P SURGEON GENERAL'S OFFICE \ X Section, OBSTETRICS: THE SCIENCE AND THE ART. BY CHARLES D. MEIGS, M. D., LATELY PROFESSOR OF MIDWIFERY AND THE DISEASES OF WOMEN AND CHILDREN IN JEFFERSON MEDI- CAL COLLEGE AT PHILADELPHIA, AND ONE QF THE PHYSICIANS TO THE LYING-IN DEPARTMENT OF THE PENNSYLVANIA HOSPITAL ; MEMBER OF THE SOCIETY OF SWEDISH PHYSICIANS AT STOCKHOLM: CORRESPONDING MEMBER OF THE HUNTERIAN SOCIETY OF LONDON ; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY ;, OF THE ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA ; OF THE AMERICAN MEDICAL ASSOCIATION, ETC. ETC. FOURTH EDITION, REVISED. WITH ONE HUNDRED AND TWENTY-NINE ILLUSTRATIONS PHILADELPHIA: BLANCHARD AND LEA. 1863. wa M 5 U »(, 1863 Entered according to the Act of Congress, in the year 1849, by LEA AND BLANCHARD, in the Office of the Clerk of the District Court of the United States in and for the Eastern District of Pennsylvania. PHILADELPHIA! Collins, Printer, 7<>r> j.vynb street. TO THE l EMINENT WE STB EN PHYSICIAN, PHILOSOPHER, GENTLEMAN, AND SCHOLAR, DANIEL DR AK E, M. D., OF CINCINNATI. PREFACE TO THE FOURTH EDITION. In this Edition I have endeavored to amend the work by changes in its form; by careful corrections of many expressions, and by a few omissions and some additions as to the text. The Student will find that I have recast the article on Placenta prasvia, which I was led to do out of my desire to notice certain new modes of treatment which I regarded as not only ill founded as to the philosophy of our department, but dangerous to the people. In changing the form of my work by dividing it into paragraphs or sections, numbered from 1 to 959, I thought to present to the reader a common-place book of the whole volume. Such a table of contents ought to prove both convenient and useful to a Student while attending public lectures, whatsoever may be the title of his text-book on Midwifery, since it refers seriatim to a great variety of topics on Midwifery, the mere reference to which might well serve to recall a whole—even a long train of thoughts upon the subject under his review. In tendering this new Edition of an American Book upon Mid- wifery, I thankfully renew my expressions of obligation to my breth- ren, who have heretofore, with much favor, accepted this labor of my heart and hands. CH. D. MEIGS. At Hamaxafsett, Aston Township, Delaware Co., Pa. December 25,1862. PREFACE TO THE THIRD EDITION. I have endeavored to fulfil the intention expressed in the last paragraph of the preface to the second edition of my work. I trust that my readers will find I have made some amendments in the style, and that I have brought the subject up to the latest dates of real improvements in our art and science. CHARLES D. MEIGS, 32-i Walnut Street. October, 1856. PREFACE TO THE SECOND EDITION. The first edition of my work, though a large one, being exhausted, I have now the pleasure to offer to my medical brethren in America, a new one, considerably augmented as to the text, and which I have endeavored to improve by recasting some parts, by cancelling others, and by an earnest attention to improvements in the literary execution of the whole. I shall not here specify all the changes that I have made in pre- paring this second edition, for the reader will be the most competent judge of them; and it is for him alone to decide, whether my labor shall prove serviceable in the object we should all lay to heart, of extending further and wider the usefulness of our calling amongst the people. It may not be out of place, however, to say that, besides the rela- tion of new cases, the recasting of my remarks on Cyanosis, and many fuller explanations of motives in practice, I have substituted for the former chapter on Puerperal Fever, a new chapter under the head of Childbed Fever. In that chapter, I trust, I shall be found to have made somewhat more clear and intelligible, the views that I deem most important upon the nature, seats, causes, and treatment of that disorder; and that I have, also, set forth with sufficient clearness, the motives that have long impelled me to reject the doctrine of its contagiousness. If only this part of my work should be favorably received by my brethren, I shall ever consider that I have, in it, done an acceptable service. Lastly, I feel most grateful for the kind reception heretofore given, in this country, to my contributions to medical literature, and most thankfully acknowledge my obligation to improve them as opportu- nity arises; but this sentiment is blended with regrets, that, amidst the agitations, the distractions, and the fatigue of a physician's life less time is allowed me for revision than is demanded by the many demerits of all that I have hitherto written. CHARLES D. MEIGS, 324 Walnut Street. April 3, 1852. A LETTER My Dear Sir: Having taken the liberty to inscribe this work with your name, which I never pronounce without a feeling of affectionate respect, I desire to say a few words to you in explanation of my views and wishes in regard to the volume. You may haply be aware that I caused to be printed, some years since, a small volume, entitled the " Philadelphia Practice of Mid- wifery :" a second edition in octavo form, and somewhat enlarged and amended, has now been for a considerable time exhausted; and although I have had proposals to publish a third edition of the Treatise, it has not been convenient for me to undertake the labor until the early part of the past summer. Upon completing my arrangements with the Publishers, and com- mencing the task, I was induced to recast and rewrite a great part of the wTork; in which I did not wholly reject the fruits of my studies in earlier years. This Treatise is, however, so different from the former, that I conclude I have a just right to present it to you as a new one; and accordingly have adopted a new title, as you will have seen. I have addressed it to the Student, and it is to him that I speak in every page. This I have done because I was not to presume to instruct those who know as well, or perhaps better than I, every point of duty appertaining to the vocation of the accoucheur, both as to the Science and the Art. I was well aware that there are many of my brethren in this country who publicly relate their experience, and explain the rationale of all the Art and Science of Obstetricy to large classes in our numerous medical schools; and I had no pretensions to know more upon these subjects than they, nor to instruct them. Induced by these views, I have been, perhaps, too elementary in some parts of the work, and addressed the Student only; but I hope it will be found that the explanations I have given may serve to remove difficulties X A LETTER. from the track of the Medical Student, while they may perhaps lend facilities to the progress of the young and not much experienced prac- titioner. I thought that young accoucheurs, who, in the distant and thinly settled parts of the country, might require a consultation where time and opportunity would not allow of it, could find herein some needful counsel and explanation, and that it would be for me a great happiness to be useful in such emergencies. Hence I have entered into many particulars, and even trivials, that are not commonly set down in the books. As to the scientific part of the work, I may say that I hope it will be useful to the Student. If I have succeeded in exhibiting just views in that department, my labor cannot be without fruit; since it is only by such means that the vocation of the Surgeon-accoucheur can be- come an elevated one. It is the Science of the practitioner that raises him immeasurably above the most dextrous midwives of the land, dexterity which indeed does not prevent their ignorance from render- ing them unsafe depositories of such important interests as those that concern the conservation of our wives and daughters, and their little children. An accoucheur who is merely dextrous, and who is not acquainted with the scientific parts of his profession, may be in a manner superior to the midwife, but in some regards he is inferior; since to his employment, his sex is an objection, which ought to be waived only in consideration of his Scholarship. I have in all this treatise endeavored, upon suitable occasions, to inculcate good motives.—Good and pure motives are very essential to the honorable estimation of this department of Medicine and Surgery.— I believe that the sentiments of good Monsieur Viardel, on these points, are quite just, and I shall take leave to cite the following fragment from his book at page 261. M. Yiardel, who was in full practice at Paris about 1670, in speaking of the Accoucheur, says :— "II doit etre propre dans ses habits, mais toutes fois vetu modeste- menr, et non en fanfaron; .* * * * * * * * * * u doitj de ^ ^ doux dans ses paroles, et agreable dans sa conversation ; * * * * * * mais surtout, il doit etre prudent et discr^t: prudent a dresser son prognostic, et a prevoir ce qui doit arriver, de peur de n'encourir le blame des assistant II doit etre discrdt, et ne point reveler le secret qu'on lui aura confUS. * * * * En un mot, il doit etre patient pour ne pas se rfbuter, humain et charitable, surtout envers les pauvres et nagirpas dans son travail pour le lucre et son interest propre mais comme dit l'Apotre, pour 1'honneur et la gloire de Dieu et pour con- server sa reputation parmi le monde." A LETTER. xi Like all books, mine has some iterations; but I thought that to make my pages useful, it was inevitable to repeat statements; without which I could not inscribe the why and how on the same pages. If this is fit to be a book of consultation, it will be more useful for this fault. Hippocrates says that art is long; still, I think that, to repeat, is really to abbreviate; for the n Sa -twn naxprj, and the n S* xpictj xo.-htrt*}, both vanish under a clear and comprehensible delineation of the Why and the How for every special occasion. I think you will find that I have in this book given a very clear relation of the new doctrines of menstruation, and that I have shown the Student the whole history and progress of the discovery of the mammiferous ovulum, from the time of the detection of the germinal vesicle by the Breslau professor, down to the last, most complete and admirable exposition of the whole subject by M. Coste, of the College of France. If this part of my publication is full and clear, I cannot doubt of its being advantageous. If I have done but this, and no more, I shall look confidently for useful results to my labor. For I know that multitudes of the younger class of my medical brethren, and especially of those that still belong to the Student-class, were formerly grossly neglected as to their instruction in these particulars. No one should be sent forth with a diploma certifying his acquaintance with all the branches of Medicine, whose therapeutical course, while uninformed on the questions referred to, could not but be a mere suc- cession of conjectures and blunders, rather than the sure steps of a learned and accurate reasoner. Apologetically, I pray the reader may know that the labor of this writing and publishing, added to my professional vocations, has been so severe as seriously to affect my health—to that degree, indeed, that I have been compelled to finish it by the assistance of an amanuensis, who has written at my dictation, and read the proof-sheets. I have not dared to examine the proofs of the last 250 pages, on account of a distressing neuralgia of the eyes, which has also prevented me from readin'g any book or considerable pamphlet since the autumn. It may be that I ought to solicit from my American brethren, a favorable acceptance of this work, the fruit of many years of painful toil in the acquisition of clinical experience and knowledge. I abstain from doing so, not because I desire not such acceptance, but only upon the certain conviction I have, that the book is no longer mine-and that, in going forth from my hands, it hath found many owners, each of whom will and ought to treat it as may seem good in his own sight. Xll A LETTER. As for you, my dear friend, I invoke your favorable construction of my design and action in publishing this treatise; and I pray you to believe that I am, with the greatest sincerity, your most obedient and most faithful servant, and attached friend, CHARLES D. MEIGS, Philadelphia, Feb. 1849. To Dr. Drake, Prof, of the Pract. of Med., Univ. of Louisville, Ken. CONTENTS. 25 Preliminary observations. PART I. ANATOMY OF THE PARTS CONCERNED IN THE ACTS OF REPRODUCTION. CHAPTER I. THE PELVIS. 29 Chief cause of the difficulty of parturition. 30 Etymology of pelvis. 31 Fig. 1 and Fig. 2. The female pelvis, illustration of. Brim, strait, &c. 32 Fig. 4. View of anterior segment of pelvis. Promontory, liuea ileo- pectinea. 33 The superior strait, with view, Fig. 4 ; and inferior strait, Fig. 5. 34 Axis of superior strait; inclination of its plane, Fig. 6. 35 A model strait is 4, 4§, and 5. 36 Pubal arch. Enumeration of pelvis pieces. The sacrum. Ety- mology of sacrum ; ieron osteon ; lutz or luz. 37 Primordial pieces of embryonal sacrum, Fig. 7. 38 Fig. 8. View of adult sacrum. Auricular facette. Foramina. 39 Base, apex, wings. 40 Xaegelti's oblique oval pelvis with Fig. 10. 41 Sacral foramina; cramps during labor; remarkable cases. 44 Os coccygis, Fig. 11. 45 Os innominatum, Fig. 12. 46 Os innominatum, Fig. 13. 47 Acetabulum. Cardinal point. Cavity or excavation. Inclined plane of ischium. 48 Fig. 14 illustrates planes of pelvis. Carus' curve. 49 Fig. 15. Carus' curve. Dubois on axis. 50 Mechanism of inclined planes. Dr. Tyler Smith's mid-plane, xiv CONTENTS. PAGE 51 Fig. 16. Foetus in utero. 52 Planes of inferior strait. Ligaments. 53 Arnold's view of the ligaments, Fig. 17. 54 Opening or relaxation of the joints in parturition ? Cases. 55 Diameters of the pelvis. A table of diameters. 57 Diameters. Depth of pelvis. The recent pelvis. 58 Kolrausch's Fig. 18. Pelvic viscera shown. 59 Duplications of peritoneum in pelvis. Douglas' cul-de-sac. 60 Fig. 19. Pelvic organs. CHAPTER II. MECHANICAL INFLUENCE OP THE PELVIS. 61 Mechanism of labor. 62 Sir Fielding Ould first taught as concerning rotation, in London, 1748. 63 A vertex presentation. 64 Fig, 20, of a vertex presentation in 2d position. How the head turns on its axis, in rotation. 65 Commencement and progress of the head's extension due to the-re- sistance of the perineum. Fig. 21. The head extending beneath the arch. 66 Restitution. . Mechanism of shoulders' delivery. Mechanism of 2d position of vertex. 67 Fig. 22. 2d position of vertex. Third vertex position. 68 4th position, Fig. 23. 69 Occipito-posterior delivery of unrotated 4th position, Fig. 24. 5th position, Fig. 25. 70 6th position; Case of. 71 Face presentations, Figs. 26 and 27. 72 Bring the chin to pubis in face cases. CHAPTER III. THE CHILD'S HEAD AND OTHER PRESENTING PARTS. 74 Fig. 28. The child's head. Figs. 29 and 30. The child's head. Size of child's head. 75 Measurements of foetal heads, with results by author. 76 Fontanels, sutures. 77 Presentations. 78 Fig. 31. Foetus in utero; vertex presentation. Departure. Stature and weight of foetus. 79 Proportion of cephalic presentations and pelvic. Two presentations only—cephalic and pelvic. 80 Fig. 32. Prolapsed arm. Fig. 33. A breech presentation. 81 .Positions of various presentations. CONTENTS. XV CHAPTER IY. THE EXTERNAL ORGANS. PAGE 82 The pudenda. 83 Account of the pubic symphysis. The labia majora. The perineum. 84 Labial thrombus. 86 Abscess of labium. Duverney's glands. 87 Nymphse. Vestibule. 88 Cohesion of the labia. The fourchette. 89 The hymen. Imperforation. 92 The clitoris. 93 Kobelt's Fig. 34, of clitoris and pars intermedia. 94 Kobelt's Fig. 35, of bulbs of the vestibule. 95 Kobelt's Fig. 36, profile view of the bulbs and clitoris. Case of wounded pars intermedia. 97 Duverney's glands and their diseases. 98 The vagina. 100 Dr. Tyler Smith's remarks on the vagina. Columns of the vagina. 101 State of the vagina in falling of the womb. 102 Fig. 37. The womb and vagina. 103 Fig. 38. Front view of the womb and vagina, 104 Structure and powers of the womb. 105 Fig. 39. Muscles of the womb—their condition in labors. 107 The place of the womb as in the pelvis; and diagnosis. CHAPTER V. THE OVARIES. 108 Graafian vesicles. 110 Fig. 40. Ovulum humanum, from Wagner. Ill Germinal or Purkinjean vesicle and germinal spot. 112 Regner de Graaf. 113 Purkinje and his discoveries, with figures 41, 42, and 43. 114 Von Baer. 116 Coste and T. Wharton Jones. 117 Rudolph Wagner and the macula germinativa. 118 Fig. 44. Prof. Coste's Figure of dissected ovary. 119 Wagner's human ovule with zona pellucida. 120 Corpus luteum with Fig. 46. 121 Author's paper in Philos. Soc, on corpus luteum. 128 M. Huschke's idea on acinus of stroma. 129 Spontaneous extrusion of ovum from ovary. Ovarian fecundation. 130 Kiwisch on the ovum. 131 Prof. Coste, extract from, on corpus luteum. xvi CONTENTS. PART II. THE PHYSIOLOGY OF REPRODUCTION. CHAPTER VI. MENSTRUATION. PAGE 135 Diagnosis, as betwixt menstruation and hemorrhage. 136 Is the menstrual discharge a secretion ? 137 Analysis of menstrual discharge. Computation of the sura of a woman's monthly excretion. 138 Relation of time, as between ovulation and menstruation. 139 Fig. 47. The womb and ovaries. 140 M. Pouchet's views on spontaneous ovulation. Doctrines as to the law of clean and unclean, and the latest date of possible fecunda- tion. 142 True menstruation is ovulation, with its sanguineous symptoms. 143 School girls, how affected as to the catamenia. Pregnant and suck- ling women. Computation of pregnancy. 144 Non-menstruating women : absence of womb, or ovaries. Case. CHAPTER VII. AMENORRHEA. 149 Emansio mensium. 150 Pabertas plena. The influence of the hsematosis on puberty. Hydremia, not anaemia; how it affects the development of the girl Statement of the case in figures of the different constituents of the blood. M. Cerise's paper on Neurosity. Case proving that in certain women, excessive hydremia does not preclude ovulation and menstruation. 153 Messrs. Quevenne and Miquelard's preparation of iron by hydrogen 154 Atresia uteri, causes emansio. 155 Torpor of the womb as cause of emansio mensium. A young girl without Graafian follicles. * S g 156 Hydremia. Blood-membrane. Membrana vasorum 157 Endangium is the membrane that makes the blood 158 M. Burdach's expression, Endangium 161 ModtngiUmf C°ntainS ^ f0FCe' °r P0wer' that makes the blood. 161 Medicines for amenorrhcea. Tonics for amenorrhea 151 152 CONTENTS. xvii PAGE 162 Louise Bourgeois, her pastilles for cure of amenorrhoea. Vallet's mass. 163 Blaud's pills. Iron by hydrogen. M. Raciborski. Diet and medi- cines. 164 Exercise for amenorrhoeal women. CHAPTER VIII. PREGNANCY. 166 Definition of pregnancy. 167 Fecundation. 168 Conception. 169 Conception is the affixation of a germ. 170 The Jews and their law of unclean. A table showing the dates of menstruations and conceptions. 171 Ovarian pregnancy; how it might happen. 172 The decidua. 173 Velpeau's Figure 49, of a decidua. Tubular glands. Membranes of the interior of womb. Coste's Fig. 50. 175 Coste, extract from, on tubular glands of womb. 176 Fig. 51. Genital organs of the Opossum. 177 Bisected ovary of Opossum. Fig. 52. 178 In the solidungula, and cetacea, the entire chorion becomes placenta. They can have no decidua therefore. First forms of the embryo heart. 179 The only part of the child that really touches the mother is the blood of the child. 180 Cervix uteri as guardian of the pregnancy. Double cervix of the porpoise. 181 Development processes, or evolution of gravid womb. 182 Size and weight of gravid womb. Womb sinks downwards soon after commencement of gestation. 183 Nausea of pregnant women ; with cases. 185 Quickening is the first perceived movement of the embryo. 186 Form of the abdomen in pregnancy. Pouting of the navel. Cramps. 187 Costiveness in pregnancy. Alternate hardening and softening of womb. 188 How the cylindrical neck becomes conical. Size of womb at term. 189 Placenta. 190 Hunter, Seiler, Velpeau, Owen, on placenta. 192 Flourens on placenta. 193 Coste's preparations of gravid wombs. Figs. 53, 54, of affixation. 194 Weber's views of placenta. Human placenta. Figs. 55, 56, 196 Gravid wombs examined by Author. 2 xviii CONTENTS. PAGE 197 Endangium, its condition in womb and in placenta. 198 Changes in constituent elements of uterus in gestation. 199 The blastoderm. 200 Processes of conception, or affixation and development of the decidua reflexa, or capsule of the ovulum. 201 Development of embryo ; its omphalo-mesenteric system, and allantois. 202 The umbilical vesicle with Figs. 57, 58, 59, 60. 203 Fig. 61. Omphalo-mesenteric vessels and cord. 204 Fig. 62. A case of embryonal exomphalos. 205 Circulation of foetus. 208 Still-born, causes of. 210 Rita-Christina, and doubled children. Pfeiflfer's monster, Fig. 63. 211 Dr. Boerstler's duplex monster. 212 Dr. Rohrer's case. 215 Duration of pregnancy. Case of Madame Ingreville. 216 Rainard's tables of gestation in animals. 217 Gestation of Elephant. Asdrubali and Signora N. 219 Anne Gideon. 221 Method to compute term-time. 223 Changes of the womb's shape and size. Fig. 67. 224 Thickness of womb-wall. Uterine muscles. 226 Obliquity of womb. 227 Pressure of womb on the vessels and its consequent. 228 Tendency to eclampsia from pressure, Puzos's views. 230 Hydatids. Are they entozoa ? Edwards. Pouchet. 232 Moles. Physometra. 233 Hydrometra. Abortion. 235 Pregnancy does not suspend the ovulations; relation of this fact to menstruation in pregnancy, and to abortions. 236 Figs. 69, 70. Aborting womb. 237 Aborting womb. Fig. 71. Conducting a case of abortion. 238 Fig. 72. Dewees's placenta hook, and Bond's forceps for placenta Fig. 73. 239 Colpeurysis and colpeurynters. 240 Braun's colpeurynter. Fig. 74. 241 Tampon. 243 Prolapsus from abortions. 244 Retroversion. Case. 246 Case of retroversion. 251 Dr. Yardley's case of retroversion ; adherent fundus. Fig. 75. 259 Case of gravid womb retroverted ; colpeurysis. 261 Extra-uterine pregnancy, with cases. 263 Signs of pregnancy. A case with dropsy of the ovum. CONTENTS. xix 266 Touching as a means of diagnosis in questionable gestation. Auscul- tation. Bruit de souffle. 267 Ausculted sounds of foetal heart. M. Depaul. Obstructions. 268 Case of denied pregnancy. 269 Quickening as a sign of pregnancy. Tympanitis. Case of Mad. T., by Depaul. PART III. THE THERAPEUTICS AND SURGERY OF MIDWIFERY. CHAPTER IX. LABOR. 273 Cautions to young beginners. 273 Caliph Al-Mamun and his physician. 274 Fournier, and "tost, seurement, et sans douleur." 275 Definition of labor. 276 Cause of labor. 277 Baudelocque's opinion on cause of labor. 278 Subsidence of womb, at approach of labor. 279 Discharges from genital organs. Labor pains: their duration. 280 Frequency—number. Saccombe's curious table of pains. 281 Differences, and effects of pains. 282 Bearing down in labors. 283 State of the cervix, dilated. Fig. 76. Constitutional effects of pains. 284 Signs of labor. 285 Touching or examination. 287 Directions concerning Touching. 288 False pains. 289 Wigand's opinion concerning pains. 291 Periodicity of pains. 292 Effect of over-full womb on labor pains. 293 State of womb in last moments of labors. 294 Separation and discharge of placenta. 295 The child, during a labor: outward thrust of its spinal arch increases the flexion and dip of the head. 296 Flexion. Positions. 297 Fig. 77 illustrates first position of the vertex. 298 Table of positions; Mde. Boivin; Mde. Lachapelle; Nsegele. 299 Prof. Naegele" at Heidelberg; his views on fourth position. 300 Mechanism of a labor. 303 Lochia. The newly born child. 304 Lochia. XX CONTENTS. CHAPTER X. CONDUCT OF A LABOR. PAGE 307 Labor—influences on the pulse, breathing, temperature and mind. 308 Case of remarkably slow pulse during labor. 309 Prof. Dewees—his use of venesection in labors. 310 State of the bowels to be regarded; a Case. 311 Decubitus during parturition. Cases illustrative. 313 To assist the flexion and rotation. 314 Failure of rotation. Vaginal vesicocele; a Case. 316 Management of the cervix and os, in a labor. 317 Effects of badly formed sacrum. 318 Influence of badly shaped pubis; a Case. The perineum; Case. 319 The conditions of the perineum; it compels extension of head. 320 Cord around the neck. 321 The shoulders in a labor. How to treat the child just born. 322 Cutting the cord. 323 Placenta; to manage its delivery. 325 Hour-glass contraction, and adherent placenta. 326 Weight and size of a placenta. Retention of it. Delivery of it. 327 Womb after delivery; to avoid inversion. 328 After-pains. Cases in illustration. 329 Cases of hemorrhage for want of after-pains. 330 The posture of the woman after delivery; its influence on floodings. 331 Danger of rising up soon after delivery; a Case. 332 Case to show the usefulness of ergot in procuring after-pains. Sitting up too soon. Hearne and the Indian mother. The heart-clot. Coagulability of blood augmented by hemorrhage. 333 Fainting after delivery. Processes of it and dangers. Author's first publication concerning heart-clot in Med. Examiner, 1849. 334- Concrescible elements of blood, solidified and driven as emboli into the capillaries. 335 Symptoms significant of forming heart-clot. Princess Charlotte. 336 Dr. John Sims' letter describing the case of the Princess. 339 Case of heart-clot. 340 Case of heart-clot. 341 Case of heart-clot. 343 Remarks on the process and result of heart-clot. Emboli, how pro- duced; and effects of them. 344 Author's claims as to first publication on suddenly formed heart-clot. Dr. Deegen de Polypis Cordis. Tampon never. True doctrine of conduct of floodings. 345 Turn out the clot. 346 The binder. CONTENTS. xxi PAGE 347 Diet for lying-in woman. 348 Suckling. Medicine. 349 Lochia. Etherization. 353 Professor Simpson's letter to author on anaesthesia in midwifery. 356 Author's letter in reply to Prof. Simpson. 361 Present views of author on anaesthesia. CHAPTER XI. PACE PRESENTATIONS. 364 Figs. 79, 80, illustrating face cases. 365 Figs. 81, 82, of face presentations. 366 Fig. 83, a face presentation; chin to sacrum. 367 Causes of face presentations. 368 Only two positions of face presentations. 369 Case of face labor. 372 Chin to sacrum, fig. 84. Prof. Dewees on face presentations; cases. 376 Madame Boivin on face labors. CHAPTER XII. PELVIC PRESENTATIONS. 379 Causes of pelvic presentations. Prof. Dubois' views. 380 Pelvic labors not preternatural. Pliny's remarks, and Raynald's. 381 Danger to the child. 382 Fatalities in breech labors. 383 M. Cazeaux's opinion on fatalities by pelvic presentations. Diagnosis of these presentations. 385 Not to bring down the feet—a good rule. 386 The breech to descend without help. Positions of it. 387 Fig. 85, breech emerging. Fig. 86, shoulders being delivered. First position illustrated by fig. 87. 389 Second and third positions. 390 Cases. 391 Fourth breech position. 393 Case showing the necessity of providing forceps in breech labors. 394 Foot and knee cases. CHAPTER XIII. OF PRETERNATURAL LABORS. CAUSES. 396 Shoulder presentations. 398 Two shoulder presentations; two positions for each shoulder. 399 Diagnosis of shoulder cases. 400 Turning in shoulder cases. Rules for turning. 2* XX11 CONTENTS. 403 Which foot? 405 Undilated os; venesection for it. 406 Warm bath. The arm not to be amputated. Cosgreave. 407 Spontaneous evolution. 408 Double-headed foetus, fig. 89, born only by Evolution. Dr. Pfeiffer. Dr. Rohrer's case of tumor on foetal head, fig. 90. Case of forced evolution, in shoulder presentation. 410 Hemorrhagic labors. Hemorrhage before delivery. 412 Post-partum hemorrhage. Placenta praevia. 414 In placenta praevia the doctrine is to turn and deliver by the feet. 416 Case of placenta praevia; Dr. Eberle. 417 Tampon to be avoided in the cases. 418 Decubitus in placenta praevia; its import and importance. Treatment when danger is great and pressing. 419 When to turn and deliver. Dilatability, not dilatation. Colpeurynter. 420 Which hand? The act of turning. 421 Review of Hunterian placenta, as relative to duty in these cases. 422 MM. Radford and Simpson; method of detaching whole placenta in these cases. Criticisms on this method. 424 Of turning in placenta praevia. Deciding on the action. Braun's colpeurynter; its advantages. 425 Concealed hemorrhage. Case. 427 Hemorrhage, following the birth of child. Clot the cause of it. 428 Invariable rule ; place the hand on region of uterus, after the delivery, and to remove coagula, as often as they are formed. 429 Hour-glass contraction of the womb, invariably attended with adhesion of the placenta. The rule to deliver by the hand. 431 Hemorrhage following delivery of the placenta. The rule, turn out the clot. 433 Mauriceau's sister; to show that to let the womb contract is the rule. 438 Convulsions. Pathogenic processes of them. 440 Wigand's idea of convulsibility. 441 Dr. Blackall first to propose albuminuria in dropsy. The toxic power of uraemic blood. 444 Bright's cases. Dr. Gourbeyre and Dr. Lever. 445 Case of convulsions with albuminuria. 446 State of kidneys in albuminuria of gestation. The urine to be tested in sick pregnant women's cases. Albuminuria, remarks on, with Fig. 91, of Bowman's capsules and tubuli. 448 Fig. 92. A Bowman's capsule with Malpighian corpuscle. 449 Dilatation of os—Is it a cause of eclampsia ? 450 Convulsions most frequent in primipara women. 451 Dr. Churchill's table of convulsion cases. Mad. Boivin and La Cha- pelle; Braun ; Author. CONTENTS. xxiii PAGE 452 Table of convulsion cases by Author. 453 Description of a paroxysm of convulsions. 454 Moment to be chosen. 455 Blood-letting as a remedy. 457 Cases. 465 Conduct of labor in hydrsemical women. 466 Exhaustion in labors. 470 Cramps in labors. 471 Prolapse of the cord. 472 Fainting in labors. 473 Hernia, and laceration, in labors. Engagement of a loop of the in- testine in front of the womb, with a case. 474 Carcinoma uteri in labors. Cases. 476 Figs. 93, 94, of carcinomatous cervix and os. 477 Fig. 95. Carcinoma. 478 Smallpox in pregnancy. 479 Never to vaccinate a pregnant woman. 480 Scarlatina. Twins and triplet labors. 482 Fig. 96. Twins in utero. Diagnosis. 485 Breech labors as preternatural. Fig. 97. The fillet. 486 The turning in preternatural labors. Fig. 98. 487 Which hand. Fig. 99. Foot prolapsed. Fig. 100. 488 Delivery of breech. Fig. 101. Bring down the cord. Fig. 102, 489 To get the shoulder down. Fig. 103. To deliver the head. Fig. 104. 490 Cases of turning. 491 The right hand in second positions. 493 Turning in shoulder cases. Right hand prolapsed, first position. Fig. 105. 494 Right hand prolapsed, second position. Fig. 106. 495 Second position of left shoulder ; arm prolapsed. Fig. 108. Which hand ? * CHAPTER XIV PRETERNATURAL LABOR FROM DEFORMED PELVIS. 497 Rickets and mollities. Naegele's pelvis. 498 Fig. 109. Naegele's oblique oval pelvis. 501 Shall turning be used in deformed pelvis ? 502 Reduction of planes of the head, like wire-drawing. 503 Mensuration of pelvis or diagnosis of deformity. 504 Pelvimeter calliper. 505 Badly-formed arch of pubis, or misformed sacrum. Case. 506 Prolapse of the bladder, with a Fig. 117. Tumors in the pelvis. 507 Laceration of the womb and vagina ; measures to be taken XXIV CONTENTS. CHAPTER XV. THE FORCEPS, RAINALD QUOTED. PAGE 510 " The byrth of mankynde," by Rainald. The uncus of Celsus. 511 The instruments of the ancients. Tertullian, quotation from. 512 Paul, Hugh, and Peter Chamberlen. Their invention of the forceps; the cochlea, junctura and manubrium or clamps joint and handles. The forceps an instrument for the child, to avoid embryulcia. 513 Hugh Chamberlen's interview with Mauriceau at Paris, Aug. 12, 1670. His preface to his translation of Mauriceau. 517 Paul Chamberlen's sons. Fig. 118. Chamberlen's vectis. 518 Figs. 119, 120. Specimens of Chamberlen's forceps, from the country seat, Woodham Mortimor Hall. 519 Figs. 121, 122. Other drawings of the Chamberlen forceps, presented by Mr. Causardine to Royal College of Surgeons. 520 Samuel Chapman, A. D. 1733. Progress of improvement in the forceps. 521 Smellie and Levret's forceps. Pean. Baudelocque. Observations on the meaning and uses of the forceps ; its construction. 523 Davis's forceps described. 524 Huston's modification of Siebold's. Fig. 123. 525 Fig. 124. Davis's forceps and child's head. 526 Forceps for child, Perforator for mother; Caesarean section for the mother alone. 528 Lever motion of forceps. Not an instrument of compression. 529 Baudelocque's experiments with forceps as compressive. 530 Forceps to be applied only to a head within the pelvis. 531 When forceps cannot be adjusted to head. Motives and manner of proceeding. 534 Fig. 125. Forceps refuse to be locked from obliquity of clamps. 535 Explanation of the lever movements of forceps. 538 To apply forceps before the rotation is completed. 540 Forceps in occipito-posterior positions. 541 Forceps in transverse positions. 542 Forceps in face presentations. 543 Forceps in locked head. 544 Impaction of the head. 546 Forceps in pelvic presentations. 547 Section of the pubis. Sigault. Baudelocque. M.Sue. E.Sherwood. CONTENTS. XXV CHAPTER XVI. EMBRYOTOMY. PAGE 551 Motives. Holmes' perforator. 552 Questions as to perforation or Caesarean section. 554 The sharp crotchet or uncus. 555 Case of embryulcia for deformed pelvis. Mrs. R., by Dr. Fox. 566 Embryotomy instruments of author, with Figs. 126, 127, 128. 569 Considerations on embryulcia, and advantages derived by author's instruments. 570 Dr. Gibson's Caesarean operation for Mrs. R. CHAPTER XVII. INDUCTION OF PREMATURE LABOR. 578 Letter from author to Dr. E. on a proposed induction of labor. 582 Results of E.'s case. CHAPTER XVIII. INVERSION OF THE WOMB. 585 Case of inversion. 587. Case. 588 Method of repositing inverted womb. 590 A case of inversion with spontaneous cure. 591. A like case. 592 Dr. Hatch's letter describing case of spontaneous cure. 595 Dr. Jno. Greene Crosse's essay on inversion, and his criticisms. 597 Crosse, Daillez and Baudelocque. CHAPTER XIX. CHILDBED FEVER. 597 Dangerous nature and sudden mortality of childbed fevers. 598 Diversity of the opinions of physicians as to the disease. 599 Necessity for independent research and reasonings on it. 600 Author's treatise on the nature, signs and treatment of childbed fevers, referred to. The milk metastasis doctrine of the fever. 601 Misleading tendency of the words childbed fever, which is not a fever, but a pure phlegmasia. 602 Affects among crowded hospitals and cities pregnant or lying-in women only. Not a cardinal fever. 603 To be cured if possible by resolution of an inflammation. 604 The expansion of the primary seats of inflammation transports the phlegmasia to distant organs. 605 Pathogenic processes. Pyaemia. 605 Pathogenic processes of childbed fevers. Causes. XXVI CONTENTS. 606 Epidemic. What may be the epidemic cause. 608 Epidemic in Hotel-Dieu, at Paris, at Dublin, London, &c. Table of epidemics from Ozanam, from 1652 to 1845. 612 Contagion assumed by some persons to be the cause. 613 The Manchester epidemic of Roberton examined. 614 Quarantine for the physician. 615 Curious sequence of cases in the practice of certain individuals. An example of this sequence. 616 Contagion continued. 619 The state of the nervous mass in childbed fevers. 621 Contagion ? 623 Mode of onset, of the childbed fever, and symptoms detailed. 625 The tympanitic state. 626 Angulation of the gut, frequently mortal. 628 Differential diagnosis of milk fever, &c. 629 Treatment. Bloodletting. 630 Alexander Gordon. His epidemic at Aberdeen. His discovery and his method, by venesection. 632 Gordon, Hey, Armstrong, and Lee's works republished by author. 633 Gordon indicates twenty-four ounces at one venesection as the cure. Dr. Collins, of Dublin, distrusts venesection in childbed fever. His case. 634 Letter from Dr. Collins. 638 Case of puerperal fever. Leeching as a cure. 639 Cupping. Emetics. Doulcet's success. 640 Cathartics. Calomel. 641 M. Chaussier's method. Stupings for the abdomen. 642 Blisters. Oil of turpentine, by Brenan. Opium. Mercury. 643 Antimonials. Enemata. 644 Tympanites, and angulated colon. 645 Oatmeal gruel and diet. Not a fever, but inflammation. 646 Metro-phlebitis. 647 Pyaemia. Intoxication. Hysteroid symptoms. CHAPTER XX. ATRESIA VAGINAE. 650 A case of atresia, by Randolph. CHAPTER XXI. ERGOT. 655 Ergotism. Nature of labor pains. 656 Michel's book on ergot. CONTENTS. XXvii PAGE 657 Ergot in cases prone to floodings. 658 Ergot to procure abortion. 659 Dr. R. Lee's case of large doses of ergot. CHAPTER XXII. MILK-FEVER. 661 Structure of the breast. 663 Case of inflamed breast. 665 Sore nipple. 666 Ointment of deer's suet for sore nipples. 667 Dr. Physick's method for sore nipples. 668 Inflamed mamma. 669 Fasciola and strophium. 670 Milk abscess. 672 Case of gathered breast. 674 Counter-sunk nipple. PART IV. THE HISTORY AND DISEASES OF THE YOUNG CHILD. CHAPTER XXIII. CHILD AT BIRTH. 679 Tying the cord. Dressing the child. 681 Dress suitable for child. 683 Food. 687 Weaning. 688 The navel. 689 The meconium. 690 Purging or diarrhoea. 692 Costiveness. 694 The gum. 695 Sore mouth or aphthae. 696 Icterus or jaundice. OBSTETRICS. PRELIMINARY OBSERVATIONS. 1. I have called this work Obstetrics, the Science and the Art, because while I look upon Obstetricy as a real Science, I consider Midwifery to be merely an Art founded upon a truly Scientific basis. 2. Obstetricy comprises the several sciences of Anatomy, Phy- siology, and Pathology, in so far as they relate to the structure, the functions, and the diseases of the reproductive organs; it also includes the whole of Embryogeny, together with the Therapeutics and Surgery • of sexual diseases and accidents, and the Disorders of new-born chil- dren. Hence it seems just to regard an Obstetrician as a physician who, to the general qualifications of men of his class, joins all the peculiar information and skill that are required in a person having special charge to treat the sexual affections, whether as arising in the Department of Midwifery proper, or as occurring independently of pregnancy, labor, or the lying-in state. Obstetricy, therefore, is the science of woman's nature, diseases, and accidents, and is a copious and comprehensive Science; while Midwifery is the mere art of assisting women in labor, and of guiding their conduct throughout the following confinement. This Art, which has existed from the earliest periods, though rude and imperfect in its beginnings, has, with the lapse of ages, and through oft-repeated experiences, and much philosophical examination of the principles that should govern its ministrations, come to such a high degree of perfection in its rules and observances, that the medical student ought to find it not only an easy study, but one interesting and pleasing to the mind; for all studies are the more agreeable in proportion as they lead to sure re- sults, inspiring confidence in the student, and convincing him that he is continually augmenting by his scientific attainments his power to do good unto his fellow-creatures. I think there is no study in Medi- 3 26 PRELIMINARY OBSERVATIONS. cine, that leads so certainly to salutary executive power under well conceived rules of action as that now under consideration. 3. Some of my readers might be disposed to call in question the claim of Obstetricy to be classed among the Sciences, and to look upon it as a sort of Collections or Fascicles of various sorts of know- ledge rather than as a real science; and here I may remark, that knowledge of things is not science, and that any conceivable amount of information that any man might acquire would, by no means, entitle him to be considered as a man of science unless the items of his know- ledge should prove to be methodized or classified; because science is classified or methodized knowledge, and nothing more nor less. If a man could be supposed to know every member of the zoological series, or every plant, shrub, or tree in the universe, he could not pre- tend to be a scientific man unless he should have a methodical know- ledge of them all: nor would his knowledge be of any use to himself or to mankind, since he would know nothing of the relations of ani- mals to each other, nor have any conception of the resemblances or differences, which enable scientific zoologists and botanists to know, almost at sight, where to collocate any newly discovered thing whether of the animal or the vegetable kingdom. He would neither know where to find anything, nor where to place it if it should come in his way. Science, then, is nothing more nor less than knowledge, classi- • fied, methodized, or arranged in an orderly manner. 4. Our obstetricy has gone so far that it certainly is possible to methodize or classify all the items of it, and enable the student at once to seize upon the connection of any one of its things or ideas with any others, or with the whole of the science. But it is only of late that such a scientific character could be justly attributed to it. Any person at all familiar with the medical writings of the Greeks, the Romans, or the Arabians, will acknowledge that their Midwifery pro- ductions ought not to rank among the sciences, however highly we may prize them as the expositors of opinion and practice in their several eras. In like manner, it is impossible to say that the works of Pare*, of Guillemeau, and Lamotte are truly scientific productions. Even Mauriceau may be questionable on this point, though he is in some respects, quite methodical. So with the early English writers Rainald, Chapman, Giffard, and Burton, who do not rise to the height of science, because they had, in their day, no classification or method. Dr. Denman, however, Prof. Davis, Dr. Robert Lee, Dr. Ramsbotham, and many other distinguished English writers, with a host of French and German authors, have so methodized or classed the various inte- PRELIMINARY OBSERVATIONS. 27 gral portions of obstetrics, that it has now a fair title to be called the science of obstetrics, on which is founded the art of Midwifery. 5. I do not suppose that any person will object to a division of the subjects to be treated of in this volume, into the two departments of Obstetrics the Science, and Midwifery the Art merely because it is a difficult thing to discover a truly natural method of our obstetrical knowledge: it is, perhaps, not easy to find out a natural method of its study; and yet it is true that the whole matter is comprised in what relates to the female pelvis, to the sexual organs, and to the new-born child. To me it seems clear that, in the above three divisions or classes I have places in which to collocate every individual item of the information I do now possess, or may hereafter acquire concerning obstetrical and midwifery matters, and that it does serve me as the basis of a sufficiently natural method of arrangement. In his Intro- duction to the "Regne Animal," M. Cuvier said: "There can be only one perfect method, and that is a natural method. This is the title given to an arrangement in which beings (subjects) of the same genus are placed nearer to each other than to beings (subj ects) of any other genera; those of the same order nearer together than those of any other orders, and so on throughout the arrangement. This is the ideal method, to which everything in natural history should tend; for it is evident, if it could be attained, we should be in possession of an exact and complete expression of all nature. In a word, a natural method would be the whole science, and every step towards it carries the science nearer to perfection." A natural method of obstetricy is the desideratum, and to get at a natural method here, it is only neces- sary to treat in succession, 6. I. Of the Anatomy of the parts concerned in the acts of Repro- duction. 7. II. The Physiology of Reproduction. 8. III. The Therapeutics and Surgery of Midwifery and Obstetricy. 9. IV. The History and Diseases of the new-born Child. 10. These four divisions, classes, or departments of obstetrics, though each suitable to be treated of in a separate book or volume, yet give us a classification easy to be remembered and referred to, and I could doubtless follow it out rigorously in these pages, though I may occa- sionally prefer to transpose the various opinions, facts, or precepts that follow, from one department to another without an unvarying adhe- rence to this exact order or method. Such an arrangement shows our obstetricy to be a real science, in so far as Method is a condition of it; and we can, by dividing our subjects in the manner proposed, reduce to classes, genera, and species, the various dogmas or facts that are to 28 PRELIMINARY OBSERVATIONS. be exposed, and so, with due pains-taking, make of this book a kind of Ledger, in which shall be posted up at page, line, and column, all the particulars we may think fit to enter into its paragraphs. 11. This work, which first appeared under the title of the " Phila- delphia Practice of Midwifery," a small 8vo. volume of 370 pages, was printed by James Kay, Jr. & Brother, in 1838. Since that time it has undergone many changes, and, as appears at the end, now comprises about 750 large octavo pages. As I have superintended the several editions of the work, which has appeared in various forms, I have felt privileged to adopt the advice of Horace, in his tenth satire of the first book:— " Saepe stylum vertas, iterum, quae digna legi sint Scripturus;" and I fervently desire that the manner of the writing might prove as he says— "Simplex duntaxat et unum." 12. Following out the design I had formed, so many years ago, of improving this American work, as I should gain greater ability by increase of knowledge of these matters, I have considerably altered the present edition, which is the fourth. 13. As to the osteological portion of the treatise, I may say that it is almost wholly re-written: and I have introduced considerable por- tions of text relative to the reproductive organs; changes which I venture to hope will be found both beneficial to the student, and inte- resting to the older reader. In many places I have altered the expres- sion, and in some of them have suppressed passages or transposed them in a way calculated to improve the treatise. 14. So many copies of the work have been taken by the country, that I have the greatest cause to be thankful to my medical brethren for so undeniable an evidence, and indeed proof of their kind accept- ance of my labors. The descending path of life in which I now walk, is made more cheerful by the conviction that, unaided by fortune or early patronage, I have been so far favored by the medical men of America as to bring this volume, and others that I have written, to repeated editions, some of them extremely large ones. There is not among the thousands of United States physicians a man to be found who is more profoundly sensible than I am of the social importance of our pursuits, of their indispensable necessity for the well-being of society, or of the stern duty incumbent on every one of us to do something to render it both more clinically useful, and socially repu- table. PART I. ANATOMY OF THE PARTS CONCERNED IN THE ACTS OF REPRODUCTION. CHAPTER I. THE PELVIS. 1. The pelvis, anatomically considered, is a structure composed by the union of several bones that are respectively denominated sacrum, coccyx, ilium, ischium, and pubis, all which, being arranged in their proper places, and bound together by cartilages and ligaments, covered with tissues of various kinds and provided with certain important viscera within, and with other organs on the exterior, require no little study and reflection by those who design to learn Obstetricy in order to acquire a competent knowledge of the art of Midwifery. It is the duty of the anatomist to particularly describe all those parts, and point out their relations to each other and to the whole economy; but, in the view of the Obstetrician and Accoucheur, the pelvis is seen to be a bony and fleshy canal, designed to contain, support and protect the organs of generation, and give passage to the fruit of the womb. 2. It is owing to the peculiarly complicated forms of the pelvic canal, that the act of parturition in women is more difficult, painful, and dangerous than in other mammiferous beings, for it is to the peculiarities of that canal that is due the power possessed by women to give birth to their children by what is called a vertex presentation, a thing impossible in all other mammifers, even those most nearly allied by form to the human family. There is not one of them that does not normally present its offspring in what is called the face pre- sentation, the muzzle and not the back of the head, or vertex, being the presenting part. In our race the ratio of volumes of the foetus and pelvis ought to be carefully studied by every conscientious student, who can never duly comprehend them until he has first become acquainted with every bone that makes part of this interesting and 30 THE pelvis. curious organ: Hippocrates long ago compared the child in its mother's womb to an olive in a narrow-necked bottle; if one of the poles of the olive presents itself to the opening, it can readily pass out; but if it presents itself transversely, its position must first be changed before it can come forth, or else the olive or the bottle must be broken for its extrication. Hence the subject of presentations is a most important one in relation to the study of the pelvis. 3. If the pelvis does offer the most considerable of those obstruc- tions and embarrassments that are met with in the practice of Mid- wifery, and if the relation of it to the child is of such vital importance in our proceedings, then every just, wise, and earnest student of Obstetricy will feel himself bound to carefully inquire into its nature and properties, and he will, I am sure, discover that, while dry and uninviting in its particular details, it is, as a whole, clothed with the very highest interest. This lively interest in the study of the pelvis is, however, not confined to its mere Midwifery connections: for, as all the organs of reproduction in the female are laid either within or upon the pelvic bones, so their whole life, power, and offices, as well as their places and positions, are inseparably allied to, aud dependent upon their osseous basis, without which they could never be de- veloped nor exist. A professional man ought to know these parts so well as to have attained to the possession of a perfect ideal of them, having them intellectually or spiritually drawn on the tables of his mind as an ever present model, with which to compare every medical case in the category presented for his opinion and judgment. With such an intellectual or ideal model ever at hand, he could measure every faulty form, crasis, or function, and every deviation in place, and so become, as it were, incapable of making mistakes in diagnosis or action; his ideal pelvis, and its apparatus, would for him be the norm, all that should agree with it being normal and all others abnormities. 4. The word is derived from the Greek rttwc, which corresponds to our English word basin. The Latin word pelvis is become a part of our technical, and indeed of our ordinary language, as it is of the French didactic language, according to Prof. Dubois. Its true English interpretation is hips or hip-bones, or haunch or haunch-bones. We do not usually employ, to express its idea, the English word basin while the French mostly call it le bassin. Italians speak of it as i 1 b a c i n o, the basin ; Germans denominate it das becken, the basin; Spaniards, la pelvis, the basin; and Swedes call it back- e n e t, the basin; whence it appears that the idea of a pelvis has some connection with the idea of a basin in all the above named languages, and with all those nations. THE PELVIS. 31 5. The annexed figure (Fig. 1), which represents a well-formed female pelvis, drawn in outline, exhibits this resemblance to a basin, though faintly, and the fainter, indeed, because the whole upper edge or front side of the bowl seems to be broken away, both above the front or pubic bone, and below it at what is called the arch of the pubis. The great upper vacuity is seen in the drawing be- tween the two angular points, one on the right and the other on the left side of the drawing— projections that are known as the anterior-superior spinous processes of the ossa ilia. Beneath the front bone, or pubis, as it is called, there is another great vacuity, shaped like an arch, which is called arch of the pubis; and, indeed, the whole bottom of the bowl or basin is wanting in the dried specimen. Not so, however, in the recent subject, in which the bottom of;the basin is closed by tissues of various kinds. 6. But, while the whole profession everywhere agree to regard this organ as *£*.«$, p e 1 v i s, bacino, backenet, bassin, becken, basin, &c, they are equally agreed to call Flg- 2l it two pelves—an upper and lower, a greater and lesser, or a true and false pelvis; and they divide these two pelves from each other at the brim, en- trance, inlet or strait, as it is vari- ously denominated.— The student will ob- serve, in Fig. 2, that I have cut the pelvis transversely by a vertical section, and I present it here in order that he may see how naturally the writers have been led thus to divide the 32 THE PELVIS. pelvis into a greater one above and a lesser one below, for it is evident that the lower portion of the drawing represents a form or a cavity very different from the broad and expanded portion above. Fig. 3 shows the front segment of this same divided pelvis, and exhibits the shape of the front inner wall of the true or lower pelvis. If the two segments should be readjusted, they would reproduce the pelvis of Fig. 1. These two figures ought to instruct the student as to the real canal of the pelvis, and show him that if any difficulties should arise in the course of a labor, on account of the bony canal, those difficulties would be connected with this true, or lower or lesser basin, and not with the great or su- perior basin, which is so capacious that ob- struction could hardly arise within its walls. Hence he ought to care- fully study the confor- mation and properties of this lower basin, if he would make himself equal to the responsibilities of obstetrical practice. 7. As the sacral bone has its sacro-lumbar facette cut so obliquely that the sacrum descends in a backward as well as downward direc- tion, producing the projection, promontory of the sac- rum, or sacro-vertebral angle, the entrance or inlet of the pelvis is rendered, by the promontory, narrower from front to rear than it is when measured either transversely or obliquely, this sharp angle of the promontory being the posterior limit of the brim. From the promontory there is a sort of raised line or ledge running round the pelvis, left and right, to stop at the top of the ossa pubis (Fig. 1), and because this raised line runs along both the ilium and the pubis, it is called the ilio-pubal line, or ilio-pectineal line. The Romans called the pubic region pecten, hence linea ilio-pec- tinea; for, as the pudenda is clothed with hair, the term pecten was applied to that region, and the bone of the pubis has been called the os pectinis. Juvenal speaks of the pecten in Sat. vi. 370. Inguina traduntur medicis jam pectine nigro. 8. Now this linea ilio-pectinea serves as a sort of stricturing band, to make the pelvis small at the inlet and produce a narrowing there. THE PELVIS. 33 This narrow passage, from the greater down into the lesser basin, is called the superior strait of the pelvis; all that is above it being upper basin, and all that is below it being lower pelvis, lower basin, pelvic canal, excavation, cavity or true pelvis; for by so many different names it is known in the profession. Hence, let the student learn what the superior strait is—its form, and its dimensions; let him well and truly learn the shape and size of the true pelvis, and he will find that while it has an inlet or abdominal or superior strait, it also has an outlet, inferior, or Fig- 4. perineal strait — the former at the beginning, and the latter at the end of the pelvic canal—all of which requires his careful study. 9. These two straits of the pelvis differ from each other very much in shape and direction, as may be discovered by inspection of the Figs. 4 and 5, which represent the superior and inferior straits of the pelvis. In Fig. 4, one is looking downwards into the pelvis, and in Fig. 5 upwards through its inferior strait. In Fig. 4, the distance from promontory to pubis ought to be at least 4 inches from a to b. The distance across the opening from e to/, should be 4| inches; and the two Fig. 5. oblique diameters, eg, eg, should be five inches each. In Fig. 5, however, the long- est line is that from front to rear, a b, and not the trans- verse cd,ef, or oblique ones, so that the longest diameters of the two straits do not coincide, which renders it necessary for the child to make a spiral turn or revo- lution as it descends from above, to be born—a turn that is techni- cally called rotation of the foetus. I shall, in another page, speak of the lower strait, as consisting of a double plane. 34 THE PELVIS. 10. Most of the bony resistance experienced in labors, is resistance met with at one or the other of these straits, though it is true that we sometimes meet with cases in which the excavation itself does offer very great obstruction to the birth of the child. 11. I have pointed out the ilio-pectineal or ilio-pubic line, and I wish to say that it is the bo u nda ry or margin of the superior strait. Let it be occupied with an imaginary superficies, and call that superficies the plane of the superior strait. A line falling perpendicu- larly upon this plane just midway between the pubis ancl the sacrum and in the middle of the transverse diameter, is the axis ofthe superior strait; or, to speak more precisely, it is the axis of the plane of the superior strait. Now, as such perpendicular line does not correspond with the long axis of the trunk of the body, but comes out of the trunk at or near to the umbilicus, and touches the lower end of the sacrum within the pelvis, the plane of the strait is an inclined plane, and it is inclined more or less according to the posture assumed by the patient or the subject. In general, the inclination of this plane is about 50°. If the individual stretches herself upwards, and leans backwards as far as possible, the plane of the strait inclines the more; but if she bows herself forward, she may bend the trunk over the strait so far as to make the opening wholly lose its inclination, and take an adjustment at right angles to the body. The annexed figure (Fig. 6) represents a pelvis and spine, with the Fig. 6. ri»ht lower extremity. If the subject lies on the back, with the knee-joint flexed, the plane of the strait (/ b) will make, with the axis of .the trunk (a), an angle of 140°; or, in other words, the inclination would be 50° below the horizon if the individual were standing up. But if the trunk should be raised up to c, or even carried forwards to THE PELVIS. 35 d, the inclination would, at c, be 22° 30, and at d nothing at all; for at d the plane would be at right angles to the trunk. 