might  doubtless  be saved.  A great 
666      MAJORITY OF  STILL BIRTH3 AMONG THE RICH.

responsibility is incurred  by allowing women with moderate
contraction of the pelvis to go on to the full time in successive
pregnancies and thus sacrifice successive children.   It is proba-
ble that the practice  of the induction  of  premature labor will
be extended from a greater knowledge or increasing apprecia-
tion of its importance,  and also from a  real increase in the cases
calling for it.  Amongst the manufacturing population deformi-
ties of the pelvis are probably on the increase, and amongst the
educated classes, the size of the fcetal head, and delicacy of con-
stitution, will form impediments to labor in an increased  num-
ber of  cases.   It is amongst the  educated classes that the
greatest number of still births occur, and  that  the  greater suf-
fering and danger to both mother and child are met with.  At
the present time there  is no point of progress in the obstetric
art of equal importance with the extension of the induction of
premature labor, in cases calling for the operation.
  The extension of the induction  of premature labor  in  cases
where mothers  have,  in  successive births, produced still-born
children, is  one of the  great means to  which we must look for
the diminution  of  the  mortality amongst  children at  birth.
Every man  engaged in the special or general practice  of mid-
wifery must have met  with cases in which healthy well-formed
women have produced  a considerable number of still-born child-
ren in successive births, or in which out of large families, only
one or two have survived the birth.  It is to  such cases  that the
induction of premature labor is peculiarly applicable, and  in
which it is at the present  time but little practised.  In  cases of
this  kind  the chances of saving the child  may be greatly
increased by the operation, without risk to the mother.  A vast
amount of prejudice has, however, to be  got over, before this
subject will be placed  on its proper footing.   I saw, a year or
two ago, a  case with  Dr. Trouncer, in which premature labor
was brought on after  the mother had given  birth to several
dead  children in succession ; on this occasion a live child was
born, but in the next pregnancy the patient declined the opera-
tion,  and another still-birth occurred.   Similar instances must
constantly happen.  In a  matter  of this kind, it is only slowly
that a great improvement can be carried out.  It  is computed
in a letter by Dr. Farr to  the Registrar-general, on  the " Causes
of  Death in England in 1854," that the proportion  of still-born 
STATISTICS  OF STILL BIRTHS.
667
to live-born children is about three dead to every one hundred
born living.  The total number of births in England and Wales
in 1852 was computed to  be 646,134.   Of these 624,012 were
born alive, and 22,122 were estimated to have  been still-born.
In France, in the same year, the number  of children still-born,
or dying before the registration of birth, was  68,267.  This  is
an immense number of children, the  great proportion  of whom
are lost during, or  immediately before, the act  of parturition.
There  can be no  doubt that the number  might  be greatly
diminished by the extension of the practice of the induction of
premature delivery in proper cases.  Carrying the mind from
England and  France to the other countries of  the  civilized
world, the mass of infant life, to the  saving of which  obstetric
science must address itself by these  and  other  means, is enor-
mous in amount.  Every man must regret the necessity which
sometimes occurs for sacrificing the ovum before it has become
viable ; but no operation can be performed with greater  plea-
sure than that which rescues the infant, or the  mother and the
infant, from the risk of death. 
LECTURE  XLVI.
                         TURNING.

  u^ntlemen :—The operation of Turning is called for under a
variety of circumstances, some of which arise out of the nature of
the presentation or the state  of the fcetus, and  others  from the
condition of the mother.   In some cases the  operation is per-
formed with a view to the safety of the mother alone ; in others,
it is the safety of the child which chiefly calls for the operation ;
and in a third class of cases  it is resorted to both on account of
the mother and the child.   It is necessary to consider the
several conditions calling for the operation, as the method of
executing it varies considerably, according to the state of the
mother and the child.  There are two chief kinds of turning or
version—one termed Podalic Version, in which the feet or a
single foot has to be brought  down ; the  other,  Cephalic
Version, in which  the head is brought into  the pelvis,  some
other part having presented  previously.   But this latter is only
practicable  or  attempted in rare cases; and by turning, the
operation  of bringing  down the feet, or a foot, is understood.
In some cases, what is  termed Pelvic version is recommended,
in which  the case  is  converted into a  breech  presentation.
Cephalic and Pelvic version will be adverted to hereafter.
  Turning, or podalic version, is required in cases of hand, arm,
or shoulder presentation, when, except in the rare occurrence of
spontaneous evolution, labor can never be allowed to proceed
without great danger to the mother and child.   It is also some-
times resorted to in  prolapsus of the umbilical cord.  It is called
for in cases of placenta praevia, as offering a much better chance
of life to the child than the detachment and removal of the pla-
centa, and, except in extreme cases, being quite as safe for  the
mother.  It has to be resorted to in a considerable number of
circumstances in which the patient is in  danger  from the con-
    668 
TURNING A  SERIOUS OPERATION.
669
 tinuance of labor, but in which craniotomy cannot or ought not
 to be performed;  such as haemorrhage occurring  during the
 course of labor, and irrepressible by rupture of the membranes
 or other means; convulsions; rupture of the uterus and escape
 of the child into the abdomen; excessive debility ; fainting; and
 dangerous vomiting.  The balance of evidence would also appear
 to be in favor of the performance of this operation in some cases
 of moderately contracted pelvis, in  which craniotomy would be
 required in delivery by the hand.  But the application of turning
 to such conditions is one of the agitated questions of the day, which
 requires the sober and dispassionate consideration of all  who are
 interested in the  establishment  and advance of  obstetrics.   In
 some cases of twins, in which the second child presents  with the
 head, but where no progress is made,  and where the head  is too
 high to admit of the application of the forceps, turning becomes
 necessary and proper.  Turning has been also recommended in
 cases where the mother has died during labor ; but the mortality
 of children after turning, in such cases, is much greater  than in
 the Caesarian section.
   Turning is a serious operation, both as regards the  contingen-
 gencies in which it is required, and  as regards the  direct conse-
 quences of the procedure to the mother and child.  Some of the
 conditions in which it is called for, as convulsions, rupture of the
 uterus, and placenta praevia, are themselves highly dangerous.
 In the performance of the  operation also, uterine  inflammation
 may be excited, the uterus  may be  ruptured or  perforated, and
 the shock of the operation is fatal in some cases.  .The danger to
 the cliild arises from the compression of the funis during  the pas-
 sage of the thorax and head, and the extension of the neck of the
 child in passing through  the  pelvis or the  ostium  vaginae.
 According to the statistical researches of Dr. Fleetwood Churchill,
in 419 cases in which the  result to the  mother was  noted, 29
deaths occurred, or 1 in 14£; in 792 cases in which the result to
the child is stated, 294 children were born dead, or rather more
than 1 in 3.  This  mortality, especially as regards the  mother,
must, however, be divided between  the operation itself, and  the
dangerous contingencies in  which it is sometimes required.
  The hand to be used in turning is a matter worthy of consid-
eration.  Two things weigh  here;  first, the hand which most
easily adapts itself to the different conditions in which  turning 
670
WITH WHICH HAND TO TURN.
is required ; the second, the hand with which the  operator  pos-
sesses most skill and  power  of manipulation.  It is best, as far
as possible, to  accustom ourselves  to  the use  of  both hands in
obstetric practice, so as to  acquire a readiness in the use of
the left hand as well as  the right; but for persons  who are awk-
ward or unpractised with the left hand, the  greater mechanical
facilities for its introduction, in some cases, will not at all  com-
pensate for the greater power  and freedom possessed  by the
right hand and arm.   One thing should be  especially borne in
mind—namely, to use at the commencement that hand with which
we shall be able to complete the operation, so as not to fall upon
the course of being obliged to withdraw one hand in order to
substitute the  other, after the operation has been in part  per-
formed.
  In placenta praevia, the hand to be introduced should  depend
in part upon the situation of  the separation of the placenta from
the os and  cervix uteri,  or, in cases of partial placental presenta-
tion, upon the portion of the os and  cervix  uteri to which the
placenta is attached.  When the placenta is separated from the
anterior or  left border  of the os and cervix uteri, or when it is
attached only to  the  posterior or right margin of the  uterine
aperture, the right hand is  most convenient.  When  the oppo-
site  state  of things  is  met  with—that  is, when the placenta
is detached or wanting,  posteriorly, or on the right side of the os
and cervix, the left  hand is most readily introduced into the
uterine cavity.  A chief object, in such cases, is to pass the hand
through the os with as little detachment of the  placenta  as  pos-
sible.  When  the  operation  is called for by some condition of
the mother, and the head presents, the mechanical facilities of
passing the hand and reaching the feet are modified by the situa-
tion of the vertex.  It is easier  to pass the  hand over the  face
than the vertex, and the feet of the child are usually found on
the same side as the face.  Thus, in the first and fourth positions,
the left, and in the second and  third positions, the right hand
would be most convenient.   When the head is known to present
but the special presentation cannot be made out, it must be taken
for granted that the head presents in the first position, that  pre-
sentation occurring in from 70 to 80 per cent, of all head  presen-
tations.  But when the  head  is so high as  not to be reached for
diagnosis, it matters  comparatively  little which hand  may be 
             TURNING WITH RIGHT HAND EASIEST.           671

used.  In turning in presentations of the upper extremity, the
hand to be used should depend on the circumstance of whether
the anterior part of the child be towards the abdomen or the spine
of the mother.  In  the first  position, in arm cases,  when the
abdomen of the child is towards the spine of the mother, the left
hand is most  convenient.  In the second position, in arm  cases,
the abdomen of the child is towards the abdomen of the mother,
and  the  right hand  of the accoucheur should be emplo}7ed.
Turning, when the right hand can be most  readily employed—
that is, when the abdomen of the child and  the extremities are
directed towards the abdomen  of the mother,  is more easy than
when the fcetal abdomen is turned towards the spine, on account
Fie. 153.
 Introduction of the hand into the uterus, and grasping the feet of the child in vertex pro-
mentation.

of the greater depth of the pelvis posteriorly as compared with
the anterior, and the less distance the hand  has to  traverse to
reach the  uterus  in  front.   In all cases of doubt, therefore, or
when the facilities of passing the hand  in  any  direction are
equal, the right should be  preferred, both  on  account of the
greater ease with which it reaches the uterus, and  the greater 
g^2                POSITION FOR TURNING.

skill in manipulation possessed by almost all  persons with  the
right hand.
                           Fig. 154.
      Withdrawa of the hand, and bringing down the foot, in vertex presentation.

  As  a preliminary to Turning,  and to all operations
within the pelvis, the bladder and the bowels should be emptied.
The position of the  patient varies in different schools and with
different teachers.  In France and America, many of the  best
authorities prefer to have the woman placed on her  back.  In
this coiintry, the ordinary obstetric position on the left side is
generally preferred ;  but the nates of  the patient are brought to
the edge  of the bed.   The accoucheur should not only bare his
arm, but take off his coat, and having introduced some lard into
the vagina, and well greased the arm and  the back of the hand
which it is intended  to use, the operation may be commenced.
The first difficulty  is at the ostium vaginae, and the introduction
of the hand into  the vagina is sometimes the most painful part
of the whole process. The fingers and thumb should be put
together  in a conoidal shape, and gently introduced during  a 
               METHOD OF INTRODUCING THE HAND.          673

 recession between the pains, in the direction of the axis of the
 outlet of the pelvis.  When the thickest part of the hand is pass-
 ing the sphincter vaginae, the patient, if sensible, generally cries
 out, and this cry facilitates the passing of the hand by relaxing
 the sphincter.   When the hand is fairly in  the  vagina, and  the
 os externum embraces the wrist, there is little suffering ; and, at
 this stage of the procedure, a short  pause is advisable, during
 which the accoucheur may make a more complete examination
 than he could with the finger alone, and decide  as to the partic-
 ular direction in which the hand  should be  carried forward
 through the pelvis.  When the arm or a shoulder presents, there
 is a difficulty in introducing the hand into the vagina, not only
 from the state of the os externum, but from the shortness of the
 unoccupied portion of the vagina, and it requires some manage-
 ment to pass the hand into  the vagina in such  a manner as  to
 retain the fingers in a  position admitting of effective manipula-
 tion upon the os uteri.   While one hand is passing through the
 os uteri,  the other should be laid upon the abdomen, so as  to
 steady the uterus, and prevent its being pushed upwards.  Cases
 have occurred in which the posterior wall has been lacerated,  or
 the posterior lips of  the  os  separated  from the  vagina by awk-
 ward and  forcible  attempts under these circumstances.    The
 direction of the hand should, on entering the os  uteri, be altered
 so as to follow as nearly as possible the axis of the middle strait.
 and subsequently the inlet, of the pelvis.
   The further steps of the operation must greatly depend on the
 state of  the os  uteri.   When the  os is fully dilated, and the
 membranes unruptured, turning is  easily effected.  The hand
 should be passed into  the uterus between the membranes  and
 the uterine parietes, the palm of the hand being directed towards
 the abdomen of the fcetus.   ISTo  attempts at pushing the hand
 forward are to be made during the presence of the pain ; but if •
 pains come on at the time of the  passage of the hand, it is to be
 held perfectly still, and slightly hollowed, so as to adapt itself to
 the walls of the  uterus.   Care must, however, be taken not to
 exert pressure upon the umbilical cord by the hand, and parti-
 cularly at its insertion  into the abdomen.  This point should be
 defended, at the same time that as little pressure as possible is
exerted upon the uterine parietes.  With the os uteri dilated,
the waters undischarged, and the uterus in  that comparatively
                             43 
674
CEPHALIC VERSION.
  quiescent state which obtains before  the' commencement of the
  expulsive stage, the whole operation up to this point is compara-
  tively easy, and need not occupy more than a few minutes.  The
  membranes have now to be ruptured by pinching them between
  the fingers ; but little water is discharged  owing to the engage-
  ment of the os uteri by the wrist or arm.  Sometimes, the knee
  or foot of the fcetus can be felt through the membranes before
  their rupture ; at others, these parts are best made out after the
  hand of the accoucheur has passed through the membranes.  If
  we could choose the time at which  turning should be performed,
  we should  select  the  moment at which the os uteri  had fully
  dilated, but the membranes had been unruptured, or we  should
  seek the time at which the membranes had broken, but before
  the violent contractions of the second stage of labor  had com-
  menced.  Most frequently, however, we have no choice in the
  matter, but are obliged to act after the membranes have been
  ruptured, and the uterus has contracted upon the fcetus.
    In some rare instances of transverse presentation, it is possible
  to raise the arm or shoulder and bring down the head, effecting
  what is  called Cephalic version.   In this  operation we  have to
  retrace the steps by which the presentation of the  head is com-
  monly converted into transverse presentations.   The head of the
  child has to be manipulated by the hand engaged in utero, so as
  to bring it to the pelvic brim, with the vertex  directed towards
  one of the sacro-iliac articulations.  After this, the case is  left
  to Nature.  Cephalic  version is very much aided  by external
  manipulation, particularly when the uterus and abdominal walls
  are sufficiently thin to allow of the different parts of the foetus
  being readily felt.  Cases are even recorded, by Martin of Jena
  and others, in which rectification and alteration of mal-presenta-
  tions have been  effected by external  manipulation alone.  In
• pelvic  version the nates  are brought down, but  this is a very
  difficult procedure on account of the lubricity of the parts ;  and
  it is not of very much greater value, when  effected, than Podalic
  version, when one foot only is brought down.
    When the  os uteri is only partially dilated, the passage of the
  hand into  the uterus is a  more difficult procedure.  It is  held
  that when the os is dilated  to  the extent of a crown-piece or
  two or  three fingers  can be  introduced, either with or without
  the rupture  of the membranes, the hand may, with care  be
  passed  in, so as to turn.  The os must be very gently and slowlv 
      TURNING WITHOUT THE WHOLE HAND  IN THE UTERUS.   675

dilated by separating  the fingers, and  urging  them on in the
cone shape used in passing the ostium vaginae, the pressure being
exerted in the direction of the inlet of the pelvis.  Care must be
taken to support  the  uterus externally, and  not to push the
uterus upwards  to such an extent as to  separate it from the
vagina.  When the os  has  been fairly passed by the hand, the
anterior surface of the foetus must be reached in the way already
described.  [This subject is treated upon in Lecture XXXIV.]
  The most difficult of all cases are  those cases of transverse
presentation in which the diagnosis has not been made out early
in labor, or in which the case, from some circumstance or other,
has gone on a long time unrelieved. Here the arm or shoulder is
found low down in the pelvis, occupying  the vagina;  the pre-
senting part is firmly embraced or grasped by the os uteri; the
waters have long flowed away; the uterus has closed with great
energy on  the fcetus,  and  is reduced  to  the smallest possible
compass  consistent with the retention of the placenta and the
non-presenting  portions of  the  foetus.  Thus,  every step  is a
laborious matter.  It is difficult  to introduce the  hand into the
vagina, and still more so to pass the hand, or part of the hand,
into the uterus and raise the presenting  parts of the child.   It is
only by slow degrees that the difficulties can be surmounted so
far as to  allow the lower extremities of  the child to be reached.
There are, however, some  circumstances which, to a certain
extent, counterbalance these unfavorable conditions.  In trans-
verse cases the shape of the uterus is considerably modified.  Its
greatest diameter is the transverse instead of the perpendicular,
and consequently the lower  extremities  of the  child are much
nearer the os uteri than in vertex cases, or in arm cases where
the waters have not escaped.  It  is therefore unnecessary, and
indeed impossible, to pass the hand far into the uterus, and fre-
quently a foot or arm can be brought down by the introduction
of one or two fingers only within  the os uteri,  the bulk  of the
hand remaining in the  vagina.  I learnt this manipulation from
Dr. Robert Lee, and I  have several times been able to turn with
only two or three fingers in the  uterus.  This is a great advan-
tage, as the introduction of the whole hand under such circum-
stances increases the risk of lacerating or bruising the uterus, or
causing the organ to rend itself by the violence of its own con-
tractions.
  Formerly the dilatation of the os uteri in cases of constriction, 
676
OF RAPIDITY IN TURNING.
or the relaxation of the uterine spasm in cases where the waters
had been long expelled, and the pain produced by the operation
were difficult  and anxious matters.   Bleeding to  syncope, the
hot bath,  emetic tartar, and opiates, were relied  on for these
purposes.   Chloroform is, I  believe,  preferable to  any of these
means, unless, indeed, bleeding should be required  by some con-
stitutional condition  of the patient.   The inhalation of chloro-
form relaxes contraction of the os uteri, the ostium vaginae, and
body of the uterus, in addition to the immunity from pain which
it produces.   I am confident I have delivered, by turning, under
chloroform, in cases  of arm presentation, where it would  have
been impossible to have turned without its use.
  The mode of seizing the fcetus, and completing the process of
version, varies  in the different  circumstances in which turning
is required.   When  we turn to save the mother from imminent
danger, the operation should be performed as quickly as pos-
bible, due regard  being had to  the fact that a too  rapid extrac-
tion of the child increases the shock  of the operation.   Under
these circumstances,  the two feet of the cliild should, if possible,
be brought down, and gentle traction should be exerted, parti-
cularly during the pains, until delivery is effected in the manner
described when speaking of footling presentations.  When the
waters are retained,  it  is astonishing what a small amount  of
traction will  effect the version of the child.  Simply holding
one foot, or both feet, in the lower part of the uterus, while the
organ is exerting its moulding and contractile efforts on the rest
of the child, will often cause the head or shoulder to  rise, and
the feet to descend.   Holding on upon the feet or foot is all that
should be attempted  during the pains. Any traction that  may
be required should be exerted while the uterus remains passive,
until the foot or feet  descend through the os uteri.  When the
object in turning is not the dangerous state of the mother, but
the condition of the child, the operation should be  performed as
leisurely as possible  until pressure comes to be  exerted on the
umbilical  cord.  With  this view, one foot, rather  than  two
should be brought down.  We have seen that  in cases where
the breech presents  the  mortality is  1 in 31, while in cases in
which  the  feet present the  mortality is 1 in  2£.  In  bringing
down one foot, we assimilate the case to breech  presentation.
In a case  in which  one foot is brought  down, and the other 
              BRING DOWN ONE FOOT IN TURNING.          677

extremity remains flexed upon the abdomen, the circumference
of the presenting part is from 11 to 12£ inches;  when both feet
come down, the  circumference of the breech is from 10 to 11£
inches.   It is therefore safer to bring down one foot  in turning
when the operation is performed with reference  to the fcetus, as
the greater dilatation of the soft parts by the pelvic  portion of
the child favors the descent of the head  and the defence of the
umbilical cord from pressure.   When it can be reached before
the foot,  there is an  advantage in bringing down the knee, as
the axis of the trunk and thigh is less than the axis of the trunk :
and the whole extremities  of the child.
  In Arm Presentations, the knee  or foot of the side opposite
to the extremity presenting should, if possible, be brought down,
as, when this is the case, version is more easily performed  than
when the foot or knee  of  the  same  side is  grasped.   To effect
this, the hand of the accoucheur should be passed up  along the
inner side of the  arm presenting, which  will  guide it to the
Fra 155.
 Turning in transverse presentation, in the abdomino-anterior position, wth the right hand.

anterior surface of the  child.   If the foot is below the knee, it
should be brought down.   The rules for distinguishing between 
678
INSTRUMENTS  TN  TURNING CASES.
the foot and hand, or knee and elbow, have already been dwelt
on, when  the  various presentations of these parts were under
consideration.    In the case of turning  on account  of pelvic
deformity, the object being to bring the head through the pelvis
as quickly as is consistent with the safety of the child, both feet
Fig. IL3.
  Turning in transverse presentation, in the abdomino-posterior position, with the left hand.
                                                i
should be  brought down if possible.   When one foot is per-
ceived, and can be  brought through the os externum, a tape or
handkerchief should be  put round it to enable the accoucheur
to hold  it  more securely.   The foot is slippery, particularly if
the child is covered with  caseous matter, and the foetus  has a
tendency to be drawn upwards on the subsidence of every pain.
In delivery, the same treatment is to be adopted as that directed
in knee or footling cases, only that greater expedition in effecting
delivery must be followed according to the special exigencies of
the child or the mother.  The forceps  ought always to  be in
readiness  to  complete, if necessary,  the delivery of  the  head.
[The  tractor referred  to in a following lecture will often be
found of service to deliver a retained head ;  the time required 
Simpson's views on turning.
679
for its introduction being half that of the forceps, and the power
nearly equal.   I have used it with success.]  After all cases of
turning,  the  patient should  be carefully watched, with a view
to the prevention of local inflammation.
   I have already referred to the question of the performance of
Turning, in the Place of Craniotomy, in cases of contracted
pelvis; and the subject is of so much  importance that I shall
endeavor to  give as  succinctly as  possible an  outline of Dr.
Simpson's theory and  practice upon this point.   I would  pre-
mise, that  seventy or  eighty years  ago,  turning in cases of
deformed pelvis was a  recognized practice, and is treated of at
considerable length by Denman and other writers of that period,
as a recognized mode of procedure;  so that Dr. Simpson's pro-
posal to  turn in  the  present day, is a revival of the  practice
which had fallen into disuse rather than an innovation.   Nume-
rous cases of deformed  pelvis are on record in which turning
has been practised from choice, or in which the  feet or nates
have  presented, and delivery has  been accomplished without
material  injury to the  mother; and  these cases  naturally  sug-
gest the  establishment of the operation* as  a  rule of  practice
under certain conditions. The following points in the anatomy
of the foetal  head with reference  to difficult parturition, are
strongly  insisted upon by Dr. Simpson.  The bi-parietal diame-
ter exceeds  the bi-mastoid diameters by from half an  inch to
three-quarters of an inch.  In delivering by turning, the bi-mas-