12. It is well worth while for the student to note these things, because the ease or difficulty, the celerity or slowness of a labor may depend upon the degree of this very inclination, and on nothing else, and he can understand why a woman who stretches her limbs quite straight out in the bed, and bends her trunk backwards by means of a pillow under the loins, should fail to drive the child's head right through the inlet, but rather force it against the top of the pubis than into the opening; whereas, if she should bend the trunk forwards in a proper manner, she would at once thrust the infant's head through the aperture and drive it down to the very bottom of the excavation. The knowledge of these circumstances, and a vigilant attention to all the details of his duty, enable a practitioner quietly to obviate much suffering for the poor female, tormented with the pains and anxieties that attend upon parturition; for the physician may direct the woman to take such a position as to adjust the inclination as he pleases. Indeed, it is an instinctive knowledge that induces almost all women in labor to bow themselves forwards, and a long experience leads the wise matrons, who come to her help, to frequently advise and exhort her to "bend forwards, my dear; bend well forward to the knees." 13. I shall conclude this part of my subject, by proposing the question : what is the superior strait, and by the answer—the superior strait is the narrow pass from the greater, downwards into the lesser basin or pelvis; it is bounded by the linea ilio-pectinea; and its plane, which is an imaginary superficies, is inclined about 50° in a person standing upright—some authors say 60°. The strait is 4 inches from front to rear, 4| inches from side to side, and 5 inches in its two oblique diameters; and these are the diameters of the superior strait. I mean to say that a superior strait, possessing these dimensions, ought to be pronounced perfect all the world over, and that while it is true that we meet with many that are larger, we also meet with many that are smaller. A pelvis is large enough when it is as large as the above proposed model. Let the student, however, remember that the larger it is the less the obstruction and difficulty it can give rise to in parturition, and vice versa. 14. When two hip-bones orossa coxalia are correctly adjusted in their places upon a sacrum, the pelvis is reconstructed, and we see the pubic arch, the great vacuity above the pubis betwixt the two anterior superior spines of the ilia, the vacuity behind between the posterior parts of the ilia, and a great notch on either side, between the wings of the sacrum and the ossa ischia, which is called the sacro- 36 THE PELVIS. sciatic notch. All this, as I before said, gives the idea of a broken basin; but not so in the living subject, for there the upper vacuity is occupied by the tendons of the external oblique muscles, by the recti and pyramidales, and by the abdominal fascia and integuments. On the posterior part, the great basin is made complete by the lower lumbar vertebrae which rise up from the base of the sacrum; by the ilio-sacral and sacro-lumbar ligaments, and by the muscular and tegu- mentary tissues that complete the round in that direction. 15. Inferiorly, the pubal arch is closed by the genitalia; the sacro- sciatic notches are occupied with ligament and muscle, &c., and the perineal strait is closed by the tissues of the perineum, &c, which thus complete the basin or pelvis, and give it a right to be so called, while it is, perhaps, difficult to see any likeness to a basin in the dried osseous specimen alone. 16. Having now taken a general view of the pelvis, let us proceed to its analysis, or to an examination of the several bones by whose union it is composed; and this, perhaps, is the only way in which we can correctly compass the important study. 17. The question that first arises, is: Of how many pieces does a pelvis consist? and the student may properly reply that it is composed of four separate bones, which are: 1st. A sacrum; 2d. A coccyx; 3d. A right, and 4th, a left os innominatum or os coxale. It would, however, be equally true to say that a pelvis is composed of eight bones, that may be enumerated as follows, videl.: 1. A Sacrum. 2. A coccyx. 3 and 4. A right and left pubis. 5 and 6. A right and left ischium. 7 and 8. A right and left ilium,; and if he should choose to say that a coccyx consists of three pieces, he would enu- merate eleven instead of only four or only eight separate members of a pelvis. 18. The Sacrum.—The most important bone of the pelvis is the sacrum, because all the others are dependencies of it, and take their character and proportions from it. Indeed, they could not exist with- out it, as the limb of the tree could not exist without the trunk from which it arises. It is difficult to understand why the os sacrum should have received a denomination indicating a quality of holiness for sacrum means holy, and that so general an idea of sanctity should have been connected with it in ancient times and by many different nations. The word, os sacrum of the Latin, and the word ieron osteon of the Greeks has the same significance probably with the 1 u t z -1 u z or 1 u z of the Jews who believed that there is a small bone of the body which is indestructible, and which at the resurrec- THE PELVIS. 37 tion will gather about it, as to a centre all the other parts of the body and rise bodily into everlasting life. M. Basnage's " Histoire des Juifs," torn. v. liv. v. Chap. XX., contains an account of the bone lutz. " The Rabbins imagined that God will resuscitate the dead by means of a small bone situated in the spine of the back, and which is called lutz. They contend that this little bone, which no one knows, is incorruptible; which they prove by the words of David, who says: God shall keep the bones of the just, and not one of them shall be broken. Christian interpreters understand by this that God shall so protect the just that none of the bones shall be broken, and they see the accomplishment of the promise in the person of the Messiah; but the Jews insist that the providence of God extends to only a simple bone which can be neither broken nor corrupted. This they prove by the example of the Emperor Adrian, who, mocking at the resurrection and at what a certain Jew said concerning the virtue of this bone, made a trial of it—so they placed it under a millstone and could not break it, and they threw it into the fire and it was not con- sumed." M. Basnage considers all this story as imaginary. The Rabbinical notion was, however, that all the parts of the human body, though dispersed in various places, do at last reassemble around this bone and form the same body that belonged to the individual during his lifetime, tt^ov oitio^ os sacrum, os sacre, Heiligen bein. See also " Vesalius," lib. I. Cap. XXVIIL, p. 126. There is an account of the bone lutz in Bayle (note) p. 483—with quotations from Manasse Ben Israel relative to Adrian's experiment. Krauss, sub voce, says: Os Judasorum, ossiculum resurrectionis. Semen resurrectionis, the He- brew—ih which is n u x, or nut. 19. In its origin, a sacrum consists of the elements of five distinct vertebrae, which, in the process of growth, become consolidated or anchylosed into one firm sacrum, and each of the several vertebrae was formed by five distinct points F'g- 7- of ossification, that are here represented in Fig. 7, ^fl^^i^ in which a is the original body of the vertebra; PJ^^^LlI cc, the right and the left transverse processes; and c(^fiLii^^«#\c b b, the rudiments of the spinous process, which a ^* also form the bridge or spinal canal. Even so late as the period of birth, and long after the season of viability of the foetus is passed, the five separate members of each sacral piece are still unconsolidated, and fall apart on being macerated or boiled. But, as the child grows in volume and stature, the bodies of the vertebrae and their transverse and spinous processes or bridges unite with each other, and the whole of the five vertebrae become fused or 38 THE PELVIS. soldered, so to speak, into one piece—the bodies making up a sort of central columnar portion—the transverse processes converting them- selves by fusion into the bony wings or sides of the sacrum, and the bridges and spinous apophyses becoming the sacral canal and spinous ridge of the bone. As the transverse processes blend them- selves together in regular succession, from top to bottom, they neces- sarily leave apertures which could not close because there the terminal brush of the spinal cord sends out the sacral nerves to make the in- ternal sacral plexus, the origin of the great sciatic nerves that pass outwards through the incisura or sacro-sciatic notch to be dis- tributed on the lower limbs, and thus it is necessary that the sacral holes remain open. 20. The consolidation of the several sacral pieces has communi- cated to the sacrum the shape of a three-sided pyramid, whose apex is turned downwards and its base upwards, forming a seat or plinth on which the lowest lumbar vertebra rests. The spines or spinous apophyses and the bridges divide the posterior aspect of the sacrum into two smaller faces, while the whole front of the bone makes one large triangular face of four inches to the side (see Fig. 8). This front face, or side of the pyramid, is not plane, but bent or curved so as to make the face quite concave and give rise to what is called the hollow of the sacrum. The degree of this curve differs in different subjects, but is generally half an inch or more in depth. 21. In studying the sacrum, it is usual to regard it as having an apex or point (Fig. 8); a base or top; an anterior face or hollow; two posterior faces, each a right-angled triangle; two wings or sides behind each of which, at the top, is an ear-shaped articulating surface or auricular facette; also eight sacral foramina, or holes for the transmission of internal sacral nerves. These holes are arranged in two upright rows of four holes for each row, which are on each side of the central columnar portion, or bodies of the false vertebrae. The apex terminates in an elliptical convexity, at which the sacrum touches the coccyx at the sacro-coccygeal joint. 22. At the base or top, is seen an oval-shaped articular surface, which is the seat upon which the lowest lumbar vertebra rests, and THE PELVIS. 39 from which, as from a plinth, rises upwards the tall spinal column. This sacro-vertebral facette being cut obliquely backward causes the sacrum to deviate from the vertical line and re- treat or go backwards and downwards behind the spinal column, and thus cause the appearance of a projection in front, overhanging the inlet or superior aperture of the basin, as in the annexed cut (Fig. 9), in which the finger is touching the promontory of the sacrum or sacro-vertebral angle, or projection of the sacrum, for it has all these names. 23. The anterior face of the sacrum is nearly an equilateral triangle, of four inches to the sides, and its concavity is deep enough, the foramina being stopped with cement, to hold an ounce or even an ounce and a half of water. It is of great moment that this curve should be just right, as too great or too small a depth is equal to a deformity, and is attended with increased pain, delay, and danger to the laborant: the child, in being born, executes a spiral turn on its long axis, a motion that is known as the rotation of the child, and which, though easy enough in a well-formed hollow, becomes very difficult, or even impossible, in a case where the curve is deficient. Excessive curvature is, also, to be deprecated, as it cannot exist with- out fault in an antero-posterior diameter. 24. Both of the posterior faces are convex, very rough, separated from each other by the bridges and spinous process of the sacrum, and each provided, like the front, with five sacral foramina for the passage of nerves to the exterior of the pelvis. 25. The five bodies of the sacral vertebrae have, by anchylosis or fusion, become consolidated into one columnar piece, out of which has been constituted the column or columnar portion of the bone, while the fusion of the ends of the transverse processes together has converted those processes into wings. It is right to consider the wings as extending along the sides from top to bottom, and not right to limit the idea of wings, to the united transverse processes of the three upper pieces only, as seems to be the intention of Dr. A. F. Hohl, in his new valuable work, Lehrbuch der Geburtshul/e, 1855, p. 30; and in his excellent quarto, Zur Pathol, des Beckens, p. 6. 26. I said the sacrum was the most important bone of the whole collection, because it may be considered as the basis or parent of all the others. Now, as the sacrum, while growing, touches the innomi- natum by its three upper segments, and by them only, the two bones, 40 THE PELVIS. sacrum and innominatum, there indent each other mutually and thus give rise to an ear-shaped joint-surface, which is called the auricular facette, in each of them. This auricular facette has, therefore, nothing to do with the fourth and fifth segments of the sacrum; those segments nowhere touch the innominata, separated as they are from them by the incisura, deep cut, or sacro-sciatic notch. 27. If, in any sacrum, the wings are correctly developed, the supe- rior strait cannot be deformed in such a way as to produce what is called the oblique ovate pelvis, for the curve or round of the linea ilio-pectinea must be, in such case, correctly drawn; but if one of the wings, which ought to be about an inch and four-tenths, should be only five-tenths of an inch long, the pelvis must of necessity be de- formed or crooked, having the pubal symphysis cast far over to the right, if the fault is in the left, and far over to the left of the mesial line if fault is in the right wing. 28. As the concavity of the wing determines the shape of the inner wall of the pelvis there, Fig-10. it is evident that too short a wing will cause the change of form above mentioned, and determine the exist- ence of the oblique ovate deformity. I should think this too evident to require any further illustration than that of the sub- joined Fig. 10, which is a camera-lucida draw- ing from an oblique ovate pelvis in my museum at Jefferson College. The left wing is seen to be the contracted or faulty one, whose shortness has caused the symphysis pubis to be placed awry, or far over to the right. The fault is connected with a bony anchylosis and arrest of development of the left sacro-iliac synchondrosis—always a circumstance of these oblique ovate deformities. 29. Great attention has, of late years, been paid to the influence of the sacrum in producing horizontal deviations of form in the pelvis, and our information on the subject is principally due to the care of the late eminent Prof. Naegele, of Heidelberg, in giving to us his work "Das Schraag Verengtes Beckens." Dr. E. Gurlt, also, in his THE PELVIS. 41 "Ueber Einige durch Erkrankung der Gelenksverbindungen Verur- sachte Misstaltungen des Menschlichen Beckens," furnishes us with copious notices of what has been done for our science in this particular up to a late date. While it is to Dr. Anton. F. Hohl, in his "Zur Pathologie des Beckens," 4to., 1852, that we are indebted for the fullest and clearest accounts of the matter of oblique oval deformations. Prof. Rokitansky's 3d vol., "Manual of Path. Anat.," p. 250, furnishes that teacher's views of the deformity, which he attributes, in some cases, to congenital, and in those that occur after birth, to rachitic causes; as does also Scanzoni, p. 149, "Lehrbuch der Geburtshiilfe," 11 Band. For the present it may suffice for the Student to reflect that faults in the wings of the sacrum cannot but bring about great faults of form in the female pelvis—the nature of which he will, from the foregoing, readily comprehend. 30. I beg the Student to examine the ten holes called sacral foramina, which he will find in the front or hollow of the sacrum (Fig. 8), that he may inspect the grooves there to be seen. As those holes give passage to large nervous cords that go to make up the right and left sciatics, let him notice, in these grooves of the sacral foramina, provision against dangerous pressure and contusion of those important nerves by the passing head of the child. Even with the protection of those grooves, which were moulded on the pre-existing nerves, serving, as it were, half to bury or hide the nerves in their hollows, few women having labor pains, fail in some one of the stages of par- turition to admit of a severe pressure of the nervous cords, and when the hard bony head of the foetus is jammed with considerable force upon the sensitive substance, the laborant is heard to cry out that she has cramp in the thigh, or the leg, or the foot. For a woman in labor, the natural labor pains are as much as she can well bear; and she can bear them well if she be of a firm courage and blessed with patience and hope; but if some abnormal and extrinsical pain comes to attack her, the course of nature seems to be turned aside or prevented, and the labor stops. Hence it is that a severe pressure on one or more of these sacral nerves, may wholly arrest the progress of a childbirth, and eventually compel the practitioner to interfere by means of instruments. 31. Case.—I think one of the most fearful instances of human agony that my eyes have ever witnessed, was that of a lady in North Sixth Street, Mrs. Th. S----y, who, being in labor of her first child, and mak- ing rapid progress towards a delivery, began suddenly to scream, with the greatest violence, often uttering the words, "Oh, the cramp! the cramp! the cramp!" She was indescribably agitated, her countenance 4 42 THE PELVIS. assumed the wildest expression, and all the persons in her chamber be- came much alarmed on account of the extreme degree of anguish, or rather agony, which was depicted in her countenance and expressed by her shrieks. I had, for many years, been accustomed to the cries of puer- peral women, to which I had become habitually somewhat indifferent, but this case deserved to be called terrible. The cramp affected the muscles of her right leg. I explained to her that the cramp was caused by the pressure of the child's head upon one of the right sacral nerves, and though the appearance of the case was appalling, I exhorted her to bear down, hoping a few vigorous efforts would push the head lower than the point of pressure and relieve her from the misery. I was disappointed: the cries ceased with the relaxation of the throe, only to return with every renewal of the contraction. So intense was her distress, that she began soon to show signs of exhaustion of nerve- force, and I have now no doubt that she was in imminent danger of death from the excess of pain, for pain can kill. The labor, as to its progress, was arrested with every renewal of the labor-pains; and it appeared that her whole life-force and perceptions were occupied with that sole agony. I was three-fourths of a mile from home; and while her husband was gone for my forceps, for which I immediately sent him, she renewed her cries about every four minutes. I think she would have died in half an hour. Upon receiving the instrument, I speedily applied it and drew the head below the compressed point, and she bore the extraction of it without a murmur, for the nerve was set at liberty as soon as I had drawn the head below it. During more than a fortnight after the labor, there was a partial paralysis of the limb, following the pinch the nerve had suffered betwixt the foetal head and the bony pelvis. It did not wholly disappear for many days. Two years later I encountered a similar scene in the same apartment. She seemed to dread nothing in the approaching labor but the "cramp!" and engaged me to be prepared with my forceps, which I unfortunately declined to do. When the head descended into the pelvis, she was seized with precisely the same kind and degree of pain; the forceps were brought to me from the same distance, and she was again as speedily relieved. In this labor as in the former, a partial paralysis and numbness of the leg followed the parturition, and did not disap- pear until the month was out. 32. In a third labor, during which I was confined to my house by sickness, she came under the care of my able colleague, Dr. R. M. Huston, well known for his skill as an obstetrician. The same scene was renewed in this third case, and the Doctor felt obliged to relieve her by extracting the head with the forceps. I have attended her in THE PELVIS. 43 a sixth labor, in the year 1846, and in a seventh on the 1st November, 1852, in which the position of the child was such as to avoid the pres- sure, and she gave birth to the infant without cramp, or any uncommon pain. 33. I was in attendance upon a lady living in Turner's Lane, two and a half miles from my house. The labor had proceeded very towardly until the head got well down into the pelvis. I was in a lower parlor conversing with her husband when we were startled by the sudden, sharp screams of the patient from' her chamber in the second story: we both hastened to the apartment, where I recognized a scene in all respects like those witnessed in the accouchements of Mrs. S----y. After vainly exhorting my patient to bear down and push the child lower than the nerve, 1 engaged Mr.----to wake his servant, for it was night, and send him on the fastest horse to the city for my forceps. Her agony was indescribable during the whole period of his absence. He had a ride of five miles—out and in. I got the instrument, and the child was delivered within two or three minutes after it was placed in my hands. No evil consequences followed the pressure in this case. She had had several children, but in none of the labors had the nerve got so severe a pinch. 34. Here, then, are four cases of forceps operations rendered indis- pensable by pressure on the sacral nerves. I have seen no accounts of similar instances in the books. I have met with many hundred labors in which cramp was more or less violent; but these cases, above mentioned, were really frightful, and I have no doubt that both the distress and the danger were sufficient warrants for the instrumental assistance, whence I infer that the student ought to know the meaning and relation of sacral foramina. 715. 35. Very violent cramp in the leg or thigh sometimes attends upon awkward attempts to introduce the forceps, because the ignorant or careless operator suffers the end of the blade to press upon one of these sacral nerves, as it emerges from its foramen and passes along its groove. Any one who is causing this pain with his ignorantly directed instrument is, at the same time, in imminent danger of tearing open the thin postero-lateral wall of the vagina, and plunging the point of the clamp into the sack of the peritoneum; let him tremble for his rashness, and instantly desist from so wrongful a proceeding. While the forceps is passing upwards, the chamber should be kept very still, no one being allowed to talk, so that the operator may immediately know, by the woman's expressions or silence, that the blade is passing in the right direction. My good friend Prof. Simpson, of Edinburgh, thinks that it is of no consequence that a woman should be what is 44 THE PELVIS. called anaesthetic—or dead drunk, with chloroform, during a forceps operation, and that an accoucheur ought to know what he is about. The best way for him to know what the point of his clamp is about, is to have the patient wide awake, and ready to scream—the cramp! the cramp! I think a man deserves the Attorney-General, who delivers such an insensible drunken creature—that is, if he made her drunk. 36. Os Coeeygis.—I here present a figure that represents the ter- minal or caudal extremity of the spinal column, of the natural size. It is called the os coeeygis or cuckoo-bone, in vulgar language the crupper-bone. It consists of three pieces, altogether about an inch and a half long, that are separable in the young, but become anchy- losed into one solid piece as advance is made in years. Two styloid processes ascend from the posterior lateral surfaces to rest upon the back part of the apex of the sacrum, and prevent the point of the coccyx from being driven too far backwards by the displacing pressure of the foetus in labor. These cornua, however, are not strong enough always to resist, and they occasionally break off with a loud sound. The sound may be heard at the distance of many feet from the woman in travail. In general, no very great inconvenience is produced by this fracture; although there are some instances in which a long-continued pain follows the accident. 37. In young women, the articulation of the coccyx and sacrum is a movable one; anchylo- sis takes place only in those who begin to grow old, in passing beyond the youthful season of bloom and beauty. Hence, it is better that a woman should have her first child before this bony anchylosis takes place, inasmuch as, when the sacrum and coccyx have become immov- ably joined together, the point of the little bone may arrest or distress- ingly retard the acts of childbirth. 38. The movableness of the coccyx upon the sacrum is much relied upon as a means of amplifying the antero-posterior diameter of the lower strait of the pelvis; but I do not think that the point of the coccyx usually recedes much during the transit of the foetal head in parturition. Though most writers attribute to the coccyx a power to recede very considerably, my own observation has led me to regard this recession as less than it is generally reputed to be, and reflection confirms this doubt. The point cannot go very far backwards but at THE PELVIS. 45 the expense of a fracture of the cornua and of the lesser sacro-sciatic ligaments, which tie it firmly in a certain proximity to the tuberosities of the ischia. 39. The Os Innominatum.—The side bones, which are techni- cally known as the ossa innominata, or nameless bones; and also ossa coxalia, or hip-bones, by touching each other in front and by resting at their posterior extremities upon the wings of the sacrum, serve to complete the whole pelvis, except the small os coeeygis at the apex of the sacrum, which has been already described. 40. An os innominatum is so irregular in its shape, that I do not think there is any person who could in any language describe it so as to be understood, unless aided by a specimen, or a drawing. I there- fore annex the figure (12) that represents an outside view of the bone, near the middle of which is seen a cup-like cavity, I, which receives the round head of the thigh-bone. This socket, or cup, is known as the acetabulum, a word often used in Midwifery, though the ace- tabulum is on the outer sur- face of the pelvis; hence, when the word acetabulum is used in our art, let it be understood as meaning the smooth surface on the in- side of the pelvis opposite to the acetabulum which is on the outside. It would be far better to say aceta- bular region, than acetabu- lum in midwifery, for that would express our real meaning, which the other does not, as there is no ace- tabulum within the excava- tion. 41. The figure (12) shows the left os innominatum, corresponding with the other half in Fig. 13. On its right is seen its broad expanded iliac portion, a, exhibiting its dorsum, bounded above by the crista or crest of the ilium b, with its anterior superior spinous process c, on the left, and its anterior inferior spinous process d, a little lower down. The posterior superior, and the posterior inferior spinous processes are at the bottom of the drawing on the right, e,f, while just behind the acetabulum may be seen projecting backwards the 46 THE PELVIS. spine of the ischium. At h is the tuberosity of the ischium, and the pubis (at i), whose descending ramus drops downwards to meet and unite with the ascending branch of the ischium, k is the foramen ovale, foramen thyroidean, or obturator foramen; I, in the bottom of the cup, is the acetabulum; g is the spina ischii. 42. I now present an inside view of the right os innominatum, in Fig. 13. Here the letter a is placed on the symphyseal end of the os pubis, which, when joined to the left os coxale, makes the pubic symphysis; b is the body of the pubis running backwards to the dotted line on the acetabulum, where it ends; c is the descending ra- muspubis, and d the ascending ramus ischii. The letter e is on the plane of the ischium, and/on the iliac fossa or venter; g, the anterior superior spinous process of the ilium; h, its anterior inferior spinous process; while i and k respectively indicate the posterior su- perior and the posterior inferior spinous processes of the os ilium. Towards the right side of the drawing may be seen, at I, the ear-shaped surface denominated the auricular facette, which, being covered with fibro-cartilage, and united FlS-13, to a similar facette on the sacrum, composes the sa- croiliac joint. The Stu- dent will please to note the three dotted lines in the middle of the figure, which indicate the respective li- mits of pubis, ischium, and ilium in that direction, and he will see that one-fifth of the acetabulum belongs to the pubis; that two-fifths of it are contributed by the ischium; while the upper and outer two- fifths are formed by the os ilium. By examining these dotted lines, he will learn what parts of the os innominatum belong to each of its three constituent members. In fact, the os innominatum, as has been already seen, was originally three separate bones; which at or about the period of puberty become consolidated by bony anchylosis, or union, into one solid os coxale, hip-bone, or side-bone. 43. If an os innominatum be taken from a subject under twelve or fourteen years of age, and macerated or boiled in water, it readily separates into three pieces; and the separation takes place because the pieces, in a tender age, are not consolidated at these dotted lines or become one firm bone, a union that cannot become complete until the THE PELVIS. 47 body has acquired such a development as to fit it to undergo the fatigue of gestation, which rarely occurs until the fifteenth year. A bone, taken from the os innominatum of a subject under twelve years old, serves to show the Student the propriety of preserving for the adult skeleton the names of the three separate pieces; for he will learn therefrom that it is very convenient to refer to them in many cases where we desire to direct the attention accurately to a certain point of the pelvis, of which we can then speak, as its ischial, pubic, or iliac portion. 44. In respect to the acetabular region, or as it is for shortness called the acetabulum, I wish the Student to observe that it is one of the cardinal points in the circumference of the pelvis, and it is highly requisite that he should know that the left acetabulum is agreed upon by the profession to be considered as the cardinal point on the female pelvis. There are various cardinal points also upon the foetus, as, for example, the vertex or point of the head, &c. Now, when the vertex, in the head presentation, is found to be at the left acetabulum, it is said to be in the first position; and if it is at the right acetabulum, it is in the second position, and so on; from which it appears that positions are classed numerically, and are, in fact, expressed as numerical relations of some cardinal point upon the child to the cardinal point of the pelvis. Thus, if, in a consultation upon the case, the question should be asked, what is the position? The answer might be, it is the first, or the fifth, or the third, and so forth, which would express the numerical position—relation of the vertex to the left acetabulum. 45. The whole pelvis is now seen to consist of a sacrum and coccyx, and of two ossa innominata, and the innominata themselves to consist, in fact, each of a pubis, an ischium, and an ilium. It has been divided into two basins that are called the greater and the lesser, or superior and inferior pelvis, that are separated from each other by the inlet, the entrance, the narrows or superior strait. 46. It is to the hollow of the sacrum that is due the cavity, or, as I am accustomed to call it, the excavation; for the sides and front of that excavation would, if the form depended upon them alone, render the pelvis a cone, which it is not, and indeed far from it, for it is an expanded cavity in which there is abundant room to effect those curious spiral movements that are known as rotation of the child—movements that could not be possible, were it not that the curve of the sacrum gives a sort of balloon-like shape to that part of the organ that lies between the superior and the inferior straits. 47. As to the symphysis pubis, we may say that its inner 48 THE PELVIS. aspect is convex rather than hollow, and as to the two ossa ischia, their inner faces are plane, and not only so, but these planes approach each other as they descend on each side of the basin or canal, so that a body that can just lie between the planes at the top can by no means do so at the bottom of them, because at the top the planes are 4| inches asunder, while they are only 4 inches apart at the bottom. The Student will please examine his specimen, or the Fig. 13, to see the shape of this famous plane of the ischium. I am truly desirous that he should get a complete idea of it on account of the influence it has in the mecha- nism of labors, for the spiral movement of the child is in a good mea- sure due to this very plane, whose form and inclination compel it to rotate or make the spiral turn, which the hollow of the sacrum only allows, but does not compel it to do. 48. I refer the Student here to a drawing (Fig. 14), which exhibits, on the left hand, a bisected sa- Fig. 14. crum, and on the right side a section of the pubis. The line m n is the horizon, a b the plane of the superior strait, and o i the plane of the inferior strait. The lines p c, q c, r c, s c, and t c also represent planes within the true pelvis, and it is evident by inspection that a b and o i are shorter than the lines p c to t c, because the sacrum is hollow, and is nearer to the pubis at its inlet and outlet than anywhere else. In this figure, the line ef is the axis of the superior strait, not the axis of the pelvis. The artist attempted to represent the axis of the pelvis by the line g k, which cuts all the planes in their centres. This is perhaps a very correct method of representation, but I greatly prefer that of Professor Carus. **•*. 49. Carus's Curve.—A far preferable method of describing and understanding the axis of the pelvis is that proposed by Dr. Carl. Gustav. Carus, Prof, of Midwifery in the Medico-Chir. Acad, of Dres- den. His views are stated in his "Lehrbuch der Gynsekologie," etc., Part I. p. 33, § 44. 50. Professor Carus directs that one leg of a pair of compasses should be set on the middle of the posterior margin of the symphysis pubis on a pelvis bisected, as in the figure 15, which I have copied from his THE PELVIS. 49 plate—the other leg of the compass being opened two and a quarter inches (I propose two inches only), which is half the anteroposte- rior diameter of the pelvis. A circle may now be drawn, com- lg' mencing at the plane of the supe- rior strait, and continued through gf, g e, and g d to the point of departure. This is Carus's circle, a segment of which represents, within the excavation, the axis of the pelvis. This curve of Cams, which is the bent axis of the pel- vis, is an imaginary curved line in coincidence with which the centre of the foetal encephalon moves as it passes from the upper pelvis through the excavation, the inferior strait, and the produced genital aperture, in the act of being born. If the head of the child in a labor should continue to move, after its birth, in the same curve it moved in while within the pelvis, the head would come back to the point of departure at the centre of the plane of the superior strait. The line a b is the axis of the plane of the superior strait, and the line g c is that of the plane of the inferior strait. 51. Such is Carus's curve, which is the bent axis of the pelvic canal __an important item of midwifery knowledge; one without which a practitioner is incompetent scientifically to deliver a placenta, and far less to extract a child by turning, or to apply and deliver with the forceps or the crotchet. I caution the Student not to fail in under- standing this point very perfectly. If he should make himself per- fectly familiar with this curve of Carus, I see not how he could make any mistake as to the appropriate direction of his efforts in any act of delivery, whether with the hand alone, or with instruments. 52. Prof. Dubois, in his "Traits Complet de l'Art des Accouche- mens," p. 6Q, after speaking of Carus's curve and commending it as being very simple and at the same time very ingenious, says, it has the fault of giving a not exact idea of the central line of the pelvis; but I consider that for all practical purposes it is far superior to any other, and I believe that the Student who well understands Carus's curve will always act correctly in his manner of adjusting the forceps and other instruments, as well as in operating with them, or with the hand alone, in extracting the head or other parts of the child, because he will clearly apprehend the line in which all movements ought to proceed. Carus's curve is truly the orbit of the foetus. 50 THE PELVIS. 53. The straits, diameters, planes, axes, and curves of the pelvis are, in an obstetrical regard, related to a certain form, magnitude, and position of the presenting part of the child, which, in its passage through the pelvis, performs certain movements that are spoken of as the mechanism of the labor, and which I shall proceed to explain after I shall have first spoken of the recent pelvis, and of the child in utero. 54. The transverse diameter of the superior strait has already been seen to be four and a half inches, and that of the inferior strait only four inches, so that a series of planes superimposed from the lower to the upper strait would be wider and wider as they approach the top, being four and a half at top, and only four inches wide at the bottom. 55. This inclination of the sides of the pelvis, due to the position of the planes of the ischia, makes it inevitable for the head, when it happens to present transversely, to spin on its axis and direct its longest diameter at last to the pubis in front and the sacrum behind. If it were not that the ischial planes are thus inclined, there would be no rotation, nor any need for it; but as it is, rotation is almost indis- pensable. A gestation would hardly go to term but for this inclina- tion : without it, the womb would continually tend to drop down and let its fruit be lost, in consequence of the upright attitude of the woman. It makes her parturitions more painful than that of other creatures, but her compensation is found in the Ovidian privilege of the o s sublime and the caelum tueri. 56. A providential care has been manifested not only in this law of the inclination of the ischial planes, but it is equally apparent in the planes of the pelvic canal. The Student has already been advertised that he ought not to adopt the notion that the pelvis has but the two planes; 1st. of the superior, and 2d. of the inferior strait; but rather, conceive of the entire pelvic canal from inlet to outlet as occupied with innumerable imaginary planes. Dr. Tyler Smith, in his "Lectures on the Theory and Pract. of Midwifery," Lancet, No. XIX., vol. i. 1856, after remarking that only the upper and lower planes have generally been deemed worthy of particular attention, says, "but it is necessary to consider a third plane situated between the other two, and which may be termed the mid-plane," and he imagines this " mid-plane" to be specially interesting, as being the point " where the rotations of the head are impressed upon it." I have always considered that the flexed head in descending, commences its spiral or rotatory motion as soon as the occipito-frontal diameter begins to rest on opposite sides of the pelvic wall; that it descends rotating, and continues to do so until the crown of the head is pressed against the floor of the pelvis, when the rotation is, or rather, ought to be complete. Hence, THE PELVIS. 51 I do not admit that there is, within the pelvis, any special plane, whether mid-plane or other that compels rotation. Indeed the whole trunk of the child, as well as the head, undergoes the spiral or rota- tory motion, and it cannot be that so important a portion of the pelvic function depends upon the so-called mid-plane. I present in Fig. 16 an illustration to show that the child is packed up in shape like an olive, and presents its cephalic or head-pole to the opening. If the head must of necessity suffer rotation in its progress, the trunk must do so no less, for it is true that this olive-shaped mass, about to be driven through the pelvic canal, is some twelve inches in length by a little less than four inches in its transverse diameter. For many years past, I have taught at the Jefferson College that the planes of the pelvis are innumerable, and that each and every one of them must be traversed by the descending foetus, at right angles to their Fig. 16. superficies, and I am greatly obliged to Professor Carus for his simple and illustrative idea of the Carus curve, which saves me the useless trouble of calculating the places of the planes, and fully an- swers the demands of the age in the question, what is the axis of the pelvis? a question to which I have taught many thousands of American physicians to answer, it is Carus's curve, which is an arc of a vertical circle projected mid- way between pubis and sacrum, and which is the track or orbit in which the centre of the encephalon, or of the trunk of the foetus moves in being born. It might well be called the pelvic orbit. 57. In my view it is pragmatical to pretend to lay down the abso- lute course of a line that should pass perpendicularly through an imaginary million of imaginary pelvic planes, and always in their exact centres. Such particularity is both useless and impracticable. The operator who adopts the idea of Carus's, or Camper's curve, when in the act of delivering, whether by turning, or with any instrument, has only to keep before him a clear view of Carus's arc, to be sure he is right in his direction of traction, and that, whether he be drawing the cranium through the plane of the superior strait, or through any one of the other planes that are inside of the pelvic canal, or in the 52 THE PELVIS. extended, produced tube of the vagina, in which sometimes the head is still included after clearing the lower strait. The accoucheur can always do this operation well, provided he has attained to a correct ideal of the pelvic canal, which he will know is in length equal to the height of the plane of the ischium, or about three inches and a half in all; for that is the measure of Carus's arc. 58. I must be allowed here to say a word concerning the plane of the inferior strait, as it is denominated. I myself have already used this word, and shall do so again, because I cannot escape from under the tyranny of custom and language. I wish, however, to protest now against the doctrine of a plane of the outlet as taught by most writers and public lecturers. The author just referred to, 1 o c. c i t., speaks, as has been seen, of an upper or lower, and a mid-plane, but there is no such lower plane in fact; on the contrary, the outlet or lower strait is so shaped that there are two planes belonging to it, each nearly an equilateral triangle, and these two planes touch each other at an angle of 90° along the transverse diameter of the inferior strait. The posterior plane descends forwards from the point of the coccyx, its two sides being bounded by the inner lips of the sacro- sciatic ligaments as far as the transverse diameter. The anterior plane descends backwards from the crown of the pubal arch until it meets its fellow, and forms with it, as I said, an angle of about ninety degrees. The child, in being born, displaces these planes, if one might suppose such a thing, pressing the anterior margin of the pos- terior plane downwards and backwards, and dividing the anterior one into two rectangled triangles that yield or open in the middle like winged valves to admit of the child's escape, and then close again. It seems to me that as I have a right to imagine a plane or planes of the inferior strait, there is an attached privilege to conceive of them as valvular. 59. Ligaments of the Pelvis.—The two symphyseal ends of the pubes are, as I said, united by a fibro-cartilage, passing interchange- ably from one bone to the other. The outer edge of this ligament is called the triangular ligament. It serves both to strengthen the joint and to depress the crown of the pubic arch, which arch is made cushion-like and lower, and elastic by its inferior portion. If the head were pressed immediately against the bony structure, that structure, from its inelastic hardness, would contuse the soft parts of the woman or those of the child; whereas the ligament is of the nature of a soft and elastic cushion. THE PELVIS. 53 60. In dividing the symphysis, there is sometimes, not always, found in its centre a very small synovial sac. 61. The ligaments of the pelvis are of great importance, for the firmness of the pelvis as an organ for transmitting the weight of the trunk to the lower extremities, and for propagating their motion in- versely to the trunk and upper limbs, is dependent upon the ligaments. I shall present the reader here with a view of them taken from a dis- tinguished author, who, I hope, will not object to my exhibiting to the American Student a copy of his beautiful drawing. I refer to Dr. Frederick Arnold, from whose " Tabulae Anatomicae," Fasciculus IV. Pars II. "Continens Icones Articulorum et Ligamentorum," fol. Stutt- gard, 1843, I have taken Fig. 17. In this figure the letter g is the Fig. 17. sacrum; s s s the posterior sacral foramina; H the os coeeygis, J the right os innominatum, of which a portion has been removed, o the posterior superior spinous process of the ilium, B the greater sciatic notch; 10 the superior ilio-lumbar ligament; 11 inferior iliolumbar ligament; 12 superior sacro-iliac ligament; 13 the posterior superficial sacro-iliac ligament; 15 sacro-sciatic ligament; 16 the sacro-spinous ligament; 17 the sacro-tuberous ligament. 62. From a mere inspection of Dr. Arnold's figures it is evident that the chief ligamentous strength of the sacro-iliac junction depends, 1st, upon the powerful ligaments on the back part of the pelvis, outside of the excavation ; and 2d, on the firm cohesion of the two ossa pubis by 54 THE PELVIS. means of the strong inter-pubic ligament. The auricular or sacro- iliac cartilage, which is not represented, is so strong that I have been much foiled in endeavoring, before my class, to tear open the sacro- iliac joint by pulling asunder the ossa pubis after I had performed the section of the pubic ligaments: the origin or insertion of the auricular cartilage must be torn out from the bone before it will yield, for the fibres will not break: they can only be torn out by the roots. 63. Opening of the Joints.—Many people among the mass of society suppose that in every labor the joints become relaxed in order to let the child pass through the bones; and a good many ladies daily take a spoonful of oil of olives or castor oil, with a view to promote this desirable relaxation, as they esteem it to be. I have known a young thing take the trouble, nightly, to anoint the mons veneris for weeks with lily ointment, to soften the joint and make the labor easy. It is understood, however, by the anatomist, that these joints do not become open and relaxed as a normal effect of gestation, of labor, or of any endermic or therapeutical measures, resorted to for that end. Yet they do, in some persons, relax, to their great injury or inconvenience; and cases of this kind are recorded in the books, and will be met with by most persons extensively engaged in the practice of midwifery. 64. I have on many occasions found the symphysis pubis to be quite loosened, and admitting of motion. One of my patients, whom I have succored in many of her confinements, has generally suffered from the relaxation of the symphysis pubis during her several last weeks of pregnancy. The articulation becomes so loose as to make a considerable cracking sound whenever she would turn in bed or walk ; and she has been good enough, in order that I might verify the fact, to allow me to cause the motion by pressing with my hands on the opposite spinous processes of the iliac bones, by which means I could cause the two opposite pubes to approach or separate from each other, or ride up and down, passing each other in the direction of the length of the symphysis. 65. When the patient, in such a state of the inter-pubal ligament, stands on the right foot, the right pubis rises upwards, while the left descends, and vice vers a—so that the act of walking is not only attended with pain, but with tottering and uncertainty. 66. The lady in question gives birth to children weighing ten and twelve pounds, but she has commonly recovered from the relaxation within about forty days after the birth of the child, and her pubic joint then remains perfectly strong and efficient, until, in the next ges- THE PELVIS. 55 tation or lying-in, the pressure or the infiltration come to loosen and dispart the bones again. 67. Case.—This lady has been fourteen times pregnant, and gave birth to twelve children at term. The joint did not give way until the sixth accouchement, which occurred October 20, 1833. The child weighed upwards of twelve pounds: the motion of the symphysis was very obvious, and quite painful; she recovered from it, however, and did not feel it again until near the close of a pregnancy which was con- cluded on the 12th December, 1835, by the birth of a son. In about a month the articulation was again as firm as ever. A daughter was born October 30, 1837, which reproduced the relaxation. She soon got over this, and in the next pregnancy and confinement felt nothing of it; this labor was on the 2d of September, 1843. When the child was three months old, the relaxation took place, and was long trouble- some. She was again pregnant in 1845, but had no return of the in- convenience in the gestation or lying-in which occurred January 20, 1846. The joint gave way again soon after her last accouchement August 17,1847 : she discovered it on the 20th day of the month, and it was so movable, that a cracking sound was produced by turning in bed. 68. The Student will readily perceive that a considerable relaxa- tion of the pubal joint cannot fail to coincide with a relaxation, more or less considerable, of at least one of the sacro-iliac junctions, and that in such case the pain, weakness, or constitutional disturbances de- veloped by the accident are readily accounted for, and can be treated wisely at least if not fortunately. It appears to me that in articular maladies or accidents of this sort, there is but one sound principle of cure, and that is absolute rest in a recumbent position: a woman could hardly fail to recover if kept quiet in bed for a long time; she could hardly recover while taking usual exercise, which is wholly incompatible with the cure of the injured articulation, for a disordered joint requires perfect rest as much as a broken bone does. In those cases in which the joint has become positively inflamed and painful, it would be useful to apply leeches, cups, or blisters, or use anaesthetic topicals, as chloroform, belladonna, opium, or aconite. I have found every attempt at bandaging a failure, on account of the impossibility of well adjusting and properly retaining a bandage in place in this particular part of the body, so that I am obliged to conclude that the best thing that can be done is to go to a protracted rest in bed. 69. Diameters of the Pelvis.—As a woman's hand, foot, or chin is not like every other woman's, so there are, perhaps, no two pelves 56 THE PELVIS. that are exactly alike. For the utilitarian purposes of clinical mid- wifery, it is enough, therefore, to know that as children's heads and trunks are supposed to be of a mean weight and bigness, so ought the pelvic canal to be of an average capacity for their transmission. Dif- ferent authors give us different means of these pelvic diameters, and it is of no very great importance that they should exactly agree to- gether in their several estimates of size. In order to reach what would be the average of ten different pelves, I measured ten of those in my collection at Jefferson College, and the result was as follows in this tabular view, which I subjoin :— Superior Strait. Inferior Strait. Pelves. Antero-Posterior. Transverse. Oblique. Antero-Posterior. Transve 1 4.2 6. 5.3 4. 4.3 2 4.4 5.5 5.5 3.6 4.4 3 3.9 4.8 4.7 2.7 4.2 4 3.5 5. 5. 2.9 4.3 5 4.2 5. 4.8 3.1 4.6 6 4.3 4.6 5.5 4.1 4.6 7 4.9 4.7 4.8 4.1 4.1 8 4.3 4.5 4.3 4.1 3.8 9 4.4 4.8 4.9 3.6 4.7 10 4.3 4.8 4.7 3.8 4.2 70. For the ten antero-posterior diameters in this table, the mean was a little less than four inches and two-tenths; the ten transverse diameters gave me 4 inches, and the oblique diameter 4.81 inches and nine-tenths, and these may be taken as correct, because those diameters do not change much in drying. As to the inferior strait, which I measured from the point of the coccyx to the crown of the pubal arch, less correct results can be expected, because in drying it generally happens that the shrinking or contraction of the sacro-sciatic liga- ments draws the point of the coccyx forwards towards the arch. Even with this consequence, the ten antero-posterior diameters gave a mean length of 4.4—say, in some subjects, four and a half, though rarely. I shall not cite from the authors the collected tables of pelvic dia- meters, because I prefer not to load the student's memory with such matters, feeling sure he will know how large a pelvis is, and ought to be, when he knows how large a child's head is or ought to be. For my own part, I do know that an American child's head ought to be three inches and eighty-eight hundredths wide, measured through the parietal protuberances; and such is its average transverse diameter. Its occipito-frontal diameter should be four inches and ten-twelfths, and its occipito-mental diameter five inches and a half. 71. In order then that an American should be born in quite a THE PELVIS. 57 normal way, the mother's superior strait ought to be four inches in antero posterior, four and a half inches in transverse, and five inches in its oblique diameters. Such a pelvis as that is proper for easily transmitting any properly developed foetus, provided it should present itself aright in the labor. 72. Diameter.—Let the Student then remember that the superior strait has four diameters to be measured; one from the pubis to the promontory, which is four inches; one from the middle of the brim to the opposite brim, which is four inches and a half; and two others, called oblique diameters, from each sacro-iliac junction to the opposite acetabulum, which are each five inches long. For the inferior strait, let him measure two diameters only, one from the pubal arch to the point of the coccyx, and call it four and a half inches; and the other across the outlet from one tuberosity to its opposite fellow, which is four inches in length. 73. Depth.—It is of great importance to have correct views of the depth of the female pelvis, and nothing is easier than to obtain them by considering that a symphysis pubis is from top to bottom an inch and a half long, which gives the depth of the pelvis behind its anterior wall as one inch and a half. The planes of the ischia are three and a half inches high, and, therefore, the depth of the pelvis at the side and all across to the other side—that is to say, its middle depth—is three inches and a half. The sacrum is four inches long, and the coccyx is an inch and a half, say five inches and a half, the depth of the pelvis at its posterior wall; so that the pelvis is an inch and a half deep in front, three and a half at the sides and in the middle, and five and a half inches.deep behind. The magnitude or dimensions of all the things that are within the pelvis may be estimated by comparing them with these diameters, and as an object that is four inches high cannot be vertically placed within the pelvis except it be near its posterior wall, so, one only two and a quarter inches high can be, like the non- gravid womb, completely within the pelvis, no part of it rising or projecting above the plane of the strait. 74. The Recent Pelvis, which is represented in Fig. 18, is ex- hibited as a cross section, the body being cut in two from front to rear to show the relative positions and forms of the viscera. 75. The figure 18 has been reduced for this work from the admirable engraving that accompanies Dr. Kolrausch's work, entitled "Zur Ana- tomie und Physiologie der Beckenorgane." 5 58 THE PELVIS. 76. It appears to me that this is the most instructive illustration that I have ever met with in books on Midwifery, and is to be entirely confided in for its correctness. The subject was a young girl 21 years of age, who committed suicide while menstruating. The specimen was prepared in such a way as to enable Dr. Kolrausch to see it while lying in a bath of alcohol covered with a glass plate. Looking down- ward through a diopter firmly fixed 24 inches above the glass plate, Dr. Kolrausch, using a pen dipped in printer's ink softened with oil of turpentine, drew every one of the lines with the utmost exactness on the intervening plate of glass—viewing them through the diopter ; so that they could not, perhaps, be more correctly taken by a photo- graph. The copper-plate was copied from the drawing. Fig. 18. 77. To the right is the buttock covering the bisected sacrum, in front of which is the rectum, which has been opened by the incision. On the left, behind the os pubis, is the bladder of urine with its urethra. 78. Between the bladder and the rectum is the tube of the vagina THE PELVIS. 59 surmounted by the uterus, 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 t^he rectum behind, and more than all by means of two utero-sacral ligaments which tie the upper ends of the vagina and the womb to a certain place about an inch and a half in front of the apex of the sacrum. I here repeat that as long as the utero-sacral ligaments remain in a healthy state, preserving by their tone a due length, the womb cannot fall downwards or prolapse, because the cervix, being inclosed within the upper end of the canal of the vagina, it cannot move down unless that upper end of the vagina move down also, which, as above said, it cannot do except the ligamenta utero-sacralia give way first. The length of the vagina determines the height of the womb's place in the pelvis. All these intro-pelvic organs are covered up beneath the serous peritoneal membrane as if enveloped in a nap- kin, which fits them so closely as to exhibit their magnitudes and forms beneath its foldings. 79. In front the peritoneum covers the anterior hemisphere of the bladder, its top and part of its posterior surface, but not all of it. The lower or posterior part of the bladder lies in contact with the vagina, and is united to it by what is called the vesico-vaginal septum or par- tition. After leaving the bladder the peritoneum proceeds to invest about one-half of the anterior aspect of the womb, its entire fundus, and the whole of its posterior wall, as far down as to about the middle of the cervix, where it leaves it to continue its downward course, in which it invests about one-third of the uterine extremity of the vaginal canal behind; then turning upwards it mounts on the rectum to inclose that intestine in its serous coating, and so passes up above the brim or strait. In investing the bladder, the womb, the vagina, and the rectum, as above, the peritoneum sends off' to the left side of the pelvis, and also to the right side, its two ligamenta lata or broad ligaments which serve to steady the uterus and keep it from falling against the sides of the excavation when the woman lies on this side or' on that. 80. The same peritoneum sends two folds that serve as ligaments backwards from the upper and lateral parts of the vagina to be inserted into the face of the sacrum on either side of the rectum. Now, as the peritoneum, after covering the hinder surface of the womb, goes on to and rises up along the rectum and the face of the sacrum, these two peritoneal folds or utero-sacral ligaments form the lateral walls of a cul-de-sac, that looks like a deep pocket between the gut and the womb, and which is called Douglas' cul-de-sac, a thing of much import because it is the place into which the fundus uteri falls when it 60 THE PELVIS. is quite turned over backwards, or retroverted. Let the Student, therefore, comprehend that the hinder wall of Douglas' cul-de-sac is the rectum and sacrum; its front wall is the womb and upper poste- rior end of the vagina, and its right and left walls the right and left utero-sacral ligaments. I wish him to know this point well, on account of its concern in retro versio uteri and in prolapsion of the bowels; but more particularly because I wish him to bear it in constant remem- brance whenever he may be thrusting the blade of a forceps upwards at the risk of bursting a way into it; for when passing the forceps up- wards, in a labor, he is very liable to force its point through the thin and distended vagina quite into the peritoneal sac, an accident that would be almost sure to kill his unfortunate patient. 81. Besides the organs now enumerated, the pelvis contains the ob- turator muscles and the large levator ani muscles, which descend like converging rays of a fan from the antero-lateral walls of the pelvis below the brim, and are inserted so as to lift or raise the end of the rectum and even the perineum upwards, so that not the rectum and perineum only, but the whole of the pelvic contents are directly or indirectly held up and sustained by these muscular organs. The stronger and more muscular the levatores ani the deeper is the sulcus betwixt the nates, and, in general, the better sustained are the contents of the basin. In the young and vigorous the sulcus is very deep; in the aged and the feeble it descends lower and lower or opens outwards, so that in very old or exhausted people the perineum becomes actually protuberant or convex. 82. Within the recent pelvis are numerous bloodvessels and nerves supplying the contained organs, besides large bundles of nerves that come from the sacral foramina and soon leave the cavity, passing outwards through the ischiatic notch to form the great sciatic nerve. 83. Here also are contained the ureters; while, overhang- ing the brim, are seen the psoas muscles, which seem to lessen the transverse diameter of the upper strait. Let the Student be particular to note the place and appearance of the psoas muscles as they pass along the brim of the pelvis; and let him observe that, when a woman, who has MECHANICAL INFLUENCE OF THE PELVIS. 61 recently been delivered, suffers from inflammation of the womb, she always experiences pain when she draws up the knees, because the overhanging bellies of the psoas muscles, in contracting to flex the thighs, press very painfully upon the inflamed globe of the uterus, which still juts up above the plane of the superior strait, filling up the whole of its transverse diameter. 84. Figure 19 may give some idea of the relation of parts in the recent pelvis, a is the aorta, and B the vena cava; c the internal iliac artery descending into the pelvic excavation; D and E are the external iliac artery and vein; F G the psoas muscles, H the rectum, I the womb, and K the bladder of urine. 85. I wish the Student to reflect that all the pelvic viscera are with- in, and not out of or beyond the pelvis; and I say so in this place to guard him against the very common mistake of supposing that any part of the womb—its fundus—is to be found jutting up above the plane of the superior strait. There are few drawings made in mid- wifery books to illustrate the inner genitalia in situ, that do not ex- hibit the fundus uteri on a level with or even higher than the plane of the strait. Kolrausch's most beautiful and admirable plate, the most perfect that has yet been produced, gives to all the internal organs their absolute right place. I assure the Student that whensoever he shall find that he can feel the fundus uteri by pressing his hand upon the hypogastrium and pushing the teguments downwards and backwards, he may make bold to say that he is touching a womb enlarged by preg- nancy or by some disease. CHAPTER II. MECHANICAL INFLUENCE OF THE PELVIS.—OF THE MECHAN- ISM OF LABOR AS DEPENDENT ON THE RELATIONS OF THE CHILD'S FORM TO THAT OF THE PELVIS. 86. Very little seems to have been anciently known concerning what is now called the mechanism of labor as observable while the head or other parts of the child are passing along the canal of the pelvis. No one can doubt that Mauriceau and Lamotte, who were keen observers, must have often noticed the spiral movements of the advancing head, the shoulder or the breech in cases of labor, for it is impossible that such circumstances should have wholly escaped their notice, or that of many other highly talented practitioners of our art in all ages of the world. Nevertheless, it is very certain that they 62 MECHANICAL INFLUENCE OF THE PELVIS. have nowhere given any clear account of the act of rotation, and I believe it is now universally agreed that we are under obligations for the first statement concerning it, to Sir Fielding Ould, of Dublin. That gentleman published, in 1748, "A Treatise of Midwifery, in three parts, by Fielding Ould, Man-Midwife. Lond. 8vo. pp. 203." Ould gives an account of the matter in his Preface, p. xvi., saying: " And to this end, I hope that the description of the head coming towards the world, with the chin turned to the shoulder, will be of very great advantage:" and he tells us of a case that occurred to him while he was in Paris, in which he seems to have obtained some obscure notions concerning rotation. His promulgation of the doctrine of rotation may be found, such as it is, at page 28: " When a child presents itself naturally, it comes with the head foremost, and (according to all authors that I have seen) with its face towards the sacrum of its mother, so that, when she lies on her back, it seems to creep into the world on its hands and feet. But here I must differ from this description in one point, which, at first sight, may probably seem trivial: the breast of the child does certainly lie on the sacrum of the mother, but the face does not; for it always (when naturally presented) is turned either to one side or the other, so as to have the chin directly on one of the shoulders." 87. In the next paragraph, which is on p. 29, Sir F. Ould explains his notions of the causes of the head's obliquity, and though he had no very exact perception of either the principles or the facts, it is doubtless to him we should look as the pioneer in this particular section of our obstetrical inquiries. 88. Since the date of Sir Fielding Ould's publication, the views of the profession upon the mechanism of labor, in so far as the volume and form of the pelvic canal and those of the foetal head are concerned, have become quite settled, and it is not difficult to set it in such a light as to make it easy of comprehension for the Student. To this end, I ought to say that the gravid womb at full term is about twelve inches in length from the os to the fundus, and from seven to eight inches across at the place of its greatest width. A child in utero generally presents its head to the orifice, and as its whole length is from eighteen to twenty inches, it cannot possibly lie stretched out at full length in a space of only twelve inches long: hence the foetus is doubled up or flexed, both the limbs and trunk, so that it may be said to rest within the womb in a state of universal flexion. The whole trunk is bent forwards; the neck is so bent forwards as to cause the chin to rest upon or near to the breast which serves to point the apex of the head or vertex to the pelvic opening; the arms, fore- MECHANICAL INFLUENCE OF THE PELVIS. 63 arms, and hands are flexed, as are also the thighs and legs. Doubled up in this way the foetal mass is an olive-shaped body, the cephalic pole being downwards, and the pelvic pole upwards. The drawing (Fig. 16), to which I here refer, exhibits very correctly this flexed state of the child in a vertex presentation. 89. A Vertex Presentation is one in which the head-pole presents flexed. If the head-pole should present not flexed it would not be a vertex presentation, but it might be a presentation of the crown of the head, of the forehead, or of the face, and whether one or the other of these three, would depend on the degree of departure of the chin from the breast. The chin, in a vertex presentation, must be at the breast, because the head is flexed or bent forward. When the head is not flexed, but on the contrary extended, it is the crown that presents, or the forehead, or lastly, the face. 90. A great majority of children in labor present by the vertex, and the most of them direct the vertex to the left side, while the fore- head is to the right side of the pelvis; but in these cases the occipito- frontal diameter crosses the pelvis obliquely from the right sacro-iliac synchondrosis to the left acetabulum. 91. The superior strait is four, four and a half, and five inchesMn its antero-posterior, its transverse and oblique diameters. The child's head is 3.88, 4.10, and 5.5 inches in its biparietal, occipito-frontal and occipito-mental diameters. The spinal column juts forwards in the belly like a half column or pilaster so as to overhang the superior strait like a promontory at the sacro-vertebral angle as well as far above it. Hence it is that the biparietal diameter of the child adapts itself to the short diameter of the superior strait, while the occipito-frontal diameter coincides with one of the longer ones, and so, it happens that the head usually comes into the strait obliquely, or as above said with its vertex to the left acetabulum, and its forehead to the right sacro- iliac junction, thus crossing the strait diagonally. 92. I say diagonally, for, although it be true that a child may de- scend through the plane in a direct position, i.e. with its vertex, or its forehead to the pubis, such direct positions are rarely to be met with; and clinical experience shows that, in the immense majority, the head sinks below the plane with the occipito-frontal diameter coincident with the oblique diameter of the upper strait, as in Figure 20. 93. The foetal head usually descends through the plane of the abdo- minal strait in f 1 e x i o n, i. e. with the chin to the breast, the vertex being turned towards the left acetabulum, while the bregma, or upper part of the forehead, points towards the right sacro-iliac symphysis: vid. Fig. 20. The occipito-frontal diameter is probably nearly coinci- 64 MECHANICAL INFLUENCE OF THE PELVIS. dent with the plane of the strait in the beginning of most labors, whence it appears that the occipito-mental diameter must dip its occi- pital extremity beneath Fig. 20. the plane. 94. In proportion as the presenting part de- scends lower and lower, the dip of the occipital pole of the occipito-men- tal diameter increases. It must be so, since the occipito-frontal diameter could not descend hori- zontally into a pelvis too narrow for it. That dia- meter which, by my averages, is 4.10, could not, without a dip or see- saw, sink into the lower part of a pelvis whose transverse diameter, low down in the excavation, does not considerably exceed four inches. 95. The deeper the head plunges into the cavity, the more strongly is the chin forced against the breast, or, in equivalent terms, the greater the* flexion of the head. 96. Now, let the Student reflect, that the two sides of the pelvis, I mean the planes of the ischia, are inclined towards each other in such a manner that the lower limits of them are half an inch nearer to each other than their upper margins, for the lower strait is only four, whilst the upper one is four and a half inches wide. If the Student will make this reflection, he cannot fail to perceive that this head, placed obliquely or crosswise at the top of the pelvis, must turn on an axis or spin round so as to adapt its short diameter to the shortest diameter of the canal, and its longest one to the longest. In other words, the head must turn or spin round, or, as it is said, rotate within the pelvis. This rotation is caused by the resistance the vertex meets with when forced by the labor-pain against the left ischial plane, which is so inclined that the vertex, which cannot bore its way into or through it must glance off from it, and so move in a direction forward or towards the pubal arch. 97. Every succeeding pain drives the vertex lower, and causes it to glance or slide more and more to the forepart of the excavation; or, to speak technically, to rotate more and more until its rotation is fully accomplished. This act of rotation, in which the vertex, that was, in the beginning, to the left or near the acetabulum, but has now come to place itself behind the pubis, is not completed until the crown of MECHANICAL INFLUENCE OF THE PELVIS. 65 the head has reached the floor of the pelvis, and is forced against it by the pains. Hence it appears that a child's head which enters the pelvis.in flexion, descends flexed and rotating until the rotation has become complete at the bottom, where the flexion begins to lessen, because the pain pushes the floor of the pelvis down by thrusting upon it the head, which slides along that yielding floor, and emerges under the crown of the pubal arch. The resistance of the floor of the pelvis (perineum)isso great that the occipital bone of the head is forced by it upwards between the rami of the pubis, and kept close to the triangular ligament under the arch. Meanwhile the floor (perineum) being thrust further and further down, the head continues to glide upon it and turn over backwards, losing more and more of its flexion, and acquiring more and more of extension, until at last, having be- come wholly extended, it escapes from the organs and is born, passing outwards with the sagittal suture lying along the middle of the pelvic floor, and the middle of the occipital bone resting exactly beneath the lower end of the symphysis pubis. 98. If the whole perineum could be cut away with a bistoury, I could suppose the child's head might come forth from the lower strait without any extension, and with the chin still at the breast; but the pains really thrust the sagittal suture in its whole length, indeed the entire crown of the head, against the elastic resisting perineum and posterior vaginal wall. These efforts, being often repeated, serve to push the perineum away from the crown of the pubal arch to let the vertex escape under it; but, while the perineum is being pushed off by this force, the same perineum jams the occipital bone of the child firmly against the crown of the arch; so that, as the vertex emerges from the genital orifice, the os occipitis is pressed, as I said, close to the symphysis, first at its lower edge, and next on its outer or front aspect. The cranium of the child is born as soon as the extension is complete, but not until then. 99. Figure 21 exhibits the manner in which the vertex touches the inner surface of the crown of the arch when the rotation is complete. The faint lines show how it rolls out under the edge of the triangular ligament, and also how it next rises up- wards in front of the outer surface of the symphysis, the head turning over back- wards as it emerges. Fig. 21. 66 MECHANICAL INFLUENCE OF THE PELVIS. 100. Restitution.—As soon as the head is born, it begins to rotate back again, outside of the pelvis, to the same point or direction it had upon first engaging within the pelvis. Its originally oblique position becomes restored, and this, which is the last act of the mechanism, as to the head, is called the restitution. 101. Mechanism of the Shoulders' Delivery.—The cause of restitution is to be sought for in the state or position of the shoulders. When the vertex is at the left acetabulum, the right shoulder is at the right acetabulum, and the left one at the left sacro-iliac synchon- drosis: but the inclined plane of the right ischium repels the descend- ing right shoulder, pushing or sliding it downwards, forwards, and to the left, until it comes to the symphysis pubis. The left shoulder meanwhile falls into the open chasm of the hollow of the sacrum that yawns to receive it freely. 102. This rotation of the shoulders, or, in other words, rotation of the trunk of the body, causes the act of restitution of the head, which, being already born, must turn coincidently with the rotation of the shoulders. 103. Such is the act, or rather such is the succession of acts, com- monly called the mechanism of the head, in a labor in which the ver- tex presents in the first position. I shall now recapitulate them as predicated of a vertex presentation in the first position. 104. 1. Flexion.—The head is flexed; the chin going to the breast. It enters the pelvis obliquely, with the vertex to the left acetabulum. 105. 2. Eotation takes place as it descends, because of the repelling resistance of the plane of the left ischium, the lessened resistance under the arch, and the incurvation or hollow of the sacrum which affords room for the movement. 106. 3. Extension commences under the upward pressure of the perineum, and continues to increase until the child is born. 107. 4. Restitution allows the vertex to seek its original direction towards the left, as it goes back again towards the left acetabulum. 108. In treating of labors, and the conduct of them, I shall have numerous occasions to refer to, and further explain, the mechanism of the delivery of the foetal head. 109. Mechanism of Labor, "with Vertex in Second Posi- tion.—In this labor the vertex is at the right acetabulum. In saying that the vertex is at the right acetabulum, it is not intended to convey the idea that the posterior fontanelle is always directed absolutely against the acetabular region. Experience will soon teach even a MECHANICAL INFLUENCE OF THE PELVIS. 67 young practitioner, that the child retains in early stages of labor the ability to rotate its head right or left within the pelvis, and that it generally exercises this faculty quite freely, spinning its head upon the cervical spine so as to turn the vertex sometimes quite close to the symphysis pubis, and then whirling it back to the top of the ischium, or even as far backwards as the ilio-sacral junction. As the cranium however, plunges deeper and deeper into the excavation, it becomes so tightly held that these free motions cease, and it only moves in the direction impressed upon it by the mechanics of the pelvis. 110. The processes by which the vertex in a labor of the second position, as in Figure 22, is brought forth, are the converse of those I have described as taking place in cases of first po- Fig. 22. sition. The flexion is followed by the rotation as the head sinks low into the cavity; the ver- tex being repelled to- wards the left by the in- clined plane of the right ischium. As soon as the posterior partof the sum- mit of the head reaches the perineum, the peri- neum, while it yields before the descending power, thrusts the occiput firmly upwards against the crown of the pubal arch, as in the first position. The extension or retroversion of the head being completed b}T its expulsion, restitution then follows by carrying the vertex to the right acetabulum, outside, and the face to the left thigh. The left shoulder turns to the right and forward to get under the arch, while the right shoulder goes back to the sacrum, and so the shoulders are delivered; sometimes, however, the pubal shoulder is the first, and sometimes the sacral one is the first to be expelled. 111. Third Position. — The mechanism of the head, when the vertex presents in the third position, differs from the two just before described, only in the absence of the second act, the act of rotation. 112. These third positions are very rarely observed; and it is pro- bable that, when they are met with, they depend upon a peculiar form of the superior strait. 113. I possess some pelves in which the antero-posterior diameter of the superior strait greatly exceeds the length of the transverse or 68 MECHANICAL INFLUENCE OF THE PELVIS. oblique diameters. In such a pelvis it is obvious that the vertex would be more likely to present itself at the pubis than at either acetabulum. In an ordinary conformation of the superior strait, a third position of the vertex presentation is extremely unlikely to occur, since, long before the commencement of labor, the prominence of the lumbar vertebrae, and the overhanging promontory of the sacrum, would be almost sure to turn off the rounded forehead of the child into the right or left sacro-iliac region; and this the more probably, inasmuch as the oblique being greater than the antero-posterior diameter, it affords an easy and inviting accommodation to the usual oblique mode of engage- ment. The three positions that have here been spoken of comprise the occipito-anterior positions of the vertex. They are those I have been accustomed to enumerate in the following order, viz: first, second, third; or vertex-left, vertex-right, and vertex-front positions. 114. We have next to describe the fourth, fifth, and sixth; or fore- head-left, forehead-right, and forehead-front positions of the vertex presentation. 115. Fourth Position.—In the fourth position, the occipito-frontal diameter crosses the pelvis obliquely, as it does in the first position, with this difference, that its frontal extremity is at the left acetabulum, and the occipital pole at the right sacro-iliac junction. See Fig. 23. 116. This is a true vertex presentation; and it must not be mistaken for a presentation of the forehead. It is a true vertex presentation because the chin is close to the breast, and there is no departure; on the contrary, the flexion is, perhaps, even strong- er than in the occipito- anterior positions. The mechanical form of the pelvis is so adapted to the wants of the econo- my in labor, that it has full power, in a major part of these fourth positions, to rotate the vertex from the right sacro-iliac junction to the right acetabulum and thence to the pubal arch; and that without any assistance given by the accoucheur. 117. It is true that this favorable rotation does sometimes require the aid of the hand, or even of an instrument, as shall be described MECHANICAL INFLUENCE OF THE PELVIS. 69 on the proper occasion. It also occasionally happens that neither the hand alone, nor any instrument can enable the surgeon to bring the vertex round to the front. In such case, it slides into the hollow of the sacrum, and the labor is thenceforward rendered more painful and more difficult. When, in fourth positions, the vertex can rotate first to the acetabulum and then to the arch, the labor is not seriously re- tarded, and the mechanism thenceforth is the same as has been already treated of and described; but when the posterior fontanel gets into the hollow of the sacrum, and will not suffer rotation, then the flexion must become greater and greater as the fontanel slides down along the point of the sacrum, over the face of the coccyx, and down the mesial line of the Fig. 24. perineum, until, having thrust away the perineum 4.10, the vertex slips over the fourchette, and immediately turns over back- wards, in strong extension towards the wo- man's back. This allows the forehead, eyes, nose, mouth, and chin successively to emerge from underneath the crown of the pubal arch, to complete the birth of the head. The annexed figure (24) of a head in an occipito-posterior position shows these truths clearly enough. 118. Such is the mechanism in all cases of birth in occipito-posterior positions, failing rotation to the front; and the Student will clearly understand that it must be so, since the length of the line from fore- head to vertex is too great to permit it to be otherwise. 119. Fifth Position. —The fifth position, as in Fig. 25, is that in which the vertex is to the left ilio-sacral space, and the forehead to the right acetabulum. Here, as in the fourth position, the mechanical power of the pelvis tends to turn the vertex first towards the left acetabulum, and thence to the arch. Fig. 25. 70 MECHANICAL INFLUENCE OF THE PELVIS. 120. Sixth Position.—The sixth position finds the vertex at the promontory of the sacrum. Madame Boivin met with only two such positions in 19,614 cases. 121. I have seen a greater number of sixth positions than were met with by that celebrated midwife, although the labors witnessed by her so greatly exceed in number all that I have seen. 122. While the facts stated in her tables are to be relied upon for their historic accuracy, her statistical results cannot be admitted as the law of any practitioner's future experience. My own experience, for example, which has been gained in a private practice, has shown me a far greater number of sixth positions than her vast clinical opportunities, in an immense lying-in hospital, brought to her view. Madame Lachapelle saw no such case. 123. Such a case of vertex labor in the sixth position occurred to me this day, of which I made the following note, in order that I might set it down here as a freshly remembered experience. 124. Case.—July 8,1848,10| A.M. Mrs. E----I----, Pine Street. This is the sixth child ; a male, born fifteen minutes ago. The pains commenced moderately, at 4 P. M. yesterday, July 7. Mrs. I. has been in pain at regular intervals all night. I arrived at quarter past nine, one hour since. The os uteri was nearly dilated; membranes unruptured. The anterior fontanel was touched through the mem- branes just behind the upper half of the symphysis pubis. By a strong pressure, I could conduct the index finger along the sagittal suture directly toward the sacrum, until I felt the triangular fontanel, leaving no doubt of the diagnosis. The left shoulder was at the right, and the right shoulder at the left ischium. The occiput was opposite to the top of the third segment of the sacrum; the flexion of the head was strong. 125. Partly by pressing with my right index the right temple and zygoma towards the right, and partly by pulling with the same finger the right leg of the lambdoidal suture towards the left side of the pelvis and downwards, I converted this sixth into a fifth position. I now discharged the liquor amnii by rupturing the bag of waters. The next pain rotated the vertex to the left acetabulum or first posi- tion, whence the vertex came forwards and to the right until it reached the arch, under which it began to extend, and was soon expelled. 126. During the act of extension and expulsion of the head, aud just before the whole head was completely born, an act of restitution commenced, and as soon as the head was free, the vertex went round again left-wards to the sacrum, and the chin of the child rested with MECHANICAL INFLUENCE OF THE PELVIS. 71 its under surface upon the front of the pudenda, the face looking up- wards. 127. This happened because the shoulders had not rotated at all, but plunged into the pelvis, the left one at the right, and the right one at the left ischium. 128. With the next pain the left shoulder came to the arch, and the right one to the sacrum, and so they were delivered. The child was about seven pounds in weight; in good health. 129. Here, then, was a clearly marked case of sixth position, not- withstanding which, the mechanical force of the pelvis and its strange adaptation to the form of the cranium, permitted me, with very slight assistance, to convert it into a fifth, and then into a first position.' This rotation was fortunate for the mother; since, by effecting it, I prevented the necessity of a dilatation equal to the occipito-frontal circumference nearly, and thus rendered necessary a dilatation equal merely to the bi-parietal circumference; the former being nearly fifteen inches, while the latter is not more than twelve inches. 130. August 4, 1856. I attended a labor last night, in which the child presented in the sixth position. I touched the ossa nasi behind the top of the pubis, yet the pelvis rotated the head, and the vertex came to the front, and was easily born. 131. Face Presentation.—When the head presents in extension instead of coming down in flexion, we have presentation of the fore- head, or of the face. If the extension be moderate, the forehead pre- Fig. 26. Fig. 27. sents; if it be very great, the face presents. When the face presents, it always comes down with the chin to one side, and the top of the 72 MECHANICAL INFLUENCE OF THE PELVIS. forehead to the other side of the pelvis; and afterwards rotates, bring- ing the chin to the pubis or to the sacrum. In the case (Fig. 26), the chin is to the right ischium and the forehead to the left ischium. The natural movement of the mechanism would gradually turn this chin to the front of the pelvis, and the top of the forehead to the sacrum, as in Fig. 27. 132. In face presentations, the chin must be born first; see Fig. 27. Here observe, that from the chin to the vertex is more than five inches, while there is no diameter five inches long to be found within the true pelvis. Hence, if the mental extremity of the occipito-mental diameter descends into the cavity before the occipital extremity, it must escape first from the outlet in order to allow the occipital extremity to escape last, and vice versa. 133. There are many cases of face presentations that appear to afford remarkably easy deliveries, and to require no aid from the hand. In all those, however, where assistance is demanded, there is an important doctrine, one that should never be lost sight of in the conduct of the cases. The doctrine is this—Bring the chin to the pubis. The figure may show that, if the chin be brought to the pubis, it will have to sink only an inch, or an inch and a quarter lower than the brim, in order to get below the level of the crown of the arch: as soon as it reaches that point, it comes out beneath the arch, and thus the mental extremity of the occipito-mental diameter begins to be born. When this first step is effected, the whole length of that diameter is soon expelled, or, in other words, the whole head is born; its occipital extremity being the last portion to emerge from the ostium vaginae. 134. Should any one, in practice, forgetting this doctrine, bring the forehead to the pubis, he would do a great wrong; for, as the chin must be born first, and the occiput last, the chin will have to slide along the whole length of the sacrum five inches: and over the ex- tended perineum two and a half or three inches before it can escape; but, to do this, it will be required that the head and half the thorax of the child shall be together jammed within the excavation; for from the chin of the child to the top of its sternum are not eight inches. Such a position is almost sure to demand an embryotomy operation for the delivery of the foetus. PRESENTING PARTS--THE HEAD. 73 CHAPTER III. OF THE CHILD'S HEAD AND OTHER PRESENTING PARTS. 135. The study of the form and dimensions of the child derives its importance from the relations of the foetus to the bony pelvis, through which it is destined to pass in the act of parturition. 136. To know the form and magnitude of the head, as related to the pelvic canal, is of the highest import; and, indeed, no man should be looked upon as a qualified practitioner who suffers himself to remain ignorant of any particular of the matter here referred to. 137. The foetal cranium, divested of the bones of the face, closely resembles in form an ostrich egg, upon the side of the lesser pole of which the facial bones are adjusted. 138. In the figure of the foetal head which is annexed (Fig. 28), it is evident that if the bones of the face were removed, the remain- der of the cranium would be oviform; as I have on different occasions shown it to be, by removing those bones in presence of my class at the Medical College. 139. In looking at the head from above downwards, as in Fig. 29, the bones of the face are out of sight, and the cranium is evidently egg-shaped, the greater pole being at the occiput, while the lesser is at the forehead. 140. The foetal head (Fig. 30) is copied with the camera from a cast of a foetal head, and gives a proper idea of the true form when covered with its integuments; the child perished in the labor, its head being too large to pass through the straits without the aid of the forceps. 141. The bones that enter into the composition of the skull, except- ing the face pieces, are the os occipitis, the two ossa-parie- tal i a, the os frontis, the two ossa temporum, and the sphenoides. These are the bones that make up the principal bulk of the object, for the face bones do not add very considerably to the magnitude of the mass. 142. The face bones are the maxilla inferior, the maxilla 6 Fig. 28. 74 PRESENTING PARTS--THE HEAD. superior, the ossa malarum, ossa nasi, ossa palati, and the vomer. It seems hardly necessary to mention the eth- moides, the ossa unguis, &c. Fig. 29. Fig. 30. 143. In a new-born child, the process of ossification is not com- pleted, and the edges of the cranial bones are not locked or dovetailed together by the serrae of the adult suture; whence it happens that the cranium is not a fixed magnitude or form, but liable to alteration under the pressure of the parts through which it is driven by the great force of the labor-pains. 144. A great advantage is found in this mobility of the cranial bones in certain instances, in which the pelvic circumference is too small, either absolutely or relatively; for, the child's head of four inches in its conjugate diameter may, by the pressure, become reduced or wire-drawn so as to pass through a superior strait of only three and a half inches, or even less; and that without injury to the head, which, as soon as it has escaped from the pressure, begins to recover its normal form again. 145. There are, however, to be met with many specimens of the foetal cranium so solid and firm in their ossification as to yield not at all in labor, which is then rendered both more painful and difficult. The young practitioner therefore should, in difficult cases, take com- fort from discovering by the touch that the foetal head is of a yielding nature, and hence not likely to resist too long the moulding or model- ling efforts of the throes. 146. Size of the Foetal Head.—In the fcetal head at term, of which there is a drawing at Fig. 30, we are in the habit of imagining certain lines called diameters, which are represented in Fig. 28. There is a line traced from the chin a, to the vertex or point of the THE HEAD. 75 head or occiput b, called by the English writers the oblique diameter, but which the French authors have induced us, of late, to denominate occipito-mental diameter, a phrase that explains itself. The next one is the line from d to e, called the occipito-frontal diameter, as indi- cating the distance from the occiput to the most salient point of the forehead. After this comes the perpendicular diameter, from c to h; and lastly, in Fig. 29, the transverse or bi-parietal diameter, which passes from one parietal protuberance to the other, from a to b; and the temporal diameter, from c to d. 147. As to these diameters, I have never deemed it expedient that the Student should charge his memory with all of them; yet he ought to know that the occipito-mental diameter is above five inches in length. He ought to know this, in order that he may also know that such a diameter cannot be see-sawed, or reversed, after the head has once fairly entered into the excavatioji, in which no space exists large enough to render such a change possible. If the extremity b descends first, it must escape first, or be returned above the superior strait; and if the extremity a descend first, it must escape from the inferior strait first, or be returned above the linea ileo-pectinea, in order to be there see-sawed. 148. The occipito-frontal diameter c a is four inches and ten-twelfths of an inch in length—a diameter too considerable to admit of its being see-sawed in the excavation, except under very extraordinary circum- stances, for there is, in general, not space sufficient for that end. I speak with very great confidence as to the above estimate, for I have carefully measured and recorded the size of three hundred crania of mature children that I received in the course of my obstetric practice. The Student will be in error if he adopts the common estimate of the authorities, which is too low at four inches. 149. In a single series of one hundred and fifty heads, I found the occipito-frontal diameter in fifty-two of them to exceed 5 inches. In 11, it was 5T'2th; in 8, 5T22ths; in 3, it was 5,32ths; in 1, 5-j42ths; in 1, 5T62ths; in 2, oT73ths; and in 1, 5i|ths. The sum of my occipito- frontal measurements was seven hundred and twenty-nine inches and seven-twelfths of an inch for one hundred and fifty crania. The mean was four inches ten-twelfths. The sum of the bi-parietal diameters of the said one hundred and fifty crania was five hundred and eighty-six inches and seven-twelfths—the mean, three inches and eleven-twelfths of an inch. The bi-parietal diameters exceeded four inches in sixty- eight of the children. In 19 it was 4.1; in 5 it was 4.2; in 6, 4.3; in 3, 4.4; in 1, 4.5; in only one case was it less than 3.6, the usual esti- mate, and in that case it fell to 3.4. 76 THE HEAD. 150. A paper containing statements of the above series was read by me at the centennial celebration of the Amer. Phil. Society, on the 25th May, 1843, and was published in the "Proceedings," &c, vol. iii. p. 127. 151. I measured one hundred and twenty-six occipito-mental diame- ters of neonati at term, of which the sum was six hundred and ninety- nine inches and five-tenths, so that the mean or average of the one hundred and twenty-six diameters was five inches and a half. I know no one who has measured so many, and I am sure that greater accuracy is not to be attained by any person. Upon these grounds, therefore, I am to inform the Student that the occipito-mental diameter of the foetus is five inches and a half, the occipito-frontal four inches ten- twelfths, and the bi-parietal three inches eleven-twelfths. These state- ments ought to show that it is not a matter of small moment whether the head presents in labor by the vertex, the crown, or the forehead. 152. Upon the presentation depends the circumference of the ad- vancing body; if the vertex presents, we have a circumference equal to thrice the bi-parietal diameter, which would equal a circle of eleven inches and three-quarters in circumference. The occipito-frontal dia- meter would give a circumference of upwards of fourteen inches, while the occipito-mental circumference would not be much under sixteen inches. 153. Fontanels.—The bones of the head are divided from each other by the sutures. In Fig. 29, showing a top view of the skull, may be seen the sagittal suture, a straight line which extends from the middle, and sometimes from the base of the os frontis, backwards, to the upper angle of the occipital bone, where it appears to divide, branching into the two legs of the lambdoidal suture. In passing from the forehead backwards, this sagittal or arrow suture crosses the transverse or coronal suture, and at the place of crossing there is a large vacuity, as to bone, which is occupied, however, by the skin and by strong membranes which constitute what is commonly called the mould of the head—technically, the anterior fontanel, the great fontanel, the frontal fontanel, or the bregma. It is of various size in different specimens. When the ossification is precocious, it is small; in the contrary case it is large, and sometimes it is found to be very large. 154. At the posterior terminus of the sagittal suture is found the posterior fontanel, often called the occipital fontanel. There is a very great difference between the anterior and posterior fontanels; the former being quite large, quadrangular, and yielding to the pressure THE HEAD. 77 of the finger; the latter being so small that it can only be distin- guished by the three suture lines that radiate from a common centre. Let the Student carefully learn to make this discrimination; for, if he should not do so, he will in practice find himself embarrassed in his diagnosis of the two fontanels. 155. Too much care can hardly be bestowed upon the mastering of these two points; nor can one become too familiarly acquainted with the differences between them; for, in trying to ascertain the precise position of any head-presentation, the accoucheur always seeks to place his index finger upon one or the other of these openings. It is clear that they must serve as points of departure in such an explora- tion—for, if the index finger be in contact with the posterior fontanel, and the place that finger occupies in reference to any fixed point in the pelvis be well understood, the surgeon ought thence to deduce the very place of any and every other part of the cranium of the foetus. To know where the fontanel is, is to know where to conduct the hand, the forceps, the perforator, or the crotchet. It has been seen, in a preceding page, that the various positions assumed by the head when it presents in labors are enumerated as first, second, &c, and that they are determined by reference to the point on the pelvis to which the posterior fontanel is addressed. 156. Presentations.—The Student who shall have made himself master of the subject of the pelvic diameters is now able to appreciate the differences that arise in labors exhibiting various presentations and positions of the head. He knows that the bi-parietal circumfer- ence of the head is not too great to admit of its ready transmission through the excavation—and he as clearly understands that the occi- pito-frontal or the occipito-mental circumference would prove too large for the canal. Therefore, in any case of delay or difficulty, he would provide for effecting a coincidence of the bi-parietal circumference with the planes (of the excavation) through which it must necessarily pass. 157. If the pelvis be only four inches in its antero-posterior diameter at the superior strait, the occipital pole of the occipito-frontal diameter must dip so as to allow the vertex to desceud, and thus become the presenting part. In fact, the foetus lies so packed up in the womb that it is truly said to be in a state of universal flexion, so that even the head is found to be flexed on the neck as a normal condition of the foetus in utero. 158. The form of the flexed foetus being like that of an olive, one pole is directed to the fundus and the other to the os uteri, which thus 78 THE HEAD. gives two distinct, primary presentations—one cephalic, and the other pelvic, as shall be more clearly shown by and by. 159. The drawing exhibits very naturally the usual presentation and position of a child at the begin- Fig. 31. ning of a labor. It represents the womb opened, with the foetus in what is called a vertex presenta- tion in the first position; i. e., the posterior fontanel is turned towards the left acetabulum of the mother's pelvis, and the vertex, or occipital pole of the cranium, dips suffi- ciently to allow of its entering the pelvis through the plane of the superior strait. The drawing . also shows how very much the spinal column is curved. It is manifest that, if pressure should be made upon the pelvic extremity of the column, in a direction from above downwards, it would be still more considerably bent—it would be an elastic resisting arch, and the outward thrust of the cervical extremity of that arch would tend to flex the head, more and more, in proportion to the increasing violence of the thrusting effort, so that the lower the head descends, the more must the chin be pressed against the breast, and the more perfect the coincidence of the bi-parietal cir- cumference with the planes of the excavation through which it happens to be passing. 160. Unfortunately, the occipital extremity of the occipito-frontal diameter does not always dip, and the frontal extremity of it is some- times found to be the dipping pole. In such an instance, the chin is said to depart from the breast, and we discover a presentation of the crown of the head, of the forehead, or even of the face, the head in the last-named case becoming completely extended, instead of descending in flexion. But the full account of these accidents must be deferred until we come to treat of those special presentations, which we hope to be able clearly to explain and describe. 161. The child at full term is about nineteen inches in length. Specimens are occasionally met with of children twenty-one inches high; but they are rare. 162. The average weight of a new-born child is somewhat above seven pounds; very many of them weigh eight pounds; and it is by THE HEAD. 79 no means a rare occurrence to find a child weighing nine, ten, eleven, and twelve pounds at birth. I have never seen one yet that weighed fourteen pounds. The largest one I have weighed was thirteen pounds and a half avoirdupois. The mother soon afterwards perished with inflammation of the womb and bowels. To witness the birth of such a monster is appalling. I have heard of children of seventeen, and even of eighteen pounds' weight at birth. Such relations always lead me to suppose that some mistake has occurred in weighing the infant- M. Velpeau shrewdly remarks that children of that weight are chil- dren of three months old, and that such magnitude is impossible at birth. 163. The head of the child exceeds, in its smallest circumference, the circumference of the thorax and shoulders, of the abdomen or the hips: wherever the head can pass, there will, therefore, be space for the transmission of the natural body. 164. The length of the child, folded up in the womb in flexion, is about eleven inches from the summit of the head to the lower ex- tremity of the pelvis or buttocks. 165. In about forty-nine out of fifty cases of pregnancy, the head is at the os uteri—in one out of fifty cases, the pelvis is at the os uteri, giving us the breech, feet, or knee presentation. When the head pre- sents in labor, it is to be supposed that it has presented during the entire gestation, and vice vers! The vulgar notion that the child lies in the womb with its head to the fundus until labor is about to commence, and then turns its head downwards to the mouth of the organ, in order to escape head-foremost, is erroneous—for the child is eleven inches long, and cannot turn itself in a womb only seven or eight inches in conjugate diameter. If, in like manner, the breech presents in labor, we infer that it has presented for many months ante- cedent to the commencement of the parturient efforts; cross presenta- tions are rare events. Either the cephalic or the pelvic pole of the foetal oval must descend, in order to its birth; and it is a matter of little moment which should be the pole, whether the cephalic or the pelvic, all other things being equal. Upon the whole, the head pre- sentation is the most favorable for both mother and child, since nature provides that its frequency shall be in the ratio of forty-nine to fifty. 166. Two Presentations only—Cephalic and Pelvic—Eigor- ously speaking, there are but two presentations in midwifery: one of the head, Fig. 31; the other of the pelvis, Fig. 33. The idea expressed in the word Presentation, is one relative to the part of the foetus that comes to the opening; while the idea conveyed by the word Position, 80 PRESENTATIONS. refers to some relation betwixt a cardinal point on the walls of the pelvis, and a cardinal point on the presenting part. Thus, in the pelvis, the cardinal point is always the left acetabulum—on the head, the cardinal point is the vertex or the chin. On the breech, the car- dinal point is the sacrum of the foetus. For the shoulder presentation, the cardinal point is the whole head of the child. 167. As to the head presentation—it may deviate, and allow a shoulder to come to the os uteri; but this is a mere accident of a cephalic presentation; an accident that has arisen from the impinging of the head upon the margin or brim of the pelvis, whence it has glanced upwards to the iliac fossa, permitting the shoulder to take its place. This is to be seen by inspect- Fig- 32. ing ^he cu^ in which the child's head, which originally presented, has devi- ated, and gone above the plane of the superior strait, lodging itself in the left iliac fossa, while the shoulder has come to the strait, and allowed the arm to prolapse. The cut may serve to show how the hand and arm have merely prolapsed; making what is commonly denominated an arm presentation: but is it not clear, the head having gone up, that the shoulder still really pre- sents, and that the arm has only fallen down or prolapsed in a shoulder case? 168. From the above, it appears that we have— 1st. Cephalic presentations; 2d. Cephalic presentations deviated, with descent of the shoulder; and, lastly, 3d. Cephalic presentations deviated, with accidental descent of the shoulder, and prolapse of the arm. 169. Here is a drawing representing a breech presentation, or presentation of the pelvic extremity of the foetal ovoid. This is the second normal pre- sentation of the child, the cephalic be- ing the first. In this case, an accidental deviation might cause the buttock to glance upwards on the brim of the PRESENTATIONS AND POSITIONS. 81 pelvis, to take its lodgment in the left iliac fossa. Such an accident would give rise to a footling labor, or to a presentation of the knees. A footling presentation, then, is only an accident happening in the course of a pelvic presentation—and the same may be said of the knee cases, which are very rarely met with. 170. I recommend these views of presentations to the Medical Stu- dent, who, if he should adopt them, will find his notions of midwifery greatly simplified, and his memory not loaded with useless divisions and descriptions that serve only to embarrass him as a student and perplex him as a scholar or practitioner. These are the divisions I have proposed in my public lectures; and, having found them conve- nient also at the bedside, I with confidence advise him to prefer them to the long catalogue of presentations in the books. Knowledge in its nature is simple, pure, non-complex; it owes its seeming complexity and abstruseness only to man. 171. If the Student should ask me where I will place the presenta- tions of the belly or the back of the foetus, I cannot inform him, for I do not know whether they be derived from deviations of the pelvis or from deviation of the head. I am sure, however, that all such cases are accidents either of the cephalic or of the pelvic presentation, which is the essential point. 172. Positions of a Presentation.—The word position, as I said, refers to a relation between a certain cardinal part of the pre- sentation, and a certain cardinal part of the pelvis. Thus, in vertex presentations, the posterior fontanel may be in the fifth posi- tion, that is to say, the occiput of the child may be directed to the left sacro-iliac junction, and its forehead to the right acetabulum; but the cardinal point on the pelvis is the left acetabulum, from which we count the first, second, third, fourth, fifth, and sixth positions. Care should be used to avoid confounding the terms presentation and position. 173. A vertex presentation is one in which the head presents in flexion. A face presentation is one in which the head presents in extension. There are six positions of the vertex presentation:— 1st. Vertex to the left acetabulum. 2d. Vertex to the right acetabulum. 3d. Vertex to the symphysis pubis. 4th. Vertex to the right sacroiliac junction. 5th. Vertex to the left sacro-iliac junction. 6th. Vertex to the promontory of the sacrum. 82 THE EXTERNAL ORGANS. 174. There are two face positions :— 1st. The chin to the right side of the pelvis. 2d. The chin to the left side of the pelvis. 175. There are four positions of the pelvic presentation :— 1st. Sacrum to the left acetabulum. 2d. Sacrum to the right acetabulum. 3d. Sacrum to the pubic symphysis. 4th. Sacrum to the promontory. 176. In the shoulder presentations there are four positions—two positions for each shoulder. First RiGHT-SHOULDER-position; the head is in the left iliac fossa, the face looking backwards. Second RiGHT-SHOULDER-position; the head is in the right iliac fossa, the face looking forwards. First LEFT-SHOULDER-position; the head to the left, looking forwards. Second LEFT-SHOULDER-position; the head to the right, looking backwards. These being the principal presenta- tions, with their several positions, I shall enter into fuller details of them when I come to treat of the special labors in which they require to be managed by the accoucheur. CHAPTER IV. THE EXTERNAL ORGANS. 177. The word Pudenda expresses the idea of those parts of the reproductive apparatus that appear upon the outer surface of the pel- vis. The expression mons, or mons veneris, refers to the elevation or fleshy prominence lying upon the ossa pubis, which, because they project to the front, are called shear bone or shear bones. The mons becomes still more prominent than it would be from the mere advance of the horizontal or body-portion of the pubis, because a quantity of adipose substance lies below the skin there, which, together with a quantity of hair that covers the whole surface, has caused it to receive in ancient times the appellation of mons. The skin and cellular tissue found in this region, the great abundance of hair-follicles and nume- rous sebaceous glands disposed there, render the mons subject to attacks of diseases of various kinds, such as abscess, folliculitis, &c, and it might well be supposed that furuncular inflammation affecting so dense and resisting a texture must give rise to very severe pain. I must say, however, that during a practice of more than half a cen- THE EXTERNAL ORGANS. 83 tury, and a large clientage among sick women, I have never been called to treat any abscess or other inflammation of the mons ; whence I suppose the cases to be rare. 178. The symphysis of the pubis is about one inch and a half in length, and it is only the upper portion of the symphyseal aspect of the bone that is covered or concealed by the lower portion of the mons veneris; the lower two-thirds of the bone being invested with tissues that are covered with mucous membrane lying inside of the vulva or genital fissure. The skin or derm therefore that covers the mons passes downwards on either side of the symphysis leaving the genital fissure or sulcus bordered on the right and left by the labia majora or greater lips of the pudenda. These labia are covered with ordinary cutis on their exterior surfaces, but are lined with mucous membrane on their inner aspects: passing downwards and backwards, they are at length lost or disappear in the perineum. As in the human lip, the outer skin gradually and insensibly changes into mucous membrane the line of demarcation between them being undiscover- able. Like the mons, the dermal surface of the labia majora is covered with hairs and supplied with numerous sebaceous glandules. They have a store of adipose cells, though a less copious one than the mons above them. The areolar tissue lying betwixt the dermal and mucous surfaces of the labia is very loose and distensible, and yields quite readily to an injecting or lacerating force. Hence it happens that women attacked with dropsy, or those who are much infiltrated with oedema gravidarum, are commonly found to complain of great dis- tension, and sometimes of very painful hardness of the labia. They are found, on occasions, to swell to the size of a stout man's arm, and now and then are observed to be so firm and solid that they feel ex- cessively hard and will not yield except to long-continued pressure. The Student who reads this paragraph ought to understand that when a pregnant woman has her legs distended enormously with the serum of an oedema gravidas, she is very likely, at the same time, to have oedema labii majoris, which she will not complain of on account of her delicacy. It is a matter of slight concern provided the oedema be slight; but not so when the legs are swollen so as to look more like an elephant's limb than like a woman's ankle: I advise him, under such circumstances, to inquire about it, and if she admits that she is very much swollen, and has some pain in the part, to insist upon ex- amining by touch. If a woman having both the labia very much swollen, should fall into labor, it is to be expected that the powerful efforts of the womb will push the child's head against the distended labia, and, by repeated efforts of the pressure, squeeze the serum out 84 THE EXTERNAL ORGANS. of the areolar cells or meshes, until at last they yield enough to let the child be born. I may even inform the Student that this good success is to be generally looked for, though not always. Such a state of the woman's general health is not always the most favorable to parturition, and it now and then happens that he may be called upon to expedite the birth by using his forceps; in which case he may find the most serious embarrassments in his operation. To lock the for- ceps upon the child's head, the part just above the junctura or lock must be pushed back towards the axis of the lower strait; but how can he push the junctura backwards against a perineum that has be- come by this infiltration as hard as a board? This infiltration of the labia does always affect the perineum more or less, and I assure the Student that I have been completely foiled in my attempts to adjust the forceps by this very cause. I remember particularly the case of a poor Irish woman thus affected, in whom neither Dr. Dewees nor I could succeed in applying the instrument, and in which by that great teacher's advice I was led to deliver the dead child by embryulcia. These remarks I now make for the purpose of persuading the Mid- wifery Student to consider what ought to be done in cases of labial oedema of pregnancy, and of advising him to insist upon his privilege rto examine the patient, and, if necessary, to let the serum escape by means of punctures in the labium. Such an operation gives very little pain, and is not followed by any evil consequence. It ought not in labors to be omitted when the part is greatly distended, and somewhat painful. It is better to do it before the patient falls in labor, though it is very well to perform it even while she is so, provided the swelling should in any considerable degree seem to oppose the delivery, which it some- times is known to do. If a sharp-pointed lancet held betwixt the finger and the thumb is allowed to project about one-sixteenth of an inch, and the swollen labium is turned well outwards, the point may, by several rapid blows, be struck through the mucous membrane into the areolar tissue of the labium, whereupon the serum immediately begins to exude from the punctures, and continues to flow out until the part becomes quite collapsed and softened again. The youngest beginner in practice need not hesitate to take this step. 179. Labial Thrombus is an accident that happens mostly to women in labor, though women in other circumstances might be affected with it. During the great distension and strain to which the genitals are exposed in parturition, a branch of the ischiatic or pudic artery or the bulb of the vestibule may be ruptured, whereupon a rapid extravasation takes place, and the blood is forced into the THE EXTERNAL ORGANS. 