                           Fic. 157.
         Section of foetal skull,  a, a, Bi-parietal; &, 6, Bi-mastoid diameter.


toid, and, in vertex cases, the bi-parietal diameter  first engages
in the pelvis.  The great question is, can the fcetal head, under 
680       COMPRESSION  OF HEAD  IN DIFFERENT PARTS.

all  the circumstances of pelvic  deformity,  pass  through most
readily with the bi-parietal, or the bi-mastoid diameter first ?
  The bi-mastoid diameter is  comparatively incompressible, in
order  to defend the medulla  oblongata, the nodus vitalis  of
foetal as well as of adult life ;  but the bi-parietal diameter may
be compressed to a  great extent without destroying the fcetus.
In children born alive, it has been found considerably flattened,
indented, or even fractured, in cases of deformed pelvis  with a
diminution of the conjugate diameter.   The bi-parietal  diameter
varies in the  natural fcetal cranium from 3£ to 4 inches, but it
may be compressed  to 2£ or 3  inches, for the short time  during
which the head  may be drawn through the pelvis, without
necessarily destroying the child.   Denman was of opinion that
the living fcetal head would bear a greater  amount of  compres-
sion than this.  In  delivery by turning, the child  is  drawn
through the  pelvic  opening;  in vertex delivery, it is pushed
through from behind;  and  there   are   many  instances  in
mechanics, in which bodies can be drawn through the  openings
which no amount of force applied from behind would make
them pass.  In the case" of the fcetal head and the deformed pel-
vis, Dr. Simpson believes that  in vertex labor, when the vertex
does not readily enter the pelvis, it is  bulged or  squeezed out
laterally, and the bi-parietal diameter increased, by the pressure
of the body of the cliild under the influence of uterine contrac-
tion.   This is illustrated by the following figure :

                          Fig. 158.
  Section of total skull. The dotted line a a,bb, o c, represents the normal outline. 12 2
•sents the alteration produced by the compression described.
  When the  bi-mastoid diameter first comes into the  pelvis  £
different form of compression occurs.   When  the  vertex des 
            ANATOMICAL  CONSIDERATIONS IN  TURNINO.        681

cends first, it is the base of the cone formed by the foetal head
which first attempts to pass through.   When the bi-mastoid dia-
meter  presents at the pelvic brim, it is  the apex of the cone
represented by a transverse section which passes first.  The ten-
denc}'-  of the bi-parietal diameter is to increase in vertex cases,
when the vertex does not readily enter the  brim; but when the
bi-mastoid diameter enters the pelvis first, and is drawn through
it by traction applied to the foetal extremities, the larger or bi-
parietal diameter is readily compressed to a considerable extent.
This point has already  been  referred  to,  and  admits of easy
demonstration.
  Other mechanical arrangements  facilitate the descent of the
head face foremost, as compared with the descent of the vertex.
The bi-temporal  diameter is usually  from three to five-eighths of
an inch less than the bi-parietal.   In vertex presentations, the
chin of the  child is bent upon the  sternum; the result is that
the vertex and the bi parietal portion of the head enters the pel-
vic strait,  first,  and  with the  bi-parietal  or  larger  diameter
opposed to the  conjugate diameter.  In delivery by turning, the
chin is extended, and the  bi-temporal diameter descends first
and  nearer  to  the  conjugate diameter, the bi-parietal  being
received in  the lateral and widest part of the pelvis.   The sub-
joined diagram  exhibits  the passage  of the head through a
deformed pelvis in turning.
  These are the chief anatomical considerations relative  to the

                            Frc, 159.
 Section of fcetal skull, a a,bb, normal outline, 11, 2, outline of skull, as compressed in turn-
ing.
proposed  mode of  practice.   Dr. Simpson insists greatly upon
the fact that it can be  performed  early, and is  in this respect 
682
TURNING  VERSUS ORANIOTOMY.
favorably contrasted with craniotomy, which must be performed
late, and after the woman has been subjected to  the perils of
protracted labor.  The patient also escapes the risk of injuries
to the  vagina and soft parts by instruments.   The foetus, it is

                           Fro, 160.
 Deformed pelvis and compressed fcetal head.  A, promontory of sacrum; B, symphisis pubis; 0,
space between forehead and ilium; D, depression in fcetal head ; E F, anterior and posterior fon-
tanelles.
well known, is in the state of an amphibious  animal, and bears
a short interruption to the utero-placental circulation without  a
necessarily fatal result; and Dr. Simpson believes that the cord
may generally be guarded to some extent by being placed at the
sides of the pelvis, in the position affording  most room.   It is
in deformed pelvis with diminished antero-posterior diameter, or
oblique deformity, that turning promises the  greatest chance of
safety to the mother and  cliild, and not in the contractions of
the  transverse diameter.  The limits of the  deformity within
which a living child may pass in turning have yet to be deter-
mined.   Dr. Fleetwood Churchill puts it at two inches and six-
eighths ; but as the  limit for the passage by  the vertex is three
inches and a quarter, a considerable latitude  for the operation
of turning exists.    The  objections to  the  measure  are—the
injuries  which may be  done to the  mother; the  difficulty
of diagnosing the proper amount of  deformity and the difficulty
of performing craniotomy when turning has been tried, in cases
where  the head cannot be delivered without  reduction.  As
regards the injuries done to  the mother, the cases on record do
not shew them ; and it was the opinion of Denman that cranio-
tomy in such cases was almost as easy as in cervix presentations,
so that  there is every reason  to hope that with the knowledge
 we now possess of  the condition of  the  fcetus  by auscultation, 
SAFETY OF  TURNING.                   683
and the advantages afforded by chloroform in such cases, turn-
ing  will  be performed, and  a chance of safety afforded to the
child, where craniotomy was considered the only resource.   It is
probable that the practice will hereafter be combined with the
induction of  premature  labor in cases of  pelvic  deformity,
where the conjugate diameter is even below two inches and six-
eighths.
Introduction of the first blade of the short forceps, with the mother lying on the side. 
LECTURE  XLYII.
                       THE FORCEPS.

  Gentlemen :—Chapman, who first published to the world an
account of the Forceps, calls  it  a " noble  instrument;"  and
well might he do so, since it has probably saved more lives than
any mechanical invention ever  discovered.  We owe the  pro-
duction of the forceps to Dr. Paul Chamberlen, who, with his
three sons, kept the matter a secret for their own benefit during
sixty or seventy years.  It has now been in use upwards of two
centuries, and  though all agree  as to  its incalculable utility,
there  are  some points respecting its formation and application
upon which obstetricians  are not yet entirely agreed.  The  first
intimation of the  discovery of the  forceps was in 1647, by Dr.
Peter Chamberlen, who gives the merit of the discovery to his
father, Dr. Paul Chamberlen. In 1762, another son, Dr. Hugh
Chamberlen, refers to the discovery as one to which his  father
and brothers had, " by God's blessing, and their own industry,
attained to."   The invention gradually became  known, but it
was not until  1733 that  Chapman published a description and
plate of the instrument.   Measureless censure has been heaped
upon the Chamberlens for their conduct in keeping the discovery
of the forceps a secret.  It is a great principle that no invention
and discovery in an art like medicine  should be withheld from
the common good; but  in condemning  the Chamberlens, we
must remember the age and  fashion of the time in which  they
lived, when monopolies in various branches of trade and  manu-
facture were held by the nobility, and even by royalty itself.
We have  evidence that  at least one of the  Chamberlens,  Dr.
Hugh, could suffer for conscience' sake, in  the fact of his flight
into Holland on account of espousing the cause of James II.
  The short straight Forceps,  termed Denman's forceps,
chiefly in use in this country at the present day, is essentially
   6S4 
CONSTRUCTION OF FORCEPS
635
the same instrument as that devised by the Chamberlens.  (Cut
161.)   The chief alterations and improvements made in it were
Short straight forceps.                        Short curved forceps.
the work of Smellie.  The most perfect Chamberlen forceps had
the handles bent in the form of hooks ;  for these Smellie substi-
tuted handles of wood.  As Chamberlen left the joint, it resem-
bled that of the common  scissors, but without the pivot, the
joint being  made secure by a piece of  tape or  cord passed
through a hole in each  blade, and wound round them after they
were put in apposition.  In  another specimen of the Chamber-
len forceps, one blade is provided  with a fixed pivot, to receive
upon it the other blade and secure it.  This is called in the pre-
sent day the German lock, and has been improved upon in the
instrument called Naegele's forceps.   In lieu  of these some-
what clumsy arrangements, Chapman invented the lock now m
use. 
686
PARTS OF THE FORCEPS.
  This forceps, known as the straight forceps, consists of two sepa-
rate blades, which are introduced separately and which, by lock-
ing, are converted into one instrument. These are called the left
hand or male  blade, and the right hand or female blade.   Each
blade consists  of a handle, a shank, and the curved  portion or
clam, which adapts itself to the side of the head of the  cliild.  The
ordinary straight forceps now described has but this one curve,
which may be called the Cranial curve, as its special relation is
to the head of the child.  The length of the curved portion of the
blade is about eight inches. The curved portion of each clam  con-
tains a fenestrum or opening fitted to receive the parietal  pro-
tuberance, and when both blades are in apposition, to allow the
foetal  head  to protrude  somewhat  through the  sides of the
instrument.   The  length of  the whole  instrument is  about
twelve inches.   The distance between the most curved portions
of the  clam is about three inches.  When the handles are in
perfect apposition, the extremities of the two clams are about an
inch apart.    The length of  each fenestrum  is  about three
inches.  When the instrument is in action upon the  head, the
extremities of  the handles are about one inch asunder, and not
close together as when the instrument is held  in the  hand.   Its
whole weight should not exceed twelve ounces.   Of course  it is
necessary  that the steel should be of the finest temper, to resist
the force which has to be exerted in some cases of  extraction of
the head.  The edges are bevelled off in every direction, to pre-
vent injury either to  the child or the  mother.  It was formerly
the fashion  to cover the forceps with wash-leather,  this  being
done with a view to make the  appearance  of the instrument
less martial, and to present a soft surface to  the maternal  pas-
sages and the  foetal head.  Some advocate this proceeding at
the present day, but the great majority avoid it, on account of
the increased bulk and difficulty of passing the blades, and also
the risk of carrying the infection of gonorrhoea or syphilis.  The
infectious  principle of contagious fever ought, perhaps, still more
to be held in dread. Some instruments are now sold covered with
gutta percha, but nothing is so perfectly clean or so easy of intro-
duction as the naked metal, anointed with oil, lard, or glycerine.
  This instrument is calculated  for the delivery of the  head
from the lower and also from the middle strait of  the pelvis or
when it has  in great part emerged from the pelvic  canal and is 
WHEN THE FORCE PS ARE  TO BE USED.
687
resting on the perinaeum.  The circumstances which all admit to
call for the use of the forceps, are the arrest of the head in the pel-
vis or at its outlet, from entire failure of the pains, or such a condi-
tion of the mother or the child as would place either or both in a
state of risk in the event of delivery not being completed.   Its
most common use is in cases of suspended labor from inactivity
or exhaustion of the uterus.  The forceps should never bo  used
when the child is known to be dead, so that auscultation will re-
quire to be carefully practised in all cases where the necessity for
the use of the forceps is anticipated.   As compared with cranio-
tomy is may be said to be  a child's operation ; but the forceps is
not entirely, as  Dr. Meigs would teach,  a  child's instrument,
since it is sometimes used  quite as much for the  safety of the
mother as of the  child.   Besides failure of uterine action,  it is
sometimes called for in consequence of moderate deformity of the
pelvic outlet.  In cases of twins  it is occasionally necessary to
use the forceps to deliver the first  child, when the head presents.
It is  used in face  cases,  particularly when  the  head of the
child is large, and the pelvis of  only moderate dimensions. In
occipito-posterior presentations, when the  head is  large,  and
especially in first labors, the forceps may become necessary. In
cases  of arm-presentation with  the head, the  forceps may also
be required.   The instrument is used in some cases of funis pre-
sentations ; in cases of turning, or breech-presentation, in which
there   is  difficulty in delivering the head; in rupture of the
uterus, when the  head is low down, and is not retracted to  any
great  extent; and in cases  of convulsion, flooding, or any other
accident of labor, which may render immediate delivery neces-
sary to save mother and child from peril.  The forceps is  more
often called for in primiparae than  multipara.
   The Conditions necessary to  the use of the  Short
Straight Forceps are, that the os uteri should be well dilated,
and partly or entirely retracted over the head of the child.   Dr.
Meigs  says that " a man shall hardly be justified who inserts his
forceps within the os uteri.  He must wait  until the neck has
risen   above  the  parietal protuberance,  and can  no longer
be  felt."  Dr. Ramsbotham states that it may be  used in
some  cases  where  as much as  a third part of  the  circu-
lar  margin  of the os uteri can be felt.   I have no doubt what-
ever that its  use  is often  perfectly justifiable, when the upper 
 688          RULES FOR APPLICATION OF FORCEPS.

 part of the blades must enter the os uteri  to extract  the  child.
 Dr. Lee insists greatly upon the full dilatation of the uterus, and
 says that the  " greater part" of the head must have escaped
 from the uterus before  the forceps  can be  safely used.   Cases.
 however, occur in which the anterior lip can be felt in front of
 the head, when it rests on the perinaeum ;  and  others are  met
 with, in which, though  the  os  uteri is fully dilated, it  is not
 retracted   above  the  head.   With  many distinguished ac-
 coucheurs  it is laid down as a rule never  to  apply the forceps
 unless an  ear can  be  felt.  The late Dr.  Merriman especially
 affirmed that no case can be " esteemed eligible for the applica-
 tion of the long forceps until the ear of the child can be dis-
 tinctly felt."    There can be no doubt of the correctness of these
 dicta, as far as the short forceps commonly is concerned.   [See
 Lecture XXXIV. on this subject.]  Another rule is, that the head
 should have rested on  the  perinaeum six hours, and the  pains
 ceased for this length of time ; but numerous cases  in which the
 forceps is required entirely contravene this dogma.   The use of
 the forceps should never  be attempted when  the os uteri is
 undilated, when the soft parts  are  in  a state of inflammation,
 when the  pains are violent, or when any considerable  pelvic
 deformity exists.
  Very numerous have been the minor modifications of the for-
 ceps, but some of the improvements of the instrument appear
 destined to last as long as the forceps itself shall be necessary.
 I have spoken of  the  single or Cranial curve  of  the original
 instrument. To this, Smellie and Levret added  another  curve,
 the convexity  of which looks towards the sacrum, and the con-
 cavity towards the pubes.  This may be  called the Pelvic curve,
 to distinguish it from the curve already referred to.   One  curve
 has reference purely to the head of the child and the safety of
 the fcetus ;  the other relates entirely to the  pelvic cavity, and is
 solely  intended to shield the  parturient  canal from injury.
 Besides this, Smellie increased the length of the shank or  space
 between the handles and clams, in  connection with the  pelvic
 curve, with a view to the extraction of the head from the pelvic
brim.  This was the forerunner of the long forceps  of the pre-
sent day.
  As regards the addition of the pelvic curve to the short for-
ceps,  authorities differ very  considerably; but  I believe that 
DOUBLE CURVED FORCEPS PREFERABLE.
689
eventually the double, or the cranial and pelvic curve will  be
universally adopted.  By the pelvic curve, less danger of those
Fib. 163.                          I^S, 1S4
's forcePs-                       Radford's forceps.
horrible accidents leading to vesico-vaginal fistula by pressure
on the pubes, and to  laceration of the whole  of the perinaeum
and fusion of the vagina and rectum  by posterior pressure will
be incurred.   The short forceps with  the double  curve  is com-
monly used [Davis's,  and Simpson's modified], we are informed
by Dr. Meigs, in America.   Professor  Siebold  of Berlin, and
many others  in Germany, have adopted the  improved instru
ment, and its use is common in France.  In  this country, to
which the forceps belongs par excellence, the  double curve has
found comparatively little favor, notwithstanding the excellent
instrument and  example  of Dr.  D.  Davis,  chiefly  as   I
                             44 
690        POSITION OF WOMEN IN APPLYING FOKCKPS.

believe because the matter has not yet seized professional atten-
tion.
  The Long Forceps is a most important alteration of the ori-
ginal instrument.  It is not merely a variation of form, but it is
applied to an order of cases altogether different from those in
which the short forceps is useful.   The short forceps is adapted
for the delivery of the head from the  perinaeum, or the middle
strait, or outlet of the pelvis.  The long instrument is suited to
its extraction from the brim of the pelvis, or  even from above
the brim.   For this  reason, the shank  is lengthened, and the
best instruments possess  the double  curve, to adapt  them  to
the axes of the pelvis and the parturient canal.  For extraction
when the head is at the  brim, the short forceps  is altogether
inadequate without risking the laceration of the soft parts of the
mother.  One of  the  earliest anecdotes connected with the for-
ceps,  is that of  Mauriceau, who relates that Dr. Hugh Chamber-
len, coming to  Paris, rashly undertook to deliver a dwarf with
deformed pelvis, who had been left to die by the French obste-
trician, and after several hours of severe exertion was obliged to
desist without completing the delivery.   It is to relieve such
cases, when the deformity is not too great that the long forceps is
peculiarly  applicable, and with the long instrument, Chamber-
len might have been spared his own  mortification and the cen-
sures  of the great French accoucheur.   Dr. Radford has devised
a long forceps in which the blades  are of unequal length,  the
short  blade being intended to go over the occiput, and the Ion"
blade over the anterior part of the head.
  As  a Preliminary to the use of the  Forceps,  the bladder
and rectum should be emptied, and  the  patient brought to the
edge  of the bed  in  the  ordinary obstetric position [upon  the
back].  It is necessary that the nates  should be brought to the
edge,  so as to project  somewhat over  it,  particularly when  the
patient  is stout, to allow of the necessary movements  of  the
handles.  If we do  not  arrange the position  of the  patient
accurately in the first instance, we may have to withdraw one
or both blades  after  the operation has been commenced  and
begin again de  novo.   In the use of the straight forceps  our
object must be to  pass the blades of the instrument  over  the
sides of the head of the child, so as to bring the  parietal  protu-
berances within the fenestra.  We are at the same time oblio-ed 
POSITION OF HEAD IN APPLYING  FORCEPS.
691
to consider the capacity of the pelvis in its different diameters,
and it is found that the blades will pass in one direction when
they will not pass in another.   But our chief  consideration, as
regards the  direction in which  the blades are passed, is to be
given to the foetal head.   The forceps may require to be passed
over the head in any of the directions described  when treating of
the mechanism of labor.  We may have  to grasp the head in any
of the  four cranial positions described.    The most  common
position in  which the forceps  is required is the first, in which
the vertex is directed against the left branch of the pubes, and
it is to this position that almost all the  ordinary descriptions of
the application of the forceps refer.  In this position, the bilate-
ral diameter of the child's  head corresponds pretty accurately
to the right oblique diameter of the pelvis, and it is in this dia-
meter that the head is generally grasped with most facility.  In
the second position, the  vertex is  turned towards the right  por-
tion of the pubic arch.   The third and fourth positions are
merely  the reverse of  the first  and second.   Practically, we
have, in ordinary cases  of head presentation, in  which  the for-
ceps may be required, to deal with the fcetal head lying with its
longest  diameter in the right or left oblique diameters of the pel-
vis.  When the head lies  in the right oblique diameter, we have
to pass the blades of the forceps  in the direction of the two
extremities of the left oblique diameter, and vice versa.  When
the long diameter of  the head occupies the transverse  diameter,
or nearly so, the blades  of the instrument must approach the
antero-posterior  diameter.   When the   head  rests  on the
perinaeum, its long diameter approaches to the antero-posterior
diameter, aud we have to manipulate with the  forceps almost in
the  transverse  diameter  of the  pelvis.   It has always  been
insisted on as a condition  absolutely necessary to the proper use
of the forceps, that we  should  know the exact position of the
head.   For this purpose we are told by  many authors of  the pre-
sent day, to pass  two or three fingers, or  the whole hand,
between the fcetal head and the pubes, to find out the position of
the ear.   But such manipulations  are  quite unnecessary, if we
are familiar with the methods of diagnosing the position of the
fcetal head by the examination of the sutures and fontanelles by
the index-finger,  as detailed when the  different presentations of
the head were under consideration.   This ought to  give us all the 
692
INTRODUCTION OF FORCEPS.
information we require  as  regards the position of the  fcetal
head.
  Taking the first position for our description, the following is
the mode of proceeding with the short forceps :  The first blade

                           Fig. 165.
Delivery by short forceps in first position.
should be held lightly in the left hand, the first one or two fingers
of the right hand being passed a  short distance over the head,
behind the right portion of the pubic arch.  The end of the
blade should now be introduced through the ostium vaginae, and
passed upwards between the finger and the head.  In this pro-
cedure the handle of the instrument requires to be  depressed
considerably.   The end of the blade should be kept lightly but
pretty closely  in apposition with the head as it glides onwards.
With the finger we should aim, if possible, to pass the instrument
over the  ear of the child, and under the rim presented by the os
uteri.  When  these cannot be felt, or when the blade  cannot be
passed, while the finger is at all deep in the pelvis, we shall find
these obstacles are best perceived  and avoided, by holding the 
CARE IN LOOKING THE  FORCEPS.
693
instrument lightly in the hand as a probe.  After the blade has
first come in contact with the head, we must go on depressing the
handle until we have reached the summit of the  cranial  vault.
After this point, the handle has to be raised until it has passed over
the side of the head, in the direction of the right foramen ovale.
Care must be taken not to damage the ear, or the  margin of the
os; and in  case of any difficulty, it is always right to withdraw
the blade partially or entirely, in order to detect the impediment.
The highest skill  in the use of the instrument is to pass it with
the utmost  gentleness.   We should, of course, know the position
of the head in all cases.  But it is not, after all, hair-breadth
knowledge  we require.  The  instrument is so admirable and
perfect  in  its relations to the  pelvis and the foetal head, that
blade, and head, and pelvis, concur in aiding the operator, and
in depositing the  instrument in the  right place.   The genius
of Chamberlen assists,  as it were, at every proper  case in which
his instrument is  employed.   When the upper  and anterior
blade has been passed,  the handle is brought towards the pelvis,'
and held there by an  assistant,  and the spare fingers of the
operator during  the introduction of the posterior or inferior
blade.   It  is more difficult to pass the second blade than the
first, owing chiefly to the  occupation of the vagina by the ante-
rior blade.   The first finger, or two first fingers of the left hand
have now to be passed over the head in the direction of the left
sacro-iliac  synchondrosis; and  the second  blade, held  in the
right  hand, is to be passed, with the precautions  already de-
scribed, over the  opposite side of the head.  The handles  should
now be drawn together, and if the blades have been  properly
applied the handles  lock readily, and the position of the blades
is rendered perfect and fixed by a moderate compression of the
handles.  Great care must be taken to guard the ostium vaginae
during the process of locking, so as not to  pinch or lacerate the
soft parts of the mother.  The inner smooth surface of the han-
dles should always be parallel with each other when the  instru-
ment is rightly applied.  If they are not even, the instrument is
pretty sure to slip or  unlock when  traction is applied.   The
handles  should not be  brought close together, but it is some-
times advisable to tie them, so  as  to prevent their unlocking in
the interval between  the pains, and also  to exert gentle com-
pression on the fcetal head.   During a pain,—when the  pains
have  not disappeared,—the first effort at traction should be 
694
DELIVERY WITH  THE F0RCEP3.
  made in the  direction of the pelvic axis, due regard being had
  to the position in which the child's head has descended.  The
  traction  should be gentle at first, but gradually increased to the
  extent that may be necessary, intervals of rest  being allowed
  when the pains are off, or in imitation of pains.   Besides  the
  efforts of traction, the handles should be  moved a little from
  side to side in extracting, so  as to use  each blade in succession
  as a lever.   As  the  head  descends,  the handles should be
  brought forwards between the thighs of the mother, and as the
  head is  expelled, they should, if the  instrument remains  on,
  sweep over the abdomen in the  direction which the head itself
  would take if its movement were  prolonged.  When the head is
  in the pelvis, we must be careful not to direct the handles too
  much backwards, as this endangers the bladder and the anterior
  vaginal wall  from the anterior blade.  When the head is com-
  ing  into the  world, the hand should not be pressed too far for-
  wards, otherwise the perinaeum is ploughed up by the posterior
  blade.   When the head is passing through the ostium vaginae,
  care must be taken not to lacerate the  perinaeum.  It is best at
kthis  moment  to unlock the  instrument, just as  rowers unship
  their oars to  avoid collision, or the posterior blade may be with-
  drawn altogether, and expulsion allowed  to take place by the
  natural  efforts.    After the operation an  opiate is generally
  administered, the vulva should be fomented carefully from time
  to time,  and  symptoms of  inflammation or  sloughing  carefully
  attended to.   I am of opinion that in cases where the patient
  does not prefer to remain conscious, or when  the head is very
  low  on the perinaeum,  chloroform should be used  in delivery by
  the forceps.   In the first case in  which I used  chloroform in a
  forceps case,  the instrument was applied  to the head without it
  by the medical man who asked  my assistance ; but the patient
  was  of nervous temperament, and on the  slightest attempt at
  traction  her movements were so violent as  to render it impossi-
  ble to proceed, and the alternative was  between chloroform or
  craniotomy.   The advantages of  having the patient quiet and
  free from pain are very great.  The forceps acts as an extractor,
  a double lever,  and  a compressor.  The limits of its action as
  a compressor must depend on  the difficulties to be overcome,
  due  regard being had to the  safety of the child.
    In the other positions of the head, or in face cases requiring 
            FORCEPS IN OCCIPITO-POSTERIOR POSITIONS.        695

assistance, the same general principles are to be followed in apply-
ing the short forceps as those already laid down.  To operate per-
fectly the blades of the forceps should always be applied to the
sides of the head;  they will thus, as the rule, occupy the diame-
ters of the pelvis opposite to those occupied by the long diame-
ter of the head.  One of the most difficult is the occipito-posterior
position, which is not very common, but it has happened to me
to meet with two  primiparous  cases of this  kind in whieh the
forceps was necessary.  One of them I saw with Dr. Guneau de
Mussy, and the other with Mr. Jonson, of Eaton Place.
  The L-ong Forceps is adapted for the completion of delivery
in cases of moderate contraction of the pelvis, especially in the
conjugate diameter, where the head will not  enter the brim, or
descend belovv it,  by  the  unaided force of the  uterus, or where
the head lodges at the brim from any other cause.  When the
head presents at the brim, it will be remembered that the  long
diameter lies in the transverse, as in one of the oblique  diame-
Fia. 166'.
           Delivery by short forceps in antero-posterior position of head.