85 meshes of the cellular tela of the labium, or even lacerates it and occasions great cavities to be formed that are filled with fluid or with clotted blood. When a labium becomes thus injured during the pro- cess of childbirth it is not always discovered by the complaints of the woman, who is generally incapable of discriminating between one kind of pain and another in the superabounding sources of agony with which she is surrounded. The discovery is, for the most part, made by the medical attendant himself, while Touching for the diagnosis or prognosis. If, indeed, a woman goes into labor without having any abnormity of the labia, and becomes affected with considerable and very tense swelling of one of them, the prima facie inference should be that thrombus of the labium has occurred, and it should at once be investigated. 180. When a bloodvessel gives way in the labium the extrava- sation is not always of necessity very great, but sometimes many ounces are driven hastily and with great injection-force among the loose internal textures of the part, which becomes black and swollen to the size of a man's arm. If the extravasation should continue, there is reason to apprehend that not the labium only, but the areolar tissue inside of the pelvis, might become infiltrated, so'as to dissect the internal structures to a dangerous extent. Any such risk as this can be obviated only by permitting the hemorrhage to have a free outlet by opening the labium by a free incision. It is very reasonable to make such an aperture, were it but to let out the fluid blood or serum and allow of the coagula to be turned out with a finger passed into the cavities. Hence, when an incision is made, it ought to be large enough to admit of the introduction of the finger. I have turned out many ounces of coagulated and fluid blood and serum by such an incision, and the evacuation has allowed the distended lip to collapse immediately. A child could not be born in such circum- stances without rupturing the swollen labium, and adding greatly to the mischief. I do not suppose that all the cases of thrombus are due to laceration of a pudic or ischiatic artery; it is very probable that those instances in particular, that occur during or subsequently to deliveries with forceps are caused by rupture of one of the bulbs of the vestibule, to be hereafter described 200—202: The bulbs are ex- cessively vascular, and so much exposed to injury by the blades of the instrument that one has more occasion for surprise at their exemp- tion than at their injury in the operation. 181. Thrombus of the labium is, for the most part, discovered after the conclusion of the labor and not before, because most of the acci- dents of rupture do take place while the child is passing through the 86 THE EXTERNAL ORGANS. external organs. I conclude, also, that post-partum thrombus is a less serious matter than that which happens before the head comes to press the external parts strongly outwards. But, in either case, the blood should have an outlet by means of the incision, which should be made on the mucous and not on the external aspect of the labium. I wish here to be understood as advising the incision only in such in- stances as may, without question, require it. In very slight degrees of extravasation the removal of the infiltration may be safely left to the absorptive powers of the parts. 182. Abscess of the Labium, like abscess in any other part, may be treated by antiphlogistic methods, provided suppuration has not taken place already. I believe that physicians will very rarely have anything else to do in labial abscess beyond the exhibition of emollient cataplasms or fomentations, to be followed by the discharge of the pus by means of the lancet or bistoury; for few women can be found who have moral courage enough to allow them to expose such a cause of alarm and distress in the early stages. Their modesty leads them to conceal their pain until it becomes insupportable, and then it is too late to expect that any measures whatever shall be able to effect a cure by resolution: the only thing then to be done, is to soothe the pain by emollient and opiated dressings, and to discharge the pus as soon as its fluctuation is made manifest. The incision is to be made on the mucous surface, and not on the outer aspect. 183. There is great liability to make a mistake in the diagnosis of these labial abscesses, which ought not to be confounded with a disease of the excretory duct of a Duverney's gland. But, as this is not the proper place to speak at length on that case, I shall postpone any further consideration of it to a future page. (See par. 200 and 204.) 184. The superior angle of the vulva is its anterior commissure, and the lower or posterior one its posterior commissure. The symphysis is one and a half inches long at least, and yet the posterior commissure is to be found about on the level of the crown of the arch, not below that level; so that, when a child's head or trunk is coming out under the arch and is distending the vulva to the utmost, this posterior commissure is thrust away from the arch to a distance equal to the diameter of the plane of the distending head, which is generally not less than ten, and sometimes fourteen inches in circumference. To obtain this degree of dilatation, the labia must become greatly strained and elongated, so that they sometimes break short off near the lower end, whereupon the child is instantly and violently ejected. The proper way to eschew so considerable a misfortune, is to support the THE EXTERNAL ORGANS. 87 perineum, and oppose the escape, while exhorting the woman to desist from all voluntary efforts to drive the child from her womb. 185. The Nymphae, which are called labia minora and labia interna, lesser lips and inner lips, are seen to be two folds of the inner mucous membrane like two flaps or valves. Near to, but a quarter of an inch below the superior commissure, the nymphae meet, and after covering the clitoris like a hood, whence the part is called pre- puce of the clitoris, they descend, each in an outward direction to about three-fourths of the whole length of the labium, where they are lost in the general plane of the surfaces. They are excessively vas- cular bodies, and probably erectile. They have been supposed to have the office of furnishing material for the ampliation of the orifice when undergoing the distension usual in childbirth. I have, on many occasions, touched the ridge of the nymphae when the head was passing out, and found it firm and undeployed. Probably the real function or office of the nymphge is to draw the glans of the clitoris downwards, and force it into strong contact with the dorsum penis in coitu., which, by increasing the friction of the glans or tentigo, must greatly increase the sexual feeling or orgasm of the congress. Such orgasm, probably, is one of the indispensable agents of fecundation, since without it the oviducts or Fallopian tubes would lie flaccid and relaxed within the pelvis; whereas, when highly wrought up by the sexual orgasm, they are known to erect themselves, and apply their fimbriae or ingluvies to the ovaries for the ingurgitation of any ova that may chance to be ready to enter their funnel-shaped orifices. 186. Vestibule.—As the nymphae divaricate in descending along the inner aspects of the labia, they leave a triangular space, terminated below by the crown of the arch just above the meatus urinae or orifice of the urethra. It is the duty of the Student to study this vestibulum upon the subject and learn that it is to serve as his director in the operation of catheterism. It has a sort of raphe or raised line in the middle. If the index finger of the left hand is first applied to the crown of the arch, and then slid upwards, it will separate the nymphae and go up near to the top of the triangle. If the palp of the finger is now slowly moved downwards again towards the crov/n of the arch, it will feel the little dimple made by the urethra's orifice, just below the crown, and then the point of the catheter may be immediately intro- duced into the urinary passage without vexing the woman with vain oft-repeated trials, and without being obliged to call for lamp or candle, 88 THE EXTERNAL ORGANS. as I have witnessed, to the mortification and humbling of the patient, and the great scandal of medical skill and proficiency. 187. Cohesion of the Labia.—In young children, it not unfre- quently happens that the inner face of the labia pudendorum becomes irritated, which ends in an adhesive inflammation, uniting the sur- faces that are in mutual contact. The inevitable evacuation of the bladder will, of course, always prevent a union of the whole extent of the labia. In all the instances of this kind that have fallen under my notice, I have found it sufficient to separate the two labia and keep them apart with the fore and middle fingers of the left hand, while, with the end of a probe, drawn down directly upon the line of union, the adhesions are readily destroyed, and that without occasioning the least bleeding. The scalpel has never been required. In performing this operation in a good light, it will be seen that the union of the surfaces has taken place by the mutual interlocking of very delicate villi, much in the same way as the placentula and cotyledon of the sheep or cow are interlocked: the villi that are pulled apart in this process are exceedingly delicate: I have been struck with this resem- blance on several occasions. I have no doubt, however, that a case might occur, in which, by long neglect, the union should acquire so great a degree of solidity as to yield only to the knife. When the labia shall have been separated, in these instances of cohesion, they may be carefully kept from coming in contact by a pledget covered with cerate, as the adhesive tendency is renewed by the very violence which is required to obviate the consequences of a preceding irritation. 188. M. Colombat, in his "Treatise on the Diseases of Females," ad- vises us to touch one, not both, of the recently separated surfaces, with a nitrate-of-silver pencil, in order to produce on that surface a state of vital action different from that existing on the uncauterized surface; which he supposes must effectually obviate the tendency to cohesion. His idea is, that, to adhere, both surfaces must possess the same adhe- sive temper. For my part, I have found it, in all instances, sufficient to direct the nurse to draw the point of the little finger, dipped in oil, strongly downwards, from the anterior to the posterior commissure. Such a process, daily repeated, effectually sets aside all possibility of re-establishing the cohesion of the labia. 189. The Fourchette.—The dermal portion of the labia is partly lost in the perineum, and in part becomes fused or connected with its opposite fellow, and where the inner dermal edges of the two labia THE EXTERNAL ORGANS. 89 unite, there is a sort of edge or fraenum, resembling the inner edge of a crescent, the horns of which are turned upwards like a fork, whence the part is termed f u rcill a, little fork, or, to use a now technical English word taken from the French, the fourchette. Inside of this fourchette, or furcilla, is a sort of depression pit, or cavity, which is concealed until the fourchette is pulled forwards and depressed. This is the fossa navicularis, or boat-shaped pit, behind which, at a greater depth within the orifice, is the front surface of the virginal valve, membrane, or fold, known as the hymen, the mark and sign of chastity and virgin purity, as is supposed by most people. 190. The Hymen is merely a crescent-shaped duplicature of the mucous membrane of the orificium vaginae which varies much in dif- ferent individuals. In some women, like a new moon with sharp and curved horns it half surrounds the orifice, being hidden within and only visible when the labia have been separated or drawn open. In some, the horns ascend but a little way, in others they go nearly across the opening above until they almost meet, and in others they do meet, and thus make a circular diaphragm or plane with a hole near its top, or even exactly in its centre: in some girls it constitutes a complete diaphragm without any the least aperture, and I saw one woman in whom the opening was not larger than a common bristle, and wholly undiscoverable except while she was menstruating. In that state she forced the mensual blood through the little orifice where I saw it like a fine dark point, certainly not bigger than the diameter of a bristle. This woman had been several years married. I cut open the diaphragm for her, and so removed the cause of her reproach of barrenness, for after her return to her own distant State she recovered from the ope- ration, and becoming pregnant, had the happiness to be a mother, a thing that all women naturally long to become, or ought to. 191. It is by no means the rarest of occurrences for girls to be affected with such malformation of the hymen as to be quite shut up, the hymen forming itself into a complete diaphragm like a small tam- bourine. In this case, nothing wrong is suspected until the age of puberty, when the poor child is observed not to change as usual with girls of her age. The health now begins to fail. Pain in the belly, constipation, and uneasy urination come on, and she grows pale and weakly. Being affected with complete atresia of the orifice, which is shut up by this unnatural hymen, she is all this time swallowing physic and undergoing a system of dieting, and is treated medically by the process of guessing at her ailments instead of by a method founded upon a physical diagnostication. The existence of this ob- 7 90 THE EXTERNAL ORGANS. turating membrane has nothing to do with her power to menstruate, and she does menstruate regularly, but the sanguineous discharge, unable to escape from its prison, accumulates within the now dis- tended walls of the vagina, and when that becomes too much filled to hold any more, the accumulation goes on within the womb's cavity, so that the collected menstrua act like a chronical colpeurynter, making of the womb and vagina one common sac or bag filled with tar-like products of the courses. The uterus enlarges more and more with each successive menstruation, and now from the evident growth of the lower belly, the poor girl is very likely to be suspected of indiscretion. It is a dreadful thing to accuse a sick virgin of the greatest woman's shame, when her pregnancy exists only in the imagination of her ignorant accusers. At length resort is had to the only possible method of diagnosis, and it is found that she labors under atresia from imper- forate hymen. The womb will be discovered by placing the hand on the lower belly where its fundus is found rising upwards above the plane of the superior strait; the hymen is found to make a convex tumor at the orifice, and if the index finger is passed upwards along the canal of the rectum, the vagina is discovered to be distended with a mass that fluctuates under the touch. Now that the truth is made known, there is nothing left but to open the hymen by means of a bistoury, taking care before making the incision, to empty the bladder by means of the catheter, and while using the lancet or bistoury to have one finger within the bowel so as to make sure of doing no injury. As soon as the cavity is opened, the accumulated products of all her antecedent menstruations begins to gush forth, in color and consistence resembling molasses, thin currant jelly or thickish tar. If the womb should have been much distended by the collection, that organ immediately tends to contractions, that are felt in the same manner as women's after-pains. 192. It would be but a prudent precaution, before doing this ope- ration, simple as it is, to announce not only its indispensability, but the no little risk that waits upon it, for it does sometimes happen that the abnormal state of the womb forces it into a state of inflammation subsequently to the operation; and such inflammation may very readily assume the characteristics of mortal metro-peritonitis. I have done this operation for several different persons, and have had cause of seri- ous concern during a few days subsequent to the drawing off of the long retained products, on account of a following inflammatory dis- position in the woman. 193. I ought to add a word concerning the Hymen as a sign of vir- ginity. It is commonly torn in the first sexual act, and if the debris of THE EXTERNAL ORGANS. 91 the crescent should be examined soon after the rupture, one might feel no hesitation in speaking as to the facts. Still, the question recurs, whether it is always torn, and we are compelled to say whether or no it is always ruptured if it does exist, and next, whether it does always exist in the virgin. Now, I am entirely convinced that it is not always ruptured in the sexual congress, and I do further know that it may escape destruction even in the acts of parturition, for I have attended in all her confinements (and she has several children) a woman in this city, whose hymen is still perfect, and which never was torn, even in her labors. If this statement is to be relied upon, then it ought to prove that a sexual union may have been perfected in a woman in whom the hymen still remains whole. Further, I have had a very extensive medical practice during many years, in the course of which I have had occasions in numerous instances to examine unmarried women, and the result of my great experience is to convince me that there are thousands of perfectly pure, chaste, and not to be suspected unmarried women in whom no vestige of the hymen is to be found. It seems to me a very singular thing that physicians and others should insist on the necessity of a hymen as a test of virginity, though it is well known that in great numbers of young people the mucous fold or valvule is so thin and delicate that it would be likely to yield if a finger were strongly pressed against it, that in some it is a deep, and in others a low duplicature, in some an eighth of an inch thick, and in other some not thicker than a sheet of paper, and yet with all these differences, the profession everywhere will insist on its universal presence during virginity, whereas, the truth is that little children of the age of two years are very apt to rupture it in scratching the parts, as most of them are prone to do on account of some irritation there. 194. If a woman have a hymen whose crescent-edge is at the top of the vagina, and not thicker nor stronger than letter paper, it is clear to see and say that she has never been violated, while in another virgin, whose fold is low, and thick and strong, its persistence affords no proof whatever that she has not been impure; therefore courts and juries, who sometimes decide on these questions, ought to know that these sayings are true, that they may avoid the risk of committing the greatest injustice by their ignorance and presumption. The question in all such cases ought to be, is the hymen present or absent? is it frail or strong? could it or could it not resist the violence of a coitus? The question is not the naked one as to whether the hymen is or is not in existence in the case. 195. Finally, vaginal examinations are to be made only under a 92 THE EXTERNAL ORGANS. conviction of their absolute necessity, especially in the cases of unmar- ried women. Madame de la Marche, in her "Instruction familiere et utile aux Sages-femmes pour bien practiquer les Accouchemens, etc.," p. 5, insists that such examinations should never be made except in consultations, lest the midwife, finding the patient without a hymen, she should be accused of having ruptured the membrane with her hand, and the good lady concludes: "En fin ce seroit un grand malheur, si celle etoit pucelle, de la Toucher." 196. The Clitoris is a small body composed of two corpora cavern- osa and a corpus spongiosum, and is, in many respects, so much like the male organ of generation that it might well be regarded as a min- iature production of the same kind. In the male organ the two cor- pora cavernosa are attached by their crura to the pubis, and receive, in a groove that runs along the middle of their under surface, the corpus spongiosum, which, commencing in the bulb, proceeds to the extremity of the penis where it terminates in the glans penis. In the woman, in like manner, each corpus cavernosum arises from a ramus pubis; and when the two have converged and become united, they rise upwards along the face of the pubis for a short space, and then turn downwards at an acute angle, being buried all the while beneath the mucous membrane investing the parts below the superior commis- sure. The outer extremity of the conjoined corpora cavernosa is crowned with a glans composed of a true corpus spongiosum, as in the male apparatus. This glans has also a true bulb, or rather two bulbs, which, instead of lying on or near to the cavernous body, are found on each side of the arch of the pubis, below the crown, and covered with the constrictor cunni muscle, so that, instead of existing in the form of a bulb of the urethra, as in the other sex, thev constitute the two bulbs of the vestibule; the only real difference between them in male and female being their place or location. 197. In men, when the bulb of the urethra is strongly compressed by its muscles, which contract under the sexual excitement with a sort of tenesmic force, the blood in the vessels of the bulbs is forced for- wards along the whole length of the corpus spongiosum urethras and compelled to fill up and greatly distend the glans penis, which is only then in a state of perfect erection when the glans has become com- pletely filled with its capillary circulation. This being effected, the sexual excitement attains a high stage, which coincides with a certain hyperesthesia of the nerves contained within the genitalia. 198. Now, in the gentler sex, the bulbs of the vestibule are the analogues of the bulb of the male urethra, and they are in like manner THE EXTERNAL ORGANS. 93 compressed by their proper muscle, the constrictor cunni, which, by its tenesmic contraction, drives the blood forward from these bulbs and forces it along the pars intermedia, which is for them a corpus spongiosum, into the glans of the clitoris, which being now filled and intensely distended and hyperaesthetic, arouses the whole erotic force of the subject. When this excitation of the external organ has reached its height, the oviducts, commonly called the tubes of Fallopius, parti- cipate in the Excitement; they become erected, and, as their tissue fills, they are compelled'by their attachments, which serve as a sort of mesentery, to adapt their fimbriated extremities to the surfaces of the ovaries; and if perchance an ovum is ready to fall, or is already fallen, it is ingurgitated and swallowed by the tube or oviduct and so, trans- ported into the womb's cavity. 199. I am indebted for the above account of the clitoris to the admirable work of Dr. Kobelt, which was translated from the German by Dr. H. Kaula, under the title "De lAppareil du Sens Genital des deux Sexes," &c., 1851. 200. To make it easy for the Student to comprehend the above account, I here give copies of Dr. Kobelt's figures, and in Fig. 34 I present the magnified drawing of the clitoris, representing that body, however, with the cms removed, so that only the body of the organ with its glans is exhibited. Let the Student compare the glans with that of the male organ, and he will see that the structures are very exactly alike, with the ex- ception that there is no canal of an urethra in the female. In fact, the canal of the urethra is lower down; and yet it is true that when the urine does flow, it jets forth between the two bulbs of the ves- tibule, which seem to surround the urethral orifice. The great dorsal vein and the artery are marked in the drawing—and the copious convolutions of bloodvessels seen passing upwards from below, and which are called pars inter- media, are channels that convey 94 THE EXTERNAL ORGANS. the blood from the bulbs of the vestibule upwards to conduct it into the capillaries of the glans clitoridis just in the same way as the bloodvessels in the corpus spongiosum lead the blood from the bulb of the male outwards to the glans penis at the extremity of the cor- pora cavernosa. 201. In Fig. 35 is represented the arch of the pubis and its sym- physis, on which is seen the clitoris, bent downwards at an acute angle. Beneath the crown of the arch, and on each crtis, is lying a bulb a of the vestibule, from each of which, on the right and the left, is seen mounting upwards the network or plexus of bloodvessels e that conduct the blood of the bulbs into the glans of the clitoris/. If these bulbs become turgid with blood, and then are subjected to pres- sure by the constrictor muscle c underneath which they lie, the blood is forced by jets through the pars intermedia up into the glans, which becoming thus erected, the erotic life is strongly developed in it, and so communicated to the reproductive system. 202. Fig. 36 is a three-quarter view of the same structure. It par- ticularly illustrates the nature, proportions and place of the right bulbus vestibuli, a, with its pars intermedia c as con- nected with the glans of the clitoris. Dr. Kobelt remarks, that if one examines these textures in a dead body, they do not seem obvious to the research, and that though the orificium vaginae is surprisingly dilatable; but, if matter of injection be first thrown in so as to fill all the vessels of the external genitalia, the bulbs become so filled and distended, that it is difficult even to pass the finger through the THE EXTERNAL ORGANS. 95 os externum, so tightly is it embraced by the distended masses of the bulbs. I trust that the illustrations now set before the Student, will assist him to understand all these points sufficiently to give him clear Fig. 36. views of the accidents and disorders to which they are liable. 203. The question might be asked, why I should have placed these illustrations in my book, since such drawings, to say the least, seem fit to make the cheek tingle with shame. I am quite conscious that a book of medical practice ought to be written with a decent regard to decency, a thing very difficult to do even in dis- quisitions on the disorders of the di- gestive and the renal organs. In this particular department, I take to myself the consolation of reflecting, with Heurnius, that si non erubuit D. 0. M. hos creavisse, I may well escape blame if I but properly set forth the nature of these tissues with a view to teach the young beginner in medical practice how to obviate the dangers and inconveniences that sometimes attend on their peculiar nature and situation, and I have been led to cite the above from Dr. Kobelt's most admirable monograph, because I never could account, before I read his work, for certain occurrences that I have met with in practice, but which are now clear enough, both as to their nature and treatment. The cases to which I here refer, are hemorrhages proceeding from rupture of the pars intermedia of the bulbs of the vestibule caused by the woman falling upon some sharp stick that lacerates the part, and these hemorrhages are so violent and alarming, and even so dangerous, that it is quite necessary for a medi- cal man to be well informed as to their nature and source. I have met with a good number of them, and heard of others in the practice of my friends and acquaintances. Here is one— 204. Case.—Mrs. ----, the mother of four children, returned to her home from a ride on horseback. The servant brought a common country chair for her to dismount. The chair terminated in two sharp turned tops. When the lady was ready, she threw herself from the saddle, and as her foot lighted on the edge of the chair, carelessly held by the groom, it turned forwards, and she fell. The sharp turned top 96 THE EXTERNAL ORGANS. of the chair was driven against her riding skirt, and forced her clothing just against the under edge of the arch of the pubis. In a moment she was streaming with blood, and being taken to her apartment, she bled until she fainted; when the hemorrhage was stayed, only to return again with the renewed force of her circulation. Being at a consider- able distance from town, I did not see her for some time, and then found her greatly exhausted from loss of blood, and the flowing still going on more or less freely in proportion as she was less or more faint. Her state was truly alarming. I introduced a tampon into the vagina, and distended it as much as I thought fitting, and then apply- ing compresses of lint on the face of the pubis and vulva, I found I had resisting points sufficient to command the outflow, in fact, the method was sufficient, for the hemorrhage was controlled, and the lady recovered. I had a similar case some time ago, in a woman who, sitting on a night-vase, was wounded by a sharp fragment of the vessel which broke under her weight. The hemorrhage was very severe, and likely to prove fatal. Women are sometimes hurt in this way, with sharp-pointed splinters or sticks, or fragments of the night-vase broken by sitting down ; and I think that these copious bleedings are more commonly derived from laceration of the bulbs, or of the pars intermedia, than from wounding of parts behind the. symphysis; for, although there be bloodvessels within, these outside ones are not only the most exposed, but they furnish the most copious outpourings, and these cases require to be understood in order to be well managed. If I should again have a case of the kind to treat, I would make a tam- ponade for the purpose, causing the vulva to bulge more outwards, or to be as convex as possible, and then I would lay upon the ramus of the pubis and on the face of the symphysis, masses or trusses of scraped lint or raw cotton, which I should confine by a closely drawn T band- age and compress. I have no doubt that such a dressing would suffice instantly to control the most desperate hemorrhage from a broken bulb or a lacerated pars intermedia. I shall not detain the Student to speak of other causes that might give rise to severe bleeding, in these tissues, it is enough to have called his attention to the general facts in which he will find not only the indications of his practice, but my apology for introducing in this work a topic so unacceptable. I refer the curious in such matters to my American 2d edition of "Colombat on Diseases of Females," pages 84 and 85, where numer- ous citations may be found. At page 85 is the case reported by me, with a drawing of a very singular disorder of this organ. THE EXTERNAL ORGANS. 97 205. Duverney's Glands.—In the year 1846, Dr. P. C. Huguier, of Paris, read before the National Acad, of Med., a paper on the dis- eases of the secretory apparatus of the external genitalia in women. This paper is contained in the 15th vol. "Mem. Roy. Acad. Med.," 4to., Paris, 1850, and extends from p. 427 to p. 844, with four plates, having numerous drawings. Dr. Huguier divides the secretory organs of the genitalia into two great classes, vid. the sebaceous and piliferous folli- cles and the muciparous organs. The muciparous organs are of two sorts, some of them being isolated mucous follicles, found here and there about the orifice of the vagina, or agminated and gathered into patches, the others massed together and enveloped in a common cover- ing, and all of them connected with a single excretory duct. These latter compose two glands to which M. H. applies the title of vulvo- vaginal glands. These glands, which, according to the author, were known to Plazzoni, Duverney, Bartholin, Garengeot, Haller, &c, appear to have eluded the attention of modern teachers, and wholly escaped the researches of authors. They are conglomerate glands, situated just within the vaginal orifice, near the lower end of a nympha about one centimetre above the upper face of the hymen, behind the inner face of the ascending ramus of the ischium. In size they are as large as an apricot kernel, and more resemble the lachrymal gland than any other organ: One of these glands may be ovoidal, amygdaloid, reni- form, triangular, semilunar in shape, or it may even be a plaque of glandules like the glands of Peyer. The excretory duct of this vulvo-vaginal gland, or Duverney's gland, runs in a direction oblique from below upwards, from behind forwards, and from with- out inwards. The duct is generally about seven or eight lines, and sometimes eleven or twelve lines long; leaving the outer edge or margin of the gland by several distinct tubes which soon unite in a single duct, to discharge the secretion at the vulva, just behind the hymen or myrtiform caruncle, and never in front of either. A red- dish disk or areola surrounds the orifice which cannot be readily found except by pulling the labia outwards and downwards, whereupon one discovers the aperture in the bottom of a small dimple—one on each side of the orifice. Duverney's gland is the feminine analogue of Cowper's gland in the male, and like other glands is liable to be- come diseased: when indurated and enlarged it feels like a hard encysted tumor, which can be extirpated by the surgeon, as the operation has been done by Mr. Huguier. Like a parotid gland, a gland of Duverney is subject to obstructions of the excretory duct, and the disorder in such case is very like the salivary tumor met with in the Stenonian duct. If the excretory tube is an inch in 98 THE EXTERNAL ORGANS. length, and if any cause occurs that closes its outer orifice, atresia of the canal must be the consequence, and the secretion from the gland collecting in the tube causes it to swell or expand and assume at last a globular shape. If examined by the touch, it presents the appearance of a fluctuating abscess or cyst, which is commonly pro- nounced to be a labial abscess and treated accordingly. Such a dis- tended tube must eventually, and indeed soon inflame and its mucous surface become a pyogenic one, so that the tube becomes filled with true pus commingled with juice of the gland. To open this tumor with a lancet seems to be the indication, especially as the surrounding tissues have also, become inflamed and very painful; but, this ought not to be done, if it be possible to avoid it, because the discharge of such a sac will not cure the sac, which fills again and again, as is so commonly observed to occur by physicians familiar with the disorder. Taught by the fine memoir of Dr. Huguier, I have adopted his me- thod, and cured the cases by forcing the collected excretions out through the orifice. I cured one in this way in June, 1856, as I have cured others before it. By passing one finger into the vaginal orifice, and with the thumb applied outside of the labium, one may, with very gentle and slowly augmented pressure, compel the collected fluid to advance along the obstructed canal to its orifice, which is forced open by the pressure, whereupon the whole of the pus and mucus spouts out in a jet or stream until the sac is completely collapsed and emptied. On doing this, the pain is removed, except the excessive distension may have caused a sort of phlegmonous hardness and painfulness to affect the texture of the labium, and even that soon disappears after the cause is properly removed, as above. My advice, then, to the Student is to suspect Duverney's gland or its excretory duct in all those cases in which he shall be complained to of great pain, soreness, hardness, and swelling of the labium. No one need question that common abscess may exist in a labium, and require to be healed as such, but the fact is that most of the complaints of this kind that occur in practice should be suspected as somehow concerned with Duverney's gland. OF THE VAGINA. 206. Having now given some account of the external organs of generation, I have to speak of the vagina, which, as it is, according to the French terminology, a vulvo-uterine canal, is partly an external and partly an internal organ of generation. Previously, however, to passing on to the study of the inward structures, I wish to recall THE EXTERNAL ORGANS. 99 attention to the admirable wood-cut reduced by Baxter (Fig. 18) one- half, from Kolrausch's plate. I much regretted the necessity of making this reduction, which was not to be avoided, on account of the size of my page. 207. The Vagina is a mucous tube that serves as the excretory duct of the uterus. Not only the menstrual products but the mucus and the other fluids separated from the uterus find their exit through this canal, which is formed on a plan that admits of an expansion suffi- ciently great to give passage to the foetus at term. Being liable to most enormous changes of dimensions, the vagina could not be com- posed of fibrous tissue, but, as I above said, it is a mucous canal or tube, whose basement texture is a laminated areolar tissue, containing numerous glandules and follicles which yield a sort of slimy liquor that lubricates the whole. Numerous bloodvessels, absorbents and nerves, together with a few muscular fibres scantily dispersed, impart to it its peculiar life qualifications, which appear to me to be passive rather than active, having but little influence upon the general economy, a circumstance in which it greatly differs from the uterus, and some other portions of the reproductive system, very slight affections of which are known to develop the most considerable dis- turbance of the animal economy, whereas even grave disorders of the vagina do not seem to awaken a decided constitutional irritation. The lower or outer extremity of the vagina, its introitus, is sur- rounded with a sphinctorian muscle that enjoys a community of life and activity with the sphincter of the rectum, and might be considered as a sort of appendix to or prolongation of the great sphinctorial muscle: by its contractions it keeps the ostium of the vagina strictly closed. 208. In women who have not had children, the anterior and poste- rior walls of the vagina generally rest in contact. Hence the trans- verse diameter of the tube is much greater than its antero-posterior diameter. This contact of surfaces, however, does not exist in ema- ciated women, or in those who have very little stercoraceous matter left in the rectum. I believe that in most women who have what is called a scaphoid abdomen, the walls of the vagina become orbicular, or balloon-shaped. In these cases while the ostium is tightly closed, a man's fist might lie inside of the canal without touching the walls. I have found the vagina balloon-shaped, in this way, in many different women, both young and old. The above remark is worthy of the Student's consideration, inasmuch as it sets forth the important truth that the upper or uterine extremity of the vagina is excessively yield- 100 THE EXTERNAL ORGANS. ing or distensible, while the vulvar extremity of it is firmer and more resisting. The clinical application of the doctrine is found in the use of the tampon. Many doctors, seem to me to think they have made a tamponade if they but insert a sponge as big as an egg into the vagina, a thing they would not do if they but knew how distensible is the ute- rine portion of it. To insert such a sponge into the vagina that shall readily assume the shape of a balloon as large as a child's head, is simply a foolish thing; a tampon should be large enough to fill the balloon. The vagina is two inches and a half long; in the general, it ought to be about three inches long, but not one woman in a thousand has it so long, and not one in ten thousand of those who are mothers. 209. I was much surprised to find that Dr. Tyler Smith, in his "Course of Lectures on the Theory and Practice of Obstetrics," "Lancet," No. 2, vol. i. p. 30, 1856, should think that the "anterior wall of the vagina is about four inches long, the posterior being five or six inches in length." That author must have allowed his pen to slide in making such a statement, for the distance from the crown of the arch to the lower end of the fourth segment of the sacrum is but little more than four inches, even in the dried pelvis. Therefore the author has made a mistake, for there is not room enough in the cavity for so long a vagina, and a womb of two and three-quarter inches. Such a womb would lift its fundus more than four inches above the plane of the strait, which it never does when it is in the normal state, and in pregnancy not until the fifth month. 210. The authors speak of the anterior and the posterior column of the vagina, and there is some reason to say so, because the substance of the tube is thicker and firmer in front and behind than on the right and the left sides. This greater thickness is in part due to the corru- gated state of the mucous membrane in those precise localities, yet not wholly so, since the columns are observable even in multiparas who have long ago lost all their rugas or corrugations. The anterior column is thicker than the posterior one. They both grow slenderer as they ascend, so that at the points where the vagina unites with the neck of the womb, the appearance of a column is lost. 211. I like these words, anterior columna, and posterior columna, because I like to suppose that when the anterior columna becomes shorter than it ought to be, the womb to which it is fastened by one end, while the other end is anchored to the arch of the pubis, must be drawn down toward the pubis, and kept there by the contracted or condensed columna, which holds or ties it there. In some instances this anterior columna becomes so short, or so condensed, that it can only with difficulty be extended again by pushing the womb away THE EXTERNAL ORGANS. 101 from the pubis with the finger; and even when one succeeds in so pushing it away, it is brought back again immediately by the elastic contraction of the condensed anterior column, so that it renders a per- manent cure of the displacement or deviation of the womb a very difficult thing to effect. I have seen it not half an inch long. Kol- rausch's plate, Fig. 18, which is, in my opinion, perfectly dependable, shows the anterior columna to be only one inch and three-quarters long, and the posterior columna only two inches and six-tenths in length instead of five or six inches. I have certainly examined many thousands of women of all ages and in various conditions, and my sense of the case is, that a vagina whose anterior column is two inches and a half long, is long enough, for it lets the os tincaa take its true place in the pelvis. 212. It is quite necessary for the Student to know not only the anterior column, but also the two ligaments that are called utero-sacral ligaments, which are nothing more than duplicatures of the peritoneum in every respect similar to the ligamenta lata. They go in a direction backwards and upwards from the uterine extremity of the vagina to the sacrum, into the anterior aspect of which they are inserted, and their office is to hold the end of the vagina up in its proper place. Look at Kolrausch's picture, and conceive of a band or cord proceed- ing from the posterior lateral surface of the vagina to the second seg- ment of the sacrum. If such a string should be strong and taut, the vagina must keep its place, but if the string were cut, the vagina would drop down, and carry the womb along with it. The same effect, would follow upon a relaxation of the band—the vagina must slide down, carrying its womb along in its fall. Is not falling of the womb, then, the same thing as relaxation of the vagina and utero- sacral ligaments? What else could it be? It could not be, and it is not anything else. I have written so fully upon this subject in my "Letters on Woman, her Diseases and Remedies," and in my "Essay on the Acute and Chronic Diseases of the Neck of the Womb," that I must refer the Student to those works for my further views of the dis- orders of the vagina. 213. It is proper, however, for me, in this place, to say that as the vagina is the excretory duct of the womb, it is so constituted as to undergo very great changes of its capacity in parturition. The tube may be considered as a cylinder in the non-gravid state, but when the womb is enlarged by the growing ovum, and particularly near the close of a pregnancy, the cervix uteri becomes a cone, and, of course, the upper end of the vagina, which invaginates that cone, must also assume a conoidal form. But when labor is advanced, and the os 102 THE EXTERNAL ORGANS. dilated, the upper end of the vagina must dilate pari passu. It is not every specimen of the vagina that is so distensible as I have re- presented it generally to be; and when it is really a resisting body, it yields reluctantly to the force of the throes and ofttimes causes the process to be slow and very painful, so that among the numerous causes of slow and protracted labors, we must occasionally find this tube at the bottom of the mischief. It becomes rigid in this way in certain women who have suffered from chronic vaginitis, the effect of which is to give a tendency to a sort of general stricture or narrowing of the whole canal. I have often met with instances in which the organ, even in married women, presented obstruction to the passage of a Recamier speculum up to the os uteri. It is manifest, then, that such a state of the tissues might interfere with the normal develop- ments in a labor. I have published some cases of this stenosis of the vagina in my work on female diseases, and in my treatise on diseases of the cervix. A very good account of such affections is to be found in the work of Spaeth, Chiari, and Braun, already cited, as well as in my "Translation of Colombat de l'Isere's Treatise on the Diseases and Special Hygiene of Females." M. Colombat's article is at p. 96, and at 97 is a lengthy account of cases observed and reported by myself. 214. The Womb.—The uterus is attached to the upper end of the vagina. It is a pear-shaped body, compressed from front to rear, and of various length, which may be from two and a quarter to two and a half inches, rarely three inches—being larger in women who have borne children than in those who have never been impregnated. It is divided into fundus, body, and neck; the fundus being the up- permost, and the neck the lower-. most part of the organ. The vagina is united to the womb in such a way as to permit its neck to project like a nipple a short distance into that tube: in this regard also there is great variety, some women having almost half an inch of the cervix uteri hang- ing down in the vagina, while in others the connection seems to exist almost at the lower end of the cervix. (See the engraving.) The cut (Fig. 37) represents the womb b, with the vagina h laid open THE EXTERNAL ORGANS. 103 in order to show the neck and mouth of the womb B projecting into the upper end of the vagina. In it are also seen the round ligaments gg; the ovaries e e; the ligament of the right ovary F, and the Fal- lopian tubes c c, with their fimbriated extremities D. As the vagina is a curved canal, which proceeds backwards from the vulva and upwards towards the rectum, it follows that the womb lies nearer to the sacrum than to the pubis. The womb is so situated that its long diameter is parallel to the axis of the superior strait, while the vagina is more nearly parallel to that of the inferior strait: hence, at their junction, they make an obtuse angle of nearly 95°, any constant devi- ation from which implies a displacement of the womb. 215. Let the Student say the breadth of a womb is about an inch and a half; its thickness about one inch; its length two inches and a quarter; this is the mean. I subjoin a drawing that represents the Fig. 38. internal organs divided transversely from top to bottom, and showing the front or anterior half. A is the fundus or bottom of the womb, which is the uppermost or highest portion of the organ. B is the tri- angular cavity whose outlet is through the canal of the cervix (c), leading down to the orifice of the womb in the vagina, which orifice is called os tincae, or os uteri. At d d are seen the left and right Fallopian tubes laid open, to expose the narrow passage by which the ova are conducted from the ovaria ff. e e are the fimbriated extremities of the tubes, which are also called morsus Diaboli, or Devil's bit: they are the infundibula or ingluvies which take up the ova as they spontaneously escape from the ovisacs of the ovaries when expelled once a month. The wing-like expansion on each side of the womb is the broad ligament, and the round ligament is seen through it and in front of it on either side of the uterus. 216. Suppose half an inch of the cervix uteri to project into the upper part of the vagina; then if the whole length be two inches and a quarter, we shall have one and three-quarter inches of the womb above the upper end of that canal. Such being the case, the womb 104 THE EXTERNAL ORGANS. would fall over to the right or left side of the pelvis, were it not restrained or stayed by what are called its broad ligaments, which, passing from its sides towards the sides of the pelvis, keep it steady, or prevent it from assuming an oblique attitude; it would also fall backwards towards the sacrum, and sometimes become lodged or wedged under the promontory of that bone, were it not restrained from moving in that direction both by its round ligaments, called by Fallopius its cremasters, and also by its connections with the bladder. The utero-sacral ligaments, which form the lateral walls of Douglas's cul-de sac, also maintain the uterus in situ. It cannot fall forwards, for it is sustained by the bas fond of the bladder, which, by filling with urine, must, and does always push it backwards again. 217. Structure and Powers of the Womb.—The substance of which the womb is composed has not been fully understood. In the unimpregnated state, it is dense and gristly to the feel, and cuts very hard; the cut surface being of a faint pinkish hue and a fibrous ap- pearance; but those fibres are disposed without any apparent regularity or order. It is supplied with bloodvessels, absorbents, and nerves, which are very small during the unimpregnated state; but the same vessels in the gravid womb acquire an enormous size, and are exceed- ingly numerous and tortuous; so that, in fact, the ovum, at full term, appears to be contained within a vast network, or rete vasculosum, united together by a quantity of muscular fibres and other tissues. The womb, at the full term, is an exceedingly sanguine organ, being furnished with torrents of blood from the uterine and spermatic arte- ries, the former reaching it from below, and the latter from above, with free inosculation of the several channels of circulation. As to the interior membrane, or mucous coat of the womb, it is unnecessary to speak here: the cut, exhibiting Mr. Coste's view (see Fig. 50), will ex- plain the matter with sufficient clearness. 218. Various attempts have been made to demonstrate the muscular fibres of the womb, and they have been divided into layers, and planes, and fasciculi for that purpose: but the very fact of such difference of opinion is proof enough that the arrangement of them is not yet clearly known. If it were known and demonstrable, there would no longer exist any dissidence concerning it, since whatever is clearly demon- strable, ceases to be a subject of dispute or doubt. This much, at least, is well known; namely, that the contractile fibres of the womb are capable of acting partially, or so as to change the form of one part of the organ, while another part of it acts with less intensity, or not at all. Thus, it occasionally happens that we find the uterus, after THE EXTERNAL ORGANS. 105 delivery, contracted in its middle, as if a string had been passed round it and drawn tightly, causing it to assume the shape of the hour-glass. This state is familiarly denominated an hour-glass contraction. Again, we not unfrequently find the whole organ elongated, and almost of a farciminal form; its fundus being raised high upwards, towards the epigastrium, while the body of it is narrow or slender like an intestine. I feel assured that I have sometimes found it. after delivery, full nine or ten inches in length, and not more than four inches in transverse diameter, estimated by feeling it through the relaxed integuments of the abdomen. These circumstances prove that the uterine fibres which affect the conjugate diameter of the organ may act with force, while those which affect its longitudinal diameter are either in a state of repose, or of very slight action; which leads us, as I think, to the inference, that the longitudinal and horizontal fibres are separate and independent organs or parts of the uterine struc- ture. The annexed cut (Fig. 39), from M. Chailly's "Midwifery," gives a view of an arrangement of muscular fibres which seem to converge upon the tubes and round ligaments. Let the Student conceive of a separate, non-coordinate action in these fascicles of muscles, and he will perceive that such action might greatly embarrass a labor in which the contraction ought to be consentaneous and co-ordinate for the whole muscular apparatus of the organ. 219. If this be a just view of the case, it will serve for the explana- tion of occurrences in labor that would otherwise embarrass us not a little. For example, we find the woman in travail sometimes suffering under the most intense pains, and making the greatest efforts without the smallest profit; and that, too, where we know certainly that the pelvis is of the amplest dimensions. What can be the cause that the child does not advance under such vigorous efforts? We find that the head is positively stationary, notwithstanding the healthiest pelvic conformation, a sufficient dilatation of the uterus, and violent labor pains. We are at once satisfied, and relieved of anxious doubts when we reflect that the horizontal or transverse fibres are active, and the longitudinal or perpendicular fibres inert. There is a failure of co-ordination in the movements, and our duty will be clearly seen to consist in endeavors to restore the synergy of contractile effort. 8 106 THE EXTERNAL ORGANS. 220. As this circumstance generally results from some degree of local or constitutional irritation, the former occasioned by tedious or violent labor, rheumatism, officious intermeddling, or the direct stimu- lation of ergotism; and the latter by a too susceptible nervous system; by repletion, mental emotions, or vain efforts of labor long continued; it appears that, in the former case, we ought to resort to the tranquilliz- ing influences of laudanum clysters, cool air and drinks, and abstinence from impertinent handlings; whereas, in the latter, we may apply to the lancet, to a Dover's powder, to portions of morphia, or the black drop or opium, or the bath—after evacuations have been procured from the bowels by emollient and laxative injections; and that we ought to give orders for a full and free ventilation, and the use of suitable drinks. But if it does sometimes happen that the movement of the horizontal fibres is inordinate, or in excess, it fortunately hap- pens in the vast majority of cases that the powers of the longitudinal fibres are the greatest. The ovum being contained entirely within the uterus, it appears that it can only be expelled by the fundus approaching the os uteri; or, in other words, by the shortening of the womb that results from the contraction of its longitudinal fibres. Let us remember that the womb is attached to the upper end of the vagina, and that the ovum, in passing out from the uterus, must necessarily traverse that canal; it will then appear that the first contraction of the longitudinal fibres will tend to pull the circle of the os uteri open at the same time that the point of the ovum is insinuated into the enlarging orifice. This opening or dilatation of the orifice does not take place without resistance, which is chiefly perceptible, however, in the early stages; for we find that while the fundus and body of the womb are vigorously condensed during a pain, the cervix also is strongly contracted, but less and less vigorously as the dilatation be- comes more considerable; so that, indeed, it is not rare, at length, to perceive the whole circle of the cervix suddenly yield, as if without opposition, to the greater power of the longitudinal fibres. The cir- cle of the os uteri is, as it were, pulled upwards, towards the fundus uteri, by the muscular expulsive powers; and indeed it seems to be stripped over the lower segment of the ovum, over the head, or over whatsoever presenting part. I have known the whole dilatation to take place during a natural sleep. 221. Some women require only a few pains to complete the dilata- tion, whereas others suffer hundreds of pains during several successive days, before the circular fibres are conquered by the protracted efforts of their antagonists, the expulsive ones. From thirty-five to fifty are probably the average number of pains felt by parturient women. THE EXTERNAL ORGANS. 107 If four hours be a mean of the duration of labor, then the woman will be likely to have pains at the rate of one every ten minutes for the first hour—which would be six pains. She would probably have ten pains in the second hour, fifteen in the third hour, and twenty pains in the fourth and last hour of the process—say, in all, about fifty pains. While the generality of cases are so favorable, that there are multitudes of women who have not more than three or four; whereas some of them suffer from the repetition of two hundred contractions, and even a greater number than that. 222. A considerable experience and trained habits of observation are necessary to enable a practitioner to prognosticate the moment of delivery, making up his judgment from the intensity of the pains of expulsion, as compared with those of opposition or retention. It is certain that no man, be his experience ever so great or his discrimi- nation ever so acute, can with absolute certainty calculate upon the moment when any given labor shall be brought to a conclusion, since no one can absolutely predict what shall be the exact degree or in- tensity of any muscular effort, which, as it is a vital operation, so it is dependent on causes beyond our foreknowledge or perfect control. Young and inexperienced practitioners ought, therefore, to be very late in announcing their prognostic of the end of labor, as to time. 223. I have remarked that, as the longitudinal fibres pull the os uteri open, the apex of the ovum is inserted into the aperture: with each succeeding pain additional portions of the ovum pass into the os uteri and through it, until, at last, the fundus having approached very near the cervix, the whole of the ovum becomes excluded from the uterine cavity, after which the same longitudinal and horizontal fibres, meeting with no further considerable resistance, act in concert, and thereby reduce the womb down to a very small size. It returns, but slowly, to the non-gravid condition. From fifteen to thirty days are required to effect this reduction. Let it be remembered that the womb is capable of contracting equally upon an ovum at term, and upon an abortion at three weeks. 224. The planes of the ischia are three and a half inches long. The womb is two and a quarter inches in length: when it occupies its proper place in the pelvis, the top of it is not so high as the top of the ischium ; in other words, it is lower than the plane of the strait; but the point or oe uteri sinks low down towards the bottom of the pelvis. The womb does not occupy the same place in the pelvis when the bladder is full that it does when that organ is empty; but retreats when the bladder is filling, and comes forward when it becomes empty again; hence the organ is scarcely ever at rest in the same place. 108 THE OVARIES. This movableness, and constant change of place, often result in the injury or weakening of its ligaments, particularly its round ligaments, which in some women become so much stretched by an over-fulness of the urinary bladder, that they fail to contract, and so, let the fundus uteri fall downwards into the hollow of the sacrum, until the womb is quite overset, backwards, which makes a case of retroversion of the womb. 225. When the womb is retroverted, and continues so for months or years, the os remains all the time close to the symphysis pubis; and at last the anterior column of the vagina condenses itself so as to accommodate its length to the actual short distance from the cervix to the symphysis. If it be reposited, and an attempt be made by means of a globe pessary to restrain it from falling over again, the attempt frequently fails and the instrument falls into discredit. The cause of the failure is in fact in the contracted, condensed elastic anterior column of the vagina, which slowly, but surely, pulls the cervix over the top of the pessary, to bring the os back again close to the symphysis; and then the anterior column having come to a state of rest, as to its contractility, there is room enough to allow the fundus to sink again into the recto-vaginal pouch or Douglas's cul-de-sac. In old cases, therefore, the ordinary pessary will not answer; but they are always curable by means of a ring pessary, of proper construction; for, when the posterior segment of such a ring is lodged in the posterior c u 1 - d e - sac of the vagina, and the anterior segment behind the symphysis, it is clear the os cannot come forwards again, nor the fundus fall down backwards. CHAPTER V. THE OVARIES. 226. The ovaries are organs for the preparation of ova, or eggs which contain the germ of the offspring. In the mammals, there are two ovaries, within each of which may be seen, with a good lens, from twelve to fifteen eggs, or yelks, inclosed within their proper capsules or ovisacs, which are commonly called Graafian follicles or ovarian follicles. They were some time since denominated Graafian ova— because De Graaf imagined that these pellucid bullae were the ova of the animals in which they were seen by him. Let the Student early make the discrimination between the follicle, the cell, or ovisac which THE OVARIES. 109 contains the egg, and the minute egg itself, which is too small to be readily seen by the naked eye. The human ovary is about an inch in length, half an inch in depth, and more than a quarter of an inch thick; in shape, it is like a flattened olive. Each ovary is attached to an angle of the womb—one on the right and the other on the left. It is connected with the uterus by a short footstalk of a fibrous struc- ture, which is called the ligament of the ovary. The ovaries lie behind the Fallopian tubes, inclosed in a duplicature of the peritoneum, that adheres firmly to the proper covering or coat of the organ; so that the ovary is invested by a serous membrane or indusium, as the liver, stomach, or intestines are. 227. Underneath the serous covering lies the strong white fibrous coat, or tunica albuginea, which is a closed sac containing the stroma, the peculiar tissue of the organ. There is thus no proper excretory duct for this organ; nevertheless, the Fallopian tube becomes, upon occasions, the vector of its product. The connection of the vector tube with the organ exists, in all probability, only during the few moments of the sexual excitement, or orgasm. In the embryo, however, as late as the sixth month, the end of the Fallopian tube is permanently attached to the ovarium—before the seventh month, the connection is broken. (See Rosenmuller, " Quaedam de Ovariis Embryonum et Fcetuum Humanorum," p. 11.) I have a specimen of foetus at the sixth month, in which the detachment has not taken place. 228. The stroma of the ovary, with which the closed sac of the albuginea is filled, is a peculiar concrete, consisting, apparently of a rather dense cellular tela, of a salmon color. Throughout the stroma are to be seen numerous delicate arterioles and venules, that are the distal branches of the ovaric artery. It is worthy of observation, that the blood of this circulation is brought from a great distance, since the ovaric artery arises for one side from the emulgent, and for the other from the aorta itself. As the ovaries, like the testicles in the male, are originally formed high up in the abdomen, near the kidneys, an economical purpose was answered by deriving their circulation from these sources. Whether there be any further and peculiar eco- nomical end to be attained by drawing this blood from such a distant point, remains unexplained. 229. If the tunica albuginea of an ovary be divided with a scalpel, the stroma may then be readily torn asunder by pulling the edges of the incision apart with the fingers. The ovary of a mammal, when examined for the purpose, exhibits several watery vesicles, whose trans- lucency renders the largest of them visible through the indusia or coats of the organ. By cutting the ovary open, and carefully dissecting 110 THE OVARIES. them out, these vesicles or bullae may-be completely freed from all attachment, when they appear as globules filled with water, and of sizes varying from the bigness of a garden pea to that of a small bird-shot. In each ovary may be counted some fifteen of these vesicles. 230. These Graafian vesicles—for so they are usually denominated —are also called Graafian follicles, Graafian cells, Graafian ova, and ovarian follicles. They are ovisacs. .They are composed of a double membrane, one inside of the other. The outer or largest one, is united to the smaller or inner one, by a very delicate cellular bond, or magma, which, if infiltrated, serves to compress and crush the inner, while it distends and expands the outer coat or sac. Hence, if the outer sac should thus be greatly enlarged, the inner one would at the same time be crimped or corrugated, so as to give to the inner surface a convo- luted appearance. If a Graafian vesicle be punctured with a lancet, there spirts out, through the cut, a drop of water. This drop of water, when collected on a glass or knife-blade, and placed under the micro- scope, is found to consist of a pellucid liquor, in which swim a great number of small grains. Among these grains there is a portion or acervulus, in which the grains are agglomerated in greater number, and, in the midst of these, a yelk-ball is found. 231. Fig. 40 represents this yelk-ball, bounded by a white, trans- parent zone, which is called its zona pellucida. It is a perfect sphere, filled with vitellary corpuscles, oil globules, and puncta that swim in a transparent liquor. The sphere or yelk-ball lies amidst the cumulus of granules before mentioned, as may be seen in the figure taken from Rudolph Wagner's "Prodromus." It is outside of, or beyond the white zone or zona pellucida, that are to be seen the smaller granules of the cumulus or acer- vulus, so that the globular ovum above represented is bounded by the transparent or white zone. These outside granules are some remains of the granular membrane that lines the inner concentric membrane of the Graafian follicle. 232. Perhaps the physiologists go too far in calling it a granular membrane. It consists of innumerable grains that settle themselves, touching each other, upon the inner wall of the vesicle, like sediment in a vial, or lees in a cask of wine. I do not deny that they deposit themselves thus under the forces of a vital affinity, and it is even pro- bable that they do so; but whenever the vesicle is punctured, this so- THE OVARIES. Ill called membrane becomes decomposed, and floats out as loose grains along with the yelk-ball; great multitudes of them adhering to it; many being entirely disconnected, while some of them stick together in laminae, or clusters, or acervuli. This granular membrane, or tunica granulosa, is thickest, in general, at that segment of the Graafian vesicle which is nearest the surface of the albuginea, and there it forms a small heap—an acervulus or cumulus, which has been by Baer called the cumulus proligerus or discus proligerus. It is in the apex of this cumulus or cone that the egg is found, and it is generally among the debris of this acervulus that the microscope reveals the yelk, with its bright pellucid zone. 233. Upon referring again to the above figure, the Student will see that in the yelk-ball, amidst its vitellary corpuscles, there is pictured a clear, transparent, oval vesicle, with a dark spot upon it. This is the germinal vesicle, sometimes called Purkinjean vesicle, and the dark spot is the germinal spot, or maculae germinativae of Rudolph Wagner, which M. Coste calls the tache embryonaire. 234. Such, in general terms, is the human ovary, which, I repeat, consists of a closed sac, filled with ovarian stroma in which are de- veloped ova within ovisacs usually called Graafian follicles. These ova are true yelks, about one-fifteenth of a line in diameter. In each unfecundated yelk is a germinal vesicle one-sixtieth of a Paris line in diameter, and having upon its inner surface a germinal spot consisting of dark granules—the germinal spot being one-two-hundredth or one- three-hundredth of a line in diameter. I have many times observed the numerous granules, or dark puncta that may be inspected by plac- ing thin slices of ovary on the field of a microscope. There are im- mense numbers of these points, which are, by some, supposed to be nuclei, or cytoblasts—the inchoate elements of ovarian ova. Such is the opinion of Martin Barry, who gives, in his papers published in the " London Phil. Trans.," drawings of these appearances in the ova of various animals. Gerber's Anatomy also contains a plate represent- ing this microscopic view. If this notion be indeed founded in truth, then each ovary should be held to contain, not fifteen ova only, but the nuclei of hundreds of thousands of them. Perhaps, however, the microscopic view is not correct, and these points are acini of the gland, if the ovary is a gland. Supposing them to be acini, and that an acinus may, by some physiological act, be cast off' from its connec- tion with the stroma that produced it, and carry away with it, like an inoculated bud or like a spore, or a pollen grain, the metabolic and the plastic forces—by which to develop the ovarian ovule—still we 112 THE OVARIES. have, in either case, the idea of a reproductiveness in creatures beyond imagination for copiousness. 235. The ovaries are abundantly supplied with nerves derived (Longet, t. ii. 543) from three or four branches that come off' from the renal plexus, and proceed in company with the ovaric artery, to the place of distribution. They are called the ovaric plexus, and distribute their terminal fibrils within the ovary, and in part, also, upon the uterus, thus connecting the two organs in a common bond of sympathies. 236. Regner de Graaf, of Delft, in Holland, where he died at the age of thirty-two years, on the 17th of August, 1673, published his work "De Mulierum Organis Generationi Inservientibus" in 1672, and gave, as I have said, his name to the ovarian vesicles, or ovi-capsules. They were by him considered to be ova, and were long, and even until lately, by many, regarded as ova; for no one, until recently, had acquired any correct notions of the ovum of the mammiferas. At p. 181, he says: "In cuniculis autem, leporibus, canibus, porcis, ovibus, vaccis et reliquis animalibus k nobis dissectis, ea vesicularum ad in- star, ut in avibus ovorum germina solent, sese dissecantium oculis ex- hibent; quae in Testiculorum superficie existentia, communem tunicam hinc inde sublevant, atque ita per earn aliquando transparent ac si brevi exitum minarentur." His 15th plate represents the follicles as "ova." They are not ova, but merely ovisacs. 237. It is a title to immortality in the Republic of Letters, to have discovered the ovum of the mammal, and there has been a great con- tention as to the priority in this claim. It appears to me that, although one person may have first seen the object, so many individuals have been concerned in establishing and explaining the natural history and physiology of the fact, by laborious researches and patient efforts of reason, that no single person should be deemed entitled to all the credit: and it is certain, that the world is too much indebted to divers persons on this account, not to be willing to divide the honors of the career among many claimants. I feel no inclination to enter in favor of any particular person the lists of this controversy, in which I have no other than a common interest of gratitude to all the ingenious philosophers who have in this illumined my therapeutical path with floods of radiant light, freeing me from the errors and gropings of my blind predecessors, and enabling me clearly to perceive, and plainly understand many mysteries of physiology and therapeutics that were utterly hid from their eyes. But the Student of medicine ought to be somewhat acquainted with the literary history of the subject, lest he wander, and be wholly lost among authorities that have now ceased to have any claim to his obedience. Let him. therefore, understand that THE OVARIES. 113 a meeting was held at Breslau, in Silesia, in the year 1825, in honor of the fiftieth year of the Doctorate of Professor Blumenbach. At that meeting was presented a volume under the following title: "Joan. Fried. Blumenbachio, etc. Summorum in Medicina honorum semisaB- cularia gratulatur ordo medicorum Vratislaventium, interprete Joanne Ev. Purkinje. P. P. 0. Subjectae sunt symbolae ad ovi ovium his- torian! ante incubationem: cum doubus lithographis. Vratislaviae, Typis Universitatis." This volume was printed in September, 1825, but was not published, being designed only for private distribution. An edition of it was afterwards published for sale at Leipsic, in 1830, 4to., of which a copy is now before me. I look upon Professor Pur- kinje's book as the first in the series of the works of reform as to our knowledge of the ovaria. This is the work in which was first made known the existence of the germinal vesicle, commonly called the Purkinjean vesicle of the bird's egg. 238. Professor Purkinje had interested himself in the investigation of the cicatricula, or tread of the hen's egg. He was examining it in a vessel of water in order to learn the nature of the cumulus that lies directly underneath the cicatricula, and of which Fig. 41 is a repre- Fig. 41. Fig. 42. sentation. It has been very beautifully produced on wood by Mr. Gihon, from the original lithograph. 239. While, with a pair of dissecting needles he was tearing the yelk asunder under water, and removing the broken-down masses with a pip- ette, became upon a "most beautiful vesicle," partly adhering to the margin of the pore in the apex of the cum ulus, and partly detached from its bed therein. His own words are: "Haec dum lente ope per- lustro, vesicula formOsissima parte mar- gini pori adhaerens, parte libera haud parum mirabundo mihi offertur." Fig. 42 exhibits this appearance. The cavi- ty in which this Purkinjean, or germi- nal vesicle (the first that was ever seen), is contained, is represented by Pur- kinje as in the annexed cut, Fig. 43, also copied from his lithograph. 114 THE OVARIES. It is a cross section of a portion of the yelk-ball and the cumulus, with its cavity, in the hollow of which was found the Purkinjean vesicle. The transparent vesicle thus revealed is almost as delicate in its structure as a soap bubble. It can be found only in eggs that have not been fecundated, such as the pullet's egg, or yelks taken out of the ovary, in which, according to Von Baer, it exists, even in the very smallest yelks. Fecundation abolishes it. 240. The Student has now a clear understanding as to the germinal or Purkinjean vesicle, discovered and made known in September, 1825. This Purkinjean vesicle is the germinal vesicle that is found inside of the unfecundated yelk, whether of birds or women or other animals. 241. The next publication in the order of important discovery, was the "De ovi Mammalium et Hominis Genesi. Epistolum ad Academiam Imperialem scientiarum Petropolitanam, dedit Carolus Ernestus A. Baer. Zoologias Prof. Publ. ord. Regiomontanus, cum Tabula Aenea. Lips. 1827, 4to." Such is the title of Von Baer's letter to the Imperial Academy of Sciences at St. Petersburg, on the subject of the ovum of the mammiferous quadrupeds. In Von Baer's experiments, he, like Purkinje, never could find the vesicle in eggs already laid, but always detected it in even the smallest yelks of the egg bag. He supposes it to be the nucleus around which the matter of the yelk becomes sub- sequently aggregated. This was the case also in the molluscs, in the lumbricus and in the leech.' These researches led him to the discovery of the mammiferous ovulum, in the following manner. Having ob- served a very minute ovulum in the Fallopian tube of the bitch, and reflecting that such small ova could not consist of Graafian vesicles, which are much larger, and that the liquor of the Graafian vesicle could not so soon acquire the firmness and solidity of the tubal speci- men, he was led by curiosity, rather than by the hope of seeing with the naked eye through the several coats of the Graafian vesicles any ovula in the ovaries, to open one of the follicles with his scalpel, and placing the fluid that came forth upon the platine of his microscope: "Obstupui," says he, "profecto, cum ovulum ex tubis jam cognitum, tarn clare viderem, ut ccecus vix negaret. Mirum sane et inexpecta- tum, rem tarn pertinacitur quaesitam, ad nauseam'usque in quocunque compendio physiologico uti inextricabilem tractatum, tarn facillimo negotio ante oculos poni posse." P. 12. He informs us that this ovu- lum may, in some specimens of the ovary, be seen through the coats of the ovi-capsule. Everybody seems willing to concede to Von Baer the honor of this discovery, which was effected two years later than that of Purkinje, viz., in 1827. But, notwithstanding his good fortune as the discoverer, he is not the true expositor of its nature, for he mis- THE OVARIES. 115 took the ovulum or yelk for the Purkinjean vesicle, and he says: "Demonstrabo enim mammalium ova vesiculis Purkinji reliquorum animalium comparandas esse, quas in animalibus nonnullis, molluscis, acepalis v. c. et lumbricis ovorum evolutionem antecedere clare me vidisse puto;" that is to say, "he will show that the mammal ovum is to be compared with the Purkinjean vesicle in other animals, and that the evolution of it precedes that of the ova in certain molluscous crea- tures, as he supposes to be verified by his observations." At p. 32, he argues the identity of the nature of the Graafian ova and the ova of birds and spiders, which have a great quantity of vitelline corpus- cles and but little liquid, while the Graafian ova bear but few corpus- cles and much albuminous fluid. "Besides, they resemble eggs in possessing a vesicle situated in a cumulus, and surrounded with a pro- ligerous layer. Therefore, a Graafian vesicle, in view of the ovary, and in general, of the maternal constitution, is the true ovum of the mammal. 'Vesicula ergo Graafiana cum ad ovarium genera- timque ad corpus maternum respiciamus, ovum sane est mammalium.'" Von Baer, notwithstanding the tyranny of the schools, almost saw the real truth; for he remarks upon the fact, that the whole Graafian ovum cannot, as in birds, be transferred to the vector tube. "Hence in mammals," says he, "the inner vesicle (the true ovum) contains a richer vitellary matter, and as to the evolution of the foetus, it certainly proves itself to be a true ovum." In saying this, he was nearly free from the shackles of his scholastic prejudice. They were strong enough, however, to cause him to write of the ovulum, " Ovum fetale dici possit in ovo materno. Mammalia ergo habent ovum in ovo; aut si hac dicendi formula uti licet, ovum in secunda potentia." The Stu- dent, in reading the above, will candidly admit Von Baer's claims, though he will perceive how checked he was by the bonds of an old way of thinking. After all, the egg within an egg was, in his eyes, the true, separate, independent yelk-ball of the mammal. The ovum of the bitch is ^th to ^th of a Paris line in diameter, according to Von Baer. 242. Now notwithstanding M. Von Baer, as by the foregoing ap- pears, is the discoverer of the mammal ovum, it is not doubted that Messrs. Prevost and Dumas had seen it in 1825—the year in which Purkinje detected the germinal vesicle. They, on two occasions, turned out and saw the ovulum of the Graafian ovi-capsule in the rabbit. Yet, the glory is Von Baer's. 243. As to the history of the Purkinjean vesicle in the mammal ovule, it appears now to be settled that the honor of its discovery belongs to Professor Coste, of the College of France, though 116 THE OVARIES. several Germans have attributed it also to Von Baer. M. Coste, in his " Histoire Ge'nerale et Particuliere du DeVeloppement des Corps Organises," says: "I was at first accused of having copied M. Baer; but, inasmuch as the opinions I had set forth were diametrically op- posed to those of that great physiqlogist, the public early did justice to a reproach so unfounded, and the improper criticisms of Mr. Robert Froriep were promptly repelled by Bernhardt himself, in his inaugural thesis, ' Symbolae ad Ovi Historiam,' p. 25. This reproach having been set aside, an attempt was next made to bestow upon others the credit it was impossible to assign to M. Von Baer. It was pretended that the discovery was made at the same time, o r nearly at the same time, byM. Coste in France, M. Bernhardt in "Germany, and Mr. T. Wharton Jones in England. As to M. Bernhardt, it is enough for me to refer to that author's preface, in which he declares that his experiments were instituted for the purpose of ascertaining the cor- rectness of my observations. Mr. Jones's publication is later by one year than mine; a statement that might suffice for the present occasion, were it not that that physiologist has himself fully recognized my rights as to the priority of discovery, in his report on Ovology in the ' Brit, and For. Med. Review,' No. 32, 1843, a paper in which he lays no claim to it himself, but attributes it to me." Thus far M. Coste, whose remark as to Bernhardt's preface is correct, as well as his cita- tion of Mr. Jones's paper. 244. Mr. T. Wharton Jones's words are as follows: " By the dis- covery of the germinal vesicle, in the mammiferous ovarian ovum, the complete analogy between the latter and the ovarian ovum, of the bird, &c, was established, and Baer's error regarding it dissipated. The correct view of the matter had been suspected by Purkinje, but he and Valentin had in vain searched for a germinal vesicle, and it was only on renewing their investigations, after the announcement that such a vesicle had been discovered in the rabbit's ovum by M. Coste, that they, Wagner and others in Germany, were successful in finding it. M. Coste, therefore, as Bischoff observes, must, notwithstanding his very imperfect description and delineation of the germinal vesicle, be con- sidered as its first discoverer." This, it appears to me, is enough to enable the Student to see clearly the whole case; and I shall not fur- ther cite M. Coste, in his warm reclamations against M. Bischoff of Giessen. 245. It is much to be regretted that, amidst the tranquil pursuits of letters and philosophy, there should arise occasions for reproach—the more, as so much honor always remains to be shared by the diligent members of the Republic. The world is very ready to acknowledge THE OVARIES. 117 the services and merits of all those wise, learned, and good men, who, like Purkinje, Baer, Coste, Wagner, Jones, Pouchet, and Bischoff, have in their publications endowed mankind with riches impayable. 246. The discovery of the mammal ovum was rendered complete by the detection, in 1830, of the macula germinativa or germinal spot, which is diversely attributed to Professor Rudolph Wagner and Mr. T.Wharton Jones; and it may be esteemed a conceded point that it was contemporaneously observed, as it was contemporaneously de- scribed, by those gentlemen in Germany and in England. The ger- minal spot is, by Wagner, in his " Prodromus Histories Generations Hominis atque Animalium," page 4, called " primitive Keimschicht" and "maculae-germinativae." Professor Wagner, in a note, page 44, Part I., "Elements of Physiology," says: "I was myself the first to discover the germinal macula. I also described and figured the whole ovum in its successive stages with greater care and sequence than had yet been done." Wharton Jones says: "At one side of the germinal vesicle there is a small, round dark spot, discovered and described contemporaneously by Rudolph Wagner and the author of this report." (" Brit, and For. Med. Review," 1843, p. 517.) The germinal spot is from one-two-hundredth to one-three-hundredth of a Paris line in diameter. It consists of a collection of grains. Wag- ner's words, "Prodromus," p. 4, are: "If the germinal vesicle in man and in the mammifers be carefully examined with the microscope at four hundred or five hundred diameters, there will be seen in one part of the vesicle a dark round spot." In this way, he found it in mammals, birds, scaly amphibia, cartilaginous fishes, arachnids, certain crustace- ans, all mollusks, conchaceans, echinoderms, medusans, and polyps. Upon a more minute examination, under still higher powers, there is seen a compressed orbicular stratum of a lenticular shape, composed of minute molecules, closely agglutinated in form of an acervulus, &c. &c. This granulous germinal stratum appears to Wagner to be the true living animal germ, existing antecedently to the act of impregna- tion. " Hoc stratum granulosum germinativum, germen animale verum et vivum jam ante praegnationem praeformatum esse videtur." 247. Having now laid before the Student this account of the ovary, I shall annex a copy of M. Coste's magnified view of the ovarium from his grand atlas. In that superb plate, the figure is ten inches in its greatest diameter. Mr. Gihon has reduced it to this size. It was ne- cessary to make it not more than four inches in diameter. M. Coste's intention was not merely to exhibit the shape of the ovary greatly magnified, but to show by an incision the internal structure of it, and the various phases of the ovarian ova and their ovi-capsules during their 118 THE OVARIES. maturation and the dehiscence and evacuation of the follicles. It is the left ovarium that is represented. The expanded fimbria p, of the Fallo- pian tube p, is seen at the lower and right extremity of the drawing. Near this angle is seen a Graafian follicle v, the dehiscence or rupture of which has allowed a yelk, surrounded by its proligerous disk or cumulus, to escape. The opening has taken place through the tunica albuginea and the peritoneal coat, and the ovule marked ce is still rest- ing upon the exterior surface. Just above it is seen another less ma- ture vesicle v, and a still smaller one above that, while farther to the left is a very small one. The line of incision passes, near its lower angle, across a pretty large and superficial follicle, one-half of which is Fig. 44. seen through the coats of the ovary, while the other half is quite un- covered by the dissection, which laid the organ open to view. To the right and upwards from this point is seen an emptied Graafian cell v, in which e is the outer surface of the whole cell. At v is the point of dehiscence, through which the egg escaped. This Graafian cell con- sisted of two coats or membranes, one contained within the other. The broken laciniae of the double ovisac are seen at the upper end, THE OVARIES. 119 near the margin of dehiscence, where they are marked g and i. These two coats are better represented in the follicle at the upper and left extremity of the cut—in which their floating and distinct mem- branes are seen at e and at i, whereas g indicates the granular deposits upon the inside of the follicle, which is called the tunica granulosa, or granular membrane. This granular membrane is so little tenacious that upon puncturing and compressing a cell, it flows out with the water, and appears upon the microscope as a collection of innumer- able grains, that are probably cytoblasts. Very near the superficial segment of this ovarian ovisac is seen the ovulum inclosed within its proligerous cumulus. 248. In order that the Student may here have a more complete idea of the ovary, I repeat the figure 45 of the human egg, taken from Rudolph Wagner's Fig. 45. "Prodromus Histor.Generationis," in which is seen the pellucid ring, surrounding and inclosing a quantity of yelk corpuscles, among which, near the top, rests a trans- parent vesicle with a dark spot upon it. The pellucid ring is the zona pellucida of the egg, outside of which is a quantity of thegranulous membrane that always comes out of the Graafian follicle sticking to the pellucid zone. It is necessary to remark that this figure is greatly magnified, for a very strong sight is required to enable any one to see without a lens an egg, whose diameter is but the twentieth of a Paris line. The grains inside of the pellucid zone are grains of yelk—they are the vitellary corpuscles. They are yelk, true yelk, like that of a bird's egg. The oval transparent vesicle within them is the germinal vesicle, and the dark spot upon that vesicle is the macula germinativa—germinal spot or tache embryonaire. If the Student will look upon the germinal spot as the nucleolus, the germinal vesicle as the nucleus, and the vitellary membrane as the cell, he will have an idea of a true independent cell, possessing the metabolic and plastic forces that can enable it to develop itself wher- ever the proper cytoblastema, or pabulum, is afforded to it for that purpose—i. e. in the ovary, the tube, or the womb. 249. The production within the ovary of an ovum containing within it a germ, possessing, after its fecundation by the male, the power of evolution solely in the direction and dimensions of its own genus and species, is one of the most mysterious and wonderful works of God; one well fitted to overwhelm the mind with astonishment and make 120 THE OVARIES. us feel amazed at the vastness and the indispensableness of those forces that are communicated by a Divine power to the simple and microscopic elements of the macula germinativa. Burdach, in his " Physiology," t. i. 87, speaking of the tubular ovary in which the materials of yelks are secreted in the cavity of the ovaries, in order to become ova, presumes this to be the mode in which ova are formed in all the insects, in most of the inferior crustaceans, in worms, and in certain mollusks. " Moreover," says he, "there is not the least doubt that the substances of which the egg is composed, acquiring through the influence of the ovary their aptitude for a more elevated range of life, or already possessing it, tend partly also of themselves to take on a determinate form." Is it a new creature that is formed out of the macula germinativa ? is a question that has often been asked; or is it a propagation and continuation of the old or parent substance ? M. Huschke propounds that the ovary is an aciniferous organ, and that the germs of the offspring are acini, which, under a physiological law, become deciduous, but carry away in their fall the vitality and accom- panying forces that enable them to continue, after their separation, the pre-existing career of life development. I do not feel myself competent to speak with authority upon this proposition; I shall only state that very numerous and careful microscopic examinations of the ovarian stroma have not exhibited to me any evidences of the aciniferous nature of that substance; wherefore I am the more inclined to adopt the opinion of the cytoblast character of the germ point. 250. The Corpus Luteum.—Before I conclude my remarks upon the ovary, I ought to say something on the subject of the corpus luteum, a topic that has elicited an immense amount of discussion, and which still, perhaps, must remain a vexed question. Perhaps the principal interest that society has in the settlement of this question is one of a medicolegal nature; for although inquiries in this direction, of a medico-legal character, have not, so far as I am aware, led to any judicial decisions, I can conceive that important rights and interests might depend before a tribunal upon the views to be held as to the nature and interpretation of that singular product. The corpus luteum, or yellow body, is a peculiar substance found in the ovaries of animals that have lately passed through the rutting season, and in women that have lately been affected with their menstrua, or that have become pregnant. In some preg- THE OVARIES. 121 nant women, the corpus luteum is either very small, or not readily discernible. In others, it attains a large size. In the cow, the corpus luteum (vide Fig. 46) is sometimes half as large as the ordinary ovary. It has been regarded as a sure sign of fecundation. I regard it as a sign of a finished ovulation. 251. On the 18th December, 1846, I made to the American Philo- sophical Society a verbal communication, setting forth certain views I had entertained as to the vitellary nature of the corpus luteum; and on the 15th January I read a memoir upon the subject, which was pub- lished in the "Transactions," 1847, p. 131. In that communication I stated that, since the date of my first verbal memoir, I had carefully made researches both with my Chevallier's microscope and by other methods, as to the comparative appearances of vitellary matter taken from the egg, and matter procured from fresh corpora lutea. These renewed researches leave me very fully convinced that the yelk of eggs, and the yellow matter found in a corpus luteum, are of the same apparent structure, form, color, odor, coagulability, and refractive power. Having placed a small quantity of yelk on the platine, and just before I had brought the object into the focus, I have been struck with the appearance of the transmitted light; a bright yellow, which fills the whole tube of the instrument. When I have, in like manner, placed a bit of fresh corpus luteum, of the cow or sheep, on the com- pressor, and have crushed it, by turning the screw, I have found the tube filled with the same tinted light, before obtaining the focus. A portion of yelk placed beneath the objective, exhibits numerous granules, corpuscles containing a yellow fluid, and oil-globules, mixed with a quantity of punctiform bodies. Upon turning the screw of the compressor on a small lump of corpus luteum, carefully dissected out from its indusium, there is seen to escape from the crushed mass a quantity of granules, corpuscles filled with yellow fluid, oil-globules, and punctiform bodies swimming in a pellucid liquor. The appear- ances observed upon examining a portion of yelk and a portion of corpus luteum, are so similar that it would be difficult, I think, to discriminate between them, but for the exception, that along with the vitellary corpuscles and granules and globules of the yellow body, there will be found floes of laminated cellular tela, blood-disks, and other detritus of the organ, destroyed by the compressor. The trans- parent corpuscles transmit a yellow light, whether observed singly, or in clusters, or acervuli. The same is true of the corpuscles of the yelk. On crushing a bit of corpus luteum with the compressorium, there escapes much granular matter that accurately resembles the granules of the granular membrane, the proligerous disk or the 9 122 THE OVARIES. retinacula of the Graafian follicle. This is the case even when great precaution has been used to procure the bit from the outer superficies of the corpus luteum—avoiding to take any portion that might have touched the inner superficies of the crypt left by the escape of the ovulum. The similarity in the appearances leads me to suppose an identity of nature and origin. I think no person accustomed to the use of the microscope could detect any difference between the mole- cules pressed out of a bit of corpus luteum, and those that escape from a crushed mammiferous ovule, or the yelk of an egg, excepting the debris or detritus before mentioned, which is plainly referable to the destructive power of the compressorium. I have so many times examined the mammiferous ovulum that I suppose myself quite com- petent to compare its contents with those of the corpus luteum, and with common yelk. I hope I am entitled to say, that the coloring matter and the chief constituent bulk of a corpus luteum, is a true vitellary matter, deposited outside of the inner concentric spherule, or ovisac of the Graafian follicle. For the proof of the truth of this opinion, I refer to the future obser- vations of the micrographers, who will be able to confirm or to confute my statement. There is not, so far as I know, any author who has taken this view of the constitution of the corpus luteum—though that substance has been the fruitful topic of elaborate research and hypo- thesis, owing to the interest connected with it both in a physiological and medico-legal relation. 252. Previous to the year 1825, when John Evangelista Purkinje fortunately discovered the germinal vesicle of the unfecundated egg ; and down to the year 1827, when Ch. Ern. V. Baer detected the mam- mal ovum, whose germinal vesicle was detected by Coste; and the year 1830, when Rudolph Wagner ascertained the existence of the Keim schicht, or macula germinativa, all notions and opinions on the mammal ovum maybe set down as naught—since the opinions of the learned are now based on the discoveries just mentioned, which have led to a complete revolution in many most important construings of physiological action, and therapeutical indication and treatment. 253. It would be bootless, therefore, to ask what the writers of an earlier date than 1825 may have supposed upon the subject of the corpus luteum. Dr. Carpenter, John Miiller, Thomas Schwann, Henle, and Huschke, have not hinted at the vitellary nature of the yellow body. Dr. Henle, in his "Algemeine Anatomie," says: "So weiss mann namentlich, wie die Grafschen Blaschen, im folge der congestion welche den fruchtbaren beischlaf folgt, erst anschwellen und den platzen, wahrend sie zugleich von Blutt angefullt werden, welches sie THE OVARIES. 123 almahlig entfarbt, organisirt, und in eine narbensubstanz verwandelt, die zuleszt verschwindet."—P. 894. In this paragraph, Dr. Henle attributes the swelling and the bursting of the Graafian follicle to the congestion attending a fecundation. He says the ruptured cell is filled with blood, which colors it, becomes organized, converted into a scar-like substance, and then, at length, disappears. Dr. Huschke, in his Treatise on Splanchnology, elaborately details the opinions of authors on the corpus luteum; but nowhere alludes to the vitellary nature of that body. Dr. Gendrin, M. Maygrier, Dr. Robert Lee, Wharton Jones, M. Raciborskj, Ollivier D'Angers, M. Pouchet, make no mention of it—though they all enter into details. Dr. Montgomery, Dr. Swan, and, I think, Dr. Patterson, speak not of it. M. Flourens, and M. Velpeau, and Dr. Moreau, omit all allusion to the vitellary structure of the substance. Bernhardt, who was assisted in the con- struction of his " Symbolae ad Ovi Mam. Hist, ante Praegnationem," by Dr. Valentin, in which admired work is contained a complete deduction of the whole literature of the corpus luteum, alludes not to the idea. Von Baer's celebrated letter, "De Ovi Mam. et Homiuis Genesi," says of the corpus luteum, at page 20: "Me judice, minime corpus novum est, sed stratum internum thecae majus evolutum;" which expresses, with sufficient clearness, the opinions set forth in the rest of his paragraph. Dr. Bischoff, of Heidelberg formerly, now of Giessen, in his " Entwickelungsgeschicte der Saugthiere und des Men- schen," says, at page 33: " Wenn mann die erste entwickelung des gelben Kdrpers, unmittelbar nach austritt des eies, bei Thieren beo- bachtet hat, so kann mann dariiber nicht in zweifel seyn, dass die bildung seiner masse von den inner flache des Graafschens Blaschens ausgeht. Da sich nun hier die aus zellen gebildete membrana granulosa befindet, da die zuerst als gelber Korpor erkennbarre masse gleichfalls aus zellen besteht, so ist es wohl gewiss, das von einer starkeren entwickelung dieser zellen der membrana granulosa, die ich auch in der Peripherie des eies noch nachweisen werde, die bil- dung des gelben Korpers ausgeht." From this passage, it seems that Dr. Bischoff is not far from discovering what I suppose myself to have discovered; I mean, the vitellary nature of the yellow body of the ovary. It appears needless to make any further citation in this place. 254. I shall here offer the remark, that if the concave superficies of the ovisac, or inner concentric, is really charged with the office of pro- ducing or excreting the vitellary matter of the ovulum, which must be admitted, even if we allow to that body the metabolic and plastic cell- force (for it must, at least, be the producer of the cytoblastem of the cell), there is no very great difficulty in admitting that the convex or 124 THE OVARIES. exterior superficies of the same membrane may exercise the same functions as the dominant of those elective affinities which must be supposed as to every vital excrete. And such a supposition finds abundant support in the analogy of the organs; as, for example, in the periosteal and medullary membranes of bones; which, under cer- tain circumstances, are known to alternate their functional force; the medullary membrane coming to be a depositor of phosphate of .lime, instead of a remover; and the periosteum a remover, instead of being a depositor of phosphate, which is its normal office. This mutation of powers, as to the membranes of bone„has so clearly been described by M. Flourens, in his admirable paper on the production of bone and teeth, in the "Annales du Museum," that it needs no comment. But I am far from claiming this illustration for my view of the case, strong as I might deem it to be. It suffices for me to know that vitellary matter is germinal matter, germinal cytoblastem; and that the busi- ness of an ovary is to produce it—and nothing else in nature can pro- duce it. As to the microscopic results at which I have arrived, I have nothing more to do than tender them to the micrographers; and I should feel most happy if, these remarks meeting the eyes of Dr. Bischoff, or my kind friend, Dr. Pouchet, those gentlemen should deem them worthy of their attention, and confirmation or refutation. If they prove to be unfounded, I wish them to be confuted by better observers than I am. As to some other points of resemblance between yelk and corpus luteum, I have now to observe, that boiled corpus luteum becomes hardened, like yelk boiled hard. It is, in like manner, friable and granular, leaving a yellow stain on paper, like the stain from boiled yelk. Dr. Thomas Schwann found it evidently coagu- lated, granular, and friable, upon being boiled. In order to ascertain its odor, I threw a portion of corpus luteum on a live coal;—it gave out a strong odor of roasted eggs. Are the granules and corpuscles of the corpus luteum cytoblasts and cells? I have not been able so clearly to make out their nuclei as to speak positively—I suppose them to be so. But Schwann, himself, who in one place seems to regard the nucleus as a sine qua non in cell-life, says, at page 204 of that most admirable and extraordinary volume, the " Micro- scopische Untersuchungen:" "Die kernloser zellen, oder richtiger ausgedruckt, die zellen in denen bisjetzt noch keine kerne beobachtet werden sind, kommen nur bei neideren pflanzen vor, und sind auch bei Thieren selten." Non-nucleated cells, or, more correctly speaking, cells in which nuclei have not as yet been detected, are found in the lower vegetables, and rarely also in animals. And he cites, as exam- THE OVARIES. 125 pies of the non-nucleated cell, the young cells within the old cells of the chorda dorsalis, the cells of the yelk of the bird's egg, &c. &c. 255. Be the non-nucleated vesicle a cell or not, it is very certain that the milk corpuscle, and, probably, the chyle corpuscle, are of that nature, and no one can contemplate the amazing reproductive power of a cell or spore of the saccharomyces cerevisiae, without admitting for it all the properties of the cell-force. It is to the last degree reproduc- tive, as are also many of the filiform fungi, the muscardine, &c. The question at last is, whether I have made a discovery interesting to the physiologists, the practitioner, and the jurisconsult. If I am right in my opinions, it must be interesting. As a resume, I say that my views are based upon the fact that—1. Equal masses of yelk and corpus luteum are equally yellow. 2. They alike fill the microscope, before the focus is got, with a brilliant yellow light. 3. They alike consist of a pellucid fluid, in which float granules, corpuscles contain- ing yellow fluid, oil globules, and punctiform bodies. 4. These bodies, placed on the same platine, and diligently compared together, exhibit the same forms, size, tint, and refractive power. 5. Yelk, boiled hard, is granular and friable; it is coagulated by heat. 6. Corpus luteum boiled, becomes hard, granular, and friable—it is coagulated by heat. 7. Both substances, raw or boiled, stain paper alike of a yellow color. This experiment was repeated after Bernhardt, who says: "Cujus pig- mentum aurantiacum (cor. lut.), admotis digitis adhaerescebat."—P. 39. 8. There is this difference: The crushed mass of corpus luteum con- tains patches of laminar cellular tela, detritus, and blood-disks forced out by the compressorium ; which cannot occur in the yelk, as that is contained within a vitellary membrane, in which its corpuscles are free; whereas, in the corpus luteum, they are confined by the deli- cate cellular substance lying betwixt the concentric laminae of the Graafian follicle. 9. They refract alike. 10. Projected on a live coal, they alike give out the odor of roasted eggs. 256. As I derive this view only from my own perceptions, I ought perhaps to take leave of the matter here, committing it to more capa-. ble observers, in order to know whether they perceive it as I do. But, supposing that farther observations may probably confirm my views, I see no objection why I may not now offer some remarks, in the way of a rationale, upon the point in question, the more particu- larly, as I hitherto have relied only upon my own observations. I therefore state that all living beings are results of the operation of a reproductive or generative force. This is true both as to plants and animals; with the possible exception of certain fissiparous and gemmiparous creatures, as well as of certain sporiferous fungi, and 126 THE OVARIES. some creatures of a higher scale, as the nais proboscidea, &c. I say of these, that they constitute a possible exception to the law of reproduction by germs. I do not say they are exceptions. This re- productive force has the same relation to the conservation of the vege- table and animal genera, as the force of attraction has to the conser- vation of the brute masses of matter of the universe. For it is obvious that, but for this force, all the genera would die out in a single generation, and yet it is apparent that nothing is more perma- nent than the genera, which extend from age to age, touching the beginning, the whole course, and the end of time. The existing genera are the same to-day as at the commencement of the present cosmic career, and are destined to be so until the last great cataclysm of the globe. M. Flourens, in his work on generation, makes use of the mot, the saying, un e'tre collectif, a collective being, in speak- ing of the immutable permanence of a genus. This fine saying leads the mind at once to a view of the importance of the law of genesis by which so great an end is attained. 257. It would, perhaps, be superfluous to say that, but for the exer- cise of this force, all morals would be nullified and blotted out of the great scheme of Providence; for, should the genera fail or die out, the earth would become a desert; no flowers to bloom—no corn, nor wine, nor oil—no insect to sport in the sunbeam—no song of birds— no lowing of cattle—no voice of man to acknowledge, and praise, and give thanks to the Giver of every good and perfect gift. Thus the whole scheme of morals would cease and be terminated, leaving no witness here to the power of God, beyond the senseless play of the elective and gravitating attractions. Is it not clear, then, that the laws of this great conservative force must be most important laws? Can such great forces have little or no concern with the regulation and co-ordination of the other life forces ? I repeat, that for life they have the same importance as appertains to the laws of attraction for the physical bodies of the globe. This force is the true development force, not for the germ only, but for the embryo, the foetus, the child, the youth, and the man. He who shall know it truly, shall know the laws of life. It is not only a genetic, but a generic force. It deter- mines the form and dimensions of the members of the genera in an interminable succession of ages. No horrid passion, no wild lust, no insane desire, can contravene the irreversible law of the distinction of the species and genera—"each after its own kind"—which, but for its provisions, would rush into chaotic confusion and mixture—whereas they are, in truth, trenchantly divided, and set apart from each other, and forever maintained pure and unmixed. This force—this amazin» THE OVARIES. 121 force, is concentrated and summed up in a special animal or vegetable tissue. Nothing in animals, save a vitelliferous tissue, can yield or give out this force, which is the endowment of the ovarian stroma: it is the peculiar life-property of that concrete, and of nothing else. The stroma (Lager) of ovaries is a tissue developed and sustained by the combined agency of a spermatic or ovarian artery, and a spermatic nerve. The spermatic nerves possess an intimate plexual and gan- glionic relation to the spinal, the sympathetic, and the splanchnic systems of innervation—so that they are related, in fact, to all the organisms. Under the dominant formative influence of the spermatic nerve, the ovaric artery, by its branches and termini, deposits the ma- terials of the concrete of the stroma, with all its parts and mechanism. The general relations of the ovary to the whole of the innervations, while they enable it largely to influence them all, render it liable to disturbance by their derangements. Its great influence is exhibited in pronouncing the single word sex, for the ovary is the sex of the woman—the female in the abstract. But if the ovary be her sex, then the whole peculiar physical, moral, and intellectual character of the female are derived from it, as their source and dominant, and they are conformed to its wants, its powers, its offices—and often pathologically modified by its conditions. 258. The materials of development for all the organs are derived from the blood, which, without violent misapplication of the metaphor, may be said to exist within a multilocular cyst, of which the cellulae are the different sanguiferous tubes and sinuses of the vascular system. It is everywhere the same, and presents in each of the organs the same liquor sanguinis and disks—so that, although all development is effected at the expense of the blood, yet there is a constitutional, or esoteric nerve force, by which to compel those elective attractions through whose power every living concrete is produced. The phy- siologist knows that this esoteric force is nerve-force—and he will not deny that, for the development of both a general and special anatomic structure, it must possess what I desire to characterize as a generic force, else all development would be in spherical forms, and of the same constituent elements. No power can so modify the generic force of the cephalic extremity of the nascent embryotrophe as to protrude from it a pelvis or a foot; nor could a leg be possibly developed in the place of a prehensile limb. Even in the quadrumana the law holds good. A liver whose development depends on its nutritious artery and its nerves, could by no means be formed at the caudal or cephalic pole of a mammal. It must always have its central position. No example will be found of a lung placed below the diaphragm. Hence, 128 THE OVARIES. I say, the law of generic development is a law applicable not to the creature only as a whole, but to each of its several constituent parts. The whole business of zoological classification depends upon this law. This law not only operates during the embryonal, the foetal, and the puberic development, but is in force throughout the whole duration of life, perpetually repairing the organs, and maintaining their generic forms, against the wasteful detritus of life, until the cessation of life. The membrana germinativa of the ovum, which is probably R. Wag- ner's macula (Keimschicht), is an elliptical or circular disk. Let me repeat what I just now said, that no power could determine the production of the pelvic at its cephalic, or the cephalic at its pelvic segment, nor a leg from the thoracic, or of an arm from the iliac region of the disk. Hence it is true to say, that such disk is endowed at different parts of it with a generic force, operative only in that one sole direction. I say generic, since the idea is applicable to all animals whatever, and to all the parts of animals. 259. My motive for making the foregoing remarks is, that they might serve as an induction or basis as to the generic force of ova- ries. An ovary is developed by an ovaric arterial trunk and its branches, drawing the vital current from the aorta or the emulgent, and attended by the spermatic nerves, which I regard as reproductive nerves, and generic in their powers. I say reproductive nerves, since their innervative force is devoted to the evolution of germs: no other nerve has such a mission. 260. If Huschke's pretty idea, that each Graafian follicle is a cast- off acinus of the stroma, carrying away in its fall an endowment of vital force rendered complete and generic by an act of fecundation, should prove to be well founded, I cannot escape from attributing this reproductive quality to the spermatic nerve. But, without discussing the question of the aciniferous nature of the stroma, the same attribu- tion of the nerve-power is right, even under the hypothesis of an inde- pendent cell-life—for a reproductive cell could not exist but for the vitellary cytoblastem provided by the stroma, which is a vitelliferous tissue, and only that. Nothing else is so. The nature of the cyto- blastem must determine the differences of cells. The cytoblast of an oak germ is different from that of a cabbage germ, nor could they have the same cytoblastem. 261. But the sole office of an ovary is to produce or prepare germs —it is germiferous, and it is so by its power to form vitellary matter. No other combination or arrangement of animal materials can produce yelk or vitellus. The complete germ is contained within a vitellary membrane—which is the boundary of the yelk. In the mammals, THE OVARIES. 129 this yelk is microscopic. In the ostrich and the cassowary it is a very large ball, as it is in some of the larger ophidians, as in the coluber boaeformis, &c. 262. The matured germ contained within a yelk is spontaneously and periodically extruded from the ovary, in order that it may be fairly exposed to the contact of the male fecundative element—which should be deemed impossible while it remains buried within the re- cesses of the ovarium, covered by the double tunic of the follicle, and beneath both the fibrous and peritoneal indusium of the organ. 263. To effect this extrusion, this spontaneous oviposit, the inner concentric spherule of the follicle is compressed by the deposition on its external convex surface, of yelk grains, corpuscles, oil-globules, punctiform bodies, and pellucid fluid—the beginnings of the corpus luteum—which gives to the concave surface of the cell an appearance of corrugations or convolutions like those of the brain, and which, as they daily increase by the continued deposit of yelk matter on the exterior, constantly reduce the size of the interior dimensions of the follicle, urging its contents towards the least resisting point of the sur- face of the ovary, until, at length, the porule or hila being opened on the surface of the ovary by the dehiscence of the coverings, the ovulum escapes into the fimbria, or falls into the peritoneal sac. After the escape of the ovulum, the yelk-producing force is not in all cases immediately exhausted; hence the growth of the corpus luteum con- tinues for a term whose limit is not yet known. 264. It is a periodical exacerbation of biotic force that matures and opens the Graafian cell. When the process of completing a germ and expelling it has been finished, the exacerbation ceases sooner or later, and a new periodical exacerbation of this strange life-force—or germ- producing force—is devoted to the maturation and spontaneous ovi- posit of another ovulum, and so on in succession, during the menstru- ating life of the woman; at every successive pairing season of birds; and at the annual rutting time of the more considerable mammals, and in all the migratory fishes at stated times. 