ters, or more commonly in a position between the transverse and
one of the oblique diameters.   The head of the child is also in 
696
OARE REQUISITE WITH LONG  FORCEPS.
the state of Flexion—that is, with its  chin  bent upon the ster
num.  As a  consequence, the vertex, and not the apex, of  the
vault of the cranium, is the  most depending part.  Under these
circumstances, the blades of the forceps cannot be applied on
each side of the child's head, because these sides are in apposi-
tion with the pubes and the sacral promontory, between which
points  the  constriction  exists.  The forceps are in such cases
introduced with reference to the anatomy of the pelvis  chiefly,
and not to the anatomy of the fcetal head.   The two blades  are
passed up,  one on each  side of the pelvis, and they then  fall
mechanically into, or approach towards that oblique  diameter,
opposite to the diameter which is occupied by the head itself.  The
parts of the fcetal  head actually grasped by the blades  are  the
occiput and the forehead.   The grasp does not, however, seize
the long diameter of the head exactly, but a diameter between
the longitudinal and the  transverse or biparietal.  The  ends of
the blades reach, on one  side to  the  nape of the neck, and on
the other to the base of the brow, but they do not pass over  the
face.  Greater care is necessary in extracting with the long than
with the short forceps, because the direction in which extractive
power has to be exerted is more complicated, and because  the
instrument is more powerful than the short forceps. Care should
be taken not to use such force as may injure the  mother ; and if,
after endeavoring  within this  limit, to effect delivery,  we  are
obliged to resort to craniotomy, we shall perform this operation
with less hesitation or misgiving when we know that  there is
no alternative.
  No doubt, the use of the long forceps is a weighty matter, and
not to be undertaken  without due and  serious consideration.
But the alternative must be remembered—namely, the perform-
ance of craniotomy, and the inevitable destruction of the child.
By craniotomy, too, a considerable  amount of danger  to  the
mother is incurred.  In  cases of pelvic contraction, to such an
extent as not utterly to preclude the possibility of the passage
of a living child, the long forceps should  always, unless some
great peculiarity exists, be tried.  After attempting delivery in
this way, we shall, as already said, certainly resort to craniotomy
with a clearer conscience, than would otherwise be the case.
In London the use of the long forceps has been a subject of grave
dispute.  Dr. Lee, one of the most experienced obstetricians of 
DISPUTE RESPECTING  LONG FORCEPS.
697
this or any other age, may be said to represent those who oppose
its use; but Dr. Ramsbotham and others defend it.  It has long
been used in Edinburgh by Dr. Hamilton and Dr. Simpson.  In
Dublin it has found little favor, particularly at the great Lying-
in Hospital, the different masters having opposed its employ-
ment.  Dr. McClintock, the present master, a most accomplished
and unprejudiced obstetrician, who was  recently in London,
informed me that he had, within a short time, used the long for-
ceps on two occasions with success, and he expressed  himself a
convert to its  use.  Dr. Fleetwood Churchill also recommends
its employment.   Its utility is fully recognized  in  America,
and also in France and Germany.  The chief objection  urged
against the use of the long forceps is, the injury done to the

                        Fi&. 16 7.
         Delivery by Dr. Simpson's long forceps in contraction of the brim.

mother by operations above the brim.  [According to Dr. Sims,
in 70 cases of vesico-vaginal fistula, 41 only were delivered by
instruments.  Dr. Bozeman says, in 19 cases of the  same diffi-
culty, instruments  were used in but  9.]  But most  of these
injuries have been owing to the use of the short forceps in this 
698
VARIETIES OF FORCEPS.
situation, for which they are  not at all adapted.  The  impossi-
bility of introducing the forceps in distortions of the brim has
been dwelt upon, but this difficulty chiefly applies to attempts
to introduce the blades in the antero-posterior diameter.   In the
transverse diameter,  or in the oblique diameter opposite to that
in which the head  engages, there is often as much room in con-
traction of the conjugate diameter as in the normal pelvis.  It
has also  been urged that the action of  the  forceps, as a com-
pressor, acting from the sides of the pelvis, must bulge the bi-
parietal diameter, or that part of the head opposed to the con-
jugate diameter of the pelvis, and thus increase the difficulty of
the passage of the head.   But, as already stated, the forceps seizes
the head obliquely, and not in the  antero-posterior diameter, so
that any retardation  caused by the bulging of the head is more
than compensated for by the extractile action of the forceps.  The
supposed injuries done to the face of the child have  been dwelt
on, but it can be shown anatomically, and as the result of prac-
tice, that the anterior  blade of the forceps  does  not extend
beyond the  root of the nose.  The objections to the use of the
long forceps are, in my opinion, either prejudiced or invalid,
and such as, on  the introduction of the short forceps, might have
been urged with almost equal weight against that instrument.
   [The great distinction to be made  in the selection of
forceps, should arise from the necessity of the case. In most in-
stances the great object is to assist flagging pains or add a little
force  to  insufficient  uterine  efforts.   Traction  is, therefore, the
employment for which we wish to use this instrument.  This is the
only purpose required  where the  short forceps  is  the  appro-
priate  instrument save  that of effecting rotation of the head so
as to change the position.  Where the long forceps  are to be
used, traction is sometimes the result desired, and to effect this, a
light, springy instrument is sufficient. Davis's forceps, as seen in
various slightly modified forms, and especially where known as
the Hodge  forceps,  which is represented  in the cut annexed,
much used in some parts of the United States,  is well adapted to
this purpose 
elliot's  forceps.
699
  The great pelvic curvature of the lower edge of the  blade
makes more than  ordinary caution  requisite when passing the
perinaeum to avoid any injury to it.
  An  instrument  recently devised by Dr. George T. Elliot, of
New York, is especially noteworthy in this  connection, and it
is not an  untried instrument having been used repeatedly by
Dr. E. and the  staff of Bellevue Hospital.  Especially it has
 1, Elliot's forceps
closed, showing com-
parative  length of
blade, shank,  and
handle.
 2, Elliot's forceps, blades sepa-
rated, by a sliding pin between
the handles.
  8, Elliot's forceps, blades separated,
showing the location of the pin, and
• the points into which it is inserted
 —pelvic curve.
been  successfully  used  in  rotating the  occiput   anteriorly,
when offering towards the sacrum, in  accomplishing which its
slight  pelvic  curve  gives unusual  facility.   There are three
especial points in this gracefully beautiful as well as practically
•  refill instrument, deserving notice, and may be observed m the
y  «ts  annexed,  which  show it in three  position.".   First,  the 
700
FORCEPS for traction.
 uunsually long handle, which gives a firm grasp to the operator,
 and enables him  to  exercise  any possible  traction  required.
 It is evident that such a  length  of handle gives so great lever-
 age that it would make  dangerous  compression upon the head
 of the child inclosed between the blades.  This is effectually
 guarded against by  a  pin sliding between the handles, and
 thus  graduating the pressure  to any  desired  degree.  That
 this may be done without disuniting  the blades  at  their arti-
 culation, a  great breadth of shoulder is  given, which makes
 the  lock firm,  even when  the  blades are widely separated.
 In  the  New York  Journal of  Medicine for  1858, an article
 upon this modified forceps gives  a full description of its peculi-
 arities and  various  cases in which  it has been  successfully
 used.
  In thus using the forceps as a tractor, we have assisted nature,
 but nature  does  more than  forcibly to  expel  the  child.  She
 moulds the soft and easily yielding head, till it becomes  cone-
 shaped, and is enabled, thus elongated, to pass through a cavity
 too small to allow its transit  in its original diameter.  Where
 nature is thus moulding a large head so as  to adapt it to pass
 through  a small passage, we should assist nature,  and by means
 of forceps, compress the head—so flatten it  as to diminish the
 diameter to a size corresponding to the size of the strait it is  to
 pass.   For this purpose,  it  is evident  to any  one  that will
 examine  the  instruments, the forceps already  described are
 unsuitable.  I therefore have used for  this purpose the stout,
little elastic forceps invented  by Professor Ritgen, which allows
very  considerable pressure  to be made.   It has also  three
 points of  articulation, which enable  it  to be  locked,  even
 when one blade does  not pass fully up by the side of  the head.
See cut adjoining, in which may be  noted an ordinary forceps
with even blades, or with either lengthened^ will.
  That nature moulds the head is undoubted. How  much man can
modify the shape of the fcetal head is a matter of  some  dispute ;
Dubois and his school, utterly repudiating the forceps as a com-
pressing  instrument, not from the  belief that such compression
is injurious to the cliild, but because any perceptible diminution
of the diameters is  declared not feasible with  the  ordinary
French (Baudelocques') instrument.  On the contrary, Velpeau
believes  that the diminution  is often marked, having  observed 
             ritgen's  forceps FOR  COMPRESSION.          701

with Siebold and Thouret  a  diminution  made  by them of six
lines, and Osiander almost an inch.  I have repeatedly effected
a sensible  and important reduction in  the size  of the head,
easily enabling me  to  deliver a live child where the utmost
traction had been previously made by other gentlemen with non-
compressing instruments.
  Care should be taken in using these powerful instruments not
to make this pressure too suddenly, or to keep  it up too per-
sistently ; time should be taken, the aim not being a speedy, but 
702         RESULTS VERSUS RAPIDITY  OF OPERATION.

a safe delivery.  During the intervals of traction the pressure
should be  relaxed to  allow free circulation in the  head.  To
effectually insure this end, make it a rule never to tie the han-
dles of the blades together; such a proceeding produces frequent
accidental injuries to the child.]
Introduction of the second blade of the short forceps, with the mother lying on the side. 
LECTURE  XLVIII.
              THE  CAESARIAN  SECTION.

  Gentlemen :—The Induction  of Premature Labor, Turning,
and the use of the Forceps, are the great operations of what
may be termed Conservative Midwifery.  There remain to  be
considered two capital operations never to be  resorted to save
in the last necessity—namely the Caesarian Section or Hystero-
tomy, and Craniotomy.  In the one the mother is almost surely,
in the other the child is certainly sacrificed. Premature Labor,
Turning, and the Forceps are in distinct  opposition to Embry-
otomy  and Hysterotomy, and  the tendency of  all obstetric
improvements has  been  to  substitute the conservative  for the
destructive operations, and to circumscribe more and  more the
ground  which  the latter occupy.  The  Caesarian Section
was probably suggested  by cases  in which gravid women had
the mature foetus forced  through the uterus and abdominal walls
by accidents, such as falls or the goring  of bulls; or by those
rare instances in which, in cases of impassable deformity of the
pelvis, the uterus  and abdominal parietes have been ruptured
by the force of the pains and the  child extruded.   The  opera-
tion is of very ancient date, like most of the  capital operations
performed on the  human body.  Esculapius himself, and a num-
ber of other ancient and middle aged celebrities, are  said to
have entered the world in this manner.   Art does not appear to
have diminished the dangers or the mortality of the operation.
With one or two exceptions it is, and probably will ever remain
the most formidable operation which can be performed upon the
living body.
  Dr. Fleetwood Churchill has carefully collected the statistics
of abdominal hysterotomy.   He collected from foreign authori-
ties the particulars of 371 cases in which the operation was
performed.  Of these, 217 mothers are  reported to have recov-
r                                                    703 
704
STATISTICS OF CJESARIAN SECTION.
ered, and 154 to have died, the deaths being 1 in 2£.  Some of
these cases are, however, so old, as to be traditional rather than
historic;  but  the  records  of  321  operations, which  have
occurred since the year  1750, show that only 149  mothers
recovered, to 172 deaths.  Kayser collected 339  cases, in which
a fatal  result occurred to the mother in 210 cases, 129  mothers
being saved.  Drl West has noted 409 authentic cases ; in 251
the mother died, and the recoveries were 158.  The largest sta-
tistic of this operation is that of Figueiria, who gives 790 cases,
in which the deaths were  424, leaving 366 recoveries.   Many
of the  cases are of course repeated in these several collections,
but they give,  no doubt, a tolerably correct account of the mor-
tality  of the operation.   In Great Britain, the operation has
been considerably more fatal than on  the Continent,  the  differ-
ence probably arising from the fact, that  here the operation is
commonly resorted to only after labor has continued for  some
time, and after other means  of delivery have failed, while
abroad, the operation has  been performed  on healthy women,
the subjects  of deformity, at the commencement of labor.  Dr.
Merriman collected  the results of 26 cases  occurring in this
country ; of these only 2 mothers were saved, and 24 lost.  Dr.
Churchill has analyzed 63 British and American cases,  out of
which  18 mothers recovered to 45 deaths.  In the great  capitals,
London, Paris, and Vienna, the mortality is far greater than in
other  places, and with  the  single exception of Dr. Oldham's
case, where  the patient suffered from carcinoma  uteri, and died
a  considerable time after the  operation, I  believe  abdominal
hysterotomy has never  been  performed successfully  in  this
metropolis.  Within the last few years it has been performed in
London under  every circumstance which could  be  devised to
procure a favorable result, five times, with a fatal result in four
cases.  Dr.  Oldham's  case was  probably an  exemplification
of the  law, that the  abdominal  and pelvic organs while in  a
state of  disease  bear  operations  well.   The  most favorable
of these results are sufficiently discouraging, when viewed in a
tabular form.  The matter is still more tragic when we come to
the individual case, and have  to  estimate  the chances of
recovery from such a formidable operation.  It must be borne
in mind that the  known statistics of  the Caesarian section are
sure to be  more favorable  than the real results.  Successful 
DANGERS OF THE OESARIAN  SECTION.
705
cases are certain to be blazoned  abroad,  and those which  are
unsuccessful mentioned as little as possible.  Kayser  observes
that the recorded mortality from this operation in lying-in hos-
pitals, where all the cases are reported, is considerably greater
than the recorded mortality in private cases, where suppressions
are possible.  The  hospital mortality reaches to 79 per  cent.
Dr. West places  the mortality in this country, at  the lowest
estimate, at 83*6 per cent.; but even this is probably lower than
the real mortality, could every case be  collected.  Of the five
operations performed in London within the last few years, one of
the fatal cases has never, a3 far as I am aware, been reported.
  Dr.West has made a very careful analysis of the cause of  death
and the date of its  occurrence in  117 cases of death from  the
Caesarian section.   His table shows that death is distributed  be-
tween shock, haemorrhage, and inflammation.  Fifty-five  cases
died of inflammation, between the 2d and 20th day,  and 1 after
that time.  The number of deaths from shock to  the nervous
system was 33, the period of death varying from 1 hour to 6 days
after the operation.  Fourteen cases died of haemorrhage, between
the time of  the operation and the sixth day.   The deaths in  the
remaining 11 cases took place from the combined results of hae-
morrhage, shock,  and inflammation, or from  causes independent
of the operation itself.   The fatal result takes place with  great
rapidity in the  majority of cases, as shown by the fact that  out
of the 147 cases tabulated by Dr. West, death occurred in 108,
within 96  hours after the operation.  Dr. West summed up  the
peculiar dangers of the operation under four heads:   1. Hae-
morrhage, not only from the  wound but from the placental site.
2. The  shock  to  the nervous  system from the violent  inter-
ference with labor, and the injury inflicted on the uterus. 3. The
exposure  and  incision  of the healthy peritonaeum.  4. The
infliction  of an  extensive  wound upon the uterus  at a  time
when the processes of nature are prepared, not  to carry on
reparation, but to  effect the degradation,  disintegration, and
absorption of the uterine tissue.  Attention  has been especially
directed to the state of the uterine wound after  the  operation,
by Dr. West.  In many cases no  attempt at repair or  the  for-
mation of new tissue takes place; in others, actual  sloughing
and loss of substance  occurs, the wound  gaping widely,  when
death has  occurred many days after the  operation.
                             45 
706         REPETITION  OF THE CAESARIAN  SECTION.

  The Caesarian section has been resorted to for the safety of the
child more frequently than for that of the  mother,  but  the  sta-
tistics of the operation  demonstrate beyond  question that the
amount of fcetal is almost  equal  to  that of the maternal mor-
tality.   In Dr. Churchill's list of 371  cases, the results  to  the
child are given in 189 cases, 139 being saved, and 50 lost. But
we may fairly infer, that of  the  183 cases where  the result is
not given, the child was lost in all  or nearly all, which would,
omitting twins, increase the  fcetal mortality to 232.  Of  the 63
occurring in British practice, 26 children were lost  or still-born,
and the result is not stated in three cases, making  the probable
mortality 29. In Dr. Merriman's collection of 26 cases, 11 child-
ren were saved and 15  lost.   In  the  409  cases mentioned  by
Dr. West, the result to the child is stated in 347 instances.  In
227 the child was born  alive; in 110 it was  still-born.   If  we
add the unrecorded cases  to  the  deaths, the  number becomes
172, exclusive of twins.
  In a considerable number of cases it is a remarkable fact that
the operation has been performed more  than  once upon the
same subject.   In 28 women whose cases  are collected by Dr.
Churchill, the operation  was performed  74 times.  Some of
these cases have been doubted, on  account  of their antiquity,
but within our own generation, Professor  Kilian, of Bonn, per-
formed the operation four times on the same woman.  Between
the years 1S26 and 1836 it was also performed four times on a
Danish woman.   It would appear that  in women  who survive
the first operation, a certain immunity from the dangers of the
procedure is acquired.  These cases, subtracted from the tables
of the successful performance of the operation, or reckoned only
once, increase the tabular mortality in  women operated on for
the first time.                       N
   We now approach one of the most momentous questions in
obstetrics.  Fortunately it is one not often presented to us for
solution in practice.   What are the  circumstances  under
which Abdominal Hysterotomy may become justifiable
or even necessary?  No point has been more keenly debated,
and perhaps no point of importance in midwifery is less  defi-
nitely settled at  the  present time.  It  may be stated that the
operation is less held in dread upon the Continent than in Great
Britain.  This is owing in some degree to the more favorable 
           JUSTIFIABILITY OF THE CAESARIAN SECTION.       707

results of the operation, and  to  the greater value attached to
fcetal life, in foreign countries.  According to Busch and  Moser
the Caesarian section is the only practical mode of delivery when
the diameter of  the pelvis  is two inches and a quarter or less,
and the Caesarian section is indicated if the diameter is from two
and  a quarter to under three  inches, when the child is alive.
Jacquemier is of opinion that hysterotomy is the only justifiable
operation when  the child is dead, and  the pelvis is below two
inches in diameter ; or when, in the case of a live child, it varies
from  two inches to two and a half.  These are amongst  the lat-
est authorities  in  Germany and France.  Velpeau  gives the
diameter of the pelvis in  62 cases.  In 30 of  these,  the pelvic
diameter was from two inches to  two and three-quarters, the
variation in the  remaining 32 being from one inch to two inches.
Dr. Simpson truly observes, that in this country the operation
would not have  been  performed in the 30  cases in which the
diameter extended from two inches to two inches  and three-
quarters.  These measurements, it should be stated, refer to the
antero-posterior  diameter, and  it seldom happens  but that, on
one side or the other of the  pelvis, the  diameter exceeds the
diameter from the promontory  of the sacrum  to the  symphisis
pubis.  In such cases, craniotomy would certainly be  attempted
in British practice.   Dr. Lee, the most strenuous  opponent of
the Caesarian section,  does not give any positive admeasurement
limiting the operation, but he states that the operation should be
reserved for cases  in which the pelvic contraction is so great that
the os uteri and the presenting part of the child are entirely out
of reach.  He speaks, however, of a case of Sir Charles Bell's in
which the antero-posterior diameter did not exceed an inch, and
when the space  on either side did not allow the performance of
craniotomy, in  which in  labor at the  full term, the Caesarian
section  was necessarily performed.  Dr. Fleetwood  Churchill
gives it as his conclusion, after reviewing  all the points relating
to the subject, that when  the  antero-posterior diameter of the
brim is not more than an inch  and a half, there is no resource
.but the  Caesarian  section.  Dr.  Rigby considers the operation
unavoidable  when the cliild  cannot  be extracted   piecemeal
through  the natural  passages, but does not give any positive
measurements which would justify the operation.  Dr. Meigs
teaches that the operation  mqy be imperative in different diam- 
708      WHEN IS THE CiESARIAN SECTION NECESSARY

eters in different cases; and he considers it impossible  to fix a
minimum diameter through which a woman may'be  delivered.
He states that if we go to diameters of an inch or an inch and a
half, the  Caesarian section is inevitable, but that he should not
hesitate in one case to recommend it in a pelvis the diameter of
which ranged from two to two and a half inches, when a patient
was in imminent danger;  while  in another, and  less pressing
case, he  would  as certainly,  with the same diameters, advise
craniotomy.  Singularly enough, Dr. Meigs relates a case where
the diameter was not beyond two inches, in which he delivered
by embryotomy on two occasions, but in which the Caesarian sec-
tion was afterwards performed twice successfully, and once under
the sanction of Dr. Meigs.   No alteration  had occurred in the
state of the pelvis between the dates of the operations for embry-
otomy  and hysterotomy.  Dr. Ramsbotham considers the Caesa-
rian section the only  alternative in labor at the full term, when
the antero-posterior diameter is one inch and three-eighths, and a
space of three inches  and a  half at the brim laterally, or with an
antero-posterior diameter of an inch and a  half by three inches.
In two of the cases occurring in London within the last few years,
the pelvic diameters have been published.  In one case the antero-
posterior diameter was three inches, but out of  this the rami of
the pubis projected forwards,  with a beak more than an inch in
length, and about an inch in breadth.   The  distance between the
tuberosities of the ischia was 1.2, and from the point of the coccyx
to the symphisis pubis 2.8 inches. The child was saved.   In the
other case, the principal deformity was at the brim.  The antero-
posterior diameter measured two inches.   From the sacral pro-
montory  to the right pectineal eminence there was  also a space
of two  inches, and from the same point to the left pectineal emi-
nence,  two inches and a half.   The diameters of the cavity and
the outlet were not seriously contracted.   The  child was  dead
before  the commencement of  the operation.  It is impossible to
give  too  much credit  to the distinguished practitioners concerned
in these cases for their candor and skill, but it may be questioned
whether  in both cases delivery might not have been effected  by
piecemeal delivery.  At this point of the argument, we must
inquire what are the  smallest diameters through which a child
at the  full  term has  passed, either alone or with instrumental
assistance.  We  have seen  that  Dr. Meigs delivered twice in a 
            RELATIVE VALL'E OF MOTHER AND CHILD.        709

case where  the antero-posterior  diameter did not exceed  two
inches, and  he distinctly states that he should not hesitate to
undertake delivery in any pelvis of two inches in the antero-pos-
terior diameter.  I believe Dr. Lee  entirely indorses this opin-
ion,  even if he  does  not  go somewhat  beyond  it.   In  the
celebrated  case of  Eliza  Sherwood,  in  whom delivery  was
effected by Dr. Osborn, the antero-posterior diameter was only
three-quarters of an inch, but there was a space on the right  side
an inch and three-quarters broad and three inches long.  In the
case related by Dr. Simpson, a fcetus, eighteen inches and a half
long, passed through a cordate pelvis, so contracted at the outlet
as to measure three inches from the coccyx to the symphisis, but
only half an inch from the tuberosity of one ischium  to the other.
In a succeeding labor, hysterotomy wTas performed  with a fatal
result to the mother and child.  In these and other cases of the
passage or extraction of a child  through a pelvis affected with
high distortion, the cliild has been dead and in  a softened condi-
tion, with complete separation or dislocation of the  bones of the
head.  It may be said, then, that the limits for the  performance
of the Caesarian section only range between a  two-inch diame-
ter of the pelvis from deformity, and its entire occlusion by exos-
tosis.  If cases ever occur in which the operation  is necessary
above two inches, they are  instances in which death is threat-
ened or certain, before the lengthened operation of embryotomy
could be completed.  Much discussion has taken place as to the
relative value of the life of the mother  or child in cases supposed
to call for  hysterotomy, particularly  when the child has been
sacrificed again and again in the same  subject.  But apart from
the fact of the great danger to the child in cases of the Caesarian
section, I think the judgment  of Dr. Meigs to be in accordance
with the dictates of reason and humanity, when  he says  that
this  operation should  never be performed upon the living  sub-
ject, save for  the  preservation of the mother  herself, and  that
it should be considered essentially as a mother's operation, only
to be resorted to when the life of the mother is in greater danger
from the continuance of labor, than  from the hazardous  and
almost certainly fatal procedure under consideration.  The life
of the child  may be a great  consideration after the operation
has been decided on, but it should hardly enter into our calcula-
tions before that time. 
710       METHOD OF MAKING THE CAESARIAN  SECTION.

  When a patient has died suddenly, or in any other way, dur-
ing labor, or in  the  latter part of pregnancy, there can  be no
hesitation about the performance of hysterotomy, where the child
is suspected or known to be alive.  Under such circumstances, the
operation should take place as quickly as possible after the  death
of the mother.  It was  probably in such cases that the operation
was in the first instance performed.  I  have elsewhere spoken
of the performance of  gastrotomy in cases of ruptured uterus,
where the child has escaped into the peritonaeum, and cannot be
delivered per vias naturales.  This operation is also necessary in
some cases of extra uterine fcetation, when death is  threatened
from the irritation of the foetus.
  Hysterotomy is not a difficult operation.  The temperature of
the room should  be raised, wTith a  view to the  prevention of peri-
tonitis, and chloroform  administered, unless some special contra-
indication exists.  The  abdominal incision may be  made in the
direction of the  linea alba, or it may be oblique or  horizontal,
according as the configuration of the abdomen  is altered by defor-
mity.    The  situation  of  the placental attachment  should be
avoided, if this organ be attached anteriorly.   This may be learnt
by auscultation before the operation is commenced.   Great care
is required in opening the peritonaeum,  so as to avoid wounding
the intestines.  The abdominal incision should be from eight to
ten inches in length;  and the uterine incision should be of
nearly the same  length.   Some have  advised that  the liquor
amnii  should  be evacuated before the commencement of the
operation.   When  the amnion is punctured through  by the
uterine incision,  care must be taken to let as  little  of the  fluid
as possible enter the peritonaeal  cavity.   It is recommended
to be  removed  carefully with pieces of sponge or  a syringe.
When  this  has been evacuated, the fcetus is to be taken out
cautiously, as in some  cases  the  uterus has  grasped the  body
or neck of  the  child  at  the wound and rendered  its extrac-
tion a matter of  difficulty.  The placenta is to be separated by
the hand, and haemorrhage arrested by mechanical pressure, or
the application of cold, the risk of peritonaeal inflammation  being
the only objection to the latter.  After the removal of the pla-
centa,  and the cessation of haemorrhage, all blood and fluid  are to
be carefully removed from the peritonaeum, and the edges  of the
uterine and abdominal incisions brought together and maintained 
          DRESSING OF WOUND OF 0 PARIAN SECTION.      711

by sutures.  The external wound is further to be dressed lightly
with  strapping  and wet lint, and the whole  supported  by a
many tailed bandage, space being left for the exit of discharge.
After the operation, large and continued doses of opium, with
nutriment and  stimulus  in  good  quantity, appear to offer the
best chances of recovery.   Throughout, every care  should  be
given to the avoidance of peritonaeal irritation as far as possible ;
the escape of the bowels through  the wound; and the  suppres-
sion of  haemorrhage.  Dr.  Aitken has recommended  that the
operation should be peformed under water, with a view to defend
the peritonaeum and other structures from contact with the exter-
nal air, but I am not aware that his suggestion has been carried
out in practice.  As already mentioned, art and the most  care-
ful modes of operating, can do little towards insuring the safety
of the patient  under hysterotomy.  There is one point worthy
of consideration—namely,  that patients  operated upon in the
country have done better than those operated on in great cities ;
and it is probable that a good air does more than the most  skill-
ful surgeon in such  cases. 
LECTURE   XLIX.
                        EMBRYOTOMY.

  Gentlemen :—This is the most positive of all  the  operations
of midwifery.   The only other procedure with which it bears
comparison, is  the induction of  premature  labor  before  the
viability of the cliild has been reached.  In the induction of
Premature Labor  after the seventh  month;  in Turning; in
the use of the Forceps, and even  in the  Caesarian  section, a
chance  of safety is afforded to both mother and child; but in
Embryotomy, the child, if alive  before the commencement of
the operation, is inevitably sacrificed.
  The operation is considered necessary in  certain cases of de-
formed  pelvis, obstruction  from tumors, etc., when the induc-
tion of premature labor  has been neglected or omitted; in
cases of arm presentations, hydrocephalus, convulsions, haemor-
rhage,  exhaustion,  etc., when the preservation of the  mother
imperatively calls  for delivery, and when the child  cannot be
extracted by the long or short forceps, or by turning.  Under
these  circumstances, there is  no  question  amongst  the great
majority of British accoucheurs as to the propriety and fitness
of the performance of craniotomy.   As Denman justly observes.
in deciding in favor of this  operation, we are only  following
the dictates  of Nature, who, in  difficult labours,  commonly
sacrifices the child  before the mother is destroyed.  It is equally
a canon in obstetrics, that the operation  should never be per-
formed except after  consultation, and in the face of the most
urgent necessity;  and it may be said that, apart from all ques-
tion of the Caesarian section, there is a general belief  on  the
Continent, and in America, that the operation  has always been
performed too frequently by obstetricians in this country.
  It is of the  greatest importance, with reference to the most
common condition of instrumental labor—namely, slight or
   T12 
limitations of craniotomy.
711
excessive  deformity of  the pelvis, that  the limits  should  be
decided, as far as possible, within which the induction of prema-
ture labor by the forceps  may, or craniotomy should be, per-
formed.  As regards the induction of premature  labor, it may
be said that it applies to all cases of pelvic deformity, it being
the province of art to decide at what time this operation should
be performed in each particular case, and whether it should be*
resorted to before or after  the viability of the child.  There is,
probably,  no case of deformity or exostosis, where menstruation
and fecundation can occur, so profound but that the detachment
and  expulsion of the ovum might be procured within the first
twc or three  months after  impregnation, by the uterine sound,
or an elastic tube and douche.  When this has not been accom-
plished, and  pregnancy has gone on to the full term, we  have
to consider the  alternative  operations  of the  forceps,  turning,
embryotomy, or the Caesarian section.   The use of the forceps
is generally inadmissible in cases where the  distortion exists to
such an extent that  the anteroposterior diameter is below Z\
inches.  When the application of the  long or short forceps is
impossible, turning "hiay be practicable  between  the limits of
2>\ inches  and 2J inches.  The Caesarian  section comes into the
field in cases of high distortion, where the antero-posterior di-
ameter is  \\ or 2 inches or less.  Between the point at which
turning becomes impracticable, and at which there is no resource
but the Caesarian section, lies the domain of craniotomy.  It is
the proper resource in  cases where the antero-posterior diame-
ter is from  2£ inches to \\ to 2  inches.   In cases where  some
condition other than mechanical disproportion comes into ope-
ration, as in cases requiring immediate delivery, and complicat-
ed with haemorrhage, convulsions, etc., craniotomy may be some-
times necessary, but it ought in every case, as far  as possible,
to be superseded  by the forceps or  turning where  these opera-
tions are practicable.
  The statistics relating to embryotomy are of great importance
as throwing light on the proportion in which  the operation is
fatal to the  mother.  Dr. Fleetwood Churchill has  collected
342,495 cases of labor in German practice, in which embryot-
omy was performed 243  times, or in 1 in every 1,409^ cases. In
129,331 cases in British practice, embryotomy was resorted to
378 times, or one in every  342£ cases.   In France and Italy, 
714
STATISTICS  of craniotomy.
 out of 3S,908  cases, this operation was performed 69 times, or
 in 1 in every  563f cases.  Thus the proportionate frequency of
 the operation stands as 1 in every 312 cases in this country, 1
 in every 563f in France and Italy, and only 1 in 1,409£ in Ger-
 many.  In 371 cases in which the result to the mother is stated,
 deaths ensued in 69, a fatality equal to 1 in 5-1 of all the cases.
 Thus craniotomy, though a comparatively easy operation, is far
 more fatal to  the mother than the forceps or turning.   In this
 country, 1 in every 20f amongst  the mothers is lost  by the use
 of the forceps; and in France and Germany, 1 in 14f.  In cases
 of turning, the loss is 1 in every 14£ cases, including deaths from
 the complications  in which turning is  required, such as convul-
 sions, accidental haemorrhage, placenta praevia, etc.  Some fur-
 ther light is thrown  upon the comparative mortality of the seve-
 ral midwifery operations by a comparison of the results of arti-
 ficial  delivery in  this  country and  on  the  Continent.   Dr.
 Simpson gives the  comparison of the  maternal mortality  after
 artificial delivery in the great hospitals of Vienna and Dublin
 as follows: Under Boer, 1 in 55 was delivered artificially—that
 is, b}r the  forceps, lever, version, or craniotomy.   Under Arneth,
 artificial delivery was resorted to in 1 out of every  69 cases.
 In Dublin, under Dr. Collins, 1 out of  every 86 women was de-
 livered artificially;  and under Dr. Johnson, as reported by  Drs.
 Hardy and M'Clintock, 1 in 52.  Of the cases above mentioned,
 Boer lost 1 out of every 17 mothers; Arneth, 1 out of every 9 ;
 Dr. Johnson, 1 out  of every 5 ; and Dr. Collins, 1 out of every
 4.  These figures would give Dr. Collins a mortality more than
 four times greater than that of Boer, and twice that of Arneth.
 Dr. Collins, it  may  be observed,  resorted to  artificial  delivery
 less frequently than the Vienna  obstetricians; but  Dr. John-
son's proportion of artificial deliveries  was  greater than  either
that of Boer or Arneth.   On the Continent, the forceps is more
frequently used  than in this country.   The French use this in-
;>lTiiment in 1 out of 140 cases; the Germans in 1  out of every
 159; while in  Great  Britain it is only used in 1 out of every
342rV cases.  The same  may be said of turning.   The French
turn in 1 out of every 89-| cases;  the Germans in 1 out of every
97£; while in  Great Britain we turn only in one out of every
238 cases.  The maternal mortality from forceps cases in  this
country is 1 in 20|;  in France and Germany, 1 in  14f.   The 
DIFFICULTY OF CRANIOTOMY.
715
gross mortality to the  mother from turning is 1 in every 14-£
cases.   Thus on the Continent, a considerable gain of maternal
life is obtained by resorting to turning and the forceps, instead
of craniotomy.  When the child is dead, turning is performed, or
the forceps used, in preference to craniotomy; and turning is re-
sorted to in cases of dystochia, when the head of the child is above
the  brim, and  -when the pelvis  admits  of delivery without
diminution  of the head.  Artificial delivery is also resorted to
at an earlier period on the Continent and in America, when it
is considered  necessary, than in this country, and  Dr. Simpson
has shown  that no other circumstance exerts so prejudicial an
effect, as the  prolonged duration  of labor.  While it must be
allowed that in  the matter of  artificial deliveries more mothers
are lost in this country than on the Continent, the  gross mater-
nal mortality  in this  country  is more favorable than in foreign
countries.   It is not only as regards the mother that our own
statistics of artificial delivery are unfavorable.   Out of every
100 cases, Boivin lost 28 children ;  Arneth, 34 ; Lachapelle, 36;
Boer, about 47; Dr.  Johnson, 76; and Dr. Collins, 77.   If  we
can rely on  these statistics, which there is little reason to doubt,
the foetal mortality in this country in artificial deliveries is nearly
double that which  obtains upon the Continent.  The result of
these statistics is to show  very clearly that  craniotomy is an ope-
ration to be avoided upon every possible occasion, and that in no
case should it be undertaken, whether the child be alive or dead,
when turning  or the short or long  forceps can be substituted in
its stead.  It  is only less horrible than  the only alternative
which remains to us, when it is absolutely  unavoidable—name-
ly, the Caesarian section, and in the following proportions: Em-
bryotomy is fatal to the mother in about 20 per cent., while the
Caesarian section destroys from 60 to 70 per cent, on the Conti-
nent, and between 80 and 90 per  cent, of  the mothers in  cases
operated on in this country.
  When the deformity is  not  excessive, the operation  is a com-
paratively easy one.   It is only in cases of high distortion, where
what is called  piecemeal  extraction is required, that great diffi-
culties are met with in its performance.  The instruments used
consist of the Perforator, the Crotchet, the Embryotomy Forceps,
the Cephalotribe, and several kinds of blunt and cutting Hooks.
  Various forms of Perforators are used.   The most common 
716
MODIFIED PERFORATORS.
is  the scissors-like instrument of Smellie, modified to some ex-
tent by later obstetricians.  It consists of two blades with shoul-
der-stops, and cutting edges  between the stops and the points.
In using the  instrument, it is inserted as far  as the stops, and
the handles are then separated by the fingers.   The most modern
and perfect instrument is a modification of Naegele's perforator,
which is used by bringing the handles together, and gives the
operator considerable  more power than the instrument of Smel-
lie.
  [The frequent injuries to both mother and the operator  from
the use of  the  Smellie's perforator being recognized, I am ac-
customed to   use  the  instrument
modified by Charriere  with  great
benefit.  It is  made  sharper than
Smellie's, and all danger in its use
is effectually prevented by an  easily
removed shield.  Thus  guarded, it
can be  passed  up to  the required
position without  an accompanying
finger and without the possibility of
cutting or piercing the mother, and
then the sliding guard  being re-
moved,  it  can be  used more effi-
ciently  than  the ordinary instru-
ment.
  But a  far better instrument still,
which  wants  but to be seen  to be
approved is that recently invented
by M. Blot, of Paris, and called by
him a craniotome.  As seen in the
annexed representation, it differs
materially from all  previous perfo-
rators.  In its ordinary position it is
retained  shut by a spring.  It is
composed of two  blades, which
cover each  other, so that when the
instrument  is closed, the blunt edge
of one extends slightly beyond the
cutting edge  of the other, and reciprocally.
ly
When used, it is 
EMBRYOTOMY INSTRUMENTS.
717
Fie, l^
to be taken by the handle with the right hand and  passed by
the side of the fingers to the head of the foetus, and there being
no sharp surfaces exposed, but little care is required to avoid in-
juring either the mother or the operator.  It is then to be passed
through the cranial bones by a rotatory motion.  It will there
be  retained in situ by the notches which I have added to  M.
Blot's instrument, and then  by pressure  upon  the lever b, the
blades will be  divided and  thus effect as  large an opening as
may be  desired.  The advantages claimed for this instrument are
solidity  and simplicity; its safety to mother and  operator even in
the most inexperienced or careless hands; its requiring but one
hand, leaving the other free to observe its effects; that it does
not slip out of the cranium ;  power of perforation;  finally, its
cheapness as compared with  the sheathed scissors described
above.]
  The common crotchet is a modification of the earliest modern
instrument of the kind, devised by Mesnard.  It is simply a
          blade, having  the forceps curve, with a short hook
          at the extremity, having a broad cutting edge of mo-
          derate sharpness,  for insertion into the inner or outer
          surfaces of the bones of the foetal cranium.  Its con-
          struction was probably suggested by the use of the
          hooked  finger and the finger-nail.  Various forms of
          craniotomy forceps are used, some of them with sharp
          teeth, and others with serrated blades, the latter being
          in  most cases the preferable instruments.   In some,
          the scissors-joint,  and in others the forceps-lock, is
          used.   The cutting-hook, invented  by Dr.  Rams-
          botham, for cases requiring  decollation or  the ampu-
          tation of limbs, and  a blunt hook,  complete  the em-
          bryotomy instruments in general use in this country.
            In  the Cephalotribe,  a mechanism  altogether
          different is relied upon.  Immense strength in  the
           blades, and great power of  compression is obtained,
          and the fcetal head, including its base, is crushed by
          the grasp of the instrument.   The  cephalotribe  of
          Baudelocque is  two  feet in length, and weighs about
          four pounds, being  altogether a most repulsive-look-
          injr instrument.   The crushing-blades  are brought 
718
BAUDELOCQUE's OMPHALOTRIBE.
together by a screw movement.  A more modern French cepha-
lotribe, consisting of an immensely strong pair of forceps, having

                                           Fig.  HO.
Baudelocque's cephalotribe.                    Modern cephalotribe.
narrow  blades without fenestra, was exhibited at  the Crystal
Palace of 1851.  It was several pounds  in weight, and its use
must have required great strength on the part of the operator.
Recently, considerable attention has been given to the construc-
tion of cephalotribes of as light a weight as is consistent with the
requisite strength, and the ratchet and pinion have been substi-
tuted for the screw in approximating the handles.   The  latest
instrument I have seen measures 18 inches in length ; its blades
are If inches in width, and it weighs three pounds.   The lock of
the blades is the same as that of the French forceps.   It is used
by Paul Dubois and the leading French obstetricians, in prefer-
ence to  the perforator and crotchet, in cases where  the child  is 
METHOD OF PERFORATING.
719
dead, or where the  pelvis is too contracted to admit of the use
of.the forceps.  The advantages claimed for this instrument are,
that it avoids the dangers cf the crotchet, and that it is far less
fatiguing to the accoucheur than the ordinary mode of extrac-
tion.   It is not, of course, applicable to cases of high pelvic dis-
tortion.  It is impossible to  examine  the instruments used in
embryotomy, and to deal with cases requiring its performance,
without feeling that instrumentation has by no means reached
perfection in this department  of the obstetric  art.  Ultimately,
craniotomy will, in all probability, be restricted, almost, if not en-
tirely, in the case of living children, to cases requiring piecemeal
extraction.  We require instruments for this purpose better than
any which have hitherto been constructed, and it seems likely
that modifications of the lithotrity and bone-cutting instruments
used in surgery may be found very useful in breaking up and
extracting the fcetal head.
  In using the perforator, the first two fingers of the left hand
are introduced into the vagina so  as to reach  the parts of the
head  selected for puncture.   Along these fingers,  the instru-
ment is passed as on a director, and with the right hand, forced
gently but firmly, by a semi-rotatory movement, into the  head
as far as  the  shoulder-stops.  The blades   are  then  opened
widely, and the part of the head into which they are introduced
is thus divided.   The instrument is now withdrawn a little and
reinserted in a  direction at right angles to  the first incision,
when the  blades are dilated as before.  This  proceeding leaves
a crucial opening in the foetal cranium.  The point of the  head
at which the perforation should be made has been a subject  of
considerable dispute.  Some advocate perforation at the sutures
or fontanelles; but it is an objection  to this procedure,  that
when the bones become compressed, the opening is obliterated,
and the discharge of cerebral matter interfered with.  The best
point for perforation is the middle or posterior portion  of the
parietal bone,  because an opening in this  situation enables the
operator to  apply extractive  force with the head in the  most
natural and advantageous position for  its passage through the
pelvis.  When the crucial incision has been made, the perfora-
tor is  passed  into  the opening, and moved  about in  various
directions, so as to break up  the brain.  If the  child is alive,
the perforator should, if possible, be made to pass into the  fora- 
720
DELAY  AFTER PERFORATION.
magnum in order to destroy the medulla oblongata ; other-
 the child may be born living, notwithstanding the pro-

               Fig. 171.         Fig.  112.
Craniotomy Forceps.
cesses of perforation and decerebration. Sometimes the crotchet
is preferred for breaking up the brain.  Nothing  but piercing
the medulla destroys the child, which before birth possesses, to
a certain extent, the low and tenacious vitality of the amphibia.
After these steps of the  operation have been completed, it is
best, in all cases where immediate delivery is not  a matter of
great urgency, to  wait  for some time  before  proceeding  to
extraction.  The bulk of the  foetus is diminished by loss of
blood, and as  the  brain escapes, the spastic influence of the
pains moulds the bones of the  cranium  into  a smaller  and
more  convenient   shape.   Decomposition also  sets in with
great rapidity, and soon softens the whole mass.
  For extracting the child, especially when  the fcetus  is dead
before the commencement of the operation, it is sometimes suftl- 
WHERE TO FASTEN THE  CROTCHET.
721
cient to pass the finger into the opening made by the perforator,
and in this way extract the child. More frequently the crotchet
Fia. 173.
Perforation of the head.
or craniotomy forceps are required; and some  cases  tax  the
strength, ingenuity, and patience of the accoucheur to the very
utmost.
  Considerable difference of opinion has prevailed at  times as
to the  mode  of using  the  Crotchet.   Some have fixed  the
instrument on the outside, others on the inside  of the cranial
cavity ; and occasionally two crotchets, one applied  externally,
and the other internally, have been employed.  At the  present
day, obstetricans are pretty well agreed as to the propriety of
passing the crotchet through  the opening made by the perfor-
ator, and fixing it upon the cranial bones on their inner surface.
It is still  a disputed question whether  the crotchet should be
                             46                                 » 
722               HOW TO APPLY CROTCHET.