265. It surprises me to see that many able and distinguished writers still cling to the antiquated notions as to the ovaric fecundation, which M. Pouchet has shown to be an impossibility. It appears to me that my view of the vitellary composition of the corpus luteum, and the mechanical result of its development in effecting the oviposit, ought to be received as satisfactory rationale of the germ-depositing func- tion. The fecundation of germs is a mystery which I deem beyond human cognition—and likely ever to remain so. The inquiry into the corpus luteum is far more feasible and practicable. No woman can 130 THE OVARIES. menstruate but coincidently with, and in consequence of, the oviposit. Every oviposit is followed by a corpus luteum, which is larger or smaller, according to circumstances. Many women have scarce dis- cernible ones after conception—others have very large ones. The true and false corpora lutea differ only in magnitude—not in their essential nature. 266. I have no doubts as to the essential identity of nature in the corpus luteum of pregnant women and that of the virgin; and am pleased to find that the author of that admirable work, "Die Geburt- skunde mit einschluss der Lehre," etc. etc., Franz A. Kiewisch, enter- tains the same opinion. It is true that this author appears not as yet to have learned the reasons for supposing the corpus luteum to be a vitellary material, or, at least, that he has not accepted that rationale of the corpus luteum. Still, he is evidently a careful observer, as well as good thinker.—He says, p. 80: " Da diese Erscheinung bei der Lehre von der Schwangerschaft erst genauer erotert werden soil, so schicke ich hier fur die Bemerkung voraus, das die Folliculareste bei jung- fraulichen Individuen, obgleich sie in der Regel sehr unbetrachtlich zu sein pflegen, doch dieselbe Bedeutung haben, wie die bei schwangern vorkommenden gelben Korpern, und dass ich in cingelnen scltenen Fallen auch bei nich geswhangerten Individuen bis zu Kirschen- grosse entwickelte und gleichfalls exquisite gelbe Korper vorfand." Kiewisch says that the remains of the Graafian follicle, left after ovulation in maidens, obey the same law that rules in the cases where conception has followed the ovulation — and where a true corpus luteum has been developed. He further says that, in some rare cases, he has found in the virgin the exquisitely characterized corpus luteum as large as a cherry. 267. In the first edition of this work, published in 1847, my state- ment of the corpus luteum stands as in the foregoing, and I have purposely left the text up to this point unchanged. The preceding pages may show how considerable a mass is the literature of the cor- pus luteum, and how various are the opinions heretofore entertained upon the subject. It was on the 18th of December, 1846, that I read my paper on the corpus luteum, at a meeting of the American Philo- sophical Society, and that paper was ordered for publication in the " Transactions." Deeply convinced as I was that I had fallen on a true and demonstrable rationale of the corpus luteum, I was willing to wait for the decision of the learned as to the truth of my explanation. Some of the reviewers treated me with less than civility for my inno- vation ; but I perceived that they had condemned me on a prima facie examination, and that their opposition depended rather upon THE OVARIES. 131 a usual reluctance to abandon opinions already adopted, than upon any improbability of the truthfulness of my statements of the subject. Professor Coste, whose second part of his 1st vol., on the develop- ment of organic bodies, was published in the summer of 1849, has adopted my views as to the vitellary nature of the luteal body. M. Coste regards the inner membrane of the Graafian follicles, and not the magma reticulatum lying betwixt the inner and outer cell, as the seat of the deposit. It is a matter of small moment, this, though I by no means yield my opinion on the authority of even so great a name as his. Having sent my paper, from the "American Philoso- phical Transactions" of the year 1847, immediately upon its publica- tion here, to M. Coste, I cannot withhold the expression of the surprise with which I find him acknowledging the receipt of it, and at the same time saying (in 1849, two years later), that I have arrived at the same conclusions with himself on this subject; that is to say, he got my paper in 1847, and adopting my exposition, says, in 1849, that I have attained to the same views as he there so elaborately sets forth. 268. In order that the American Student may have an opportunity to become acquainted with M. Coste's views, I here translate from his "Dev. des Corps Org.," p. 251, the following passages: "Indeed, upon examining with the microscope the texture of the internal layer of the capsule a short time before the period of its rupture, we find that, besides its abundant vascular network, it is exclusively composed of small vesicles or cells, each containing colorless molecular granules ; but immediately after the dehiscence, they become so greatly developed that, when the convolutions fill up the cavity, they are found to be five or six times larger than they were at first. Hence it follows that the membrane whose wall they constitute must be proportionably thick- ened. It also becomes softer and more friable, because they cease to cohere so strongly as at first, while the wall itself becomes softened. This is the reason why, at a certain period, the capsular convolutions acquire an encephaloid appearance, the result of a modification both of the constituent vesicles and their contents, as I shall proceed to show. In process of time, a stage is reached in which the disunion of the vesicles is so easily to be effected, that it may be done by merely scraping the capsule, which detaches nearly the whole of them, after which nothing is left save the naked vascular branches that run along every plait. I have made this preparation in several follicles previously injected, so as to be able to see the facts in the clearest manner, as I have here described them. In proportion as the con- stituent vesicles enlarge, the contents are appreciably modified. In the cavity of each one of them is formed an innumerable quantity of 132 ~ THE OVARIES. molecular granules which renders them more and more opaque, and which, under the slightest pressure, pass out through the containing walls, that give way by laceration. These granules are remarkable, not only for their number, but also for the yellow tinge which slightly colors them. Now, as they are very abundant, and closely packed within the vesicles that contain them, it follows that the yellow tinge that is slight in the individual granules becomes very decided as for the whole mass of them. It appears that something takes place here like what occurs in the vitellus of the bird while taking on its yellow hue. I have, indeed, already said, while explaining the material con- ditions of this phenomenon, that it is produced by the crowding together of the granules with which the yelk corpuscles are gradually filled, and by the admixture of the oleaginous particles that are dis- seminated in it. The color of the corpus luteum seems to depend upon an analogous arrangement of the material contained in the voluminous vesicles that compose its mass," &c. 269. Let the Student do me the favor to compare this account by the learned Frenchman with that in the first edition of this work, and I feel sure he will do me the justice to admit the priority of my solu- tion of this long questioned problem. I beg leave to make one more quotation, which is from M. Coste, p. 268: "Baer first understood the mechanism by means of which the plaits and convolutions are pro- duced. Pouchet showed how they become thickened ; and I think I can establish the fact that the color of them depends exclusively on the nature of the molecular granules or the globules with which the cells that form these walls are filled, and not at all, as supposed by Raciborski and Pouchet, on an extravasation of the coloring matter of the blood. I have observed with pleasure, in a pamphlet sent to me by Dr. Meigs, that, in the last respect, that observer had come to the same conclusion as my own."!! Prof. Coste should have said that he adopts Dr. Meigs's views in this last respect. PART II. THE PHYSIOLOGY OF REPRODUCTION. CHAPTER VI. MENSTRUATION. 270. Women are subject to a discharge of blood from the genitalia, which returns very regularly once a month. This monthly periodicity of the bleeding has given it, among various people and languages, the name of menses, menstrua, menstruation, catamenia, mois, monatliche, men s tr u a gion, me'se, &c. Among us, it is called courses, periods, terms, monthlies, monthly sickness, unwell, times, and a variety of other names, hints, and allusions, that need not be here summed up. The discharge is not met with in children, unmarriageable girls, or old women. It appertains to women only as long as they are capable of conceiving. They cease to be child-bearers when they lose the power of menstrua- tion. 271. In this country the menstrual office usually commences in the fifteenth year of a person's age, and continues to recur at intervals of twenty-eight days during about thirty years, these returns being pre- vented from taking place only by pregnancy and its consequences, or by some disorder with which the woman may be attacked. The men- strual flowing commonly continues during three or five consecutive days, and the whole quantity of blood lost at each catamenial period is variously estimated to amount to from four to six ounces. As soon as the flowing or courses have ceased, the woman appears to be in all respects well until the time again approaches for her to be seized with the same kind of hemorrhage. 272. It is to be expected of every growing girl that she shall have her first change or show about the end of the fifteenth year, although it is verv common to observe the first appearance of it at the end of 134 MENSTRUATION. the fourteenth year of her age. Indeed, it cannot be esteemed an un- common circumstance for girls to have their first change as early as the thirteenth year of their age. It does not, however, invariably happen for the first menstruation to take place so early as the fifteenth, and not a few young women are advanced to the end of the sixteenth, or even far into their seventeenth year before they have their first sign. The precocity or lateness of the first eruption is connected with circumstances so various that it is often very difficult to say why one young person should begin far too early, or another postpone to an inordinately late season the performance of an office having so intimate a connection with woman's whole nature. 273. The menstrua do not in all cases obey the rule that ordains their return once during each lunation, and many women go to the full extent of the calendar month, or even beyond it, while many others come far short of the lunar revolution, being regular every three weeks, or oftener. A like irregularity is observable as to the duration of each monthly flowing, which in some women continues only one day and a half or two days, while in others it lasts for seven days or more. I consider that there are thousands of American women who are never less than seven days unwell. For example, Mrs. M. O, Fifteenth Street, told me this day (Oct. 19, 1857), that, from the first appearance of her menstrua until now, she was never less than two weeks unwell; yet her health was always good. She is now in the middle of the sixth month of her first pregnancy—she said also that the periodicity of her monthly returns was always very regular. The only abnormity, then, in her case, consisted in the long duration of each course; but, the practitioner must sooner or later learn, that, each woman in this matter has a law of her own, and that such a law is suitable to her nature. Hence, it appears that though the catamenia are governed by a principle of periodicity and of quan- tity, that periodicity and quantity are not invariable for the whole sex, and the Student should, therefore, be ready, in any case submitted for his judgment, to decide whether the condition as to such special case is or is not normal. My experience as a practitioner has afforded very numerous opportunities to observe erroneous interpretations of this matter, and to confirm my long settled convictions, that every woman though under this general law of lunar month periodicity, is in fact ruled by a cyclical law of her own individual nature. 274. In deciding concerning alleged cases of menstrual irregularity, one should not lose sight of the fact, that every sanguineous discharge from the genitalia of unmarried or non-pregnant women is not of neces- sity to be held as a menstruous evacuation ; because it may, and often MENSTRUATION. 135 does happen for women to bleed from the womb or vagina irrespective of their catamenial nature. Yet it is so natural for one accustomed to the periodical flow, to suppose every such flowing somehow dependent on the menstrual office, that we need not wonder to find so many mis- interpretations. For example, a woman affected with polypus uteri, is very likely to have some bloody show during consecutive months, or even years, and yet when she consults with the physician on the sub- ject, she is almost sure to speak of the issue as her courses, and say that she has had her courses without interruption for so many weeks, months, or years. An educated physician, however, who knows that menstrual discharges are nothing more than the signs of the monthly ovulations, ought to make no such mistake in diagnosis, nor do I pre- sume to think he would do so except from carelessness. 275. If the mean duration of each menstrual act is from three to five, or at most seven days, then all the instances in which women complain to us of courses lasting for two or three weeks, or more, should be considered due to some other cause than the ovulations, and treated accordingly. 276. Women, as has been already shown, develop and discharge a ripe ovule from the Graafian follicle once in every twenty-eight days; but there ought to be no surprise on finding now and then a person in whom the ovulative power is so vigorous as to repeat the oviposit every fourteenth day, or every twenty-first day, and I conclude that all those persons who complain to us of menstruating regularly twice a month, or once every three weeks, do actually mature and discharge their ova every fourteenth or every twenty-first day. Such examples as the above, though to be placed among the instances of menstrual irregularity, are not necessarily to be regarded as cases of bad health, but rather as the proofs of uncommon power of reproduction in the individual. They do not in general require any medical treatment, because they contain within themselves a power of cure, and it will be found that their continuance is not greatly prolonged; since if the too frequent returns result in some degree of weakness, the redoubling of the ovulations ceases with the loss of power; such, at least, are my views of the circumstance, and such are the results that I have many times witnessed. I hope, therefore, the Student will carefully dis- criminate between sanguineous genital discharges caused by ovulation, and such as arise from polypus, inflammations, cancers, and other dis- orders that women are liable to. 277. Ever since the revelation made in 1825 by Purkinje of the existence of the germinal vesicle, which led to the plenary discovery and publication of the physiology of menstruation, the old supersti- 136 MENSTRUATION. tions on the subject have been decaying and fading out of sight. At the present day, it is almost universally admitted that the last days of the maturing or ripening process of ovarian ovules are attended with a positive affluxion of sanguine humors—not to the laboring ovary alone, but to the entire system of the reproductive organs. In this sanguine molimen the womb largely participates, and becomes the seat of a considerable capillary engorgement. In most women this engorged condition of the bloodvessels of the womb is betrayed by that sense of fulness, weight, and even aching, of which they generaly com- plain. To know the anatomical structure of the womb, particularly its tubular glandules and the extremely delicate vascular network that exists there, is enough to convince any one that a considerable engorge- ment of those vessels would be likely to exhibit itself not only in the weight, tension, and pain above mentioned, but in actual extravasation of blood from those delicate vessels. It is hardly too much to say, that the tenuity of those coats is so great as scarcely to exceed the thickness and strength of a soap-bubble, so that they easily yield to the vascular engorgement, and bursting, allow the monthly-engorged womb to discharge its surplusage of circulation in the form of women's courses or menses. Such, at least, is the best interpretation of the circumstances that can be at present given, and as it is one that satis- fies all the demands and conditions of the case, I have long ago accepted it, and do now believe I shall never change it for another. 278. In this view, then, I am to teach the Student that the menstrual fluid of women is blood, and that their courses consist in a monthly repeated uterine hemorrhage, and nothing more nor less. The Stu- dent, I am well aware, is urged by many able writers and teachers to consider the discharge in question as a secretion, and not as hemorrhage; but it appears to me.that no advocate of the doctrine of secreted menstrua will now deny that those discharges do contain a large proportion of true blood, nor that they do coagulate like blood drawn from a vein. I leave it to the Student, therefore, to settle with his own judgment the question, how can blood-disks be subjects of secretory action ? Can solids be secreted ? Could not a woman as well secrete a watch or a diamond ring as one single blood-disk? Nothing can be secreted that is not fluid. A blood-disk is a solid, and not a fluid. The menstrual discharge is a hemorrhage, and it is the sign that the woman is affected with her monthly ovarian engorge- ment that has extended to the vessels of the womb: menstruation, therefore, strictly interpreted, is ovulation, and the sanguineous discharge that is vulgarly considered as the principal point, is far less principal than the ovarian ovulation, of which, indeed, it is only the MENSTRUATION. 137 outward mark or symptom. To fail in giving discharge to the monthly outflowing blood is thus, far less important as relates to the woman's health than to fail in the ovulation. The latter failure is evidence of serious embarrassment of the vital forces; whereas failure of the former is due to some mere want of sympathy between the womb and its ovaries. There are constantly to be met with women, especially school girls, who ovulate with perfect regularity, but who do not give out the sign thereof in a bloody evacuation from the womb; and I may venture confidently to assert that such amenor- rhceas are of little import, and demand nothing beyond some judicious hygienic directions. 279. Inasmuch as I have thus confidently stated my opinion that the menses consist of extravasated or hemorrhagic blood, it seems proper here to compare the analysis that has been made of these fluids, I mean blood and menstrual fluid. It is universally known that healthy human blood consists of water 790, fibrin 3, blood-globules 127, and albumen 80, which equal in sum one thousand parts. The analysis of menstrual fluid made by Denis, and stated at p. 172, of M. de Bois- mont's "Treatise on Menstruation," gave of water 825, while the other constituents, as globules, albumen, extractive matter, fatty matter, salts, and mucous substance, amounted to 175; so that while the solid constituents of healthy blood are 210, those of the menses are only 175. Rindskopf's analysis (Simon's "Chem. of Man," 337) gave 820.830 of water for one trial, and 822.892 for a second trial; while Simon's analysis yielded 785.000 of water, only 5 less than that of healthy blood. In like manner an analysis by Dr. Letheby ("Lancet," May 2, 1845) gave of water 857.4; so that, taking into consideration the circumstance that the menstrual fluid is destined to pass through the canal of the neck of the womb and through the whole length of the vagina, in which it sometimes lingers on its way, we may understand why the blood of the menstrual hemorrhage should contain somewhat more water than blood taken direct from a vein, since it could not but become more or less mixed up with the moisture of the genital pas- sages. Perhaps these statistical statements are, after all, superfluous for those Students who agree with me that a blood-corpuscle, being a solid, cannot possibly be a thing secreted, but one that can escape from its containing bloodvessel only by an act of hemorrhage. 280. As to our professional measures for ascertaining in the cases whether the patient has too much or too little of the menstruous dis- charge, it seems proper to put the Student in mind, that as women, while menstruating, usually apply a napkin in the form of a T band- age as a receiver, we can judge pretty correctly concerning the amount 10 138 MENSTRUATION. by learning how many receivers are necessary from the beginning to the ending of each menstruation. I believe it will be safe, as a general rule, to allow half an ounce of blood to each separate receiver, so that if only six be required we may assume that the patient loses about three ounces; but if twelve or eighteen changes are considered neces- sary, then we may conclude that she does lose some six or nine ounces of blood monthly. Though the above quantity seems to be very great, yet I doubt not that thousands of women do part with such a great amount at each catamenial return; and the strangest part of the case is the indifference with which the constitution tolerates so great a periodical waste. I even think it by no means a very uncom- mon thing to find women who never employ fewer than twenty receivers for each season of return, and it is to be observed that they generally lose a great deal of blood besides what is absorbed by the napkins; say one-third more. 281. So great are the differences in the menstruation of different women, that while many of them part with eight, ten, or fifteen ounces without the least inconvenience, but become indisposed if they lose only two or four ounces, there are thousands of healthy women who are so sparing of their blood that they take no precautions against an exposure—never making use of any other receiver than their che- mise—and guarding their modesty against some possible blood-stain by putting on an extra thick petticoat. It is evident that this sort of women must bleed very little indeed, or the flowing would immedi- ately run down to the shoes, or come as a broad stain through the outer garment. Yet these sparing women would, perhaps, be very ill if they should lose as much as those other copiously menstruating ladies, who would also esteem themselves to be sick if not flowing freely. How true, then, is it to say that every woman, in her courses, has a law unto herself, and how important for the Student to know and acknowledge that truth, as a guide in his practice. 282. In examining the subject of menstruation, the question must somewhere arise as to what is the precise relation of time betwixt the rupture of the Graafian cell and the commencement of the flow. Does the woman begin to bleed before or after the escape of the ovulum from the ovarium? This is a problem that remains to be settled by future observers. In the mean time, I consider it true to say that when a woman's body is examined by the Anatomist, he can always find the opened and emptied Graafian cell, provided the individual should have died while discharging the menstrual blood, or within some few days after the cessation; I have examined a considerable number of such subjects, and never failed to detect the open hila through which MENSTRUATION. 139 the little egg had passed outwards. The vestige is usually a bloody or reddish point. If a probe be pressed upon it, it passes down- wards into the empty cell which had contained the egg, and which generally fills after its escape with some coagulated blood. The wood- cut that I subjoin (Fig. 47) represents the appearances in the womb and ovaries of a young girl who died here on the eleventh day after the eruption of her courses. As she perished with an acute disease, it may be that the healing or reparative processes in the opened vesicle may have been less rapid than is usual. On receiving the specimen, I perceived the open hila from which the egg had escaped, and inserted a probe deep into the deserted cavity of the vesicle. Upon cleaning the margin of the hila, it was plain that the opening had been made by the absorbents and not by any violent rupturing force. The whole of the circumjacent tissue of the ovary was highly injected, and red with full capillaries and small branches, as is commonly found to be the case. I next divided the empty Graafian vesicle by splitting the ovarv with a bistoury, carrying the incision down through the middle of the open pore to the bottom of the cyst, which contained the usual clot of blood. The letter A in the figure is at the fundus uteri; the os is seen in the open vagina. At B is the left ovary; c is the trace of an incision made there through a scar left after a preceding ovulation; E is the right ovarium, and F points to the empty crimped cavity of the recently evacuated Graafian cell. The internal surface of the cell was raised up into convolutions like those on the surface of a brain, an appearance always to be observed, and which depends on the filling up of the space between the outer coating and the inner coating of the ovicapsule. This insertion or impaction of substance betwixt the two coverings causes the inner coat to be crimped, folded, or convoluted as above mentioned, a process which probably tends to press the 140 MENSTRUATION. escaping egg towards the opening hila from whence it is at last, by this mechanism, quite expelled. 283. The late Dr. Joshua Wallace presented to me a few years since the womb and ovaries of a young woman who died suddenly while menstruating. The cavity of the womb contained a portion of the menstrual fluid. In that specimen I found the bloody pore or hila of the Graafian cell, which as usual contained a clot of blood. I need describe no others of the numerous specimens of the same kind that I have had in my hands; it suffices to say that no woman who dies while in the act of menstruating, fails to exhibit such vestiges to the dissector who seeks for them. Nevertheless, no one yet knows at what moment the hila is prepared, and we have only to consider it probable that the uterine engorgement is coincident with that of the ovaries, and that, as soon as the ovicapsule becomes empty, the less- ening of the ovaric tension allows the ovarian molimen to begin to lessen. It is, under all circumstances, most probable that the egg escapes very nearly at the time that the womb begins to bleed, and that the uterus continues to pour out its blood until its own vascular congestion and nervous erethism are dissipated by the hemorrhagic discharge. 284. Writers of a late period have persisted in believing that the discharge of the ovum is due only to an act of impregnation or fecunda- tion ; but the modern Student of medicine knows that the germ could not be fecundated while locked up within the recesses of the ovisac, itself buried beneath the indusium and tunica albuginea of an ovarium. On the contrary, he knows that ovulation being a spontaneous act of ovipositing, fecundation of the egg can take effect only after it has been set at large by the act of the absorbents. Therefore, he also knows that a woman can be subject to fecundation only within some un- known but short season succeeding her menstruation. M. Pouchet, of Rouen, whose learned researches have thrown a flood of light on this before obscure department of physiology, seems to feel quite sure that the period after a menstruation during which the discharged ovule remains subject to fecundation, does not extend beyond the twelfth day, and I cannot gainsay that decision of the celebrated naturalist and physician. I am, however, sure that it does extend to the eighth day, and probably beyond it, because Jewish women among my patients, and very prolific ones too, have assured me that they never did violate what they regard as a religious duty, that commands them to avoid the approach of their husbands until eight complete days have elapsed after the entire cessation of the mensual flux. They have assured me that in a very large Jewish sect this law is scrupu- MENSTRUATION. 141 lously fulfilled, and if so, we have in this religious custom a positive proof that the escaped egg remains apt for fecundation during the eight Jewish days of abstention. Why may it not also be true that M. Pouchet's law of twelve days is as correctly ascertained? There is surely no reason to suppose that the discharged ovule must necessarily perish or decay sooner than the twelfth day after its separation, since it may lie perdu within the fimbria or in the canal of the Fallopian oviduct, ready at any time to meet the conflict with the male zoosperm, which causes its fecundation. 285. However probable or even true it may be that a woman is unlikely to be fecundated later than the 12th day, it is by no means sure that she can safely indulge illicit passions under such an hypo- thesis, because, while it is absolutely true that ovipositing is a periodi- cal phenomenon repeated every twenty-eighth day, and accompanied with menstrual hemorrhage, it does not necessarily follow that a ripened germ may not, now and then, be cast off irregularly by a vigorous ovarium, without occasioning any hemorrhagic molimen and flowing. A woman, therefore, who believing that the period within which fecundation is possible has fairly gone by, and who consequently indulges in the sexual approach, may be caught and brought thereby to an open and palpable shame. I have been informed by more than one married woman, that her abstention, practising on the above principle, was of none effect. 286. The former doctrines of menstruation .give us no clear indica- tions of a therapeutical treatment of the disorders so frequently con- nected with that periodical act. It was foolishness to assign as a cause of the menstrual periodicity an influence of the moon, since observa- tion and experience showed to all inquirers that there is no coincidence of the act with any particular phase of the moon, millions of women being always to be found just beginning, just concluding, or midway between the periods of monthly evacuation. 287. The doctrine of a general plethora, peculiar to the sex, and required of them as a means to the end of reproductiveness, was easily refuted by the always obvious facts of persons menstruating regularly even when very much reduced by sickness or other causes of oligaemia. 288. The true doctrine was that of a local plethora, or, in other words, a state of periodical hyperasmia of the reproductive organs; and now that doctrine is not only established, but it is made plain to the understanding, for the periodical paroxysm of stromatic force, that hurriedly concludes the ripening of the most perfect ova, establishes the affluxion that fills the capillaries of the reproductive organs, and engorges them, or renders them hvperaemic to the point of causing the 142 MENSTRUATION. monthly hemorrhage by which the hyperaemia is removed, leaving behind it no trace of indisposition. This admirable exposition, for which we are so greatly indebted to its discoverers, preserves us from the most serious errors in our practice; while it reveals to us a vast deal of information as to the state and wants of women in whom the catamenia have become disordered, or in whom they have never appeared. 289. Heretofore, physicians have looked to the bloody sign alone as the act; hereafter, they will be likely to look upon the maturation and discharge of the ovarian ovule as the physiological act of men- struation, and upon the sanguineous effusion only as the sign that the physiological act has been or is being performed. 290. True menstruation is the regular periodical evolution and ex- pulsion of an ovule ; it is ovulation. This act may suffice to cause the woman to bleed mensually, or it may prove insufficient to that end: it is, for the most part, a matter of irid iff er ence whether it does or does not cause the mensual hemorrhage; for the essential thing is to mature and deposit the ovule. There are many circumstances of the menstruating girl or woman that are able to prevent her from bleeding, notwithstanding she may enjoy all the other faculties of perfect health. • 291. As to the woman—a married woman who conceives in the womb does not necessarily upon that account cease to mature and. deposit her germs. On the contrary, she retains a strong tendency to menstruate up to an advanced period of gestation. Yet she does not, as a very general rule, discharge the mensual fluid. Yet there are many examples of women who do actually retain, in the early months of pregnancy, the power to pour out from the vessels of the womb the usual product of menstruation; an act that should lead them to abortion. Probably a woman has a much greater liability to abort at the time of her mensual crisis than at any other time; which can only depend upon the occurrence of the catamenial effort under the periodical exacerbation of the germiferous force. The same is true of the woman who gives suck. 292. A woman with a nursling at the breast does not, in general, menstruate until the child is seven months old; and thousands of women do not menstruate until they have weaned the child. Yet these women are liable to become pregnant; indeed, there are many who do become pregnant again and again before they have weaned their children, and before they have had the return. I say there are many such persons, so many, indeed, that the case is quite a familiar one to the accoucheur. A lady told me, on the 14th December, 1849, that she was pregnant again, and that she had not seen since the MENSTRUATION. 143 birth of the child which was born before the infant she was, at the above date, nursing, and which she must now wean before the due time of weaning. Such facts are proofs of the continuance of the germ-production i n the ovary, as well as of the ovulation. 293. As to the young girl—a young female who has been brought up at home in the country, is rarely sent to a boarding-school to finish her education without soon finding herself the subject of a catamenial derangement. She may have been perfectly regular at home; but, soon after she takes her place upon the school-form and daily devotes many hours to study, the menses are apt to be suspended, and to re- main suspended until she leaves the school, and ceases to consume her nerve-force in those mental or intellectual operations, that require for their effectuation all the biotic power she is capable of evolving. The consumption of this force leaves her destitute both of the power and the necessity to discharge the menstrual blood; not depriving her, meanwhile, of the force required to fulfil the true physiological office, the ripening, to wit, and the discharging of her monthly ovulum from the stroma. Her ovulation goes on regularly, and she is well> though not apparently menstruous. I have found many young wo- men thus affected; but, the health being in all other regards perfect, I have not ventured to interfere beyond the interference of recommending a lessened devotion to mental labor, a more abundant and exciting diet, and a proper amount of daily exercise in the free air. Such amenorrhceas cease as soon as the girl leaves school. Similar obser- vations are to be met with in the writings of medical authors. 294. The pregnant and the suckling woman do not menstruate, because the life-force is fully occupied otherwise, yet they fulfil the germiferous law. In the same way, the studious and sedentary school-girl does not menstruate visibly, because her nervous mass is already preoccupied. She performs, meanwhile, the physiological act of the ovi-ponte or ovulation, yet she does not bleed. Let the woman miscarry, or wean, and she will soon perceive the visible sanguine sigu of her ovi-posit. Let the overtasked school-girl cease to call upon her nervous mass for impossible supplies of biotic force, and her menses will speedily return, and be regular in time and in sum; for her nervous energy is no longer misdirected, and improperly consumed in studies beyond its power of supply. 295. It is time to say a few words upon the catamenia, as connected with a computation of the commencement of pregnancy. I presume that a woman cannot be fecundated except it be coincidently with the ovi-posit. As a rule, then, a woman is liable to become pregnant only at, and about the periods of her monthly sickness; and, in com- 144 MENSTRUATION. puting the commencement of pregnancy, we shall commit the fewest errors if we begin the count at the day following that on which the flow ceased. Two hundred and eighty days should be allowed as the usual duration of a gestation. One who is regular ought to s e e every twenty-eighth day. If she sees for three days only, then she ought to be twenty-five days without seeing. In what portion of these twenty-five days is it that she is liable to impregnation ? Dr. Pouchet insists that the liability extends to twelve days after the drying up of the discharge, and not beyond that time; and it seems probable that the ovule should retain its vitality without fecundation, so long as twelve days after its escape from the follicular pore. In July, 1848, a young girl destroyed herself by taking arsenic, just before the expected return of the menses. Dr. W istar, of this city, who examined the body, informs me that in one of the ovaries was a blood-red spot, the size of a lentil. There was no absolute rupture of the crypt as yet, nor any blood in the uterine cavity. 296. I repeat that we do not, as yet, know at what period of the mensual act the vesicle bursts. The above example proved to me that the rupture took place in the young girl, previous to the drying up of the discharge; so that, in the case of the Jewish women, if the same rule holds, we perceive that the ovule may be discharged, and yet retain its vitality without fecundation for eight days, and even more than eight days. But we do not know exactly where it rests in such a case, from the period of its escape from the ovarian ovule, until it becomes fecundated eight days later. 297. After the foregoing, I am clearly not called upon to say at what precise period after the courses, a woman cannot possibly con- ceive. I have no doubt there is such a period. Time, and opportu- nity to observe, can alone settle this point. The celebrated case of the birth of Louis XIV., and the advice of the court physician, Fernel, relative thereto, ought not to be cited, since they have none of the characteristics of rigorous truth. It shows, however, the old date of opinions on this point. I am for the present very willing to believe, with M. Pouchet, that a woman shall not conceive later than the twelfth day, as a general law, though it may be that, occasionally, the fecundation may occur even later. (285.) 298. There are questions connected with this topic that ought not to be lost sight of by the diligent Student, who desires to prepare himself upon all the points of a professional duty. For example— Some women are to be met with who never menstruate, and who yet preserve a most perfect physical and mental health. Among these exceptional creatures are to be found those in whom the ovaria or the MENSTRUATION. 145 uterus has never been developed. Dr. Renauldin, on the 28th of Feb., 1826, reported to the Royal Academy of Medicine the case of a woman who died at the age of fifty-two years. She had never had any appear- ance of menstruation. The breasts were not developed. She had only a cervix uteri, which was of the size of a writing-quill—there was no womb proper—and the ovaries were scarcely developed. Such a woman could not menstruate because of the double failure of uterus and ovary. There could be no sexual passion; indeed, such a creature was scarcely sexual. When Percival Pott, the illustrious surgeon, removed the ovaria of his patient under an operation for hernia, he took away with them the power of menstruation. There are nume- rous examples of females who did never menstruate, owing to the absence of the ovaries. When our domestic animals are subjected to the operation of spaying, they are totally deprived of the power of ovulation; and with its loss the sexual sense disappears as well as the sexual attraction also; or if any remains are discernible, they are very imperfect. 299. As to the cases of absence of the womb, they are less rare than the former, and ought not to be lost sight of by the inquirer, lest he permit his ignorance to lead people into a grievous unhappiness. A woman ought not to be married who has never menstruated, until it shall have been clearly ascertained that she is not amenorrhceal from faulty development. I have seen several pretty women, one in 1862, who were suffered to marry before it was ascertained that they had no wombs. All attempts that were made, in either of these cases, to bring on menstruation, are well fitted to cast ridicule upon the physicians. A physician should never be otherwise than cautious in all his dealing with cases of absent or suspended menstruation. I state the following instance, in order to show the evil effects of a want of medical cautiousness. 300. Case.—Mrs. Blank, aged twenty-two and a half years, was mar- ried to her present husband more than two years ago. She is of a middling stature and fair complexion, and presents all the exterior appearances of a person in perfect health. She is not fat, but has a cer- tain embonpoint, a good figure, and a very feminine and most agreea- ble expression of countenance. She is, indeed, a handsome woman. She has never menstruated, nor has she suffered from catamenial pain, or severe attack of any disease. Seeing that she did not menstruate at the proper period, medical advice was sought and followed in the treatment of the case. The treatment was unsuccessful, and she was married with the expectation of her friends that the union would be followed by an eruption of the catamenia. The mammae were, at the 146 MENSTRUATION. period of the marriage, well developed, and the pudenda was amply supplied with hair; indeed, all the phenomena of a perfect develop- ment of the sexual system were present except those connected with the menstrual office. The husband found, however, that some un- known cause acted as an impediment to the congress, and after more than two years of concealment, he consulted me on the subject. An opportunity being allowed to me for a full investigation in presence of the mother, I found the external organs perfectly formed, the mons large, the labia and the nymphae, as well as the clitoris, perfect, and the os magnum of a natural appearance; but the vagina was a mere cul-de-sac, not more than two inches, and probably less than that, in length. Upon pressing the point of the finger strongly against the bottom of the cul-de-sac, it seemed to have no connection with any vaginal part above it. I requested the lady to lie on her back; and, introducing the index finger of the right hand as far as possible into the rectum, I explored with it the excavation of the pelvis, in order to discover any tumor or organ that might be contained within the cavity; but, as all the tissues were ductile and very yielding, I began to suspect that there might be no womb at all in the case. Therefore, laying the fingers of the left hand upon the lowest part of the hypo- gaster, and pressing them firmly towards the finger that was used in exploring the internal parts, I found that they could be brought so near to each other as to make it perfectly clear that there was no womb in the case; otherwise, I must have felt it, so near was the approximation of the fingers of the right to that of the left hand. Having, by the most careful exploration in this manner, discovered the unfortunate state of the young lady, I felt obliged, in a conscien- tious discharge of duty, to tell her the whole truth, which I did in the best way I could; and yet, as may be readily supposed, the knowledge of her situation was accompanied with all the manifestations of that violent distress and agitation which might naturally flow from such unhappy circumstances. The aphrodisiac sense in this lady is very strong, which might well be the case where the ovaria are fully developed, even though the uterus had never been evolved in her constitution. I was deeply impressed myself with the melancholy fate of two estimable persons, who would never have placed them- selves in so unhappy a condition if. by a proper exploration of the parts before marriage, the real state of the case could have been dis- covered. The case also seems to show how improper it is to permit the rites of marriage to be solemnized for persons who do not possess all the attributes properly belonging to the sexes. I do not contend that every case of failure to menstruate at the proper season is indica- MENSTRUATION. 147 tive of the necessity for exploration by the touch; but I think no case of extraordinary protraction of an emansio mensium, and especially where any question of contract of marriage is likely to arise, should be allowed to go on without the acquirement, by a medical adviser, of true and perfect knowledge of the facts as to the organization of the parts. 301. Case.—In the early part of the year 1848, I met with another example of similar want of development in a comely young person, who had been married some three months before. A shallow vaginal cul-de-sac at the bottom of well-developed external genitalia, mammary glands of full size, warm aphrodisiac temperament, and abundant hair, showed that all the sexual physical attributes were present, save only as to the absence of the uterus, no trace of which could be detected by Dr. Pancoast, Professor of Anatomy, by Dr. Jewell, of Philadelphia, or by my own careful exploration. No doubts were left upon our minds of the complete failure of uterine development. 302. Case.—December 24, 1852, I visited Mrs.------, S------n St., aged 22, of a delicate form and stature, but healthy and vigorous. She had been married eighteen months, and had never yet menstru- ated, nor suffered from any catamenial disorder. The external geni- talia are fully developed, and covered with hair, though less abundantly than is seen in many women. The mammae are well formed, and of rather full size; the nipples large, with very dark areas. The hypo- gastric region soft and yielding to the touch, as in the healthiest women. Pressing the integuments down to the plane of the strait, no tumor or unnatural resistance is found. The vagina is a thin, mem- branous cul-de-sac, an inch and a half in depth. I could not discover any central stylus of indurated tissue, as would have been discovered had there been atresia from cohesion of the vaginal walls, whence I infer that the cul-de-sac stops at the bottom of the cavity, which never has been any deeper than now. The sexual desire is strong, and attempts of coitus frequent. I pressed the left index finger as far as I could reach into the rectum, and also a female silver catheter five inches into the bladder. Carrying the point of the catheter backwards until I could touch it with the finger in the rectum, I could ascertain whether she had a womb or no; she had no womb. 303. Case.—I saw a similar case of absence of the womb here on the 3d of January, 1833. The persons interested in this unfortunate situation, though less sensitive than those mentioned above, were ren- 148 MENSTRUATION. dered unhappy by so grave a misalliance; probably the last conse- quences of it may be greatly to be deplored. How important, then, is it that medical attendants, the only persons who can be competent, should be always cautious and watchful as to these points of duty. 304. Not only on account of the risk of fatal mistakes of the kind above mentioned should we be ever attentive to the duty of making accurate diagnosis, but there are a great many other shoals and quick- sands in the track of the young practitioner, who fills his sails with the prosperous and flattering winds of his earliest successes. He would find himself under obedience to a good rule who should firmly resolve never to pronounce any opinion as to the catamenial disorder until he has taken measures to form a solid and inexpugnable judgment on the cases submitted to his decision. 305. The consultations relative to this class of diseases are very numerous for medical men engaged in business. Well, let it be a rule to suspect of pregnancy every married woman who complains of ame- norrhoea. This, though so obviously proper, is a rule often lost sight of by the medical practitioner, whence it happens that we encounter now and then the ridiculous circumstance of reiterated and vain attempts made by medical men to bring on menstruation even in mar- ried women, who prove in the end to be pregnant. I have met with many such instances, 306. Let every married woman who does not menstruate be, there- fore, treated as if reasons exist for supposing her to be gravid. If, by the lapse of time, or by the occurrence of circumstances, a solid conviction can be attained that the patient is not gravid, she may be sufficiently early subjected to treatment conformable to her wants. In like manner, in young unmarried women failing to menstruate, yet exhibiting no other evidence of disordered health, there is always time enough to consider what may be requisite in the treatment: the more especially, if we may believe, what I consider undeniable, that such a woman, healthy, vigorous, and in all respects enjoying the complacency that can only exist in those that be well, either does really perform her physiological act of menstruation—to wit, in the regular deposit of her germiferous ova, yet without manifesting it by the sign, I mean the mensual hemorrhage; or else, that pregnancy prevents the exercise of menstruation. 307. It will, perhaps, appear to be almost a rudeness to make this assertion, and I should not venture to make it in this place, but under a sense of the duty I owe the young Student, which calls upon me to put him early upon his guard. I have so often been nearly deceived in instances of this kind, that I am convinced that nothing but a AMENORRHEA. 149 constant cautiousness has saved me from making the grossest mistakes. Many have been the occasions of my being consulted for catamenial obstruction, with a design to entrap me into the administration of drugs that might remove the difficulty by procuring abortion; but, like all those who will resolve to adopt the rule which I suggested above, I have hitherto escaped so distressing an error of commission. Should a female, presenting all the appearances of brilliant health, complain of such obstruction, I should be sure to come to one of the conclusions indicated in the paragraph—viz: either the ovarian stroma is active and regular in the performance of its physiological act of ovulation without the sign, or else that a gravid state prevents the sign of the ovarian act from becoming manifest. CHAPTER VII. AMENORRHEA. 308. A young woman is sometimes observed to reach the usual age at which the menstrua commence, without having any appearance of the discharge. This is a case, which is denominated emansio mensium, a form of amenorrhoea. When a person who has before been regularly affected ceases to have the periodical returns, she is more properly to be said to have amenorrhoea; for the term emansio belongs to the former, aud the other term, amenorrhoea, to the latter class of cases. I have already, in Letters to the Class, fully expressed my opinions as to those puberic conditions that may inter- fere with the regular exercise of the catamenial office in those who do postpone the first exhibition of it or who derange or suppress it after they have shown that they had once attained the full power of it. 309. Many people are met with who become alarmed if the young persons under their care fail to menstruate at the usual age; but I wish the Student to reflect that, while it is usual to look for the event when the girl is about fifteen years old, we have no reason to be alarmed even though she should advance to her sixteenth, or, indeed, to her seventeenth year without changing, provided her health should be in other respects good. It is only when the failure to menstruate coincides with some other evident sign of weakness or disorder, that the individual should be held to be out of health, and to be treated as a patient. 310. The power of ovulating should always be looked upon as the 150 AMENORRHEA. complement of the physical forces of the sex; and it is reasonable to believe that instances must now and then occur of girls who, having attained to the apparent perfection of all other physical forces, are unable to rise to the height of this last and finishing evidence of generic and genetic power. 311. I deem it to be quite consistent with the facts of the case to believe that where failure to attain to what is called complete puberty (pubertas plena), is not clearly connected with some evident topical lesion, the failure should be attributed to an hydraemic condi- tion of the girl. The healthy constitution of the blood is expressed by 210. of solid elements, and 790. of aqueous portion. A rapidly growing girl, who, in approaching the period of puberty makes ex- cessive demands upon the solid constituents of her blood for the pur- poses of nutrition and growth, is liable to call for a quantity beyond the power of supply, and so come at last to carry the figure for the aqueous constituent from 790 to 800, or even to 820 or 850, while the figure for the solid constituents, or the true blood, must go down to 200, 190, or even so low as 150. 312. It should be observed that in reality the blood is the solid constituent, or portion of the sanguine mass, the production of which cannot be effected save by a power of haematosis, appertaining to a living solid. The evolution of it must therefore bear some ratio to the powers of the special solid upon which it depends. Such power may be greater or less at different times, and therefore is liable to be more or less completely exhausted. As to the watery, or diluting portion of the blood, it should be observed that it is not formed by the solids, but only taken in by absorption or endosmose, and there- fore costs nothing to the constitution. But the solid elements, such as the fibrin, albumen, and corpuscles of the blood, are products created by vital forces that may be exhausted by overtasking those forces. If six hundred ounces might be regarded as the mean quan- tity of blood in an adult in good health, then it will happen that, when the solid constituents are too rapidly consumed, though the whole quantity within the vessels shall not be less than six hundred ounces, yet the blood shall be weakened by the abstraction of a por- tion of its essential or solid parts, and by the addition to the remainder of a sufficient quantity of water to keep the whole up to the figure of 600; for, in the extremest degrees of hydrasmia, the vessels are to be supposed equally full as in the extremest cases of plethora. The difference between plethora and hydraemia is not a difference in the whole quantity, but only a difference in the ratio of the aqueous and the solid constituents. I think the foregoing may serve to show that AMENORRHEA. 151 where a growing girl, by using too abundantly the solid constituents, has obtained an excess of the watery element of the blood, she ought not to be expected to do more than carry on, and that imperfectly, the ordinary operations of her physiological forces. It ought not to be expected that she could do this, and at the same time attain to the possession of her complement of forces. A fruit-tree, in a soil too poor to afford ample nourishment, may live and grow, but it will not blossom and bear fruit, because it is destitute of both the elements and the stimulus that are requisite to enable it to attain the blossom- ing and fruit-bearing complement of its living forces. The fruit tree derives its nourishment from the soil in which it is planted. The blood, on the other hand, is the source whence all the solids of the girl are derived ; if the blood becomes impoverished, by an inordinate addition of water to the solid constituents of it, the girl, like the fruit- tree, cannot attain to the complement of her powers. 313. To show how this impoverished state of the blood, or hydraemia, must act on the health, let me say that the whole class of the insects are supplied with oxygen by means of tracheae, the fishes are aerated by branchiae, while other animals are furnished with lungs. But whether the machinery of respiration consists in tracheas, branchiae, or lungs, the purpose of all this machinery is to afford a convenient access of oxygen to the molecules of the animal tissues, particularly to the nervous mass of the creature. In warm-blooded creatures that have lungs, the oxygen can have no access to the tissues save as it reaches them in the blood. Hence the blood is, in such animals, the oxygeniferous medium or organ. It is the transporter or conveyer of oxygen. Where oxygen cannot go in a living creature, there is asphyxia. If the nervous mass does not receive a due supply, the nervous force is not duly extricated. Nothing appears to me clearer in physiology than this, viz: that neurosity (nervous force, or innervative force) is the immediate product of the combination of oxygen with nervous mass or nerve-corpuscles. Certainly nothing is alive that is not in presence of oxygen, for no living thing can exist in carbonic acid gas, or azote, or hydrogen alone. 