fixed upon the anterior or posterior part of the head.  Suppos-
ing the head to be in  either of the occipito-anterior positions,
Fra 174.
Employment of craniotomy forceps.
in applying the crotchet to the  anterior part of the head, we
can pass the fingers of the left hand  up over the frontal bone,
to the part opposite to that upon which the crotchet  is fixed,
and in this way steady the instrument, assist its extractive force
and guard against the injury of the soft part in case of the slip-
ping of the instrument.  But these advantages are more  than
counterbalanced by the circumstance that we in this way bring
down the  anterior  part  of the head,  and force  the  cranium
through the pelvis in its largest and most unfavorable diameter.
  [The simplicity and effectiveness of the crotchet is unequalled
by any other instrument used in extraction after perforation of
the head. Many attempts have been made, therefore, to so con-
struct a guard to the sharp hook as to render  its use less  dan-
gerous, for when it slips from the bone, or tears  out from the
scalp, it sometimes causes  dangerous wounds either upon the
hand of  the operator, or if he has  neglected thus to guard the 
VARIOUS GUARD-CROTCHETS.
723
point, upon the soft parts of the mother, lacerating the vagina or
rectum, producing a nucleus from which subsequent irritative
or puerperal fever may arise.   The guard  crotchet of  the late
Dr. Gordon, of Charleston, S. C, has been much used, but being
in two parts, and it being necessary to fasten one portion before
the other is  applied, renders its use difficult, tedious and  inef-
fectual.  That of Dr. Bedford  is ingenious, but liable to the
objection that when the guard is slid up to the point, it pushes
against the vaginal walls, and is not only thus obstructed in its
free movement, but may irritate or lacerate the mucous mem.
brane, and thus  make a nidus,  from whence inflammation may
spring.  This instrument is also  ponderous and expensive.
  I present above cuts of a guard-crotchet which I have designed,
and which has been made by Tiemann & Co., the well known
instrument makers of  New York.  The point a, which enters 
724
NEW GUARD-CROTCHET.
the head, is made tapering and cone-like—all previous instru-
ments being made broad and with an  entering point nearly a
half inch in width.   When the guard is not in use, it lies close
upon the shank of the instrument, wrhich may thus be used as if no
guard was affixed, as it in  no manner incommodes the operator
or endangers  the patient.  When  the  hook  is  fastened,  the
guard is raised by the handle b, to the desired extent, and  then
slid forward upon the slot  c, by the spring seen under the han-
dle, as far as allowed  by the thickness of the portion between
it and the point of the hook—the guard is withdrawn with the
greatest  facility  by  means  of the thumb  resting upon the
roughened portion of the  handles of the guard.   A projecting
portion of the main handle d, assists in making such  traction
as is  desired.  The instrument thus made  adds  no material
complication  to it, it being complete without the guard  and not
burdened,  nor its  use  impaired by it.   One  hand  only  is
required in all the  manipulations with it—it is compact,  neat,
and not expensive.]
  In fixing the crotchet on the thickest portions of the occipital,
parietal, or temporal bones, we, on the contrary, bring the head
down with its smallest diameter opposed to the pelvic straits,
and in this way  expedite delivery, and avoid the danger of
bruising and lacerating the soft parts of the mother. Cases may
occur in which we have little choice, and in which the head must
be extracted or broken down as it lies ; but when we can select
any part of the head, or are able to alter its position,  undoubtedly
the greatest chances of safety are  given by following as closely
as possible the natural order of labor,  and bringing the posterior
and superior  angle  of one of the  occipital bones first  through
the pelvis.   Sometimes the Craniotomy Forceps, the blunt
hook, or even the ordinary forceps, are used after  the  collapse
of the head, to effect delivery;  and in the worst cases, the
craniotomy forceps  is more serviceable and less dangerous than
the crotchet.   With any of these  instruments the greatest  care
is necessary in guarding the soft parts of the mother from injury
and avoiding lacerations  of the vagina and  perinaeum by the
instrument or by spiculae of bone.  Great force is sometimes
required with the crotchet and craniotomy forceps, and the com-
pletion  of delivery may occupy many hours.  As  far as possi-
ble, it is  a rule  in craniotomy to  save the  scalp and inte<ni- 
                 MODIFIED CRANIOTOMY FORCEPS.            725

 ment, so as to cover and guard  the bones  from injuring the
 mother.

                          [The craniotomy  forceps  in gene-
                       ral use as represented  in  figures  171
                       and  172, is  a very uncouth, unwieldy,
                       heavy and  inconvenient  instrument.
                       Some  years ago, Mr. Tiemann  made
                       at my instance the  instrument repre-
                       sented in  the  cut  annexed.   It  is
                       much  lighter,  yet very strong, easy
                       of use, with a curved handle to facili-
                       tate  in traction, and a joint  opening
                       as the jaws  close. By its use  the dan-
                       ger to the mother from the sharp crot-
                       chet is avoided, and by it  more force
                       may  be  safely  applied than  by  the
                       latter  instrument.   Bone  after bone
                       of the  cranium can  be  torn  away
                       and  removed   and  the  necessity  of
                       the cephalotribe avoided.   This  in-
                       strument is  not   intended,  as   in  cut
                       174,  to embrace the head,  but  one
                       blade is to pass  into  the opening made
                       by the crotchet and the other  exter-
                       nally.  One adapted  to this purpose is
                       the recent invention  of Dr. Thomas of
                       this city, representations of which  are
                       inserted on page 726.   It  consists of
                       two similarly  shaped  blades,   of  the
                       length of  an  ordinary long  forceps,
                       locking also in  the same manner and
                       provided  with similar  handles.   The
blades are about half an inch  in thickness and something more
in breadth.  These blades,  are to be passed over  the  child's
head  securely fastened  together and then the screws seen in
the handles are  to  be turned. The effect  is to slowly pro-
trude a series of sharp teeth, which imbed themselves  in  the
sides   of the  head.   Traction may then be made with any
 
726
thomas's craniotomy forceps.
              required degree of force.  In case
              the instrument is desired to be re-
              moved, the teeth may be  again
              extracted,  by turning the screws
              in an opposite direction.  The in-
              strument is a highly ingenious one
              and recommends itself by its ap-
              parent simplicity.]
                In embryulcia, when some other
              parts than the head present, the
              abdomen and thorax require to be
              perforated, and the child extract-
              ed as in  breech cases.    Occa-
              sionally, it is necessary to  effect
              decapitation.   In  some  cases,
              when craniotomy has  been per-
              formed, and  the head  extracted, it is difficult or
              impossible to deliver the -trunk, and  the  thorax
              and abdomen require evisceration.  Dr. Oldham
              has for such cases invented  a  vertebral hook,
              considerably longer in the  shaft than the ordi-
              nary  blunt hook, and calculated to  be of very
              great service.
                In  cases of high distortion, such, for instance,
              as those  described  by Dr. • Osborn and Dr.
              Meigs, extraction by any instruments would  be
              impossible without the assistance afforded  by
              the decomposition  of  the  fcetus.   These cases
              sometimes spread over two  or  three  days,  in
            the soft parts of  the fcetus  ar,e reduced  almost
       diffluent  pulp,  and  the  loose bones are contained
       the skin  somewhat as in  a bladder.  The fcetor  in
these  cases is  intense, and the uterus may be distended with
gases  resulting from decomposition ; but less mischief arises from
these  sources, or from the delay and pressure, when the cranium
has been decerebrated, than from forcible attempts at  extrac-
tion.   It  is very common with those obstetricians wdio have
most distinguished themselves in such cases, to express a regret,
at the termination  of their cases, that they did not wait more
m
which
to  a
within
time 
decomposition an obstetric agent.
727
patiently, and trust more to the aid  afforded by putrefaction.
It is almost incredible how small an aperture a fcetus in a state
Fig. 175.
Embryulcia.
of decomposition will pass through.  Dr.  Simpson, in a case
occurring at Cupar, was able to draw a child 18£ inches long,
in a state of considerable decomposition, through an opening in
a piece of iron only 2f inches long by -J of an inch wide. When
we have to deal with a dead  foetus, the circumstances under
which craniotomy can be performed in high  distortion, are the
most favorable which can exist; but when  the fcetus is des-
troyed early in  labor, a  few hours  will  do much towards pro-
moting   decomposition, while  if  extraction can be  delayed
twenty-four or thirty-six hours, the foetus becomes greatly dis-
organized.  Death, the admission of air, and the high tempera-
ture  kept up  by the uterus  and  liquor  amnii, afford  very 
728       FAVORABLE CONDITIONS FOR PUTREFACTION.
favorable  conditions for putrefaction in the comparatively soft
structures of the foetus.   It were to be wished  that art could
Fig. 176.
supply some  means of making foetal decomposition still more
rapid in such cases.   But even  in cases of decomposed foetus,
the cranium has, in the worst cases, to be picked out bit by bit
and bone by bone, or the large bones have to be broken up.  In
his case of pelvis of two inches in the antero-posterior diameter,
Dr. Meigs  relates that he was  several  hours getting  away as
much osseous matter as would go to make up a parietal bone.
  Considerable difference of opinion has existed as to the Time
at which Craniotomy should be performed.    Dr.  Collins
has especially laid it down, with  almost the distinctness  and
positiveness of a law, that in difficult labor the child is  always 
THE VECTIS.
729
dead before the mother is placed in such a position of danger as
to require  immediate delivery.  Drs.  Hardy and M'Clintock
have followed Dr. Collins to a considerable extent in this par-
ticular.  The wisdom of the  rule thus sought to be enforced by
these  eminent  accoucheurs  may,  however, be  questioned.
When there is  distinct evidence that the child cannot be born
alive, when turning is impracticable, and when delivery by the
forceps has been  vainly attempted,  there is no object to be
gained by delay.   There is little difference, in a moral point of
view, between standing by while the foetus dies, and the actual
performance of craniotomy;  but it  may make every difference
to the chances of safety to the mother to have a dead foetus, upon
wThom perforation has been  performed, and  in whom the  pro-
cesses of putrefaction and softening are going on, and with the
solid head of a living child, pressing under the force of uterine
action upon the soft contents of the pelvis.   No  doubt it must
always be a satisfaction to know, when the certainty arises that
craniotomy  is inevitable, that the  child is already  dead; but
this event cannot be waited for except with risk to the mother.
It would probably be better to be without  auscultation alto-
gether, in such cases, than to  make  it  the ally of timidity and
procrastination.  In every case where the least promise of such
a solution of the difficulty exists, turning or the  application of
the long 6r short forceps should be attempted; but the moment
we are positively certain that the head  cannot pass naturally or
artificially without perforation, but that with perforation it may
pass, we should prepare for craniotomy, with little reference to
the question of whether the mother can bear an hour or two of
additional suffering, or  whether the child may linger  a  few
hours more before it expires from compression.
   [No mention of the  Vectis is made by the  author of this
treatise, which  is indeed an obsolete and little used instrument,
although  holding a  place,  made  for  it by the  instrument
makers, in every obstetric case.  The ordinary vectis is about a
foot in length, and is intended to act as a lever to  move the
head into any desired position.  To  effect this a point d'appui
is required.  If this  point is  the bony pelvis, certain injury is
done to the soft parts  of the mother, if upon  one hand  of the
operator, sufficient power cannot be applied with the  other to
effect the  result.  I  have, therefore, contrived an instrument. 
730
IMPROVED VECTIS OR TKACTOR.
represented in the cut annexed to which I have given the name
of a tractor.   It is of about double the length of the ordinary

c           a               A                           b



vectis, and for convenience is capable of being folded upon itself,
but firmly fastened when intended for use by a screw button or
a wooden movable handle in the centre, A.  At both ends are
fenestras of unequal sizes and  curvatures,  for different  appli-
cations.
   In  its application it is to be seized with the right hand at or
near a, while fenestra b is  to be placed  upon the elbow or out-
side of  the fore-arm  as  convenient.   The fenestra c  is  to  be
passed over the head of the child, and fixed as desired.  Thus
we  have a the power, b the fulcrum, and c the resistance, and
the instrument, a lever  of the third kind.   One  hand  only is
now employed with the instrument while the other may manipu-
late internally or externally.   Used as  a lever, no pressure is
made  upon the hard or soft parts of the  mother.  As  a tractor
its power is wonderful.  The  pressure  of b  upon the  elbow,
holds  c fast to the side of the  head, allowing no  slipping and
permitting any possible amount of tractile force to be made in
a straight line.  It almost equals the forceps in power and has
the advantage  of but one  blade, a valuable feature in some
cases, where the introduction and locking of the second  blade
is found to be impossible.
  The vectis or tractor is to be introduced in the same manner
as the forceps, and is to be slipped over the portion of  the head
upon  which it is  desired to act—over the occiput, when  the
 
METHOD OF USING THE  TRACTOR.
731
object is to flex the head, or upon the parietal regions in the lateral
inclined positions—especially in some of the posterior positions of
the face, treated of in Lecture XXVL, when too far engaged to
admit of version.  Where it is used for flexing the head and
depressing the occiput, it is passed like a blade of the forceps
directly upon the vertex and as much as possible upon the occi-
  The mode of using the vectis or tractor to pull down the occiput or flex the head.

put.   When the occiput is to the right, as in the cut, the point
d'oppui is  not, as in the previous representation, upon the  out-
side of the fore-arm but along its  inner surface.  In  this posi-
tion the hand seizing the instrument is not twisted, as when the
occiput is  to  the  left.  Those who may be  ambi-dexter, may
for convenience, when the occiput is to  the left, use  the  left
hand,.
   This  instrument  I have  found  of service in  delivering a 
732
CHLOROFORM.
retained head in breech  cases, or where I have turned.  It may
either be applied over the head in the hollow of the sacrum or
under the pubis.  As but one blade is to be passed, and no time
is spent in locking, its superiority to the forceps as a time-saver
in those cases will be recognized.
  That this modified instrument is one of value,  and worthy of
more respect than  the old vectis, is attested by a recent report of
the obstetric section of the New York Academy of Medicine, to
which I beg leave to refer all interested in it.

  Chloroform has been incidentally alluded to as an adjuvant
to obstetric operations in various parts of these lectures, but not
with  that fullness which  its  merits so  eminently entitle it to
receive.   At the present day, few  would willingly  enter upon
general practice without  the use of anaesthetics of some kind, be
it any of the various ethers, amylene or chloroform— which I pre-
fer  for its general agreeability, less irritating qualities to the
throat and fauces, the small quantity required,  and  its more
speedy and  certain results.  Any person sufficiently  educated
in medicine to take charge of a case of labor will have  learnt
the proper method of its  administration, the  care to be exercised
and the dangers to be met and avoided.  I shall not, therefore,
here enter upon the method of its administration further than to
state that, for my own  practice, I keep  a large cup-shaped, fine
sponge for this purpose ;  the chloroform  is placed in its internal
apex, and then the face buried in its  cavity, thus a full  supply
of ordinary air is inhaled with  the vapor.  I do  not expect by
anaesthesia to facilitate any operation except  that of turnino-:
but for this, its service  is all-important.   The difficulties of this
operation are enlarged upon in previous  pages; and it is recog-
nized as perhaps equalling in difficulty to the operator, in shock
to the patient, and danger to the offspring any obstetric  appli-
ance.  Chloroform relieves the operator from the benumbing
effects of the powerful  uterine contractions, mitigates  if not
annihilates the shock to  the mother, and adds  greatly to the
chance of the child's  life; rendering the  operation  not only
often desirable, but feasible, where without it, some more destruc-
tive procedure would otherwise necessarily be requisite.  In
applications of the forceps I would advise against its use espe-
cially if there be  any  supposed difficulty in their application. 
WHEN CHLOROFORM IS  USEFUL.
733
The sensations  of the  mother are very  valuable to  guide the
operator,  lest by  some accident or maladresse  the  soft parts
be injured, by  inclosing a portion of the mucous membrane in
the lock, passing the blades external to  the os uteri, using too
much force in an improper direction, and the like.  After the
instrument has  been applied, then the use of anaesthesia is justi-
fiable, although it is desirable not to give it to full anaesthesia, so
as to overcome the involuntary uterine action.  It is of no prac-
ticable importance in embryulcia; but so far as it interferes with
the uterine efforts, it retards the delivery.
  As a simple assuager of pain, both by diminishing the length
of the labor and deadening the sensibilities, its use is valuable,
and to be recommended.   Particularly in those cases where the
straining of the patient is dangerous by reason of diseases of the
heart, lesions of the lungs, aneurisms, etc., which may be rup-
tured and cause death by the effort; less  danger is frequently
to be apprehended from  the anaesthetic than from the  efforts
of expulsion.   Its use  relaxes the os uteri, softens the rigidity
of the vaginal muscles and perinaeum, induces a  flow of mucus,
lubricating the passage, cooling the heat  and lessening the sensi-
bilities ; thus, although arresting the voluntary efforts of expul-
sion and diminishing the strength  of the  uterine contractions,
frequently converting a lingering labor into a speedy one.  As
is evident, it may be given in the first stage, to  effect the dila-
tion of the os; in the second, to overcome vaginal contractions ;
and finally, to relax the perinaeum.   It may commence with the
labor, continue  through its course and mitigate the closing  pang;
then the satisfactory contraction of the uterus being attended to,
a teaspoonful may be put into a vial and inhaled as each after-
pain approaches,  thereby mitigating or  destroying its annoy-
ance.
  In the event  of puerperal convulsions and puerperal mania,  it
is not unfrequently called for.  The peculiarity  of  the cases
where it is serviceable, where innocuous and where injurious, are
noted in the lecture upon that subject.  In cases  where the pla-
centa is  retained  on account of hourglass contractions, by the
use of anaesthetics the hand Can be more easily passed through
the ring and the delivery thus effected with more ease to both
mother and operator.
  Finally, in the sensitive condition of the nipples at nursing, 
734         SUBSEQUENT EFFECTS OF CHLOROFORM.
 without fissure or abrasion, the nipple may, immediately before
 applying the cliild to the breast, be put into the large neck of a
 bottle containing chloroform, not being wet by it, but bathed in
 its fumes for five or  ten minutes, thus not unfrequently giving
 great relief in this most annoying affection.  Great  care  should
 be taken to have pure medicaments, Squibbs' tests of chloroform
 being applied to all specimens used, if not manufactured by him,
 Duncan  and Flockhart  of  Edinburgh,  or  equally  careful
 chemists.
  There are two or three points which, even in this  brief notice,
 should not be passed  by without  a  word: and first,  the subse-
 quent effects upon the mother's health.  In my own experience,
 not the slightest ill result has occurred which could by any pos-
 sibility be traced to anaesthesia.  The uterine contractions have
 been as prompt and  as  efficient, and  never  any subsequent
 haemorrhage has ensued.  No cephalic  disturbance nor even a
 headache, although, according to some, insanity is ascribed to its
 use.  Indeed, those patients with whom I have used chloroform,
 having been saved the nervous shock, have invariably  " got up "
 better, and with less  fatigue, muscular soreness, etc., than those
 not using it.
  Whatever doubts there may be expressed as regards the effects
 of anaesthetics upon the mother, I think no  one ascribes any
 bad results to the  child from  their use.   Certainly, in my
 experience, children  born while the parents had been several
 hours entirely unconscious, have struggled and cried  as lustily
 at the  moment of birth, and  remained as free from subsequent
 stupor, as  children born without the use  of anaesthetics.]

  Addenda.—I  have already intimated that Chloroform is  of
very great value in all  the more important Obstetric Operations,
when no contra-indication to its employment exists.  I believe
especially,  that it enables the accoucheur, under many circum-
stances, to  turn or deliver by the forceps where, but for its use,
 he would  have to resort  to  craniotomy.   Anaesthesia must, it
appears to me, be recognized  as being  quite as important  in
operative midwifery  as it is in operative  surgery.
  As regards the employment of Chloroform in Ordinary Labor,
the current of all experience,  since the invaluable discovery of
its anesthetic properties by  Prof. Simpson, has been to show 
THE USE OF CHLOROFORM.
735
 its general safety and  utility.  At its first  introduction, I had
 scruples as to its use, but I have now no hesitation in employing
 it whenever the pains of labor are severe, and when the patient
 and her friends desire  it.  There are,  however, certain circum-
 stances which I have seen reason to bear in mind in its adminis-
 tration.  Although it is often of very great value in producing
 sleep and  quiet  in  puerperal mania,  I believe I have seen in-
 sanity caused after delivery by its  liberal  employment in some
 cases.  I have also seen it suspend uterine action, and I would
 therefore be cautious as to its use  in cases of uterine inertia or
 in  patients subject  to  haemorrhage after  labor.  Some of the
 worst cases of laceration of  the perinaeum which I have  seen
 have occurred in patients delivered under the influence of chloro-
 form.   This  agent is without doubt useful in relaxing the os
 uteri and the perinaeum.   But in cases of rigidity of the perin-
 aeum,  the  existence of pain  and full  consciousness causes the
 patient to exert, by the controlling  influence of volition, a power
 over the peristaltic and reflex actions of the uterus and respira-
 tory muscles, which retards the passage of the head to such an
 extent as to preserve the perinaeum when patients are insensible
 to pain, but  retain some amount of consciousness. They will
 often make  greater efforts than  usual at the time the head
 presses on the perinaeum, and urge it through the ostium vaginae
 with  such  force  as  to  tear up  the perinaeum.  Greater care,
 therefore, than usual should be taken when using chloroform, to
 prevent the too rapid birth of the head.
  In the employment of anaesthesia in ordinary labor, the same
 objections  to  its use in cases of fatty heart  or diseases of  the
respiratory organs obtain, as  those  which  apply to the general
operations  of surgery.  The anaesthesia  need not, however, in the
practice of ordinary midwifery, be so profound as  in surgical
operations  or in the operations of midwifery.  I believe the best
method of  administering  it is that which is employed by the
discoverer  of its anaesthetic  powers—namely,  to pour  a little
chloroform on a towel or napkin, and suffer the patient to
inhale it at the commencement of every pain. 
LECTURE   L.
                        CONCLUSION.

  Gentlemen :—Having considered the principal subjects which
relate  to  the  Anatomy, Physiology, and Pathology of  the
Reproductive Processes, I propose to devote the present Lecture
—the  last of the course—to the Causes of the Mortality
which attends Parturition and the  puerperal period, and to
the modes by which the  amount  of this mortality may be
diminished.  The latter forms the end and aim of all improve-
ments in the Theory and Practice of  this department of Medi-
cine.
  The  seventeenth annual  report of  the  Registrar-general of
births,  deaths, and marriages in England, published during the
present year, contains a letter on the  causes of death in 1854,
by Dr. Farr, the  eminent vital statistician, in  which  the mor-
tality of women in child-bearing is very ably  handled.  From
this document it appears that during the eight  years from 1847
to 1854, inclusive, to every 10,000 children born alive in Eng-
land and Wales, 54 mothers died.  This makes  a maternal mor-
tality of nearly 1  in every 189 deliveries.   In  the seven years
no less than  3,232 mothers died, on the average, annually.  It is
a gratifying  fact, that in the seven years the mortality decreased
from 60 in 10,000, in  1847, and  61 in 1848, to 47 in 10,000 in
1854.  Since 1848 the  declension has  been  progressive,  the
numbers per 10,000  being 58,  55, 53, 52, 50, and 47.  Still,
in the most favorable year, 1854, 3,009 died either during child-
birth, or in the puerperal period—an enormous  fatality to attend
the performance of a natural function.  The most minute parti-
culars in his report relate to the year 1852.  In that year there
occurred in this country 618,902 child-bearings, and the number
of women who perished was 3,247.   We may at the present
time consider 3,000 per annum as the number of women  des-
 T36 
mortality in childbirth.
737
         fined to perish from childbirth in England and Wales.   This
         mortality, it must be remembered, refers to women in the prime
         of life,  who,  up  to the time  of labor, enjoy excellent health.
         From the  numbers given  in the seven years, out of every
         100,000 child-bearings, 530  women died from causes incident to
         labor.   In the year 1848, 61 mothers died  to every 10,000 child-
         ren born alive.  For the year 1852, we have the exact number
•        of child-bearings  given.  In  this year, 617,902 women were
         delivered.  Of these, 3,217  died in childbirth, or  in the puer-
         peral period.   The  estimated  number of still-born children was
         22,122.   The deaths from child-bearing bear a considerable pro-
         portion  to the entire mortality during  the child-bearing period
         —viz., from the ages of 15 to  55.   Amongst women of the age
         15-25, the annual mortality  per cent, from all  causes was .861,
         of which the JTst part, or  .41, is  by childbirth.  At the ages
         25-35,  and 35-45, the  annual mortality per  cent, from all
         causes was 1.090, and 1.296, of which .098 resulted from child-
         birth.  Thus,  between the  ages 25-35, 1 in  every 11 deaths
         from all causes is from  childbirth.  At the age 35-45, 1 out of
        every 13 deaths is from  childbirth; and in the case of women
        of the age 15-25, the mortality is increased  by childbirth in
        the ratio of 5  to 9.  It is difficult to put the mortality from par-
        turition  in a stronger light than this.  In the English schedule
        there is  as yet no column for the ages of the parents of the child-
        ren registered.  In the Swedish  returns  this  defect does not
        exist, and Dr. Farr has determined the  deaths from  childbirth,
        at the respective ages as they occur in this country, by applying
        the data drawn from  the  Swedish  tables to  our  own.   The
        results show that a mathematical  law governs the  calamitous
        deaths of childbirth.   Between the  ages of 15 and 25,  the
        maternal mortality, as already stated, amounts to 668 in every
       '100,000, in childbirth.  In the second child-bearing decenniad,
        from  25 to 35, the mortality  from parturition is  only 425 in
        100,000 labors.   It rises to 633 per 100.000, between the  ages
        of 35 and 45, and to 883 in the last decenniad, namely, from 45
        to 55.  It is in the first decenniad that the  largest proportion of
        first births occur; but more than one-half of the deliveries which
        take place at all ages, occur between the years 25 and 35.   This
        is, in fact, the  great child-bearing epoch, and the age at which
il 
738
mortality in childbirth.
parturition is most safely performed.  At the age of 15 to 25,
one woman out of every sixteen bears a child in the year.  At
the age of 45 and upwards, the number bearing children  is
inconsiderable, but from the age of 25 to 35, one woman in every
four bears during the  year  in  this country   The  most fatal
decenniad is the last, between the ages of 45 and 55, when tlie
deaths are more  than double the proportion of the deaths occur-
ring in childbirth  between 25 and 35.  The female  population
between the ages of 45 and 55 is estimated at 782,010 ; of these,
7,545 are  computed  to  bear  children in the year, and a fatal
result occurs in 66 cases, or at  the rate of .883 per  cent.  The
comparative mortality in the four decenniads may be represented
by the figures, 3, 2,  3, and 4.   This increase in  the mortality
from parturition at the two extremes of  the child-bearing epoch
is in accordance with the results of common observation.  All
radical defects and deformities in the child-bearing  organs are
tested in first pregnancies, and it is in the first and  last periods
that rigidities of the soft parts  are most  marked.   Towards the
end of the child-bearing period, women then becoming pregnant
for the first time have  their peculiar  dangers;  while in women
who have borne numerous  children, and  in whom the reproduc-
tive organs  are  worn  out, as  it were,  the results  of uterine
inertia, and the occurrence of  rupture of the uterus, from its
imperfect development in later  pregnancies, increase the mor-
tality.  Other affections, such as fibrous tumors and mollities
ossium, also increase in importance  as  impediments to labor,
towards  the close of the  child-bearing epoch.   It may be
.observed  that in all returns relating to obstetrics, the amount of
mortality from  causes  connected with child-bearing is rather
under than over stated, from the natural repugnance of practi-
tioners to refer to this condition as a cause of death.
   If we come  to  inquire into the special  causes of death  from
parturition, we find Metria or Puerperal Fever to be the monster
source of childbirth mortality,  when compared wTith any other
-single disease or accident attending labor.   In the eight years
 1847-55,  25,868  mothers  died in   childbirth; of these, 8,154
 perished  from  puerperal fever.  More  than 1,000 women die
 annually in  England from this  cause alone.  The particulars of
 t;iis are  set forth in the following table: 
STATISTICS of death  in childbed.           739
DEATHS OF TVOMEN IN CHILDBIRTH IN THE EIGHT YEARS 1847-54.
YEARS.	Number of Deaths from			Deaths of Mothers to 10,000 Children burn alive.
	Metria and other causes.	Metria or Puerperal Fever.	All other Accidents of Childbirth.	
1847 1848 1849 1850 1851 18j2 1853 1854	3326 3445 3339 3252 3290 3247 3060 3009	784 1365 1165 1113 1009 972 792 954	2442 2080 2174 2139 2281 2275 2268 2055	60 61 58 55 , 53 52 50 47
8 yrs., 1847-54	25868	8154	17714	64
  After puerperal fever, haemorrhage and exhaustion, the opera-
tions of midwifery, rupture of the uterus, puerperal mania, and
convulsions, are the principal causes of death,  Certain diseases
quite distinct from parturition, such  as small pox or scarlatina;
and visceral inflammations, such as idiopathic peritonitis, car-
diac, pulmonic, and cerebral inflammations, are vastly increased
in danger by the concurrence of pregnancy or parturition.  Sta-
tistics yield some interesting and important facts respecting  the
ages at which metria and  the other disorders and accidents of
childbirth are fatal in  different  proportions.   These facts  are
exhibited in the following  table :

COMPARATIVE MORTALITY OF WOMEN BEARING  CHILDREN AT DIFFERENT AGES, FROM
       METRIA AND ALL OTHER CAUSES, IN THE SEVEN YEARS 1848-54.
Age of Mother.	Deaths by Metria.	Deaths by other Accidents of Childbirth.
15-25 25-35 35^5 45-55	2085 3401 1791 86	2939 6378 5536 380
15-55	7363	15265
  Thus it appears that during the first  child-bearing decenniad,
L5-25, somewhat more than  two-fifths  of  the childbed mor-
tality is  from metria or puerperal fever, but under this head all
inflammatory disorders of the uterus are probably included.  In 
740   metria, the great cause of death  in childbed.

the second decenniad, 25-35, rather more than one-half of the
deaths of women in  childbirth are attributable to metria.  In
the third  decenniad, 35-45, rather less than one-fourth of the
deaths take place from metria, the  proportion being 1,791 from
fever, to 5,568 from the other accidents of  childbirth.  In the
limited  number of cases occurring in the fifth decenniad, a still
smaller  proportion of deaths from metria is observed.  It results
that, between the  ages 15-35, women are greatly more suscep-
tible of  puerperal  fever than between the ages 35-55.   On the
other hand,  between  the ages 35-45, and 45-55, while the
chances of death from puerperal fever are  diminished, those of
death from the other accidents of childbirth are increased in a
still  greater  proportion.  The great era of puerperal fever is
before the age  of 35, when  it exceeds one-third of the total
deaths from  childbirth.   After the age of 35, the other acci-
dents and disorders of childbirth largely exceed puerperal fever
in importance, the proportion in  the  seven years being 5,998
from the ordinary accidents and disorders of childbirth, and only
1877 from metria.  I am not  aware that the attention of obste-
tricians  has ever before been  drawn to  these remarkable facts in
connection with death from  child-bearing.   That  they have a
practical bearing of the first importance, is at once obvious.
   We have seen that the great single cause of death amongst
childbed women is  Metria,  or  Puerperal Fever.   There can
scarcely be any  hesitation in  declaring that this disease ought
hereafter to be as absolutely extinguished in this country as the
plague  of former times.   It stands in the  same category as
typhus,  and the rest of the zymotic diseases, which wre may rea-
sonably hope are in gradual process of extinction by preventive
medicine.   This  extinction, if  possible, cannot but be  hastened
by the earnest direction of the professional mind to the subject,
since it  is one which is very much within the control of medical
men.  As regards cure, or effective treatment,  the disease in its
various forms is  utterly beyond all  the known resources of our
art; and there is no reason to imagine that we shall ever deal
with it effectually, save in the way of prevention.  In this point
of view, everything  in  the history of the disease leads us to the
conclusion that  its virulence  and frequency mav be moderated
to almost any extent, or that it may even, in process of time be
entirely annihilated. 
PREVENTION OF PUERPERAL FEVER.
741
  And first, as regards the Sporadic origin of this disorder.  The
state of the lying-in woman is  one in which, as we  have seen
again and again in the present Lectures, the blood  and secre-
tions  are  necessarily vitiated to a certain  extent.   Puerperal
fever may almost be produced  at will, by crowding  a number
of lying-in women together in the wards of a lying-in hospital.
It is generated in individual cases, by inattention to the  lochial
and other secretions, the absence or neglect of ventilation,  in
the small rooms of the poor, where the lying-in chamber is often
the abode of the rest of the family, and is used for all domestic
purposes.   In fact, where there is risk of typhus to the non-gra-
vid woman, there is more  than  an equal amount of  danger of
metria to the puerperal woman.
  In the way of Infection  and  Contagion, it may, I  think, be
demonstrated, that puerperal fever may be carried  from one
patient to another by the proximity of lying-in patients, and by
attendants  and nurses  conveying the infectious principle from
one patient to another.   There can be  no doubt whatever that
the exposure of a lying-in woman to the influence of the fomites
or other impalpable or  material  agencies, derived from erysipe-
las, typhus, hospital  gangrene, scarlet fever, small pox, decom-
posing animal bodies, especially of persons who have  died from
any form of fever or inflammatory disorder, and  other  condi-
tions, conveyed to the  lying-in woman by the breath of those
about her, or the  hands and clothes of her attendants, will pro-
duce the disease.   When the disease prevails in lying-in hospi-
tals, and acquires a certain virulence, it is apt to prevail epi-
demically, all the lying-in women exposed to the danger becom-
ing affected; and it is believed  to prevail in  certain districts
and seasons, as an  epidemic, apart from all influences of con-
tagion and infection.
  The  prevention of  Sporadic   cases belongs in part  to the
general sanitary questions  of dwellings for the  poor, draining,
ventilation, water-supply, and other matters bearing  upon the
physical condition of the poorer classes of society ; and in part
to the attention given to  cleanliness, the  removal of morbid
secretions, and other removable  causes of disease, in individual
cases.  As regards lying-in hospitals, it may be questioned whe-
ther they have not proved in many respects an injury,  instead of
a blessing, to those classes they are intended to relieve, and cer- 
742
PROPRIETY OF LYING-IN HOSPITALS.
tainly, I believe, the feeling  of  the  profession is  against any
extension of  the  system  of  lying-in hospitals.   Th^y have
demonstrated  more  emphatically  than  the facts derived from
any other source, that puerperal fever is a  contagious and pre-
ventive disease.   A large amount of the mortality from puer-
peral fever in large cities has occurred within their walls, and
from these institutions it necessarily spreads by medical atten-
dants, nurses,  patients, and wet-nurses, to other lying-in women.
It is evidently unsafe to congregate lying-in women, in any num-
bers, in the same building.  This  is the opinion of Dr. Eobert
Lee.  Dr. Simpson has suggested that, lying-in charities should
consist  of  detached buildings rather than of hospitals.  Dr.
Ramsbotham  declares himself very emphatically  against such
institutions, and relates that he once refused a valuable appoint-
ment in a proposed new charity of this  kind.  Drs. Lever and
Oldham, when the managers  of the splendid income of Guy's
proposed to erect a new lying-in hospital, exerted their influence
against the origination of such a  building.   Dr. Copland, who
for a long time held an appointment as consulting physician to a
lying-in hospital, has given a very emphatic opinion respecting
the dangers arising from  such institutions.   There  can be little
doubt that the suppression of such hospitals would effect a great
saving of human life.  No care that ever yet has been devoted,
can render the mortality in lying-in hospitals in this country,  as
favorable as the mortality amongst women confined under the
most miserable circumstances  at their own homes.  Meantime
while lying-in  hospitals exist, every care  should be  given to the
ventilation of  the  wards,  the  allotment of sufficient  space  to
each  patient,  and  the removal of infected patients to separate
wards.  It has always been the laudable practice, when puerpe-
ral fever has prevailed in lying-in  hospitals, to shut up infected
wards, or to close the institutions  altogether.  What applies  to
lying-in hospitals, holds good also with respect to the admission
of lying-in patients into the wards  of general hospitals.
  As regards  the care of  individual  childbed  women with
reference to the sporadic development of metria, much depends
upon the nurse.  It is in this respect of the highest importance
to have  trained and educated nurses, understanding the subjects
of diet and ventilation, and made  well aware of the importance
of cleanliness  in  all that  relates  to  the management of the 
           MIDWIVES  AND NURSES CAUSING DISEASES.        743

lochial and lacteal secretions.  I have already referred to the
relation of questions of drainage, the construction of dwellings,
and other sanitary matters, to the sporadic  production of puer-
peral fever.  In this particular concern our profession is at pre-
sent very much at the mercy  of the public.  We  are  not res-
ponsible  for the great causes  of zymotic disease which exist.
With the improvements in our sanitary arrangements, puerperal
fever will diminish like  other diseases of the same class, or be-
come far more  easy of prevention.
  When  epidemic puerperal fever, or  the conditions which give
rise to it, exist,  what can be done to prevent its development or
extension?  It  has been proposed to keep  lying-in women in
suspicious  circumstances,  constantly  under the influence of
quinine,  iron, or  some other  tonic or antiseptic remedy.  But
the extent  of the powers of such medicines are  matters  rather
of reasonable supposition or belief than of actual proof.  I should
be disposed to  place great confidence from what I  have seen of
its use, in the chlorate of potash as a prophylactic against puer-
peral fever, in doses of from five to ten grains three times a day.
This drug appears to act by liberating in the economy, the oxy-
gen and  chlorine  it contains.
  In considering  the spread of puerperal fever by Infection and
Contagion, the  different circumstances under which the poison-
ous element is circulated must be borne in mind.
   It is obvious  that women who are in the latter months of preg-
nancy, and in whom delivery may be  expected from day to day,
should be secluded as far as possible from proximity to patients
suffering from  the exanthemata, erysipelas, hospital gangrene,
scarlet fever, putrid sore-throat, or any other disorder the miasma
of which admits  of conversion into the puerperal poison, and
that any indirect  communication by third parties or in any other
way should be  prevented to the greatest practicable extent.  The
relations  of   Medical  Men,  Students, Midwives.  and
Monthly Nurses, to the propagation of  Pnerperal Fever,
require separate  notice.
   According to  the present  arrangements  of  our  profession,
there is  no class  of medical men exempt from the risk of con-
veying to puerperal  patients, infectious or contagious matters
from disorders  capable of producing  metria.  Those who prac-
tice midwifery as a specialty, may meet with sporadic cases of 
744               PROPHYLATIO TREATMENT.

puerperal fever capable of furnishing infectious matter, or  they
may be called  to see cases  of puerperal fever in consultation.
Men holding hospital or dispensary appointments are also ob-
liged to see the puerperal patients  of such institutions.   Sur-
geons in general practice, necessarily attend cases of infectious
disease, convertable into metria, when conveyed to tlie lying-in
woman.  Surgeons holding hospital appointments, who perform
operations and  practice midwifery, as Dr. Simpson has forcibly
pointed out, have  to deal with  lying-in  women, and also  with
cases of an infectious and contagions nature, such as phlebitis or
erysipelas.   If students attend midwifery cases while their ana-
tomical and surgical education is  going on—and it is difficult
to seclude  themselves  entirely from such subjects—they  una-
voidably expose patients to  the risks arising from their dissec-
tions; from their attendance upon medical  and surgical hospital
practice;  and  also their  pathological studies.   Midwives fre-
quently convey the disease from one patient to another, and the
same may be said of Monthly Nurses.
  Since it is impossible, or  next to impossible, considering the
frequency of infectious  or contagions diseases, for any man in
practice to escape  entirely from the risks of infecting or inocula-
ting lying-in women, especially when  such patients  are under
circumstances favorable to infection or inoculation, the question
arises as to the best mode of rendering these risks nugatory or
of destroying them  altogether.  In the Lecture on  Puerperal
Fever I have given the evidences which appear to me to prove
that the blood and the breath of the practitioner is a very com-
mon medium of infection.  This would  point  to the propriety
of neither going nearer to, nor remaining longer in, the vicinity
of a patient suffering  from puerperal fever, or any convertible
infectious disease,  than is necessary; and of not approaching so
near to a recently delivered woman as to expose her to danger
from the breath.  Where the presence of  infection  is very evi-
dent, the propriety of changing the clothes is obvious, and gen-
erally practised; and many expose  their  clothes to the fumes
of chlorine after exposure to risk.   After  touching any wound
or purulent surface, the hands should be not merely washed, but
washed in a solution of chloride of lime, or some other disin-
fecting fluid.  It would only result in good and  in confidence on
the part of the patient and  practitioner, were the practice com- 
DANGERS FROM DISSECTION.
745
mon, if  the hands were habitually washed in a solution of chlor-
ide of lime, before attending a labor, and, in suspicious circum-
stances, before  and after every vaginal examination.  The fin-
gers of the practitioner are evidently a fertile source of con-
tagion.  Dr. Simpson compares the fingers  of an  accoucheur
who has been touching wounds or pathological specimens to the
armed points used in vaccination.  The small amount of matter
conveyed by the hand, which is capable of producing disease,
is  almost  incredible.   A practitioner has been known  to have
an outbreak of puerperal fever in his  practice—to have freed
himself by absence from home so as to have attended cases with-
out risk—and then to have had a second outbreak after wearing
a pair of gloves which he had worn during the first attack.   It
has been recommended that gloves should not be worn at all by
accoucheurs, and certainly, considering the interests at stake, no
precautions can be too minute under circumstances  of suspicion.
Keeping the nails closely cut is another  point worthy of atten-
tion.  The condition of the utero-vaginal canal is, it must be re-
membered, the most favorable which can be conceived, for in-
oculation.  The mucous surfaces are in a state of  high  excite-
ment ; abrasions and slight lacerations of the vagina and peri-
naeum are extremely common.  The removal  of epithelium from
the surface of the os uteri, at the time of labor, is almost uni-
versal, and it is to this part, of course, that the finger of the ac-
coucheur is necessarily directed during his examinations.   With
respect to the attendance of students on cases  of midwifery, some
time ought to be set apart for their attendance upon midwifery
cases, during which they should neither dissect nor attend the
ward's of the  hospital, or the deadhouse.  The dangers  arising
from the attendance of students upon lying-in women, when they
are dissecting and attendiug autopsies, is exhibited in the most
startling form  by the statistics of the Great Yieuna Lying-in
Hospital.  In this institution, in the six years from 1840 to 1846,
22,120  women were delivered.  Of these, 2,260 died ;  the mor-
tality beino- in the enormous ratio of  1 in every 10.   The mor-
tality has since been reduced to 1 in 74, and the reduction has
dated from the time when Dr. Semelweiss enforced the  regula-
tion, that every student should, before  and  after each vaginal
 examination, wash his hands in a solution of chloride of lime
 and also interdicted the students from touching dead bodies. 
746
STATISTICS  OF DEATH IN LABOR.
  As regards the deaths arising from accidents and other disor-
ders during childbirth, there is also much hope of diminishing
the amount of mortality.   Everything points to the importance
of only allowing qualified persons or advanced students to attend
women  in parturition.  In no  other circumstance or opera; ion
whatever, where the mortality  was 1 in 189, would ignorant wo-
men or  unqualified persons be allowed  to practise.  The  com-
mon feeling has been, that any one might safely attend a woman
in middle life who had already borne children; but  the  tables
I have given show that rather more than 800 women perish in
England yearly from the various accidents and diseases of child-
birth, between the ages of thirty-five and forty-five.   The atten-
tion and anxiety of practitioners are commonly" given to first la-
bors; but statistics show unerringly that the  greatest and most
fatal risks from accidents, etc., attend the delivery of women
who are mothers of families, and above the age of thirty-five.  It
is in these women that death occurs most frequently from haemor-
rhages, puerperal mania,  rupture of the uterus, exhaustion, etc.,
while they  are comparatively exempt from the dangers of puer-
peral fever.  On the other hand, our  care  in guarding young
lying-in women from their greater risk of taking metria should
be most unceasing.   The proportion of deaths from haemorrhage
are very large.   As far as the statistics from which I have quoted
are  available,  the  deaths from flooding alone  are more than
10  per  cent, of the  total deaths  from childbirth.  Now, there
can be no doubt that, with the appliances and means we at present
possess, this large item of childbed mortality might, in the hands
of educated obstetricians, be greatly diminished, and that death
from flooding ought rarely to  occur.  Another large reduction
might be made by substituting the induction of premature labor,
or turning,  or  the forceps, but especially premature  labor, for
craniotomy.  By the employment of turning  or the forceps, the
mortality is considerably diminished;  but by the induction of
premature  labor  the risk of death to  the mother from  the  per-
formance of craniotomy becomes  very slight indeed.   We have
seen that in almost all cases the induction of abortion or prema-
ture  labor  might, by the exercise of foresight,  be substituted
for craniotomy.  Taking the annual number of deliveries—the
proportion  of craniotomy cases—and the scale of mortality from
this operation, we have the data for an  approximative estimate 
MORTALITY BY CRANIOTOMY.
747
of the maternal  mortality caused by  craniotomy in England.
This would amount to nearly 400  deaths per annum from this
cause alone, all or nearly all of which might  undoubtedly be
averted.
[Still another accident of childbirth, which has till lately been
frequent cause of a prolonged life of suffering, alike disgusting
 
748
FORMS OF VESIOO-VAGINAL FISTULA.
to self and friends, and finally ending in a miserable death from
its wasting and irritating influences, is vesico and recto-vaginal
fistulas.  These are sometimes complicated with ruptures of the
uterus and perinaeum.
  In one case that came under my care, the  child, with a breech
position, was nearly delivered, when  it suddenly retreated, and
was found out of the uterus in the peritoneal cavity.   On subse-
quent recovery, she was found to have had a rupture extending
through the neck of  the uterus in a longitudinal direction, tear-
ing through the vesico-vaginal septum and leaving a permanent
fistula there, which was subsequently entirely cured by Dr. Sims,
at the Women's Hospital, N. Y.
   By his permission, I am enabled to present here several en-
gravings showing various forms of this disease; according to the
belief of most of the accomplished accoucheurs of the present day,
these accidents might in very many cases be avoided by the time-
ly use of instruments, by the induction of premature labor in cases
of deformity, and  thus  another reduction in the mortality and
miseries attending childbirth may be  here also effected.  They
are mostly the  effects of sloughs, resulting from prolonged pres-
sure of the head upon the soft parts.   Examination  of  the cuts
here annexed will show most incontestably, how impossible it is
for forceps to effect any laceration such as here delineated; for
unless used with the intent to bruise or lacerate the soft parts,
they  could not be made to touch the locality where the injury
us seen to be effected.] 
CONCLUSION.
749
  In concluding the present course of Lectures, I cannot but look
forward to the time when the present mortality from child-bear-
ing will be  greatly lessened.  This is a subject in which we of
the present day must bear our part, and it is consolatory to know
that every succeeding generation of students and practitioners
will come to the work with added means of science and experi-
ence, until at length we  may hope that no unnecessary mortality
shall' take place in parturition.  Women, it has been remarked,
were ordained to bring  forth children «in sorrow," but certainly
not in death.
FINIS. 
 