314. Now let the Student consider, the figure for healthy blood being, 210 for the solid constituents, what must be the effect on its oxygeniferous power of reducing the, 210 to 150 and raising the, 790 which is the figure for the water to, 850? Will he not say that, as it is not the water of the blood that takes up the oxygen of respired air, then, when the figure becomes reduced from 210 to 150, there must be concomitant reduction of its oxygeniferous force, and consequent diminution in the evolution of the neurosity, as M. Cerise denominates 152 AMENORRHEA. it? He perceives a clear rationale of the debility of the anaemical or chlorotic girl: he will say that her tissues, especially her nervous mass, being incompetently oxygenated, the fruits of such a state are manifested in great weakness, not of the limbs only, but of all the functions and powers of the economy. The hydrasmie girl must hence be weak—weak as to all her functions—quite too weak to afford us any reasonable expectations that she shall attain to the complement of her forces, while the hydraemia remains uncured. Although it is quite true that an impoverished state of the blood strongly tends to pro- duce amenorrhoea, there are individuals whose menstrual force is proof against the most excessive hydraemia, of which the following case furnishes a most striking and conclusive example. Miss----, a maiden lady about 30 years old, was seized, March 24,1853, with copious haematemesis that left her pale, faint, and much enfeebled. She had weak pulse, cold hands, and was so sunken as to require doses of brandy and water. On Thursday, the 30th, she was some- what revived, but unable to sit up in bed. Friday, March 31, another very violent and alarming hemorrhage came on. On Saturday, April 1, no attack, but a violent one came on Sunday, the 2d, and another on Monday, the 3d. By these enormous effusions of blood she was reduced to almost hopeless exhaustion. On Tuesday, April 4, she had a hemorrhage, which was the fifth in the series, and which left her to the last degree hydraemical; yet notwithstanding these dreadful losses, and her almost dying state, her mensual evacuation commenced regularly on Wednesday, April 12, and exhibited the appearances usual for her. This exceptional case shows conclu- sively that a general plethora is by no means essential to the regu- lar returns, and has nothing indeed to do in the establishment of a regular periodical menstruation. The method of cure in cases of hydrasmic amenorrhoea should consist not in the employment of emmenagogues, but in the proper regulation of diet, digestion, cloth- ing, exercise, change of scene, travelling, and suspension of studies; by requisite lapse of time, and, as a medicinal agent, by iron. Atten- tion to these points will very rarely fail to bring about the cure in such cases as I now speak of. 315. As to iron, I take this opportunity to say that it is iron which the patient requires, and not some certain salt of iron compounded by the chemist. As every act of digestion is accompanied by a process of acidification, the acid produced in the p r i m a v i as will always be capable of combining advantageously with impalpable particles of iron-by-hydrogen. It is probable that, where a salt of iron is exhibited by the practitioner, the article is always first decomposed during the chymification, and afterwards recomposed according to the state of the AMENORRHEA. 153 organs of digestion, and that is a work of supererogation for the phy- sician to present to those vital organs a salt, when they want only the base to do with it what is right, of which their organical entelechia can judge better than any man. I have come to a conclusion that, since we have obtained the beautiful preparation of Messrs. Quevenne and Miquelard, I shall never hereafter prescribe my chalybeate doses in any other form than that of the impalpable powder procured by hydrogen from the oxides of iron ; and that I shall always entrust to the vital chemistry the task of making up the salts for itself. 316. Let us now advert to other circumstances that may prevent a young woman from menstruating when she has reached the usual age for the appearance of the menstrua. I need not speak of those cases in which some considerable disorder of another and important organ or part serves to concentrate upon itself the powers of the living economy which they divert from a general to a particular use or determination. Among these are all those affections that tend to set up a hectical irritation in the system, such as consumption, chronic rheumatism, or diarrhoea, painful and long-continued inflammations of the articulations. These causes of amenorrhoea are too self-evident to require more than an allusion to them; and any sensible man, even in the very beginning of his career, might be supposed capable of seeing in them the causes of the frequent failure to cure, and of trust- ing, when they are cured, to find the function in question at liberty to re-establish itself. 317. It is of more importance that the Student should know that some women are now and then met with who have emansio mensium from the want of a womb with which to menstruate, or of ovaria to provide the sources of menstruation in regular periodical ovulation. It happens that organs become blighted during the embryonal or the foetal life, and never grow nor develop themselves after the birth of the child. As these organs are not essential to the mere animated existence of the infant, it may grow up in the apparent possession of all its faculties and attributes. Should such a blight or abortion of an ovary, a womb, or vagina occur, it would be very likely to escape detection until the age of puberty, and then disclose the remarkable truth by a state of emansio mensium. I have already mentioned several married women, neither of whom had ever menstruated, and all of whom were wholly destitute of any discoverable traces of a womb. Yet each of them was in all other respects a highly sexual creature, being fully provided with all other sexual attributes and marks. But they can never admit of the consummation of marriage, nor menstruate. Their strong sexual propensities gave evidence of 11 154 AMENORRHEA. the perfection of their ovaries. I have no doubt that all those women performed with the utmost regularity, the monthly acts of their ovu- lation, nor that they were the subjects of the monthly ovarian and uterine hyperasmia; but they gave no visible signs by the mensual discharge of blood. Such cases admit of no medical treatment. 318. Again, certain women grow up and attain to a good old age, without experiencing any, the least sexual excitement, and without once menstruating during their whole lives. Upon examination after death, it is found that the ovaria were wholly wanting, or that their development having been arrested in the foetal stage, they had never been evolved beyond their foetal form and nature. Such cases are also beyond the powers of the medical art. 319. In some young women, the canal of the neck of the womb, or the cavity of the body and fundus uteri, is found to be annihilated in consequence of inflammation, that has filled the cavities with plastic ex- udation resulting in a fusion of the walls into one styliform substance. Whether the occlusion depends on cohesion, or non-development of the canal of the cervix uteri, the womb may pour out the blood of the menses, which is retained within its distended cavity: another and another menstruation adds to the accumulation, until the uterus, pregnant as it were, and distended with the product of repeated men- struations, either causes the barrier to give way through over-disten- sion, or until the surgeon, become aware of the truth, perforates the obstructed canal with his bistoury or trocar, after which the courses are seen to regularly return with every ovulation. 320. The uterus and ovaries may be healthy while the vagina may be closed by want of development in the embryonal stage, or in con- sequence of inflammation ending in cohesion and artretism. Here, as in the case last spoken of, the menstrua are regularly poured into the womb and vagina, and retained until relieved by accident or by means of the surgeon's art. The same may be said as to the cases of imper- forate hymen. 321. All these possible causes of emansio mensium are to be remembered in extraordinary examples of failure to menstruate at the proper age and when the time arrives to make the needful inquiries, those inquiries should be made with the greatest care, and in reference to these possible causes, in order to avoid mistakes in diagnosis. 322. Such are my views in general as to emansio mensium. But I do not intend to deny that some of the cases of it do depend upon a torpid, sluggish, or obtuse nature of the bleeding organ, the womb itself. It must, however, be always a very difficult task to verify such a diagnosis, except by means of experimental prescription. AMENORRHEA. 155 323. If, upon scrupulous inquiries as to all the possible causes of the emansio hereinbefore described or alluded to, the Student should be left to the reasonable and indeed only remaining conclusion, that the fault rests with such a torpid and insensible uterus, then he might well attempt to excite within it a more active, vigorous life, by means of the stimulating articles that are called emmenagogues. Let him provoke a frequent, moderate tenesmus, by means of aloetics and gum-resins of various kinds; let hirn stimulate the nerves of the pelvic region, both internal and external, by baths, fomentations, cataplasms, embrocations, sinapisms, dry cupping or blisters, used as endermic treatment, while, at the same time, he stimulates the internal nerves of the pelvic region with Dewees's vol. tinct. of guaiacum, or compound tinct. of aloes and canella, elixir proprietatis, Lady Web- ster's pills, tincture of black hellebore, or tinct. of cantharides, etc. etc. Forasmuch as all the above-named medicines and means do tend to increase the vital activity of parts about the pelvis, a reasonable pro- bability exists that they may usefully coincide with general constitu- tional measures in arousing the dormant sensibilities of the womb, and placing them in just relation to the powers of the ovary in its acts of ovulation. 324. In my opinion, though the causes just enumerated are not rarely to be regarded as lying at the foundation of amenorrhosal affections, most of the examples are dependent, not on the womb, but upon a less- ening or cessation of the force by which ovarian vesicles are evolved and matured. Patients suffering with chronical maladies, attended with protracted amenorrhoea, exhibit, in the ovarian stroma, no vestiges of the Graafian vesicles. I lately examined the ovaria of a girl who died after some eighteen months of severe chronical ailments, during which she did not menstruate. Those ailments had no primary connection at all with any state of the reproductive organs, yet, upon carefully examining the ovarian stroma of both the ovaries, it was found to be a compact, whitish tissue, very similar to that which we observe in women long past the change of life. No trace of the ovarian vesicle existed in either of them. It is generally so, as I have found in not a few instances. It was clear from the dissection that this lady could not possibly have menstruated, if the doctrine be true; and fur- ther, that, in case her health could have been restored as to her chronic malady, many days, weeks, or months must have elapsed before the ovarian stroma could have developed the vesicles, or matured and discharged them, so as to give rise to the sanguineous sign of the mensual act. It is useless to ask, in this place, what powers are pos- 156 AMENORRHEA. sessed by the menagoga, speedily to restore the discharge in such cases of amenorrhoea. 325. Hydraemia.—Having in the earlier part of this chapter expressed the opinion that most of the cases of emansio ought to be regarded as results of a real hydraemia, or watery state of the blood, I feel disposed, before I close the subject, to lay before the Student some further views, and especially certain opinions on that subject, that appear to me likely to throw light upon his path in the study of those strange disorders, and I therefore proceed by calling his atten- tion first to a few simple propositions. I beg him to weigh them, and judge whether they appear to him to be consistent with truth, or with a, high degree of probability as to the truth, which it should be the object of all men to know. The opinions, that I am now to utter again in this place, have not been favorably received in certain quar- ters, though in others they have made such impressions as I expected them to make. But, whether accepted or not, all that I desire in regard to them is that they may be received and spread abroad if they be true, while I hope they may be utterly confuted and rejected if they be untrue. Truth belongs to no man. Truth is God's: he is the sole source and fountain of truth: any man who boasts, saying this is my truth, this is my fact, is a fool and a braggart; since the utmost that man can do is to perceive and recognize truths which, themselves, are mere proclamations or acknowledgments of God's law and will as to physical and psychical things. 226. Blood-Membran e.—The first proposition that I shall here offer to the Student is this, videlicet: The living body consists of fluids and solids—which might be otherwise expressed by saying that it consists of the tissues and the blood. The blood contains all the materials out of which the tissues are to be constructed; so that it is true to say, with a celebrated physiologist, the blood is the fluid body, the body is the solidified or concreted blood. The body is separated from the blood by a membrane or tissue which serves as its outward boundary, and prevents the blood from mixing with the whole mass of the tissues. So that, while the blood permeates all the tissues, it is con- fined within certain strict channels of the bloodvessels. This delimi- tary membrane is generally known as the membrana vasorum communis, or common membrane of the vessels, and is the inner lining of all the arteries, veins, and sinuses of the living body. It might be regarded as a multilocular cyst or sac—the several arteries, veins, or capillaries representing each a separate 1 o cu 1 u s or cell of the general sac. This sac is the only living tissue with which the blood ever comes in contact. As long as the blood remains in con- AMENORRHEA. 157 tact with, or in normal relation to this sac, it retains its health, its vigor, and crasis; because, as the blood exists only by its connection with and through its dependence upon the nervous mass, this mem- brane is the organ of induction into it of the nervous force, or life- force: it is certain that, whenever the connection betwixt the blood and the living solids is destroyed, the blood perishes. Whether we regard the blood-disks as cells or not, we cannot deny that they are living entities; but their life is rather epizootic than self-substantial, there being but one circumstance in which they can maintain their existence, and that is the one above-mentioned, to wit; they cannot exist save in the presence of the membrana communis, since through that organ they receive their inducted life. If that organ of induction be perfect, the corpuscles may become perfect: if the organ become imperfect, or if it lose its vitality, they fail or they die along with it. 327. From the foregoing, I deduce that the membrana communis is charged with the faculty, not only of restraining the course of the blood in the bounds of circulation, but that it contains within itself the power to make the blood, and is indeed the blood-membrane. If it may be healthfully constituted ; if it may enjoy in perfection its crasis and its powers; then it may also, under certain circumstances, be subject to modifications of both crasis and power that shall affect the state of the blood-corpuscles, and render them unhealthy, or im- perfect ; for, inasmuch as the membrana communis is occasionally affected with inflammation, with weakness, with contusions, wounds, and other disorders, and as it is capable of those vital processes that are called adhesions, inflammations, suppuration, etc., it is impossible to deny, not only that it may be strong or weak, or healthy or un- healthy, according to circumstances, but that the crasis of the blood must depend upon the state of the blood-membrane. 328. Endangium.—I have been condemned for using in my writings a word, endangium, which I derived from the illustrious Professor Burdach, who ought, it should seem, to be held sufficient authority for the introduction of a word into our medical terminology. The very persons who have railed at me for using Burdach's word have no hesitation daily to employ a similar one. Such, for example, as the words endo-cardium and en do-car di tis, from *v or cvSov and xapfita, by which they mean to express the idea of the lining membrane of the heart, or an inflammation of that lining membrane. For my own part, I cannot discover any unreasonableness in Burdach's suggestion of the term endangium, from tvSov and ayy^ov, inner- vessel, to express the idea of the lining membrane of the aorta, of the cava, of a great artery, vein, or sinus, since the Greek word ayystoy, 158 AMENORRHEA. and the other Greek word en or e n d o n, express an idea of the same membrane where it is called endocardium, but only as being not con- fined to the cavities of the heart alone. To repeat, or to write the long sentences, membrana vasorum communis, or membrane com- mune des vaisseaux sanguins, or the lining membrane of the bloodvessel system, is a useless toil; wherefore, I shall beg the Student, hereafter, to allow me to speak of it by using M. Burdach's short and euphonious term, endangium. So much I have thought it incum- bent on me to say in my own defence; and now I come to the question, whether the endangium is, in fact, charged with the important offices I have supposed; and here I must invite the Student to judge for himself upon an examination of the facts, particularly the following facts, that will nowhere be denied. 329. A child, in its mother's womb, touches her only by its placenta, which consists of the vascular tufts into which the umbilical arteries are divided upon reaching their place of destination in the after-birth. The placenta takes out of its mother's blood the oxygen and plasma sanguinis required by the foetus. The child in utero takes nothing but plasma, which is water, with a certain protein, probably under the form of dissolved albumen and salts. It takes no blood, but only plasma. But the blood, out of which the whole body of the embryon is made and maintained in its status sanitatis! Whence comes this blood, this generator of the body ? 330. I have neither purpose nor time to enter at length into an exa- mination of the principles of the hasmatosis. Such an essay requires not a few pages, but a volume; but, without entering at large on the subject, I may, in hopes of explaining myself, state a few particulars for that end. The blood is daily renewed by means of the alible mat- ter digested in the stomach and bowels, and absorbed by the lacteal absorbents, by which it is transferred to the bloodvessels. The whole of the blood is contained in the heart, the arteries, the capillaries, the erectile tissue, and the veins. The only tissue that the blood touches is the endangium, which is the lining or interior membrane of all bloodvessels. In the viscera—in all the organs, indeed—it is pro- bable that the ultimate ramuscule of a vessel consists solely of endan- gium, the stronger coats being unnecessary in the last distribution. The endangium, to use the idea of Prof. Burdach, separates the blood from the body, as the scarf-skin separates the body from the external world. The endangium is the delimitary membrane of the blood. The blood perishes, or changes very soon, almost immediately, after it escapes from within the endangium. It is converted—or it is coagu- lated, or it dissolves, or it ceases to be blood, upon leaving the cavity of the endangium. AMENORRHEA. 159 331. Notwithstanding that the chyle—particularly chyle taken from the upper end of the thoracic duct—contains vesicles or globules, or corpuscles that are of a reddish hue, and that are the results of the earliest morphological operations of the haematosis, it is not proper to regard these corpuscles as blood. Soon after the chyle is poured into the cavity of the endangium, and becomes exposed to the influences of the oxygen in the lungs, it acquires the character of perfect blood. The foetus in utero touches the parent only by the placental tufts that it has developed at the extremity of its umbilical artery. It is only by these placental tufts that it can receive from the parent the ma- terial supplies for its haematosis. This material enters into its sangui- ferous system only, since it comes into the vena cava by the umbilical vein. If the child has a power to make its own blood, it is clear that it makes it within the walls of its endangium. There is no other solid that the alible material of the child can come in contact with. Therefore, either the blood makes itself, or the endangium of the embryo makes it. It is, therefore, not to oxygen alone that it is indebted for its morphological developments. 332. Contact with the endangium is essential to that development, since the blood loses its physical character as soon as it ceases from that contact. The endangium contains the force that makes the blood. This proposition, which I put forth in my " Letters to the Class," has been denied. I reiterate it here; and I ask what violence is done to probability in this doctrine, seeing it is uni- versally admitted that the power of a cell—a far more simple and ele- mentary body—is so great that it can, out of the alible cytoblastem in which it exists, produce, by its metabolic and plastic energy, cartilage, ligament, skin muscle, aciniferous viscera, nerve, and, indeed, all solids of the body? If the to ffntafimixov x 424. In addition to the cases of disproportion effected by dropsical collections, there are instances of accidental disproportion resulting from the union of two foetuses in one. The celebrated example of the Siamese twins is familiar in the United States, and it is easy to con- ceive that such a union could not but render difficult and preternatural a labor in which such twins should.be born. The instances of children with two heads are not rare, numerous examples of them being con- tained in the books. The example that has been so admirably de- scribed by M. Serres, in his "Anatomie Transcendente," appears to me to be particularly worthy the Student's attention. This monster was born at Sassari, in the kingdom of Sardinia, in the year 1829. There were two heads, a double thorax, with four arms, and one abdo- men with two legs. Being christened, the one on the right took the name of Rita, and the left one that of Christina. Rita- Christina was brought to Paris and exhi- bited there, until death closed the exhibi- tion when the monster had attained the age of eighteen months. I subjoin a figure (63) which represents a case of double-headed foetus, born in Adams County, Penna., in 1844, under the medical care of Dr. Pfeif- fer, a German physician in practice there, who brought the monster to this city. I engaged Mr. Neagle, one of our best ar- tists, to paint a portrait of it, from which this small cut is taken, and represents it very correctly. In this figure, repeated at 685, it is seen that the monster possessed only a right and a left arm, whereas Rita- Christina had four arms, because, in her case, the cervical, dorsal, and lumbar ver- tebras were complete for each child; whereas in this sample, the cer- vical and dorsal vertebras only of each child were complete, while they united in a common or single lumbar spine, and one pelvis. Rita and Christina each had its own ribs, and a sternum for each, yet admitting of a single thoracic cavity for two hearts, and only two lungs. The liver was a compound of two livers; there were two stomachs, two PREGNANCY. 211 duodenums, two jejunums, and two ilia, uniting, towards their lower extremities, into a single short ilium, inserted into a single cascum. There was but one colon and one rectum, and one bladder of urine. The "Comptes Rendus" of the French Academy of Sciences for Sept. 4th, 1848, contains a description, by M. Valenciennes, of a porpoise with two heads, but having, like the child in Fig. 63, only two arms. There is, in my collection, a specimen, consisting of two children united by the ileum intestine, which comes out from the navel of each child covered by the umbilical cord. The two cords, midway betwixt the children, merge into a single umbilical cord, inserted into one placenta. This specimen was presented to me by Dr. Clarke, of Phila- delphia County. The children are separated by the omphalodymic cord about four inches; and there are twoapertures in the cord, each of which is an accidental anus, from which the meconium escaped freely. There are also two apertures, open u r a c h i, from which flows the urine produced by the children. There are many cases to be met with, of children with only one head, yet possessing two bodies and four legs; and some, in which the heads are united at the summit, or crown. I refer the Student to the "Amer. Journal of the Medical Sciences" for July, 1855, p. 13, for a paper illustrated with engravings repre- senting a double foetus, presented to me by Dr. G. W. Boerstler, of Ohio. As those illustrations are copied from fine photographs by M. Root, of this city, they are to be relied on as faithful portraits. Here (Fig. 64) is a correct portrait of a foetus that was shown to me by Dr. Rohrer, of this city, soon after its birth under his professional care. The great tumor on the vertex consisted of scalp lined with the ordi- nary encephalic meninges, and filled with the water of a vast dropsy of the brain. The posterior part of the parietal and occipital bones was wanting; some hairs grew on the part of the tumor near the ver- tex ; the rest was bald. The child was in other respects well formed, and very large. The tumor was soft and fluctuating, but not reducible in size by pressure in the hands. Its greatest length was nine inches. I shall refer hereafter to this figure, to that of the double-headed mon- ster of Dr. Pfeiffer, and to Rita-Christina, and to Dr. Boerstler's speci- men, to show the necessity and nature of what is in Midwifery called Evolution of the foetus in all such cases. Observations on the mid- wifery of the case would be out of place on this page. (686.) 425. M. Serres's work, and that of M. G. de St. Hilaire, exhibit a great variety of Teratological foetuses, to which I must merely allude, as the limits of this volume will admit of no extended observations upon them. I have mentioned them here, chiefly with the view to put the Student on his guard as to the midwifery of such cases; and 212 PREGNANCY. Fig. 64. still more in order that he may early learn that these monsters are merely results, not of excess, but of failure in development. The double-headed foetus, Fig. 63, has two stomachs, and probably two hearts, but only one intestinal canal, composed by the union of the two jejunums, or the two iliums, into a single jejunum or ilium, a colon and rectum. This child is a twin, which has not acquired a superfluous head, but which has lost, one a left, and the other a right arm; one the right, and the other the left half of its thorax—one kidney—half the colon and rectum, half the bladder, testes and penis, and a right or a left leg. This double-headed foetus then has lost, not gained: it has been fused, or, to use a term in horticulture, grafted. The right child has sunk part of its body in that of the left child, which in like manner has sunk the right half of its body in the left half of its twin brother. In Rita-Christina, if both children happened to be asleep, and one should tickle Rita's foot, she would wake and smile: so, if Christina's foot were tickled, it would cause her to laugh, without at all affecting her sister, for the left leg was Christina's and not Rita's, and vice versa. 426. Happily, when twins are conceived, they inhabit each its own amnion, and in some instances, its own chorion—which insulates them. When the development of the amnion fails, and the two germinal membranes are suff'ered to come into contact within the womb, they PREGNANCY. 213 Fig. 65. may unite, or weld, or engraft together, under a certain law; but the back of one cannot unite to the abdomen of the other, nor the head of one child to the other's pelvis. In order to unite, only the edges of the still unclosed germinal membrane can weld—that is, the left edge of one with the right edge of the other, and mutatis mutandis. Hence the law of development is binding; that law ordains that the right edge of the membrane, when bent over to shut in the trunk, should unite with the left edge turned inwards in like manner. Hence, it may fuse with the left or the right edge of its foetal twin. 427. If we might suppose the germinal area of the germinal mem- brane to be in shape a long oval, like Fig. 65, and a the cephalic pole; b the*pelvic pole; e d the brachial, and ef the crural regions; we may conceive that no sublunary power could develop a pelvis at a, or ahead at b; a leg at c d, or an arm at ef; for even in this microscopic mass the generic law is as imperative and coercive as the attraction of gravitation is for the whole universe. There is nothing generically in common or identical in a and b, or between e d and ef; c unites with d only, and e with/only; when the scaphoidal germinal mem- brane has become completely bent so as to bring into apposition the edges c e and df to make the cavity of the belly and thorax, d could not unite with e nor c with/. 428. If in the adjoined diagram, Fig. 66, the two ovals may represent the germinal areas of twins, not separated by amnia, then a and I may unite if brought into apposition, or b and m; c and g, and e and i, have no affinity. If d and g, which have affinity, should unite, the result would be a foetus with one head, two arms, and four legs; if/and i be placed in contact in utero, their affinity would cost a left leg for the right hand membrane, and a right leg for that on the left. Thus we should have a Rita Christina. It is a curious subject of reflection, that of the individuality or du- ality of a creature with one head and two bodies, or with two heads and one body! Rita-Christina was dual, as was Dr. Pfeiffer's monster, Fig. 63; but as to the monster figured in Serres's Plate 12, it is to be doubted whether the personal identity was absolute for each of the children—as there was one common cerebellum. Doubtless it is not possible, in Teratology, to suppose that half of one child should sink Fig. 66. 214 PREGNANCY. into and be totally lost in half of another child, thus making out of two independent personal identities a single one. In nature, the union must take place from the liver upwards only, or from the liver down- wards only; whence, it cannot happen that the whole right symmetri- cal half of the left twin should he sunk in the left symmetrical half of the right twin. We may therefore expect to meet with cephalodym or hepatodym or pelvidym, and not with such a union of two personal identities as would serve to personify the ancient fable of Salmacis and her lover. All such fusions imply loss, not gain of substance— monstrosity by default, and not monstrosity by excess. If a child is born with six fingers on either or each hand, or six toes on either or each foot, it presents a case of excess of development, or monstrosity by excess; and the samples of five-legged calves, &c, that are com- monly met with, are, perhaps, cases of monstrosity by excess. 429. There was a singular example of cephalodym here some four years ago; it was a healthy pig with one head, two fore legs, and two abdomens, with four hind legs. It was a remarkable fact that the genitalia of this creature were not under a common influence of its cerebro-spinal system. When the animal was in heat, it was either as to the genitalia of the right or those of the left trunk; but they were not observed to be in heat or rut at the same time, one trunk appearing to become the subject of the periodical excitement about ten days after the other had ceased to be so. What was the real con- dition of the identity of this monster ? 430. The instances of monstrosity by default of development are sufficiently numerous; as, for example, in the cases of spina bifida, of anencephalous and acephalous foetuses, and of foetuses with imperfect limbs; and those with imperforation of the rectum, and with other atresias. The Student will have little trouble to understand and ex- plain these strange freaks of nature, if, in all cases, he will remember that the monstrosity is dependent either upon fusion of the parts of two different children, or excess in the development of otherwise natural parts, or on cessation, during the embryonal stage of life of that growth and progress which, but for the arrestation, would have finished and rendered complete, parts that now exhibit the appearance of the most shocking deformity. 431. We meet with numerous cases of ectopy; cases in which or- gans or parts are displaced or deviated. In Fig. 62, page 204, is the picture of a child born here under my care. It lived for several days. The tumor on its belly is an exomphalos, consisting of the entire liver of the infant, which was contained within the root of the umbilical cord. There was no covering of this liver save the deciduous matter PREGNANCY. 215 of the cord. Of course when the cord should fall after five or ten days, the liver would be wholly exposed. Such an accident renders the child absolutely non-viable. I possess another specimen, in which every abdominal viscus is outside of the belly inclosed within the um- bilical cord. 432. Duration of Pregnancy.—The duration of gestation is ordi- narily computed to be nine months or 280 days; and the Women, who understand these questions by a traditionary learning, commonly make their calculations with sufficient accuracy. According to the Civil Code in France, a pregnancy may properly be held to continue until the 300th day ; which is allowing a latitude of twenty days be- yond term. I have been surprised to find how prevalent has been in all ages the opinion that a great latitude exists as to the duration of pregnancy, and that some of the ablest men of our profession, both ancient, mediaeval, and modern, have admitted a latitude far greater than that allowed in the French Code. I rejoice that this is the case, be- cause, having myself had reason to believe that pregnancy may endure even beyond twelve months, as I shall relate in another page (437), I conceive it desirable that the truth should be established for the con- servation of the credit and peace of individuals or families, in cases where such extraordinary postponement of the term might give rise to the greatest injustice, as well as unhappiness. In 1764 a great con- troversy arose in Europe, which was carried on by various writers until 1770, and brought out the opinions of the most celebrated medi- cal men of the time; a collection of pieces on this subject, in three volumes, is in my library. The dispute arose on the question of legi- timacy of a child, whose father, Charles, born January 15, 1689, was more than 72 years old when he married Rene'e, Marchioness of Ingre- ville, who was at the time 30 years of age. He lived four years with his wife, and had no children. On the night of 7th-8th of Oct., 1762, he fell sick with fever and violent oppression, which continued until his death. During his illness, his wife Renee did not sleep in his apartment. He died with gangrene of the leg, on the 17th of Nov. ast. 76 years. More than three months after his death, Rene'e gave signs of being pregnant. She was observed and carefully assisted by order of the collateral heirs, and gave birth to a son, Oct. 3d, 1763. From Oct. 8th, 1762, to Oct. 3d, 1763, is one year, lacking five days. The question was submitted to various leading medical persons for their opinions as to the legitimacy of the child, and the said three volumes exhibit the most striking examples of the disagreement charged among doctors, many strongly denying the possibility of 216 PREGNANCY. Rente's purity, and others as earnestly vindicating the legitimacy of her son. 433. It would seem that the most common and ordinary observa- tions and proofs are incapable of expelling from the public mind opinions long established, upon whatever foundation. There is hardly to be found an old wife in the country, who does not know that the term of incubation of the barn-door fowl is uncertain; and that, though it ordinarily lasts twenty-one days, the chick may be found to escape from its shell on the twentieth, or to linger in it, sometimes, to the twenty-second or twenty-third day. Similar facts as regards the ges- tation of our domestic quadrupeds are abundant, and sufficient to de- monstrate the latitudinarian character of what is called term. To show the differences in gestation, I subjoin the following tables which I find in M. Rainard, "Traite" complet de la Parturition des principals Fe'melles Domestiques," torn. i. p. 233, et seq. The date of the Covering was noted as to fifteen mares, of which eight foaled after 340 days, three after 342 days, three after 343 days, and only one at 346 days. Brugnone, in like manner, in fifty-five mares found that the foaling took place in 1 in 10 months and 7 days 5 in 343 days 1 " 11 u " 1 day 2 u 344 ii 2 " 330 days 3 11 345 it 2 " 333 u 4 11 346 u 2 " 334 11 4 u 347 u 2 " 335 u 1 u 348 u 4 " 336 it 2 ti 351 u 2 " 337 u 2 It 352 u 2 " 338 ti 1 u 353 u 1 " 339 It 1 If 356 u 3 " 340 (( 1 li 357 ii 1 " 341 ti 1 11 369 ii 3 " 342 it 1 11 389 " or 13 months " The difference between the most precocious and the most pro- tracted gestation amounts here to seventy-seven days, or two months and a half. From his table, Brugnone concludes that the gestation is not complete in less than one year, and that, when it goes beyond that term, there is no fixed period."—P. 233. M. Tessier found that in the gestation of 200 mares, there was a latitude of eighty-three days.—P. 239. The "Journal d'Economie rurale Beige," 1829, finds a minimum of 322 days, a mean of 347 days, and a maximum term of 419 days; difference, ninety-seven days.—P. 234. M. Grille's state- PREGNANCY. 217 ment, " Mdm. de la Socie'te' Industrielle d'Angers," No. 2, lle annee, p. 55, shows in 114 mares a difference in gestation of ninety-three days.—P. 239. The observations made by order of Earl Spencer, as to the gestation of 764 cows, show that the shortest period of gesta- tion is 220 days, though the ordinary duration is of 284 or 285 days. P. 235. Among sixty-five sows, two littered on the 104th day; ten from the 110th to the 115th; twenty-three from the 115th to the 120th; twenty-seven from the 120th to the 125th; two on the 126th, and one on the 127th day. This is a latitude of twenty-three days. M. Rainard further gives, from the "Bulletin de la Societe" Industri- elle d'Angers," the following statement of the duration of gestation in 154 rabbits, viz: one littered on the 27th day ; seven from the 28th to the 29th; fifty-three on the 30th ; sixty-one on the 31st; and twen- ty-nine from the 32d to the 34th day. These statements show with sufficient clearness that the duration of gestation is by no means a fixed term in any of the observed genera, and I should suppose that the least reflection might lead one to the same conclusion, since the nature of the womb, as well as that of the child, is such as to render it impossible that the laws that govern the contractility of the one or the rate of development of the other, should operate in all cases in equal times and force. The womb of one individual, as well as the foetus within it, may be ready for the act of parturition earlier or later, according to the force of a variety of causes to the operation of which they are subject. 434. The duration of gestation must bear some necessary relation to the mass of the foetus to be developed. Yet, in the elephant, the young at birth stands only about three feet high, which is not higher than the new fallen calf or foal, though the weight must be far greater. In this animal, the gestation lasts twenty months, according to the showing of Mr. Corse Scott, who had one born of a dam in his pos- session in India. He noted that the gestation commenced about the 1st July, 1793, and terminated about the 1st April, 1795. An ac- count of this elephant may be found in the " Brit. Cyclop, of Nat. History." 435. Professor Asdrubali, in his account of the thirteen months' gestation of the Signora N., cites the following passage from Spigelius, who, in speaking of the causes of labor, or ofthe completion of preg- nancy, says: "Hasc nulla alia esse potest, quam maturatio, et per- fectio foetus, quas fit in utero incerto tempore et variis i n - terdum men si-bus, ob facultates corpus foetus gubernantes vel debiliores vel robustiores." The same author, Asdrubali, in his " Trat- tato generale di Ostetricia Teoretica e Practica," torn, v., gives us a 15 218 PREGNANCY. succinct relation of the pregnancy and confinement of the lady, the Signora N., who carried twins in the womb oveV thirteen months. Probably so great an extension of the uterine life of the foetuses may excite the reader to feel surprise, and even to a denial of the facts of that case. But I should think that that elegant and learned Scholar, who gives us the history of the pregnancy, ought to be held worthy of our confidence; and I believe it would be difficult to read his fifth volume, which is devoted to the examination of the subject of pro- tracted pregnancy, without being convinced, not only of the sincerity, but of the truthfulness of the author. And it seems to me a very desirable thing that that case should be fully reported in the works on medical jurisprudence for the better information of our courts and juries. I shall at least make an abstract of it in this place. 436. Case.—The lady, aged 26 years, was married on the 15th of April, 1793. She became pregnant in March, 1795, after having been married 21 months. The child, which was born in December of the same year, died on the 8th day. About the first of March, 1796, she was affected with symptoms which induced her to suppose she had again conceived. On the 13th of the same month, she removed to a neighboring district. Upon returning to her residence, she was shocked to find her husband, who was a nobleman, ill with a disease of which he died on the 22d of the same month. To the grief occa- sioned by the loss of her spouse were added great distress and embar- rassment connected with the inheritance of his estate, and notwith- standing she early declared the existence of her pregnancy, she was much tormented and baffled by the relatives of her deceased husband, who treated her declaration of pregnancy as false. At the beginning of the fourth month of gestation, she perceived the quickening in the womb. Throughout the fifth and part of the sixth month, the movement in the womb was so violent as to have the appearance of constant convulsive action. Towards the end of the sixth month the motion almost wholly ceased. The abdomen appeared to be cold; the breasts became hard, and there was a discharge resembling whey from the nipples. It was about this time that her family quarrels, in- sults, and disappointments became most aggravated, and in this con- dition she passed through the sixth, seventh, and eighth months. At the commencement of the ninth month, she was seized with pains like labor-pains, and discharged from the womb a great quantity of watery fluid. The pains continued to recur during eight consecutive days. They now ceased, as well as the watery discharges, and the lady again began to feel the motions of the fruit of the womb, while the lower PREGNANCY. 219 belly again recovered its feeling of warmth. The abdomen, which had ceased to grow, resumed its process of development. The breasts ceased to flow, and became-flaccid. During the tenth and eleventh months, she experienced a sense of weight in the hypogaster, and had difficulty and pain in the act of urinating. In the course of the twelfth and thirteenth months, she was assailed, first every eight and then every fifteen days, with pains like those she had felt in the begin- ning of the ninth month. These pains lasted sometimes four and sometimes five hours alternately. On the 22d of April, 1797, she was attacked with symptoms of labor, and on the 29th gave birth to twins. The gestation seems to have continued from March 1, 1796, to April 22, 1797, a period of thirteen months and twenty-two days. Such is a compendious relation of the case, of which the particulars are given in long detail by Prof. Asdrubali. I lay it before the Student with the assurance that I cordially accept the story of the accomplished author, and that, notwithstanding it presents a rare example of pro- crastination of the Term, I find in it nothing impossible to believe, the more particularly as I have confidence in the correctness of the following statement of a case that fell under my own clinical care, having admitted the patient to my ward in the Pennsylvania Hos- pital, and having observed and attended her up to and in her accouche- ment, I rely on the facts as trustworthy. 437. Case.—Saturday, August 1, 1840. Being at the Pennsylvania Hospital, a lady came to me, and requested that, as a medical officer of the House, I would see A. G----n, in Clark Street, Southwark, in order to her admission into the Lying-in ward. I was told that her confinement, which had been looked for in April, had not yet taken place, that she was suffering under the effects of this unnatural preg- nancy, and that the neighbors thought she ought to receive the cares of the Institution. Upon proceeding to Clark Street, I learned that she was twenty-six years of age, that she had been confined in the Pennsylvania Hospital on the 18th of February, 1839, and was again pregnant in the month of July, 1839, while suckling her son. Being very much indisposed, she called a physician, who directed her to wean the child, as she was doubtless pregnant. She did not, however, wean him until September, when she felt sure of her pregnancy. On the 20th of November she quickened, and her husband very distinctly perceived the motion of the child at Christmas. On or about the 10th day of April, 1840, being very large and lusty, she was taken in the night with the symptoms of labor, and called in her neighbors. She said the waters broke in the night, and wetted her profusely. After 220 PREGNANCY. the rupture of the membranes, the pains were great, and she supposed the child would be soon born; but as the pains not long afterwards grew easier, she did not send for the doctor till morning, at which time, they had become much less distressing; in short, they gradually left her: but she continued big, and could daily, and even now, feel the child when it moved, which gave her great pain. She was laboring under a decided hectical fever and irritation, that had already very much reduced her flesh and strength. She obtained but little sleep, and had a poor appetite. She daily suff'ered acute pains in the abdomen. I gave her a ticket for the Lying-in department, to come in on the 4th day of August. The os uteri was found to be not dilated, though the cervix was fully developed, having lost entirely its tubular or cylin- drical form. The form of the abdominal tumor was conical, the umbilicus being at the apex of the cone. Two or three inches above the umbilicus was the commencement of an oblong tumor, extending to within a very short distance of the xiphoid cartilage, and about three inches in width by two in height. This was a hernia produced by the separation of the linea alba, through which protruded a quan- tity of the intestine, thinly covered, and restrained by the peritoneum and skin. She remained in the ward, suffering daily and nightly with abdominal pains, until she fell into labor on the 11th of September, and the child was born on the 13th of September, about daylight. I sat up with her all night, being deeply interested to observe all the phenomena of the case. The child, a male, was of a medium size, weighing seven or eight pounds; in good health. The labor was ex- tremely tedious and distressing. She had a pretty good getting up, but the hernia of the linea alba caused great weakness, which was in a measure relieved by a truss made expressly for her. She was dis- charged October 11th, 1840. Of course, in relating this case, I do not consider myself responsible for the truth of its statements further than as they are worthy of confidence in view of the character ofthe patient herself, and as the facts came under my notice. She had the appearance of perfect candor and sincerity in all that she said about it, and I have no doubt she thinks her pregnancy began in July, 1839, and ended, as I have said, on the 13th of September, 1840, having endured near fourteen months, or four hundred and twenty days, in- stead of two hundred and eighty, the usual term of a pregnancy. In July, 1841, she is pregnant again, and still suff'ers from the protrusion in the upper part of the linea alba. 438. Lamotte, t. i. 313, Obs. xci., relates the case of Madame de----, who had had children of former pregnancies, and who conceived in the month of January, during which she experienced all the incon- PREGNANCY. 221 venient sensations to which she had been accustomed in antecedent gestations. In the middle of May, she quickened at the same period as on other occasions. She made her computations for the term for September. Supposing herself about to be confined, she summoned the monthly nurse, who remained near her until the labor terminated by the birth of a child much larger than the other children had been. She was delivered of the child at the beginning of February, making a case of gestation protracted through thirteen months. 439. Dr. Merriman, of London, has published, in vol. xiii. part ii. of the "London Medico-Chirurgical Transactions," a paper on the Period of Parturition, which contains an interesting table of the births of one hundred and fourteen mature children, calculated from, but not in- cluding, the day on which the catamenia were last distinguishable. By this table it appears that three were born in the thirty-seventh week, thirteen in the thirty-eighth week, fourteen in the thirty-ninth week, thirty-three in the fortieth week, twenty-two in the forty-first week, fifteen in the forty-second week, ten in the forty-third week, and four in the forty-fourth week, of which latter, one was born at three hundred and three days, one at three hundred and five days, and two at three hundred and six days. Dr. Merriman states that he has cal- culated a great many more cases in the same manner, but has restricted his table to the above one hundred and fourteen cases, because he was able completely to verify them. The others gave results so nearly similar, that he has no doubt of the general correctness of the principle he desired to enforce, which was, that conception takes place, in gene- ral, soon after the cessation of the catamenial flow, and not just ante- cedently to its expected return. The table is highly interesting, in the relations for which I would use it, showing, as it does fully, that there is a considerable latitude in the duration of gestation. "Mr. Gaskoin communicated an account of suspended animation, during four years, at least, in a specimen of helix lactea, now living in his possession. A remarkable feature in this case is the fact that utero- gestation was suspended, and resumed its process with the resumption of vitality."—"Athenasum," Nov. 30, 1850. 440. Computation of Term.—The ordinary term of a gestation is attained in about two hundred and eighty days, and it is customary among medical men to assign the two hundred and eightieth as the day on which the child may be expected to be born. In making the computation for my patients, my own habit has been, to inquire as to the day and date of the disappearance of the last menstrua; to 222 PREGNANCY. commence the series on the day following the disappearance, and add two hundred and seventy-nine days to it. This mode has answered my purpose well enough, but it is clear that it would not answer for the calculation of term, in the case of a religious Jewess. That ex- perienced practitioner, and most judicious author, Professor Naegele, of Heidelberg, in his "Lehrbuch der Geburtshulfe," 8vo., 1842, in a remark at the foot of page 82, gives the following method of computing term. Let the woman reckon three months back from the day when her menses ceased, and to the said three months let her add seven days. The day thus found is the one on which she ought to expect her confinement. If, for example, she had her courses last on the 10th of June, let her reckon backward three months, to March 10th, to which she should add seven days, which would bring the calculation to the 17th of March. This would be the day, to wit: March 17th, on which the woman ought to expect her lying-in. Such is the method of calculation recommended by Dr. Naegede, and it must be admitted that, as no man in Europe enjoys a more enviable reputation as a teacher and practitioner in our art, one might feel safe in following his example in the practice of it. Still, I cannot perceive why the seven days should be added to the three months, or, rather, to the whole term, since the Professor gives no reason for us to suppose that the ovulum is not both mature and ready for fecundation as soon as the catamenial flow has ceased, and the genitalia have recovered their fitness for the congress of the sexes. As I have had no reason hitherto to find fault with my own method, I shall continue to com- pute from the day of cessation; so that, if my patient should inform me she saw the last stain on August 27th, I should reckon back- wards to July 27th, June 27th, and May 27th, which day I should indicate as the one on which the labor might be expected to com- mence, and not June 3d. My opinions as to the connection of the men- strua with the acts of ovulation are so settled, that I do not expect they shall be changed hereafter. Still, those opinions do not prevent me from supposing it sometimes possible for an ovulum to become mature, and even to escape from its ovisac, without exciting the usual mensual molimen—and even, also, that this escape might take place just before the period for the catamenial return, or at any other period. Under such fortuitous circumstances, a fecundation might be possible just before the period of return; and if so, the calculations as to term would be liable to give rise to a disappointment. In general, however, one may venture to rely that a general rule will hold good—while no great surprise ought to arise when an exceptional instance happens to fall under notice. PREGNANCY. 223 441. Changes in the Womb.—The form of the womb changes with the progress of pregnancy. The vaginal cervix grows shorter, and at length wholly loses its cylindrical, or tubular shape, leaving at the upper end of the vagina a convex or conoidal protuberance with a dimple in its apex, which is the os tineas of the womb at term. As the ovum expands, it carries the uterus along with it, at first making use of the cavity of the fundus and body of the organ, and only dis- tending the upper part of the cervix in the first months of preg- nancy ; so that, if an examination should be made of a woman three months pregnant, the cylindrical cervix uteri would be found to have undergone very little shortening. The cervix certainly becomes fuller and larger, at a very early period 6f pregnancy, and presents, in this respect, a sensible difference from its unimpregnated state. At the close of pregnancy, the tubular cervix uteri seems to have wholly disappeared, and the womb, instead of exhibiting a straight or cylin- drical neck, is become conoidal, the os tineas being at the lowest end. No decided change in the length of the cylindrical part is discovered by the Touch until after the fifth month, or, according to certain au- thorities, the seventh month. From that period it grows daily shorter, until the last days of gestation, when the cylinder is no longer dis- coverable : a pregnant woman, therefore, in whom it has wholly dis- appeared, is said to be ready to commence the process of labor. The attack of labor pains may begin very soon after the disappearance of Fig. 67. the cylinder of the cervix, or it may be deferred for several days, from causes which are not understood ; hence, one should be cautious in making prognostication founded on this state of the cervix and os; the most one should do would be to announce probabilities. Figure 67 exhibitstheformofthe gravid uterus, which maybe 224 PREGNANCY. compared with that of the unimpregnated organ, Fig. 47. 442. In all instances that have fallen under my notice, the thickness of the walls of the womb, when at term, has been rather less than in the non-gravid organ. The tissue is much looser and easier to cut, and yields to any distending force far more readily in the gravid, than in the non-gravid state. It is incomparably more vascular, so that, in the last weeks of gestation, it may be compared to a purse or network of bloodvessels, with abundance of loose cellular tissue, and muscular fibres interspersed. I have sometimes compared it to a vast hollow aneurism by anastomosis, in order to express an idea of the abundant vascularity with which it is now provided, and by the agency of which it is enabled to fulfil the wants of the foetus as to aeration and nutri- tive absorption. The uterine arteries and veins which reach the womb near its lower extremity, inosculate freely with the ovarian or sper- matic vessels, that enter its texture betwixt the folds of the broad ligaments, to supply the ovaria, the Fallopian tubes and upper por- tions of the womb. Smellie, vol. ii. p. 19, says that he had opportu- nities, in 1747 and 1748, of opening the bodies of two women who died at the full term of utero-gestation. The membranes were unrup- tured. The walls were each about a quarter of an inch thick. The same was the case with another specimen in his possession, which was in the eighth month of pregnancy. He had seen several others, in which the woman died soon after delivery, the womb not being much contracted, when the thickness of the walls was about the same as the above. But where the death did not occur for several days after deli- very, and the womb was contracted, he found its parietes from one to two inches thick. In the cases that I have seen of autopsy of the pregnant woman, I have always found the head of the child to present at the os uteri. I cannot agree with the opinion of M. Paul Dubois that the child is instinctively compelled to turn its head downwards, for I can neither discover any such instinct in the unborn foetus, nor power to obey it if it should exist. M. Dubois's paper on this subject in the "Transactions of the Royal Academy of Medicine" is, however, well worthy of a perusal. 443. Uterine Muscles.—With regard to the muscular structure of the womb, I shall remark that no person who has witnessed the exercise of its muscles in labor, can doubt of their immense power; particularly should he have felt its force while the hand has been com- * pressed by it, in turning a child in utero. Some years since, a gentle- man of this city found himself obliged to introduce his hand com- PREGNANCY. 225 pletely into the womb, in order to extract a retained placenta. While the hand was employed in separating the afterbirth from the uterus, the os uteri closed upon his wrist with such force as to give him very severe pain, and he found it impossible to withdraw the hand, which was completely fastened by the contraction. After various unsuccess- ful attempts to extricate himself from such an unheard-of difficulty, he sent for a Bleeder, and, after causing a large quantity of blood to be drawn from the lady's arm, the spasm of the cervix ceased, upon which he was liberated from an imprisonment of two hours. His wrist was marked, as if a cord had been strongly bound round it; the red traces of which impression were visible even the next day. 444. The operation of turning the child in a powerful womb, from which the waters have been entirely drained, not unfrequently pro- duces from pressure, a degree of numbness so great as to make it necessary to withdraw the one, and introduce the other hand—the sensibility and motion of the first one being wholly suspended; the resistance to be overcome in the expulsion of a grown foetus requires a muscular force which cannot be exactly estimated, and must, doubt- less, be immense. Different writers describe the arrangement of the muscular fibres of the uterus in different manners. The very discre- pancies of these authors ought to con- vince us that their arrangement is not yet understood; and, indeed, it is of no great consequence, in a practical view, that it should be demonstrated. It is enough to know that the fibres are so arranged as to tend, by their combined contractions, to reduce the uterus back from the gravid size to that of the unimpregnated organ. When their contraction is co-ordinate, the fundus tends to approach the os tineas, and the sides tend to approach each other. Whatever is contained within the cavity of the organ is, under these circumstances, expelled therefrom. 