INDEX.
Abortion, 177 ; frequency of, 178; causes
  of, 179; methods of producing, 180;
  by oxytoxics,  181 ; caused  by syphi-
  lis, 181, 188; by albuminuria, 182; by
  fissures of the cervix uteri, 183, 204;
  an exfoliation, 184; from fatty dege-
  neration  of the placenta, 185;  from
  apoplexy of placenta, 187 ; congestion
  of placenta, 189; disease of cord, 191;
  symptoms of, 192; treatment of, 193 ;
  periodic, 194; instruments to assist in,
  196 ; condition of ovum in, 199; me-
  chanism of, 199; dangers of, 200; he-
  morrhages  from, treated  by avulsion
  of the placenta, 531; recovery from,
  200; tetanus in,  200;  prevention of,
  202 ; cause of, when repeated, 205.
Abdomen, size  and form  of, 133; dark
  streak on median line of, 135 ; pendu-
  lous, bandage for, 161;  cause of foetus
  being retained in the uterus over  the
  term,  164.
Abdominal pregnancy, 244.
Abrasion of os uteri, 174.
Abscess,  mammary, 380.
Acetabulum,  284.
Accoucheur, first male, 27 ; in New York,
  27 ; first duty of, 527.
Anaemia of pregnancy, 174.
After-pains,  355,  595;   how relieved,
  377 ;  by chloroform, 733.
Albuminuria, 154; effects of, 155 ; treat-
  ment of, 156; cause of abortion, 182 ;
  a cause of oedema of labia, 616  : cause
  of  convulsions,  616, 619 ;  treatment
  of, 621.
Allantois,  108.
Amnion, 105.
Anatomy of  the pelvis,  ante Christum,
  15, 294; of foetal head, 309.
Ancesthetics,  26; first used  in America,
  26; religious objections  to, 26 ; in
  abortion, 198.  See Chloroform, 732.
Anchylosis of hip joint, 603.
Animalcules, 35.
Annul at a, 40.
Anteversion of gravid uterus, 162, 535.
Apoplexy of placenta, 187 ; ovum, 190;
  cord, 191 ; mother, 654.
Area germinativa, 103.
  "  pellucida, 103.
  "  vasculosa, 103.         .
Areola, 60; change  in,  a  sign of preg-
  nancy, 132 ; pigment in, 133.
Arms,  delivery of in breech cases, 404;
  treatment of, 411; presentation  of,
  417; diagnosis of, 419; turning for,
  426 ; statistics of, 427 ; misplacement
  of in labor, 554.
Arteritis, 652.
Arterial obstruction the cause of  phleg-
  masia dolens, 652 ; symptoms of, 653;
  treatment of, 653 ; a cause of  sudden
  death, 654.
Articulations of pelvis,  289.
Artificial delivery for convulsions, 618.
Ascaris  lumbricoides,  36;  a cause of
  abortion, 179.
A scites of foetus, 549; of mother, 134,154.
Asphyxia, congenital, 371.
Atresia of vagina, 512.
Avulsion of placenta, 531.
Axes  of  pelvis, 302; inlet and  out-
  let,  305.
Auscultation, utero-foetal, 141 ; first ap-
  plied to diagnosis of pregnancy, 25 ;
  during labor, 140, 365 ; little value in
  determining breech presentations, 409.

                  B.
Ballottement, 144;  method of, 145; dif-
  ficulties of, 146 ;  spurious,  146.
Bandage, abdominal in  pregnancy,  161;
  after labor, 359.
Barrenness, biblical history,  14.
Bassin petit, 294.
Births, plural, number of 18 ; cross, 417.
Bladder, affected by displacements of the
   uterus, 162 ; distended, causing retro-
   version  of  the uterus, 164; after la-
   bor, 382 ; fistulas of,  697, 748.
Blastoderm, 102. 
752
INDEX.
Blisters in convulsions, 622.
Blood, its character in pregnant women,
  147.
Bloodvessels of uterus, 69.
Bloodletting  in  convulsions, 611 ;   in
  puerperal fever, 646.
Body of uterus, 62.
Bones  of pelvis,  284; analysis of  dis-
  eased and healthy,  484.
Bowels, constipation of, after labor, 382.
Breasts, treatment of, 379.
Breech presentations, 400; statistics  of,
  416.  See Pelvis presentations.
Bruit placentaire, 140.
Brow, presentation of, 383.
Bulk, a sign of pregnancy, 134 ; of child
  a cause of its death, 317.


                  C.
Casaridh section, date  of,  17 ;  morality
  of, debated,  23 ; the operation, 703 ;
  statistics of, 704 ; dangers of, 705 ; re-
  petition of, 706  ; when justifiable, 706 ;
  when necessary, 708 ; method of, 710 ;
  after dressing of wound,  711;  safer in
  country than in cities, 711.
Calculus in the bladder, 515.
Cancer of os and cervix uteri, 511;  of
  bones of pelvis, 504.
Caput succedaneum, 326.
Carunculae myrtiformes, 54.
Catamenia, 85; its character, 89 ; causes,
  90;  source,  90; state  of the uterus
  during,  94 ; abnormal, 95 ; suspension
  of, 129.
Catheter, 382 ; Sim's self-retaining, 383 ;
  use of, 51;  difficulties in using, 52.
Caul, 372.
Cephalalgia in pregnancy, 157.
Cephalotribe invented, 19 ; use, 77.
Cerebral irritation in pregnancy, 157.
Cervix uteri,  62; changes of,  in  preg-
  nancy, 137 ; Stolz's view of,  138 ; fis-
  sures of, the cause of abortion, 183,
  205 ; mucous plug  of, 237 ; dilatation
  of, 267; operations on, see Os  uteri,
  518.
Chair, accoucheur's, 13.
Change of life, 86.
Child, care of, after birth,  383 ;  care of,
  after face  presentations,  399; after
  breech do.,  415.
Chloroform, anaesthetics discovered,  26 ;
  first used in U. S., 26 ; use of, for  dis-
  orders  of  pregnancy, 151 ;  in  abor-
  tion, 198 ; in rigidity of os uteri, 519;
  in puerperal mania, 601; in convul-
  sions, 615, 621 ; in turning, 670 ; with
  forceps, 694; after pains, 733; tests
    " 734; in  ordinary  labor, 734 ; peri-
  neum relaxed by,  733; suspending
  uterine pains, 735.
Cholera in  pregnancy, 175.
Chorion, 114; villi of, 115.
Chlamydomonas, 37, 38.
Clitoris, 49 ; dislocated, 49.
Coccyx, mobility of, affecting  diameters
  of pelvis. 297  ; morbid states of, 505.
Coitus, 56, 58 ; time of labor from a sin-
  gle one, 211; influencing several ge-
  nerations, 45.
Cold in convulsions,  614, 622.
Colostrum, 378.
Colpeurynter, 25.
Colpeurysis, for retroversion  of uterus,
  166; for producing abortion, 180; for
  haemorrhage  of placenta praevia, 432 ;
  in rigidity of os uteri, 527 ; for con-
  vulsions, 622.
Commissure, superior, 48 ; inferior, 49.
Conception, 97 ; date of, after coitus, 212.
Congestion of placenta, 189; uterine, the
  cause of abortion, 204.
Convulsions, puerperal, 605; centric, 605;
  excentric, 607 ; physical, 606 ; uremic,
  620; physical, 606; from irritation of
  uterine passages, 607 ;  irritation of os
  uteri, 608; from dead foetus, 608; irrita-
  tion of vagina, 609 ; of intracranial ex-
  citor nerves, 609 ;  of viscera, 610 ;  of
  mammae, 610; from albuminuria, 616,
  619; treatment of, 611; by bloodletting,
  611; by  tartar emetic, 611 ; by tra-
  cheotomy,  613;  by sprinkling  with
  water, 6i4 ; by cold, 614 ;  by opium,
  615 ; by  chloroform, 615, 621 ;  regu-
  lation  of emotion, 615 ;  by cupping
  the head, 616 ; by cathartics, 617 ; by
  enemas,  618 ; by  artificial delivery,
  618 ; treatment of uraemic convulsions,
  621;  blisters, 622; effects  on  child,
  6 '2 3.
Cord, umbilical, 124; cause  of convolu-
  tions in,  126  ; morbid enlargement of,
  191; diseases of, and knots upon,  191;
  haemorrhage  from,  384;  apoplexy  of,
  191;  how  to tie,  and when divide,
  868;  management of, 384; in breech
  cases, 413.
Corpus luteum,  82.
Crania bifida, 549.
Craniotomy first taught, 16 ;  when ne-
  cessary, 712 ; limitations of, 713 ; sta-
  tistics of, 713 ; difficulties of, 715;  in-
  struments for, 715 ; how to  perforate,
  719 ; forceps made, 25, 72(t; time  to
  operate,  729 ; mortality of, 747.
Crochet,  date of, 17, 717  ; new guarded,
  722; how to use, 721.
Cross-births,  frequency  of, 417;   with
  placenta  previa, 448. 
INDEX.
753
Cul-de-Sac, Douglass', 75.
Cumulus proligerus, 77.
Cysticercus, 35.
Cystocele impeding labor, 515.
                  D.
 Deafness from labor, 18.
 Death in labor, first recorded, 13 ;  from
   hemorrhage  during, or after labor,
   560; sudden cause of, 654; from  fatty
   degeneration of the heart, 655 ;  from
   air in the veins, 654; coagula in the
   heart, 654 ; apoplexy, 654; statistics,
   746.
 Decapitation, 728.
 Decidua, when discovered, 22; vera, re-
   flexa,  109;  Goodsir's   views,   111;
   Coste's views, 112 ;  Lee's views,  113 ;
   serotina,  113.
 Decision of attendant imperative, 30,435.
 Decomposition, effects of,  727.
 Delivery, artificial, for convulsions,  618;
   premature, 657.
 Diet of the  puerperal woman, 381.
 Digestive organs, derangement of, 130.
 Disorders of pregnancy, 162.
 Displacements of the gravid uterus,  162.
 Distortion of pelvis, 471.   See Pelvis.
 Douche, 25 ; in rigidity of os, 520, 663 ;
   in flooding, 561 ; in  convulsions,  622;
   in premature labor, 520.
 Draught, 355.
 Dropsy, ovarian, simulating pregnancy,
   134 ;  in pregnancy, 154.
 Dysenteries  in pregnancy, 175.
 Dysmenorrhea, membranous, 95, 223.
 Dystocia, 645-

                  E.
 Ectopy, 553.
Embriotomy.  See Craniotomy.
Embryo, removal of, 197.
 Embryulcia, 727.
Emotion, 262.
Entozoa, 34; spontaneous generation of,
   35.
Entozoon, 36.
Epilepsy in  pregnancy, 175.
Ergot,  virtues of,  discovered,  25; in
  abortion,  181, 196, 208; in funis  pre-
  sentations, 467 ; in tardy labor, 641.
Eructations  indicative of pregnancy,  130.
Evolution, spontaneous,  first  records,
   13; how effected, 422.
Examination digital per vaginam, when
  to be made, 357 ; method of,  860 ; in
  face presentations care required, 399;
  with speculum, 172.
Exomphalos, 553.
                  48
 Exostosis, 491.
 Expulsion, spontaneous, 423.
 Extra-uterine gestation, 234, 239.

                  F.

 Face presentations, 386 ; peculiarities of,
   387;  cause of,  388 ;  frequency of,
   339 ;  first position  of,  389; mechan-
   ism of, 390 ; flexion in, 391; termina-
   tion of, 392 ; second position of, 392;
   varieties  of, 393 ; diagnosis of, 394 ;
   management of,  395;  Baudelocque's
   operation in, 397 ; treatment of, 398;
   care of child after, 399.
 Faces, accumulated, resembling  preg-
   nancy, 134; impeding labor, 515.
 Fallopian tubes, 69.
 Fatty degeneration  of placenta, 661;
   cause  of abortion, 185; of heart, 655;
   of uterus after labor, 256.
 Fecundation, male elements of, 98; me-
   thods  of,  99 ; twin, 234.
 Fenestra of forceps, 686.
 Fever, milk, 381;  puerperal, childbed,
   624 ; preventive medicine, 624; a dis-
   tinct poison, 625 ; sporadic, 625 ; epi-
   demic, endemic,  626;  contagious or
   infectious, 627 ; identical with  other
   puerperal  diseases,   630;  communi-
   cated  by breath,  631; by nurses and
   physicians, 631, 743; from dissections,
   633, 745; secondary symptoms  of,
   634 ; symptoms, 635; hydrosis in, 635;
   morbid changes of, 636  ; a fever with-
   out lesion, 637;  Dr.  Clark's  views,
   637 ; arising from injury, 638 ; from
   pus in uterine sinuses, 637; perito-
   nitis in, 639; pulse in,  640; suppura-
   tion in, 641; pyemic abscesses, 641;
   uterine phlebitis,  642 ; lochia in, 643;
   prevention  of,  645; treatment  of,
   645 ; prophylactic treatment of, 646;
   744; by  calomel, 646;  by antiphlo-
   gistics, 646 ; by venesection, 646; by
   opium, 647 ; by veratrum viride, 647.
 Fibre, muscular, of uterus, 252.
 Fillet, 20.
 Fibrous tumors in connexion with labor,
   513, 516.
 Fistulas, vessico-vaginal and recto-vagi-
   nal, caused by forceps, 697 ; sequele of
   labor, 748.
Flexion of head, 324; the  normal condi-
   tion of the foetus, 387.
Flooding.  See Hemorrhage.
Foetal head,  309.  See Head,
Fmtation-super, 233.
Fatus, first  motions of, 139 ; pulsatior
   of heart,  140; maturity of, the  ca
   of labor, 215; flattened by pre 
754
INDEX.
   228 ; position of, in  utero, 21, 270 ;
   cause of position, 274;  statistics of,
   273 ; ovoid shape of, in  utero, 272;
   voluntary  movements of, in  utero,
   275 ; hydrocephalic, 278, 545 ; change
   of its position, 282 ; spiral motion of,
   344 ; position dependent on bony sur-
   faces, 345; at what age viable,  659.
Follicles Gh-aafian,  72, 76 ; development
   of, 97.
Fontanelle, 311, 313 ; characteristics of,
   314.
Food, yolk, 78 ; for child, 385; for par-
   turient women, 374.
Footling, 18 ; presentations, 411.
Forceps  invented,  20;  improved,  25 ;
   craniotomy, 25;  with rigidity of os
   uteri, 528; through  an undilated  os,
   528 :  use of, 684 ; shape, 686; when to
   be used,  687 ; conditions for short and
   straight, 687 ; rules for use, 688 ; pel-
   vic curve, 688 ;  cranial  curve, 686;
   double-curved, 689;  long, 690, 695 ;
   care  required, 696 ; preliminaries to
   use of, 690 ; position of woman, 690 ;
   position  of foetal  head, 691 ; method
   of introduction, 692  ; care in  locking,
   693 ;  delivery with,  694;  chloroform
   with, 694 ; in  occipito posterior posi-
   tions,  695; selection  of, 698; Rad-
   ford's, 689 ; Smellie's, 685 ; Hodge's,
   Davis',  698;  Elliot's,  699 ; Ritzen's,
   701 ; for traction, 698; for compres-
   sion,  700; results, not rapidity, de-
   sired, 702; for craniotomy, 720 ; new,
   725 ; Dr. Thomas', 726.
Fossa navicularis, 49.
Fourchette, 49.
Frenulum,  49.
Fumigations in difficult labor, 16.
Fundus uteri, 62.
Funis umbilicalis, 124; convolutions of,
   126; disease of, the cause  of abortion,
   191 ;  knots upon, 191; management
   of, 384;  hemorrhage from,  384; in
   breech cases, 413;  presentations of,
   458 ; causes of, 458;  statistics of, 459 ;
   symptoms of, 460; mortality  of, 461  ;
   dangers  of, 462;  treatment of, 462;
   reposition of cord, 463;  instruments
   for,  464;  safety in,  while pulsation
   lasts, 463 ; operations  for, 466 ; turn-
   ing for,  466 ; ergot for,  467 ; vectis
   and forceps in, 467 ; stimulating mea-
   sures, 467 ;  postural treatment, 468;
   Dr. Thomas' rules, 469.

                 G.
   mglion, hypogastric, 259.
    'ralgia in pregnancy, 152.
 Generation, spontaneous, 33; equivocal,
   33 ;  fissiparous, 37 ; by segmentation,
   37 ;  gemmiparous,  39; conjugate, 41 ;
   hermaphrodite,   42;  alternate,  43;
   sexual, 43; virgin,  44; oviparous, 45;
   ovo-viviparous, 47 ; organs of, 48.
 Germ-cells, 43.
 Germ-yolk, 78; mass, 101.
 Germinal vesicle,  78; spot,  78; mem-
   brane, 102.
 Gestation, length of,  210 ;  comparative,
   213; extra-uterine, 234,  239 ;  pro-
   longed, 18, 215.
 Gland, vulvo-vaginal, 54; Huguier's, 54.
 Goitre in pregnancy,  153.
 Graafian vesicles, 72, 76.
 Graafian follicle,   development of,  in
   human female, 97.
 Gravitation, physical, of child, 273.
 Gregarina, 36.
 Haemorrhage before labor, 208 ; in abor-
   tion, 208,  565 ; from detached  pla-
   centa,  209;  character  of, when from
   fundus uteri, 269 ; from hydatids, 229 ;
   from placenta previa, 209, 430; from
   moles, 229; after the birth of child,
   556, 563 ; source of, 556; symptoms
   of, 557;  with  uterine  contractions,
   558;  from   loss  of  decidua,  559;
   effects  of,  559; treatment of,  560;
   puerperal pallor from,  560; preven-
   tion  of, 560; cold douche in, 561;
   transfusion  in, 662-; nature in, 564;
   with adherent placenta,  566; tampon
   in, 568 ; at  full  term, 570 ; from  irre-
   gular contraction, 571; from mechani-
   cal impediment  to uterine  contrac-
   tion, 571;  hand  in uterus  for, 572;
   compression of the aorta, 573 ; stimu-
   lants in, 573 ; after  symptoms of,  574.
Haemorrhoids,  158.
Head,  foetal, 309;' diameters of,   310,
   312 ; measurements of, 311; diversity
   of size in males and females, 315; size
   of, dependent upon civilization; de-
   formed by bandages, 319; presenta-
   tion of occiput, 321  ; positions of, 323 ;
   first  position,  324; mechanism  of,
   325; flexion  of,  324; obliquity of,
   326 ; rotation  of, 326 ; re-rotation of,
   327 ; what is meant by the presenting
   part, 327; extension of, 327 ; restitu-
   tion  of, 327 ; second position of, 328;
   third position, 331; first and third po-
   sitions  contrasted,  333 ;  fourth posi-
   tion, 334 ; variations of the four posi-
   tions, 335 ; possibility of jts compres-
   sion  in different  parts, 680.
Head, eize of,  of Webster, Cuvier, and
   Dupuytren, 317.
Headache in pregnancy, 147, 157. 
INDEX.
755
Heart, pulsations of fetal, 140; double,
  142 ; imitative sound, 143 ; diseases of
  mothers   aggravated by  pregnancy,
  175 ; fatty degeneration of, 655 ; clot
  in, cause of sudden death, 654.
Heart-burn indicative of pregnancy, 130.
Hernia in labia, 161.
Hippocrates' obstetrical writings, 15.
Horns of uterus, 252.
Hourglass  contraction, 544; cause of,
  593.
Hospitals, lying-in,  propriety of, 742.
Hydatids  resembling   pregnancy,   18,
  134; character of, 224; symptoms of,
  230.
Hydrocyanic acid in pregnancy, 151.
Hydrocephalus  of fetus, 278 ; producing
  rupture of uterus, 547.
Hydrosis, 635.
Hymen,  53;   cartilaginous  impeding
  labor,  516.
Hysterotomy, date of, 16.  See Caesarian
  section.

                   I.
Icterus of newly born child,  384.
Ilium, 284.
Impregnation, methods of, 46, 99.
Infant, management of new-born,  383 ;
  food of, 385.
Infanticide, alleged, 544.
Infusoria,  34; spontaneous  generation
  of, 35.
Innominatum os, 284.
Insane, puerperally, case  of, 603.
Insanity, puerperal, 596.


                   K.
Kiestien, 146.
Kreasote in disorders of pregnancy, 151.


                   L.
 Labia majora, pudendi, 48;   minora,
   50; edema  of, impeding  labor, 516 ;
   varicose, 516 ; tumors of, 516.
 Labor, early views of its mechanism, 21,
   24; cause  of,  210; ovarian theory,
   216;  missed, 246;  mechanism of,
   321;  stages  of,   346;   preliminary
   stage, 346;  stage of dilatation,  347 ;
   duties during, 360;  stage of  propul-
   sion, 348 ; duties during,  363 ;  expira-
   tory-reflex,  actions of, 350;  expira-
   tory, voluntary actions of, 311;  stage
   of expulsion, 352;  close of,  356; ma-
   nagement of, natural, 357  ; matters
   required by accoucheur,  357 ; length
   of, 362  ; shock of,  374;  obstructed,
   605 ;  from  rigidity of os, 506,  518 ;
 tardy, 533 ;  precipitate,  533;  from
 fibrous tumors, 510 ; from  carcinoma
 of os and cervix, 611; from  contrac-
 tion and rigidity of vagina, 511; from
 contraction and rigidity of perineum,
 517 ; from vaginal  polypi, 512 ; ova-
 rian tumors, 513; recto and vesico-
 cele, 515; fecal collections, 515 ; stone
 in the bladder, 515 ; swelling of soft
 parts, 516 ; cartilaginous hymen, 516 ;
 by  edema,  or tumors of labia, 516;
 thrombus, 517 ; misplacement of arm,
 554.
 Tardy,  from  general debility,  534;
   from position of the uterus,  535;
   from double uterus, 536 ; from  ute-
   rine disease, 537; from hydroce-
   phalus, 547 ; from ascites of child,
   549 ;  from rheumatism, gout,  and
    neuralgia of uterus, 537 ; from short
    cord,  554;  from rigidity  of the
    membranes, 554; from uterine iner-
    tia, 538;  from plural births,  554;
    from pulmonary, cardiac, or dropsi-
    cal affection of mother,  539 ; treats
    ment of, 541; oxytoxics  in, 541.
 Precipitate, 542 ; causes of, 543 ; treat-
    ment of, 544 ; effects of,  544.
 Difficult, from  hydrocephalus,  555;
    mechanism of, 546;  treatment of,
    549 ; from twin monsters, 551.
  Premature,  23; treatment  of,  231,
    657; induction of, 657 ;  dangers of,
    658 ;  at  what age  of fetus,  659,
    664 ; morality of,  659 ; when neces-
    sary for  mother's safety,  660; for
    child's preservation, 661;  how pro-
    duced, 663;  by puncturing  mem-
    branes, 663 ;  by electricity, 663 ;
    cupping  glasses  to mamme, 663;
    by sponge tent,  520; by water
    douche, 520 ; statistics of, 666 ; in-
    strumental.
Lactation  prolonged,  11 ;  excessive,
  381, 603.
Laminae dorsales, 103.
Lamina: ventrales, 104.
Leucorrhoea in pregnancy, 170.
Lever, 19.  See Vectis.
Ligaments of ovaries, 71; of uterus, 73;
  of pelvis, 289.
Linea Albicantes,  133 ;  ilio-pectinea,
  294.
Liquor amnii , 106; draining off, 364.
Lochia, 375; resemblance to menstrual
  flux, 376; offensive in puerperal fever,
  631.
Longings, 152.
Loxodes Bursaria, 38.
Lymphatics of the breast, 61; of ut
  69;  inflammation, 651. 
756
INDEX.
                 M.

Macula germinativa, 78.
Malacosteon, 472.
Males the result of long gestation, 215 ;
  parturient accident more frequent than
  with females, 317.
Malpresentations,in&\ience of, on mother
  and child, 416.
Mamma;,  58 ;  anatomy of, 59 ; arteries
  of, 60; lymphatics  of, 61;  swelling
  and  pain of,  indicating  pregnancy,
  131;  after  labor,  378;  abscess  of,
  380 ; irritation of producing abortion,
  179,  663.
Mammitis in early pregnancy, 154.
Man, what he is, 106; first midwife,  27.
Mania, puerperal, a cause of, 381, 596;
  causes of, 597; predisposition to, 598;
  symptoms of,  600;  leeches and vene-
  section in treatment of, 600;  chloro-
  form in, 601; hospitals, 602 ;  differ-
  ence from other forms of insanity, 502;
  produced by undue lactation, 603.
Marasmus in pregnancy,  151.
Mastodynia, 132.
Meatus urinarius, 59.
Meroiiium in face presentations, 395;
  in breech, 410.
Medusae, 40.
Mechanism  of labor, 21, 24.
Membrana granulosa, 77; decidua, 109.
Membranes, 108, 120; double, 124; dys-
  menorrhea!,  95, 123;  carneous  de-
  generation of, 225  ; rupture of, 348;
  how and when,  363, 544 ;  rigidity of.
  544 ; remaining  after delivery, 199 ;
  puncturing in placenta previa, 433;
  puncturing in convulsions, 618.
Menstruation, 81,  85  ; influence of,  89;
  cause of,  90 ;  physiology of, 91; vica-
  rious,  96  ; state of  uterus during,  94;
  post-mortem appearances during,  94;
  in pregnancy, 171; with an inverted
  uterus, 583.
Micturition, to  be attended to,  of  mo-
   ther,  583 ;  in  convulsion,  618 ;  of
  child,  383.
Midwifery,  history of, 11.
Midwives instituted,  12 ;  character of
   their services, 13, 28; first taught, 22.
Milk,  "the draught" of, 59; a  sign of
   pregnancy, 133; after  delivery, 378;
   fever, 381.
Misdach, 18.
Mishnah, on Cesarean section, 17.
Missed labor, 246.
 Molar  pregnancy, symptoms  of, 229;
   hydatid, 229; hemorrhage from, 229;
     ^atment of, 231.
       223.
Mollities  ossium  in   piegnancy,  176;
  character of, 483.
Monas crepusculus, 34.
Monstrosities, cause  of,  105;  in  preg-
  nancy,  171; cause  of dillicult labor,
  5.31 ;  instrumental assistance, 552.
Mons veneris, 48.
Morning sickness,  131.
Movement  of  child,   139 ;  peristaltic
  uterine, 140.
Muscles of uterus,  252.

                  N.
Nature  in breech cases, 411; in pla-
  centa previa, 431;  in hemorrhage,
  564.
Nausea  indicative  of pregnancy, 130.
Negro fetal scull, 320.
Nerves, hypogastric, ganglion and plexus,
  257;  uterine, direct action of,  264;
  peristaltic, 265.
Neuralgia, facial,  of  pregnancy,  153 ;
  of uterus, tardy  labor from, 537.
Nipple, 59 ;  tenderness,  a sign of  preg-
  nancy,  132 ;  abraded and  cracked,
  treatment of, 380; relieved by chloro-
  form, 734.
Nymphae, 50.

                  0.
 Occiput, 311 ; presentation of,  821.
 (Edema gravidarum, 154, 159 ; of labia
  from  albuminuria, 516.
 Offspring of different colors, 234.
 Os innominatum,  284.
 Osteo sarcoma, 491.
 Os  uteri, tince,  62;  papille of, 66;
   division in rigidity of, 25 ; tampon-
   ing, 25; abrasions  of,  in  pregnancy,
   170;  fissures of, the  cause  of  abor-
   tion,  183  ; dilatation  of,  267;  time
   required for, 362 ; when difficult, 353;
   obstructed labor from rigidity of, 518 ;
   spasmodic rigidity of,  518 ; obstinate,
   529 ;  fibrous, 529 ;  cartilaginous, 529;
   treated  by douche, 520;  by chloro-
   form, 519, 733;  sponge tent,  509,
   520;  incision of, 507, 521; authorities
   upon, 524; scarification of for rigidity,
   526 ; value of its integrity,  527 ; use
   of forceps through, when undilated,
   528;  irritation, 531 ;  delivery of pla-
   centa through when rigid, 531;  dilated
   by colpeurysis,  527;  laceration  of,
   508,  523 ; entire occlusion  of,  507;
   adhesion  of, 508;  carcinoma of, 511 ;
   turning through when undilated, G74.
 Ova,  35 ;   impregnated  at  different
   periods, 234.
 Ovaria, 71; experiments on, 219.
• 
INDEX.
757
Ovarian disease,  simulating pregnancy,
  134 ;  pregnancy, 239, 242.
Ovario-tubal pregnancy, 239.
Ovisac,  79.
Ovipjsition, 80.
Ovule, 77 ;  dehiscence of,  42.
Ovum,  early  development of, 97, 104;
  microscopical  anatomy  of, 102;  car-
  neous  degeneration of,  225;  hydat-
  iginous, 221; blighted,  228.
Oxytoxics,  causing abortion, 181 ;  in
  tardy labor, 541.
                  P.

Pains of labor,  Bible history  of,  14;
  " taking a pain," 359 ; pulling, 367 ; af-
  ter labor, 355,595 ; how relieved, 377 ;
  by chloroform, 733; in mamme, 147.
Pallor  of pregnancy, 174;  from rup-
  ture of fallopian tube, 240 ; puerperal,
  from  hemorrhage, 560 ;  danger from,
  567.
Palpation, diagnosis by, 661.
Paramecium aurelia, 38.
Parthogenesis, 44.
Parturition difficult  with  males,  316;
  comparatively  with  civilized  races,
  317 ;  mechanism  of, 336 ; a volumin-
  ous motor function, 353.
Pelvis,  284; separate bones  of,  2S4;
  false  and  true, 294; diameters,  296;
  depth of cavity, 296, 306 ; planes of,
  297;  brim of, 298 ;  boundaries of,
  300;  deep and shallow, 307;  axis of,
  302 ;  direction of, 304; canal of, 305 ;
  external measurements of,  307;  dis-
  tortions of, 471; from rachitis,  472;
  from  malacostea,  472; character of,
  474; Dr. Duncan's views of, 476 ; molli-
  ties ossium, 483; Naegele's views, 486;
  obliquely distorted, 486 ; diagnosis of,
  487 ; cause of, 489; from exostosis, 491;
  bony  growths within the pelvis, 592,
  503 ;  osseous  deposits within,  493;
  equabiliter justo minor, 493 ; equa-
  biliter justo major,  497; abnormally
  small, 481; abnormally large,  497 ;
  equally contracted, 495 ; infantile, 496 ;
  masculine,  496 ;  distorted  from in-
  creased curvature of the sacrum, 498 ;
  from  flatness  of  the sacrum, 498 ;
  from  fractures, 499 ;  oblique,  590 ;
  diagnosis of,  501; aids to labor with
  distortion of,  502 ;  abnormal  sharp-
  ness to edge of bone, 504.
Perinaeum, 54; how to support,  365;
  care  of, in face  presentations, 399;
  dilatation of, 352; incision of, for ri-
  gidity,  517 ;   laceration from preci-
   pitate labor, 514 ;  relaxed by chloro-
   form, 733.
Placenta, relative size of muscular fibres
   449 ; action of the arteries, 450; line of
   safety in, 453 ; cervical detachment of
   the placenta, 455; removed by avulsion,
   531 ; through an undilated  os, 531;
   retained,   544 ; attached, 566 ; he-
   morrhage with, 560; danger from, 507;
   how  removed,  569;  encysted,  590;
   results of, 591;  adherent, 566;  cause
   of hour-glass contraction, 594; fatty
   degeneration of, 661.
Placental delivery, mechanism of, 370.
Placentitis,  189.
Planes of pelvis, 297 ; of inlet, 298 ;  of
   outlet, 3ul ; of strait, 300.
Poison of puerperal fever, 625; con-
   veyed by infection, 626 ; contagion,
   627;  by breath,  631;  identical with
   other  puerperal  diseases, 630; aris-
   ing from  erysipelas, 632; dissecting,
   633.
Polyps, 38 ;  reproduction of, 40.
Polypi  of uterus,  134;  fibrous degene-
  ration of after labor, 510.
Positions of fetal head, 323 ; first, 324 ;
  mechanism  of,  325 ;  second,   328 ;
  third,  331;   first   and  second  con-
  trasted, 333;  fourth, 334; variations
  from  the  four,  335;  frequency  of,
  336 ;  Naegele's statistics  of,   337 ;
  left oblique, frequency of, 338; an-
  alysis of terminations, 329 ;  diagnos-
  ticated by palpation, 661; of woman
  in labor, 347.
Pregnancy,  term of,  14;  extra-uterine
  first recorded, 18; molar,  symptoms of,
  229; treatment of, 231; signs of, 127 ;
  first indications of, 128; local  signs
  of, 129 ;  physical  signs of,   130 ;
  doubtful signs of, 133 ; silver streaks
  in skin,  135 ;  milk a sign of,  133;
  tubal, 240; bulk a sign of, 134 ;  extra
  uterine, 18 ; change of cervix uteri in,
  187 ;  Stoltz's view of, 138; fetal heart
  in, 143 ; ballottement in, 145 ; ovarian,
  239, 242;  various signs,  147; ovario-
  tubal,  239 ;  occasional   signs,  148;
  abdominal,  244; headache of,  147,
  157 ; varicose veins of, in, 158 ; ven-
  tral, 239; edema of limbs  in, 159,
  174 ;  interstitial,  239 ;   incontinence
  of urine in, 160 ; hernia into the labia,
  161 ;  kiestein  in,  146 ; change  of
  color  of hair in,  147 ;  pruritus  in,
  148; pruritus in, treatment of,  170
  color  of vagina  in, 148; cutanr
  eruption  in, 147; disorders of.
  149 ; nausea, 149;  vomiting
  marasmus  of,  151 ; longi1 
758
INDEX.
   mammitis of, 153 ; facial neuralgia of,
   153; goitre in,  153;  salivation in,
   154; dropsies in, 154 ; albuminuria in,
   154 ; urea  retained in,  155 ;  phos-
   phatic diathesis  in,  156 ; cephalalgia
   in, 157 ; central irritation in, 157 ; he-
   morrhoids in, 158;  strangury in, 160;
   veins ruptured in,  159; rheumatism
   of,  169 ; leucorrhoea in, 170;  men-
   struation  in, 171; speculum in,  172;
   general pallor in, 174;  anemia chlo-
   rotic in, 174; abrasion  of os uteri in,
   174; small-pox in, 175; scarlatina in,
   175 ; cholera in,  175 ;  dysenteries in,
   175; syphilis in, 175 ; phthisis in, 175 ;
   epilepsy  in, 175; puerperal convul-
   sions in, 176; mollities ossium in, 176 ;
   abdominal bandage in, 161; diagnosis
   of by auscultation,  143; diagnosis by
   auscultation first applied, 25 ;  diag-
   nosis of by toucher, 25,  143; duration
   of, 210;  length  of,  210;  length of
   influenced by age of parents, 214.
Perforators, 715 ; Blot's modified, 716.
Periods, monthly, 88.
Periodoscope, 220.
Phlebitis uterine, 642.
Phlegmasia dolens, 648 ; symptoms, 650;
  causes,  651;  treatment, 651;  from
  arterial obstruction, 652;  from  in-
  flammation of lymphatics, 652 ; treat-
  ment, 653.
Phosphatic diatheses, 156.
Phthisis in pregnancy,  175.
Physometra, 134.
Placenta, 109; its  formation, 115; an-
  atomy of, 118,122 ; maternal and fetal
  divisions,  117 ; pulmonary capillaries,
  120; size, 123; of plural births, 124;
  auscultation of sounds,  141; ancient
  method of delivery, 16; fatty degenera-
  tion, 185 ; apoplexy of,  187 ; conges-
  tion of, 189; detached, 209; previa,
  209,428 ;  how detached, 354 ; extrac-
  tion of,  369; presentation  of,  428;
  symptoms of, 429 ; hemorrhage from,
  430; dangers from,  442; nature in,
  431; treatment of,  432,  454; ergot
  in,  455; galvanism in, 455; plugging
  vagina for,  432 ; styptics,  457 ; col-
  peurysis  in,  432; puncturing  mem-
  branes, 433 ; turning in,  434; artificial
  extraction of, 435 ; source of hemor-
  rhage in,  436 ; detaching, Simpson's
  views of,  436;  extraction  advised,
  439;  statistics  of, 440; spontaneous
   ■^pulsion of, 431,441; Barnes' theory,
     ';  time when  hemorrhage ceases,
       limit of placental  detachment,
        ~*r.  Barnes' zones, 445,  451;
           evidences  of, 446; location
   of the rent of membranes, 447; fre-
   quency of with cross-births, 448.
 Premature delivery.  See Labor.
 Presentation,  first  recorded, 12;  first
   classified,   24;  of occiput,  321;  of
   face, 386;  of pelvis, 400 ; mechanism
   of, 401;  pelvis, second variety, 404 ;
   anomalies of, 406 ; diagnostics of, 407 ;
   peculiarities  of, 410;  treatment of,
   411 ; funis in, 413 ; terminations of,
   414; statistics of,  416; mal-influence
   on mother and child, 416 ; transverse,
   417; of arm,  417; of  arm, varieties
   of, 418; of arm, diagnosis of, 419 ;
   of arm, cause of,  420; of arm, im-
   portance  of  early  diagnosis,   421 ;
   of arm, with twins, 421; of arm, aid
   in, 425 ;  of  shoulder,  424; of  arm
   turning in, 426; of arm, statistics of,
   427; of funis, 458; of placenta, 428.
 Presentation and Position of  child diag-
   nosticated by palpation and ausculta-
   tion, 661.
 Primitive trace, 102.
 Prolapsus of uterus during labor, 623.
 Proligerous disk, 77.
 Promontory of sacrum, 286.
 Propagation rapid, 13.
 Pruritus  vagina;,  148 ;  treatment of,
   169.
 Pubis, 284.
 Puberty, 86.
 Puerperal insanity,  596; convulsions,
   175, 605; fever, 624; prevention of,
   741.
 Punctum saliens, 20, 105.
 Purkinge, vesicle of, 78.
 Purgatives causing abortion, 80.
 Pus in veins,  643 ; in joints, 644.
 Pyaemia, 644.


                  Q.
 Quackery, 32.
 Quickening, 139.

                  R.
Rabbinical traditions on obstetrics, 15.
Races, parturient accidents among  the
  civilized and savage, 317.
Rachitis, 472; pathology  of, 480;  con-
  stituent of bones in 483; progress of,
  481.
Rachitic consumption, 482.
Ready Reckoner, obstetpic, 222.
Rectocele impeding labor, 515.
Reproduction,  diecious, 41 ;  marsupial,
  47.
Respiration, fetal, how established, 372;
  Dr. Hall's method, 373.
Rest after labor, 381. 
ENDEX.
759
 Rigidity of os uteri, 518 ; of perineum,
   517; 733.
 Rotation of head, 326; of breech, 402;
   of body of fetus,  403.
 Rut, 81.
 Retinacida, 77.
 Rheumatism of pregnancy, 169.

                  S.
 Sacrum,  286 ; promontory of, 285 ; in-
   creased  curve  of,  498 ;  flatness of
   498.
 Sage-femmes taught, 22.
 Salacine  for disorders of  pregnancy,
   151.
 Salivation indicative of pregnancy,  131.
 Scarlatina  in pregnancy, 175.
 Screw, the fetal head a male, 342; the
   pelvis of mother  the female, 343; in
   deformed pelvis manifested, 484; ac-
   tion of pelvis, 297.
 Segmentation, 101.
 Semen, 15,  98.
 Seven months' child  living, 17.
 Shoulder presentation, treatment of, 424.
 Silver streaks in abdomen, 133.
 Skeleton, earthy matter of, 485.
 Small-pox in pregnancy, 175.
 Souffle uterine,  141; changes in, 141;
   value of,  142.
 Speculum in pregnancy,  25, 172.
 Spermatozoa, 43, 98.
 Spermatic filaments, 98.
 Spina bifida, 549; prognostics of, 550.
 Sponge tent, 25 ; how made, 494;  dila-
   tation of  os uteri,  494.
 Spontaneous evolution, 422.
 Statistics of breech presentations, 416;
   of arm presentations, 427; of placenta
   previa, 440;  of funis presentations,
   459 ; of  rupture  of uterus, 576 ; of
   puerperal fevee, 624,  738;  of  the in-
   duction of premature labor, 666 ; of
   still-born  children,  667 ; of turning,
   669 ; Cesarian section, 704 ;  of crani-
   otomy, 713 ; of the mortality of par-
   turition, 736 ; of death in labor, 746.
 Still-born, statistics  of causes,  sex most
   subject to, 316.
Stone in bladder impeding labor, 515.
Strangury,  160.
Strongylus gigas, 35.
Suckling undue, 174.
Superfaefation,   218,  233;  theories of,
   238.
Sutures,  312; characteristics  of,  314;
  situation in labor,  325, 331,
Symphysis pubis, 292; bony growth on,
  492; sacro-iliac, 290; movement  of,
  292.
 Symphysiotomy proposed, 23, 292.
 Syphilis in pregnancy,  175; the cause
   of abortion, 181, 188.


                  T.
 Taenia serrata, 36; crassicolis, 36.
 Tampon, 25.
 Teratology,  551.
 Tetanus in abortion, 200.
 Thrombus of vulva, 517.
 Thyroid gland  enlarged in pregnancy,
   153.
 Tone in fetus, 279.
 Toucher proposed, 25, 361.
 Tractor, 25, 730 ; mode of using, 731;
   in breech cases, 732.
 Transverse presentations, 417 ; causes of,
   420 ;  transfusion in flooding, 562.
 Trichina spiralis, 35.
 Triplets causing tardy labor, 554.
 Tubes, fallopian, 69.
 Tubal pregnancy, 240.
 Tumors of  omentum resembling preg-
   nancy, 134; fibroid, 134;  osteo-sarco-
   matous, 491 ; fibrous, 510; of ovary,
   613;  encysted, puncture of, 517.
Turning in arm presentations, 426, 677;
  in face presentations, 395; in placenta
  previa, 434;  in prolapse of cord, 466 ;
  a  serious   operation,  669 ;  podalic,
   668;  with which hand, 670; matters
  preliminary to, 672; method of intro-
  ducing  hand,  673 ;  cephalic,  674;
  through undilated os, 674; without the
  whole hand  in uterus, 675;  chloro-
  form, with, 676;  assisted by  instru-
  ments, 678 ;  tractor  with,  732;  a
  substitute  for  craniotomy,  679; an-
  atomical considerations in, 681; safety
  in, 683.
Twins, first recorded case of, 13;  fecun-
  dation, 234;  of different colors, 234;
  position of,  in the  uterus, 277; arm
  presentation with, 421; causing tardy
  labor, 654.

                 U.
Umbilicus, 124.   See Cord.
Umbilicdl vesicle, 107.
Uramiia, 619; treatment of,  621.
Urea retained in pregnancy,  155.
Uterine plethora, 168.
Uterus, 62 ; nulliparous, 62 ; multiparous
  67 ; os, 62, (see Os uteri);  appearance
  of, in  pregnancy, 129;  cervix, 62 ; cer
  vix, fissures of, cause of abortion, IP
  fundus, 62, 18 ; body, 62,18 ; cv
  arteries of, 116; mucous memb
  cavity, 65;  bicorporeal,  23" 
760
INDEX.
pi  of,  resembling pregnancy,  134;
rise of, cause, 136 ; change in  neck
in pregnancy, 137; gravid, anteversion
of, 162; displacement of,  162;  dis-
placement a cause of tardy labor, 535;
prolapsus of, 162 ; procidentia of, 162;
retroversion of, 168; retroversion first
taught, 22 ;  retroversion, symptoms
of, 164; retroversion, treatment  of,
165;  retroversion, Gariel's instrument
for, 166; double, 235; ossified with its
contents,  247 ;  rupture  from  preci-
pitate labor, 344;  in pregnancy, 155;
gravid, 249; virgin, superficies of, 249;
form of, 250; arteries of, 251; lympha-
tics of, 251;  nerves of, 257; muscular
structure of, 252 ; involution and de-
volution of, 255; fatty degeneration of,
256; whether the nerves increase, 258;
motor functions, 261; action of, reflex
and   peristaltic,   263; action  after
death, 265 ; character of muscular ac-
tion, 267 ; ovoid shape of, 271;  posi-
tion of twins  in,  277; adaptions of
shape to its contents, 278 ; form of, in
deformed  pelvis, 283;  irritability of,
after  labor,  344; condition of, after
labor, 375 ; deficient action of,  533 ;
double cause of tardy labor, 536 ; gout,
rheumatism, and neuralgia of, a cause
of retarded labor, 637;  inertia  of,
538 ; hourglass contraction, 544 ; in-
version, 555 ; rupture of, 675 ; rupture
of, statistics of, 576; rupture of, with
first labors, 577 ; rupture of, with boys
and girls, 578 ; rupture of, from  thin-
ness of walls, 759 ; rupture of, from
injuries, 580 ; rupture  of,  from ergot,
579;  rupture  of,  forewarning symp-
toms  of, 580; rupture of, symptoms
of its having  occurred, 581 ; rupture
of, prevention, 582 ; rupture of, treat-
ment, 682; inversion  of,  585 ; symp-
toms  of, 586 ; diagnosis of, 587 ; from
malpractice, 688 ; treatment of, 588 ;
treatment by reposition, 689;  exci-
sion of, 589 ;  hour-glass contraction,
592;  hour-glas3   contraction,  treat-
  ment of, 593 ; hour-glass contraction,
  from adherent placenta, 694; irregular
  contractions, causing after-pains, 595.

                  V.
Vagina, 55 ;  ostium, 53 ;  functions  of,
  67; secretions of, 57; tamponing  of,
  25, 432; color   in  pregnancy,  148;
  materials for plugging,  432 ;  cicatri-
  zations   of,  511;  contraction and
  rigidity of, 511.
Vagitus, 280.
Value of mother  and  child,  relatively,
  527.
Vasa omphalo-meseraica, 101.
Vectis invented, 19 ; improved 25, 729.
Veins, varicose,  158;  ruptured,  161 ;
  valves in, 382; inflammation of, 651 ;
  air in, 654.
Venesection'm convulsions, 611; in puer-
  peral fever, 646 ; in puerperal mania,
  601.
Ventral-pregnancy, 239.
Version, podalic,  cephalic, pelvic.  See
  Turning, 668.
Vertebra, fifth lumbar,  part of false pel-
  vis, 288.
Vesicles, Graafian,  72,76 ; germinal, 78 ;
  of Purkinge, 78; umbilical,  107.
Vesicocele impeding labor,  515.
Vesicula alba, 108.
Vestibule, 60.
Villi, placental anatomy,  119 ; of cho-
  rion,  115.
Volvox globator, 38.
Vomiting, indicative of pregnancy, 130;
  treatment of, 149.
Vorticella convallaria, 37.
Vulva, 55 ; thrombus of, 617.

                  W.
Weed, 381.
                  Y.
Yolk, germ, 78; food, 78.

                  Z.
Zona pellucida, 78, 103. 
 
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