445. It should be always understood that, in speaking of the mus- cular structure of the womb, we speak of the gravid womb only, in which the magnitude and condition of those fibres are immensely different from those of the virgin or the non-gravid organ. Fig. 68 is a representation of their arrangements, proposed by M. Chailly, which diff'ers from the very beautiful drawing of a dissection of them, that is 226 PREGNANCY. given in Dr Moreau's Atlas. Both of them are unlike Madame Boi- vin's figure—and I have no doubt that every successive representation will diff'er from those that do, or may, precede it. My own attempts to extricate the tangled maze of muscular fibres leave me convinced that the only anatomy of them to be depended on, is the Transcendent anatomy—or that which is performed by the reason and not by the scalpel. He who has felt the womb contract upon his hand in a Caesarean operation, or in repositing an inverted uterus after labor, or in extracting the placenta in hour-glass contraction, or in turning the child long after the waters are gone off, will have a better conception of the muscularity and of the arrangement and distribution of the muscles than he who trusts to the dissecting knife alone. 446. The action of the muscles of the womb ought, if normal to be perfectly co-ordinate, all its parts acting together, and at the same time. It is, however, true that, in the state of contraction, all the parts do not always begin and cease to act at the same moment. Labor does not always proceed with regularity. The muscular power of the womb is occasionally found to be morbidly exercised. Those fibres that tend to bring the fundus near the os tineas, sometimes fail to act, or act imperfectly; while those that tend to approximate the sides of the womb act .with such force as to compress the body of the foetus, and, instead of expelling, rather confine and detain it within the cavity. We frequently observe women to suffer under the most violent uterine pains, which nevertheless do not move the child downwards in the least degree; such pains should be suppressed, if possible, in order to admit of the co-ordinate and regular operation of all the fibres being restored, by temporary cessation or repose. It is such an action as this that constitutes the hour-glass contraction of the womb, which takes place in consequence of the non-separation of the placenta from the uterine surface—thus disabling that placento-uterine quarter from contracting equally with the rest of the organ. When this happens, the placenta is, of course, shut up within a cell, above the hour-glass contraction. 447. Obliquity.—The gravid uterus commonly occupies the middle of the abdomen, in hale young women, notwithstanding both the pro- jection of the sacrum and the intrusion of the spinal column tend to give to it an oblique direction; hence, we generally find it to be in- clined towards one side of the abdomen in persons of a lax and flaccid habit of body. So far as my observation enables me to speak, it is oblique to the left more frequently than to the right side. Great de- grees of obliquity are scarcely met with in first pregnancies, in con- PREGNANCY. 227 sequence of the vigorous contractility of the symmetrical abdominal muscles, which constrain the gravid womb to remain in the mesian line; whereas, in women who have borne many children, those mus- cles acquire such a laxity and want of tone, as to allow the organ to librate from side to side, or fall to the front, according to the attitude of the patient for the time being. A right or a left lateral obliquity becomes very evident if the woman stands on'her feet. In general, if the organ bears over to the right side, its faulty direction will be cor- rected by turning upon the left, and vice versl In anterior obli- quity, the fundus falls so far foward as to make the patient seem more lusty or larger than she really is. The figure is greatly improved, in such cases, by wearing a suspensory bandage, which assists the recti and obliqui abdominis to hold the gravid organ up nearer to the back bone. When a patient suffers herself to be annoyed by what she sup- poses to be an inordinate development of the womb, her fears may sometimes be allayed by showing her that, notwithstanding she is apparently enormously large, she is, in reality, not more lusty than common, and that the false appearance depends upon an anterior obli- quity of the womb, which causes the belly to protrude unnaturally. 448. Pressure of the Womb on the Vessels.—Interference of the gravid womb with the functions of the kidneys, is now universally conceded to give rise to a convulsive disposition in pregnant women, that exhibits itself under the form of eclampsia, commonly known as puerperal convulsions. When the uterus has become inordinately large and heavy, and when the woman is at the same time affected with costive and overloaded bowels, it can scarcely be supposed that the great emulgent veins should not suffer more or less from pressure, obstructing the course of the blood returning from the interior of the kidneys. One could easily imagine that this pressure upon the emul- gent veins should have an obstructing power almost equal to that of a ligation of the vessel. Under such circumstances, the Bowman's capsules, which contain the essential secretory apparatus of the kidneys, would be so distended as to suspend, in a good measure, their offices and so the azotized elements appointed to be carried off by the urine would remain, and continue to accumulate in the blood. The nervous disorders consequent on this vitiated condition of the circulating fluid, are signs of urasmia; and the convulsions, and other signs—as paleness, weakness, delirium, &c, are symptoms of an urasmic intoxi- cation. Any woman approaching the period of her confinement, who has a swelled, or oedematous leg, may well be suspected as prone to urasmic intoxication, and, provided she is vexed with headache, nerv- 228 PREGNANCY. ous twitchings, or any disorder of the senses of sight, hearing, &c, she should be at once taken care of, and all proper measures should be adopted to prevent the explosion of an urasmic convulsion. (701.) 449. Women in whom the abdominal muscles have not lost their tone, by repeated extensions in pregnancy, compress the uterus strongly, in a direction towards the back ; wnereas, those whose abdo- minal muscles have become weakened by repeated gestations, carry the child very low, to use a common term, allowing the enlarged womb to rest upon the muscles in front of it. In the former case, the pressure of the organ against the spine must, to a greater or less degree, interfere with the current of blood in the great vessels of the abdomen. Hence the aorta and iliac arteries, and some of their branches, will pass on their contents with less freedom than is natural, whereby the upper parts of the body become supplied with more than their due proportion of the arterial blood. Headache, vertigo, flushings of the face, and tendency to paralysis and convulsions, may fairly be attributed to excessive momentum ofthe blood thus distributed to the superior parts, and rendered doubly noxious by an accompany- ing urasmia. Sighing, praecordial distress, dyspnoea, and coughs are also found to depend upon the same principles, and are to be treated with a view to lessen this vicious distribution and sur-accumulation of the vital fluids. Venesection, looseness of the bowels, light diet, warm baths, and whatever tends to produce moderate relaxation of the muscular forces, are in general employed with signal success in these circumstances. Dr. Collins, App. 199, remarks, that "Puerperal convulsions occur almost invariably in strong plethoric young women, with the'ir first children, more especially in such as are of a coarse, thick make with short necks." He adds, at p. 201, "that of thirty cases occurring during his Mastership, twenty-nine were in women with their first children." 450. Can this excess of propensity to eclampsia in primiparas be attributed to any other cause than those excessive sanguine determin- ations to the head, above indicated, and the disordered function of the kidneys, above spoken of? Ought we not to expect convulsions in women in the first labor, when we reflect upon the tendency to hyper- asmia of the brain, caused by the above mentioned restraints of the downward circulation? My experience in Midwifery having long since taught me to be watchful of the signs of any excess in such determination of the blood, I rarely permit my patients to lie on the back to be confined; for I have been for some time impressed with the opinion, that women who lie on the back in labor, especially in first labors, are more liable to convulsion on account of the greater pressure PREGNANCY. 229 against the large vessels within the belly; a pressure which, at least, is always relaxed during the absence of pain, in such as lie on the side. 451. I have frequently met with coughs in the latter weeks of preg- nancy, which proved rebellious against all treatment, until the delivery of the patient; after which they yielded to the common means of cure: the pressure of the womb on the abdominal vessels being removed, the pulmonary engorgement and hyperaemic irritation pre- viously sustained and reinforced thereby proved no longer indomita- ble. The same pressure of the enlarged womb, above spoken of, interrupts the return of the venous blood from the extremities, and the transit of the contents of the lymphatic absorbents. Hence, when that pressure has reached its maximum, the feet and legs become oedematous, or anasarcous; the veins of the feet and legs acquire an enormous size, become permanently varicose, and in certain instances burst, so as to cause effusion of blood to take place. In like manner, as has been stated of the superior or arterial engorgements, this inferior or venous engorgement ceases upon the abstraction of its cause; limbs, when swelled even enormously, are observed to recover their natural size in three or four days after the accouchement. That worthy old author, M. Puzos, whose "Traite* des Accoucbemens" was published in 1755, gives, at page 84, a sensible account of the causation of this oedema gravidarum: "On sgait que cette enflure ne vient que de la difficulte que les liqueurs ont & remonter de bas en haut, et a entrer dans le ventre ; parceque le poids de l'enfant se fait bien plus sentir lorsque la femme est deboiit que couche'e, et s'oppose plus fortement au retour de la lymphe, dans cette situation, que lors- qu'elle est horizontale." 452. Puzos, it is true, makes a just discrimination betwixt this accident in Midwifery and a true dropsy; but the Student will be misled, should he not be convinced that the vast majority ofthe cases of infiltration, no matter how extensive, are owing to pressure on veins and absorbents, and not to a true hydropic diathesis. This accidental dropsy from mechanical obstruction requires no treatment by drugs. Puzos's explanation as to position ought to be remem- bered, and a confident expectation should be indulged as to a cure, a spontaneous cure, as soon as the obstructing cause shall have been removed, by the birth of the child. Women sometimes grow appa- rently very fat in the last weeks or days of pregnancy; but the ap- pearance of embonpoint is false—the delusion arising from an insensi- ble watery infiltration of the whole of the superficial cellular tela: instead of increasing her embonpoint, she is really losing flesh by the constant waste of the elements of her blood, and when she comes to 230 PREGNANCY. her lying-in she complains, a few days afterwards, of growing thin, whereas she may be in reality growing fatter. The deception consists in the elimination of the water of infiltration, which lets her contour down to the true state and expression of her real embonpoint. 450. Hydatid Degeneration of the Ovum.—A woman who has conceived in the womb, and in whom the pregnancy may have gone on for several weeks, or even for some months in the most regular and orderly manner, is nevertheless liable to subsequent faulty progress in the development of the ovum. For example, the whole mass of the placenta may become the seat of an hydatid dege- neration. Hydatids are transparent vesicles or bullae, colorless, and distended with water resembling pure water. They are supposed by many authors to be independent animals, and were by Laennec de- nominated as the cysticercus. Mr. Milne Edwards, in his "Elemens de Zoologie—Animaux sans Vert&bres," speaks of them as belonging to the class of the Helminths or Entozoars. Under the order Cystoid Helminths, genus Hydatins, he says: "Finally, the Hydatids are generally considered as the last link in the series of intestinal worms; but the bodies described under this title are perhaps not real animals, and seem rather to be mere pathological products." M. Pouchet, also, in his "Zoologie Classique," p. 537, torn, ii., says: "It sometimes happens that women, affected with all the symptoms of pregnancy, discharge a considerable quantity of delicate vesicles filled with an aqueous liquor, that are perfectly analogous to the cysticercus, and that have hitherto been regarded as hydatids. The vesicles seem to adhere by a pedicle to the organ that produces them. Bremser lboks upon them as helminths, and says they are really endowed with indi- vidual life, and constitute a peculiar species of animals. But several French physicians do not partake of this opinion of the celebrated German helminthologist, and thiuk that these pretended entozoars are commonly nothing more than a pathological degeneration of the product of conception. Such are the opinions of Messrs. Desormeaux, Velpeau, and Orfila, &c." I have translated the above passages from Milne Edwards, and Pouchet, in order to confirm the opinion I have to express as to the pathological and accidental nature of the pla- cental hydatids. I am inclined to regard them as depending upon an hydropic state of the villi of the chorion, which, by a process of endosmose, under some maladive condition of the life-force of the ovum, is able to convert them into cysts, to the ruin of the product of the fecundation. 454. When a villous chorion begins to be generally subject of this PREGNANCY. 231 hydatid generation, it is to be deemed that the embryo must necessa- rily perish in consequence of the destruction of its branchial organ, the placenta, which, after all, is nothing more than a cellulo-vascular process from the chorion. I have seen many examples in which the placenta, at healthful term, has exhibited several of these hydatid vesicles without harm to the foetus—while in others, the embryo has been prematurely discharged, accompanied with the debris of a pla- centa filled with innumerable small bullae resembling white grapes in bunches. 455. Let the Student observe that the ovum, when invaded and conquered by this attack, continues to augment in size, its progress being governed by no ascertained law of rate. The healthy ovum has an exact rate—it is finished in nine months; but the hydatid has no certain rate—it compels the womb to distend for its accommodation, and that at a rate which is uncertain. I have seen a young woman, at the fourth month after conception, as large as she ought to have been at the sixth month. It is easy to infer that such a rapid deploy- ing of the womb, one so different from the gentle and lawful rate of a true pregnancy, must have the effects of a pathological, rather than those of a physiological force. The term to which the development of placental hydatids may attain in any special case cannot be fore- seen. The uterus may cease to tolerate their presence in the 3d, 4th, 5th, or even in the 7th month of gestation. 456. The signs by which they are known are either inferential or positive. We infer that the womb contains hydatids whenever we discover it to be increasing with preternatural rapidity; a rapidity that could not be predicated of twins, of polypus uteri, or any tumor. We know that the case is one of hydatids whenever, upon Touching, we can find a softish mass in the cervix which bleeds upon being rudely pressed, and which discharges upon the finger or the napkin specimens of the aqueous vesicles. As soon as the diagnosis is made, one is ready to take advantage of the commencement of any dilating pain, to provoke the earliest possible discharge of the hydatid mass. This may be done by introducing the index finger into the os uteri far enough to reach and break up the mass. It mostly happens here, as it does in turning out coagula from the womb, after labors, that, as soon as a portion, even a small one, is broken off and discharged, the uterus begins at once to contract upon its now lessened contents, so that, in general, the whole product rushes forth from the violently contracting organ. When, upon the discharge of a quantity of the hydatid mass, the labor-pain ceases too soon, it is well again to break in pieces the rest, so that, when the pain next comes on, there may be 232 PREGNANCY. less resistance to its expulsion. The Touch reveals to us the truth at last, as to whether all the product is driven off or not. In any ca.se where it might be desirable to expedite the expulsion, resort should be had to a colpeurynter. I have observed that, in the course of a labor for the expulsion of hydatids, the hemorrhage is occasionally most violent, and even alarming. The tampon constitutes an unob- jectionable means of arresting such a too troublesome waste of the blood. Intense constitutional irritation accompanies the hydatid pregnancy in those examples of it where the growth is violently rapid. The over-hasty development of the womb or matrix of the mass may be compared to a bursting process. I leave it to the inge- nious Student to study out the problem of the amount of constitu- tional disorder and its signs, likely to be made manifest upon such sudden and preternatural impetuosity of the uterine growth. 457. Moles.—Moles are altered ova. In the case of a false preg- nancy or Mola, as it is called, we are to presume the conception was normal, but that, upon some accidental failure of the development of the embryo or the secundines, the embryo perished and disappeared. In the mean time, by the operation of a principle of vitality com- municated through the uterus, the mass continued to exist and to grow, until the womb, no longer tolerant of the foreign body, must commence a series of contractions, by force of which it is expelled. The mole, like the hydatid, is called a false conception. Neither of them is a false conception; but a true conception, changed afterwards by some accidental diseased action. 458. Physometra.—There is said to be a false pregnancy called physometra or wind-pregnancy. I have recorded my opinion as adverse to this pretended state, in my "Letters to the Class," and in a note to "Colombat" on this subject at p. 372. I cannot con- ceive of a womb distended like a balloon with gas. Some of the reviews with which my " Letters" have been honored find fault with my recusancy as to Physometra and Hydrometra. I receive with the greatest respect, and even thankfully, the strictures that have appeared together with a certain flattering amount of commendation of that work. Notwithstanding the remarks of my critics, I feel constrained to maintain the opinions I there expressed, to which I beg leave to refer the Student. Authorities, however respectable, are after all to be regarded only as so many men or women. Authorities are not always lawgivers, but if they were, I must confess that I owe obedi- ence to the higher law of my own perception. The curious on this PREGNANCY. 233 matter of Physometra may consult p. 605 of Schenck's "Obs. Med. rariores." Fol. Lugd. 1644. 461. Hydrometra.—This is a state in which the womb becomes filled with water. The woman, supposing herself pregnant, suddenly finds herself deluged with water that, as is pretended, gushes in a tor- rent from the uterus, whereupon the signs of the pregnancy vanish away. Inasmuch as I cannot imagine the state of hydrometra, inde- pendent of some enormous sac, cell, vesicle, or acephalocyst in which it is contained, and as the supposition of such vast cells is impossible, I adhere to the opinion that Hydrometra is an hypothesis merely. I prefer to suppose the case to be one of over-distended bladder, and the water of the supposed hydrometra to be urine. If the womb should become affected with atresia of the os tineas or cervix, and it should then fill with a great quantity of fluid, that fluid could not be water. I respectfully, therefore, claim to adhere to the dissenting opinions expressed in my "Letters," to which again I refer the Student. 462. Abortion.—The ovum, however well protected by its re- condite situation against the operation of any extrinsic causes of destruction, is, nevertheless, obnoxious to several influences that may cause its miscarriage. There are also many intrinsic causes that tend to effect its death; for, since the embryo is composed of a struc- ture, and has functions that are vastly complicated and mutually de- pendent, it must be liable to disorders that may interrupt its growth or health, and at last cause it to be thrown off as an abortion. The embryo is so delicately organized, that very slight changes in the solids or fluids which compose it are sufficient to determine its destruc- tion. Its blood, out of which all its tissues are composed, is moved by its own powers of circulation, and it must, like all other living beings, be subject to engorgements, inflammations, hemorrhages, and all the other maladies that consist in derangements of the circulation. Such a creature might perish from very slight faults in the power of the omphalo-mesenteric vessels, or the umbilical vessels—and unequa- ble development of its more important internal organs doubtless serve, in many instances, to deprive it of vitality. Of the vast number of cases of early abortion, I presume a large majority depend upon dis- orders of the embryo itself, and not upon disorders or accidents hap- pening to the mother. While this is probably true, it is to be observed that the union of the placenta to the surface of the womb is so slight, that it is easily peeled off; so that a blow upon the region of the womb may destroy its connection, and blood become, at once, 16 234 PREGNANCY. effused betwixt the placenta and the uterus; if a great quantity be effused, the whole surface of the placenta may be speedily detached or loosened, and of course, the ovum, now deprived of the sources of growth, must perish. A sudden and very violent excitement of the bloodvessels, as by surprise, anger, &c, -may cause the effusion of blood from the placental superficies of the womb. A contraction of the womb may break the connection. A violent concussion of the body, as by falls, jumping or rude motion in carriages or on horseback, may cause a detachment to take place; or the membranes of the ovum may be so weak and delicate as to burst upon very slight compression of the womb, as in coughing, straining at stool—upon any sudden and powerful exertion, as pulling, lifting, &c. Thus it appears that the abortion may be caused by the death of the embryo; by disease of the secundines ; by sudden violent movements of the blood, caus- ing the effusion of that fluid behind the placenta; by direct violence, or by the discharge of the water of the amnion. If the ovum be ruptured, there is a discharge of water from the vagina, the quantity of which will depend upon the age of the embryo. This is sooner or later followed by pain, and flowing of blood. The pains, which are uterine contractions, become more and more frequent and considerable, until the ovum or its remains are expelled, when the bleeding begins to diminish, and, for the most part, the pain returns no more. If any cause should have been applied that could detach a portion of the placenta without rupturing the ovum, many hours, or even several days might elapse, before the blood that follows the detachment should appear at the orifice of the vagina: the blood must first force its way betwixt the chorion, and the internal surface of the womb; but as soon as it reaches the orifice, it falls into the vagina, and then there is what is called a show. If the foetus perishes by an internal dis- ease, or in consequence of some disorder that happens to seize upon any part of the ovum, the further development of that ovum, or of the embryo, ceases, and it is cast out by the contractions of the womb, sooner or later, according to circumstances. For the most part, the ovum, soon after it has lost its vitality, becomes an irritant or excitant of the womb. On not a few occasions, however, the dead ovum re- mains within the uterine cavity for weeks or even for months, without exciting its contractility—cases that are among the most embarrass- ing, on account of the diagnosis, that the obstetrician can possibly encounter. The dead ovum of three months may not be expelled until the seventh or eighth month of pregnancy. It undergoes no putrefaction, unless the membranes have been ruptured; in which case, it cannot remain very long undischarged. PREGNANCY. 235 463. There are some individuals in whom there seems to be so great an irritability of the muscular fibres of the womb, that the presence of the fruit of a conception never fails to bring on the contraction before the completion of the term of pregnancy; and I apprehend that this excessive irritability is among the common causes that produce abor- tions. This view seems to be sustained by a reference to what hap- pens in those who have already miscarried, since such females are found to be greatly disposed to miscarry again, at about the same period as that at which they had sustained the first misfortune; which appears to me to indicate that the repeated accidents of this kind are attributable, rather to an excessive or abnormal irritability of the womb, than to any of the other circumstances that are enumerated as causative of abortions; for it is far more reasonable to suppose that the same uterus is endowed with too great a degree of muscular irritability, than to suppose that several successive germs should be so constituted as to perish always at about the same period. 464. A woman becomes pregnant by the fecundation and sub- sequent fixation of a deposited ovulum. The act of fecundation can only take place after the ovi-posit has happened. The concep- tion does not necessarily put a stop to the periodi- cal development of ovarian ova —nor to their matura- tion and fall. But a woman who menstruates because of her ovi-posit, will tend to menstruate at regular periods, though she may have already conceived in the womb. Some women have this tend- ency so strongly, that they do actually menstruate during the earlier months of their gestation. Mrs. K. menstruated until the eighth month of her pregnancy. Every woman who menstruates in her pregnancy is trying to miscarry; and she would miscarry if the monthly hyperasmia, by giving rise to menstrual hemorrhage, should cause the outflowing blood to destroy the connection between the ovum and womb. If she does not miscarry in such cases, it is because the blood escapes from the uterine superficies below the surfaces occu- pied by the ovum in the cavity of the organ, or because the connection of the ovum to the womb had become a sufficient bar to the discharge of blood from its uterine vessels. 465. The above may serve as an explanation of the very common opinion that a woman is most liable to abortion at periods coinciding with the menstrual effort, and there is good reason to believe that a great number of abortions do take place at those conjunctures. It is reasonable to suppose that the periodical hyperasmia of the reproduc- tive organs that causes menstruation would, should it occur in preg- 236 PREGNANCY. nancy, expose the woman to the risk of miscarriage—and it is equally reasonable to take especial precautions against stfbh an occurrence for those women who have, on former occasions, suffered the loss of the ovum, at or near to the menstrual periods, and without any other assignable cause than the menstrual effort. 466. Whenever, in abortion, the contents of the gravid womb come to be expelled from its cavity, that expulsion is effected by a real labor, often severely painful, and requiring for its completion many hours of greater or less suffering; sometimes many days. I have had the medical charge of the same women in regular labor and in abor- tion ; and they have informed me that, for acuteness and severity of pain, the abortion has far exceeded the labor at term. This is not always, nor perhaps most generally, the case. The reason why some women suffer so acutely in miscarriages is, that the canal of the cervix uteri requires for its dilatation, in the early months, a great deal of power to be employed in forcing the embryo, which at that time is contained in the cavity of the body and fundus, down through the long narrow canal of the cervix uteri; and the distress produced by this dilatation of a long and rigid canal must often be as great, and might a, priori be supposed as great, as that occasioned by the dila- tation of the cervix and os uteri at term, which in the last days of pregnancy have become thin and yielding; whereas, in the early months, the whole cervix, as well as the os uteri, is of an almost cartilaginous hardness and rigidity. Fig. 69. Fig. 70. 467. At the beginning of the effort to miscarry, the womb is shaped like Figure 69. The egg lies in the cavity made out of the expanded PREGNANCY. 237 corpus et fundus; but, before the ovum can be expelled, the long cylindrical neck must first be converted into a cone, like Fig. 70. But, after the cervix has been altered in shape, so as to become a cone, the ovum cannot escape until by a further process of dilatation that cone is turned into a wide open cylinder, whereupon the ovum is thrust forth and falls into the vagina, as in Fig. 71. Abortions sometimes take place very easily, with little pain, and almost without hemor- rhage ; but the quantity of blood lost in some instances of miscarriage is enormous; pro- bably on account of the extreme degree of uterine irritation or sanguine molimen which the act of abortion develops. The hemorrhage is apt to continue until the contents of the womb are expelled; and it is, therefore, highly important to expedite that occurrence by all reasonable means. Un- fortunately, these means are few. 468. Upon taking charge of a case of abortion, it is the student's duty to ascertain which of two indications he ought to pursue. First, he should decide whether he will attempt to save the pregnancy, by preserving the vitality of the ovum ; and second, he should determine whether any moral probability now exists of the death of the ovum. In the latter case, it may demand his respect no longer; in the former, he will act against duty if he fails to do whatever may hopefully tend to the conservation of the fruit of the womb. The quantity of blood lost already may serve in some degree to enable him to decide both these questions; for, if the pregnancy be not much advanced, the loss of a considerable quantity of blood is evidence of so incurable a de- tachment of the fixed ovum as to preclude any reasonable expecta- tion of its continuing to live in the womb. Besides his inquiries and observation as to the quantity and force of the hemorrhage, he should carefully ascertain by touching the existing condition of the os and cervix uteri. Therefore, whenever the flow becomes so considerable as to affect the pulse and the complexion of the patient, it is impera- tively required that the medical man should ask for an examination per vaginam; and he will sometimes find that the ovum is sticking in the cervix, and needs only a little aid to escape from it—but, while it remains, it cannot but keep up the hemorrhage. The fore-finger may, in such instances, be pushed as far as practicable within the canal of the cervix, alongside of the ovum, and then bent so as to resemble a 238 PREGNANCY. blunt crotchet. By the aid of the finger, used in this way, and the assistance of powerful bearing down on the part of the woman, the offending cause is without much difficulty removed, and the effect ceases. When the finger cannot be employed, Dr. Dewees's placenta- hook may be employed. 469. I annex a figure (Fig. 72) of Dr. Dewees's placenta hook or crotchet, which is on some occasions a convenient instrument for pull- ing down the ovum when merely held by the cylindrical grasp of the cervix. Fig. 72. 470. Dr. Henry Bond, a late eminent practitioner of this city, has proposed a placenta forceps for the delivery of the secundines in abortion, of which Fig. 73 is a representation. Dr. Bond's instrument Fig. 73. is ten inches in length, and so rounded that it is difficult to conceive of an operator awkward enough to pinch with it any of the parts of the mother. An inspection of the drawing suffices, without further explanation, to give an idea of its usefulness. 471. While I lay before the Student these instruments for the ex- traction of the dead ovum, I ought to warn him against too facile a disposition as to the employment of them, and to assure him they will often disappoint his expectations, and sometimes, where they do succeed, lead to evil consequences as to the mother. The ovum, in abortions, inhabits the body and fundus uteri. The cervix stands guardian as facultas retentrix over the deposit, and reluctantly yields it a passage. In doing so, the conical neck of the womb must •become a cylindrical canal, into which the fundus and corpus uteri thrust their intolerable burden. When this cylindrical canal hath received into its calibre a small ovum, or the remains of one, it has, of itself, little or no power of expulsion, but merely grasps the ovum and holds it fast. It holds it sometimes for many days. I have found it to hold the ovum in this manner for many consecutive days, because the very os uteri would not let it escape, failing to yield, chiefly per- PREGNANCY. 239 haps because no dilating pressure was applied. In the long run it yields, the os tincae becoming wide open, and then a bearing-down effort, a fit of coughing, or straining at stool or urine, drives it forth into the vagina. (Vide Fig. 71.) Now, until the canal has become truly cylindrical, Dr. Bond's forceps and Dr. Dewees's hook are not to be employed without much care aud gentleness. For the most part, it is better to wait until all is prepared, aud then remove the object with the index finger. 472. In those cases in which a proper attempt to extract the debris of the ovum has failed, those who like the support of high authority may console themselves by referring to Puzos, who at page 193 says that "cette terminaison est bien moins affrayante; mais elle est bien plus longue; j'ai vu de ces fontes durer six semaines a deux mois; et pendant tout le temps, ou les vuidanges sont si fcetides, j'ai vu ces femmes tourmente'es de fi&vres irre'gulieres de degoiits et d'inquie*- tudes." He thinks these cases ought to be left to nature. (478.) 473. If, upon making examination in abortions, the state of the cervix is found to be unfavorable to the speedy expulsion of the offending cause, and the hemorrhage be not too threatening, recourse may be had to the application to the hypogastrium and pudenda, of napkins wrung out of cold vinegar and water; to the administration of dilute aroma- tic sulphuric acid ; to the acetate of lead, with opium; or to the pre- parations of secale cornutum—as the powder, in doses of five to ten grains repeated pro re n a t a, or its vinous tincture, of which a tea- spoonful may be given every half hour, or at intervals of one or more hours, according as the events of the case seem to demand. A powder consisting of five grains of alum and one grain of nutmeg may be given as a hemostatic every half hour or hour. The lancet may be resorted to, to aid both in diminishing the hemorrhagic nisus and in favoring the dilatation of the cervix, to which nothing contributes more powerfully than venesection. This, however, should be used with great and good discrimination. 474. Colpeurysis is a process or method of treatment used in cer- tain sexual disorders, the employment of which is daily becoming more general in Europe and America. The instrument by which colpeurysis is effected was proposed and introduced into practice by Dr. Carl Braun, assistant physician at the Lying-in Clinic at Vienna. An account of the matter is contained in a work in three parts entitled " Klinik der Geburtshilfe und Gynaskologie," published in the course of the years 1852 to 1855, by Messrs. Chiari, Spaeth and Braun. In part I. p. 126, is an article on colpeurysis by Dr. Braun, with a figure 240 PREGNANCY. of Braun's colpeurynter, of which I annex a copy, Fig. 74. Colpeury- sis is from the Greek *oa.po$ and tvpwu>. The compound word is intended to express the idea of vagina and dilater. Previously to Dr. Braun, physicians and surgeons were accustomed to the use of various methods Fig. 74. of dilating the vagina or the cervix uteri, such as sponge tent, the tam- pon, &c, but the apparatus delineated in Fig. 74 is found so convenient that it will doubtless become much in vogue in practice. The colpeu- rynter is a vulcanized gum-elastic bag fitted into a small hollow cone of horn. There is fitted to the apparatus a ring for holding a strap and buckle which serves to secure it from falling away when duly adjusted. There is also a stopcock, as seen in the drawing. The vulcanized rub- ber bag when empty may be introduced into the vagina, and then filled with air or tepid or cold water in quantity sufficient to distend the bag at discretion, so that the walls of the vagina may be made to expand as much as they do when distended by the foetal head in labor. This colpeurysis may be carried on so slowly and gently as to give no distressing pain, and if it be continued for a certain length of time it inevitably causes the neck of the womb to dilate. Hence it is a neck dilater as well as a vagina dilater, and is used daily for hastening the dilatation in abortions, in hemorrhagic labor, and other cases in which it is desirable to precipitate the delivery of the woman. This colpeurynter makes a very good tampon, and possesses the great advantage of being employed warm or cold, as it may be distended with water of any desirable temperature. I have used it as a tampon in placenta praevia in a case that required speedy dilatation to enable me to turn and deliver by the feet, and I have used it in various other states of the female genitalia which I propose to speak of on the proper occasion; for the present I mention its use as both a tampon and dilater very appropriate in abortion cases. The Student doubtless understands that if the vagina should be very much distended with a PREGNANCY. 241 colpeurynter, the cervix uteri must sooner or later yield to the force, or be pulled open by the upper end of the vagina which arises from the whole outer circumference of the neck. 475. Tampon.—But among the various means of putting an end to troublesome hemorrhage, I ought to name the tampon, or plug. This tampon may be composed of a sponge; or, what is far better, of pieces of cotton or linen cloth or patent lint, torn into squares of from two to three inches, which may be pressed into the vagina, one at a time, until the entire canal is filled and distended with them. They should be kept there by a napkin, worn as for the menstrua, or by pressure with the hand of a nurse, a napkin being interposed, until the flow is effectually checked, at least. The tampon may be allowed to remain in situ from six to twelve, or even twenty-four hours in winter. When removed, it is generally followed by the ovum or its remains, which are frequently found attached by a coagulum to the upper part of the tampon. Should any dysury be caused by its presence, the bladder may be readily relieved by the catheter while the woman preserves a horizontal posture, which should never give place* to a vertical one until all probability of a return of the hemorrhage has disappeared. 476. I do not understand how a woman can be permitted to die with hemorrhage, in an abortion, while a colpeurynter or the materials for a tampon are at hand-, since the discharge may always be effectually controlled. The remedy gives no pain, if properly used; and, so far as my experience of its employment bears me out, it never causes any considerable inconvenience; while, I may add, it always succeeds. 478. A good many cases of abortion, in the early stage, as from the sixth week to the tenth week, have fallen under my notice, in which the uterus was unable to expel the debris of the ovum, and in which I could not extract it. The female, in such instances, save one, has always recovered without the ovum having been visibly discharged; but there always was an excretion, continued for many days, of offen- sive dark-colored grumes and sanies, which I accounted for by sup- posing that the substances in the uterus had macerated, and came off in a state of semi solution, as in the instances mentioned by Puzos. (472.) I think that there is no danger in leaving such occurrences in the hands of nature; and that it is better to do so than reiterate attempts to extract by force, that have already proved quite vain; especially, considering that there is as great danger of exciting inflammation by those attempts as could be anticipated from the gradual maceration of the ovum. Let the Student reflect upon the illustration made by 242 PREGNANCY. my Figures 69, 70, and 71, and he will perceive that an attempt to take away the ovum, before the womb has become changed from Fig. 70 to the form of Fig. 71, not only ought to fail, but must fail of success. I am not disposed to deny that the presence of a putrefying substance, even of a small size, in the womb, is capable of developing inflammation and fever; but it has not happened so in my cases, and I have advised the same course to some medical friends, by whom I have been consulted, without the least cause to regret having given such advice. Let me be clearly understood, however, to recommend that the last remainders of the ovum should be brought off, where it is practicable, by employing reasonable efforts to do so. 480. I shall not omit the present opportunity for repeating, with regard to the tampon, that it is not a proper remedy for those cases in which any hope is yet entertained of saving the pregnancy. Let us suppose an instance in which the placental attachment has taken place at the fundus uteri; that a partial opening of the decidua reflexa has oc- curred ; and that the blood, having forced its way in a narrow stream or rivulet betwixt the womb and the outer surface of the ovum, has at length made its appearance at the pudenda. Nothing is more common than to see such cases of show suppressed by venesection, recumbency, an opiate, some doses of elixir of vitriol, or cold lemon- ade. Should any practitioner, anxious to promote the formation of a coagulum, and thereby stop the effusion of blood and save the preg- nancy, have instant recourse to the tampon, what would be the con- sequence? The blood, instead of escaping externally, would be forced back on the ovum, while newly effused portions of it, instead of flow- ing by the route already formed, would continue to dissect off or separate the ovum more and more, until the whole of it should be detached, and at last come off, enveloped in the centre of a compressed clot. To use the tampon, therefore, is to insure the abortion; hence, it is only a remedy for the hemorrhage of abortion, and not a remedy for miscarriage, which it not only cannot prevent, but actually insures, or renders certain. The blood which continues to flow into the womb after the vagina has been closed by the tampon may be compared to a river dammed across its channel, whose waters, in consequence, overflow their banks, drowning the adjacent country. With regard to the tampon, I wish to add that its employment in advanced stages of pregnancy, although allowable in certain instances, demands very great discrimination, inasmuch as it is capable of converting an open into a concealed hemorrhage, as we shall have occasion more fully to remark when we come to the consideration of uterine hemorrhage in labor. It may, under the proper indications, be with safety employed PREGNANCY. 243 up to the close of the fifth month of gestation, since the womb, until that period, is incapable of admitting a sufficient quantity of blood to give any well-grounded fears of a fatal concealed hemorrhage. But at a later stage, the capacity of the uterus is so much increased that the tampon, if employed at all, ought only to be used while the practi- tioner himself carefully observes its effects, remaining at hand to re- move it in case the uterine cavity should become distended and filled to a threatening amount with either fluid or coagulated blood. I was told, not long since, o£ an instance in which a gentleman, treating a case of hemorrhage after delivery, was pressingly called for to visit another woman in labor, and as he felt compelled to go, he tamponed the vagina with a handkerchief, by which he effectually suppressed the apparent hemorrhage, but upon returning shortly afterwards, he found the patient dead, the womb having filled with blood instead of expel- ling it from the vulva, just such a conclusion to the affair as ought to have been expected from the use of a tampon under such circum- stances. It has happened to me to see the tampon injudiciously em- ployed in this way on several occasions. Two of the persons were nearly expiring, when I arrived and immediately removed them; and one other, for whom it had been applied early in a flooding labor, without placental implantation, was expiring when I reached the house—a dreadful case of mala praxis, to which I shall recur in a future page. 481. Prolapsus.—It is commonly thought that women who suffer under repeated abortions are quite as much, if not more subject to a consequent prolapsus uteri than those who are confined at full term. The natural tendency of labor is to produce a prolapsion of the womb, and that tendency must be much greatest where the vagina has been much distended and pressed out of its ordinary form. This might lead one to deny that abortions are as likely to bring on a state of prolapsus as labors at term. But those women who miscarry are, for the most part, not sick any longer than during the actual miscarriage: they generally get up, most imprudently, the next day, or in some instances even on the same day. The solid and weighty substance of the uterus now bears down the vagina, to whose upper extremity the organ is attached; and weakened and relaxed by the discharges of the miscarriage, and ofttime's after abortion affected with vaginitis, the vagina makes less resistance than is common, so that the womb takes permanently a lower level in the pelvis than it ought to have. All the difficulties and embarrassments likely to accrue from this vicious situation of the womb might be obviated by a little patience and 244 PREGNANCY. prudence in the beginning. The woman should be warned, in clear intelligible language, that too early a getting up exposes her to the risk of suffering from a falling or bearing down of the womb, which may ruin her health, and thereby render her unhappy for life. Un- fortunately, she feels too well to believe that our words are other than useless and needless vaticinations, and so she is not willing to maintain a recumbent posture more than one or two days. It should be con- sidered that while a woman, lying-in, is in a physiological state, one laboring under miscarriage is in an opposite condition—that she is sick, and often needs care not less sedulous than the other one requires. The womb is in fault, as to the miscarriage in some of the cases, and any man conversant with the events of our obstetric practice knows that the organ is occasionally left by abortions inflamed, or hyperasmic, and irritable to the last degree. In these instances, the organ is situated much as it is when affected with hypertrophy. Long-con- tinued uterine tenesmus, sanguine affluxion, enfeebling discharges, and persistent pain, might well be expected to result in a descent or pro- lapsus, scarcely to be avoided by those who suffer frequent distressing abortions, and especially by those who pay not the least regard to the common sense dictates of the medical man. 482. Retroversion.—In proportion as pregnancy advances, the womb increases in longitudinal diameter; so that, if it should from any cause happen to be turned over backwards, the top of the fundus uteri would lodge in the hollow of the sacrum, while the os tineas would be pressed upon the symphysis of the pubes, or above it. There is no reason to doubt that the uterus is frequently turned over backwards, but not retained; for the urinary bladder, when very full of water, extends backwards and downwards, pushing the top of the womb along with it. If this happen to a woman about two and a half or three months gone with child, she will scarcely fail to have a serious retroversio uteri, which will probably continue until the organ is reposited by some skilful hand. There are persons who bring on these uterine deviations by a habit of retaining the urine until the bladder becomes over-full. Such, at least, is the opinion I have formed from inquiries addressed to the patients themselves. Some women, from a fastidious delicacy, or from circumstances of the society in which they pass their waking hours, fail to yield to the ordinary solicitations of nature as to the discharge of the urinary bladder, aud allow it to become so distended that it equals the bulk of a pint or even a quart measure, before they take notice of it. ■ So great a bulk as this occu- pying the space behind the lower portions of the abdominal muscles PREGNANCY. 245 and betwixt them and the sacrum, cannot but put upon the stretch both of the ligamenta rotunda, which is equivalent to the eff'ect of thrusting the fundus uteri down upon, and even below the promontory of the sacrum; but when the womb does turn over backwards, the cervix comes forwards by a see-saw motion of the organ, and this it cannot do without inordinately stretching the utero-sacral ligaments which become in this way, for many women, completely relaxed and ruined. Some women who have what is called retroflexion of the womb seem to have very sound and strong utero-sacral ligaments, which restrain the cervix from coming forwards to the pubis, as happens in ordinary retroversions. Can there be any doubt that such a habit, persisted in for years, would result in the state of retroversio uteri ? 484. Case.—I saw this day, July 12,1848, a young lady of 22 years of age, who has been married now ten months. She presented all the external characteristics of fine health. She has never conceived. She has a constant pelvic pain, and has suff'ered for eight years with the most distressing dysmenorrhoea, informing me that she never had her catamenia without violent pain; yet the menstrua are abundant and regular. She uses a dozen napkins at each period, and sometimes more than a dozen. There is severe pain in coitu, which cannot be perfectly effected. I found the os tineas half an inch behind and below the crown of the pubal arch—though the fundus uteri occupied the recto-vaginal cul-de-sac. It was bent, with a short turn, backwards. Upon causing her to turn over upon the face, I readily reposited the WOmb—but it came down again upon the least motion. When I pressed the index finger firmly on the lips of the os tineas or on the cervix, she felt acute pain, and said the pain was the same in kind as that of her dysmenorrhoea. Her habit has always been to retain the urine long, so that sixteen or twenty ounces frequently collect before she discharges it. Now this person had never had any considerable illness, or met with any accident. Can there be any doubt that this habit is the cause of the retroversion ? There is no other discoverable cause. , 485. Suppose the fundus of a gravid uterus to be caught and de- tained under the promontory, as above mentioned, and that the child proceed in its growth, carrying with it the womb in which it is in- closed ; the consequences must be a complete impaction of the womb into the excavation—a total prevention of the flow of urine from pres- sure on the urethra—a stoppage of the canal of the rectum—severe pressure upon the internal sacral foramina, with their nerves; and, 246 PREGNANCY. unless by timely measures obviated, the certain and miserable death of the patient, as in the case related by me and illustrated by a plate in "American Journal;" for in the case examined by Dr. Hunter, so completely impacted or jammed was the womb into the cavity of the pelvis, that, after the death of the patient, it was found impracticable to get the uterus up out of the excavation, until the pubis was cut through with a saw, in order to admit ofthe enlargement of the brim of the pelvis. In my case, reported as above cited, the pubes were cut away to enable us to remove the uterus with its' contents. It is difficult to conceive of a situation more frightful than that of a patient under such circumstances. Hunter's case, with the fine illustrative engraving, is contained in his tables of the gravid womb. 486. My experience teaches me that most of the instances of retro- version are attributable to a distended bladder, whether after parturi- tion or no. The modest delicacy of young women often compels them to resist the most urgent desire to pass off the urine. A female riding in a carriage, or placed in such a situation that she cannot withdraw from the company without being suspected of a desire to urinate, will allow the bladder to fill almost to bursting; and if she be pregnant about three months, she will scarcely fail to bring on retroversion of the womb. When at last she obtains an opportunity to evacuate the bladder, she finds she has a partial or total retention of urine. The usual recourse is had to spirits of nitre, to watermelon-seed or parsley- root tea, and perhaps a dose of castor oil may be resorted to; but as relief can only come by some mechanical remedy, the medical man is at length, and reluctantly, sent for. 487. Case.—A few years ago I was called to a young woman who had been a short time married. She arrived in town by one of the public conveyances from the eastward. She had a constant and irre- pressible desire to urinate, and could only succeed in getting off'a few drops at a time. She told me she was pregnant; had just arrived from a journey; and that she was suffering the most acute distress from the constant inclination to urinate. As the disorder had come on sud- denly and in a state of high health, I at once told her she had a retro- version, the nature of which I explained to her, and she submitted to the necessary investigation; upon which I found her womb turned over, and upon repositing it she was immediately cured. I suppose that, in travelling, her bladder, for want of an opportunity to empty it, had become very much distended; that its bas-fond had pressed upon the anterior superior face of the womb more and more as it became more and more distended, until the fundus uteri, jammed PREGNANCY. 247 under the promontory of the sacrum, could not get out again, without the aid of a physician.—See my "Letters to the Class," sub voce. One of my critics condemns the rapidity of my diagnosis in the case. I respectfully refer him to the passages in which I explained that, by using the method of exclusion in the analysis of the symptoms, I could not possibly arrive at any other conclusion. To see a healthy- looking woman seized with complete retention of urine, without hav- ing been before the subject of any urinary ailment, is always warrant enough for us to suspect a retroversion of the womb, especially if the patient be at the time pregnant, and not advanced beyond the fourth . month. The symptoms of which such patients complain are either a total retention, a stillicidium, or a great dysury; with pains about the region ofthe pubis and sacrum; constant tenesmus, or bearing down, and a sense of obstruction or stoppage in the rectum. No case like this ought to be suff'ered to pass without making an examination per vaginam. For this purpose, let the patient lie on her back, near the right side of the bed; the feet drawn up near to the breech; the head and shoulders raised with pillows. The physician should stand by the bedside, and with his left hand placed upon the hypogastrium, ascertain if the bladder be much distended: it will sometimes be felt almost as high up as the umbili- cus. The forefinger of the right hand may next be carried into the vagina in order to seek for the os tineas, which is to be found behind the symphysis pubis, and even thrust over and above it: the vagina seems to be obstructed by a hard body, which is the bas-fond of the womb, whose fundus is turned down into the hollow of the sacrum, and jammed into the cul-de-sac composed of the reflexion of the pe- ritoneum, which lines the upper posterior third of the vagina and the front of the rectum. 488. Having thus verified the existence of a retroversion, the next steps required to be taken are those that are demanded for the re- positing the womb. Among the most pressing indications of cure, is the relief of the suppression of urine, which in general is easily ful- filled by the introduction of the catheter. A long elastic male one is the best, because the womb, in changing its own position, carries up the neck of the bladder, and thus elongates the urethra so very con- siderably, that it will be found convenient to use a long instrument for the evacuation of the water. Inasmuch as the most ordinary cause of retroversions is a distended bladder, it has been thought that the removal of this distension is the sufficient remedy, it being supposed that the uterus might recover its place as soon as the pressure which overset it should be taken off. Indeed, there are cases in which the restoration takes place soon after the bladder becomes emptied. I 248 PREGNANCY. have related, in my " Letters on Woman, &c," cases of retroversion cured by the catheter alone, and one, from an English authority, in which a most dangerous case of retroversion, in pregnancy, which could not be cured by the hand, gave way to the use of the catheter, left for a long time in the bladder, by which means that organ was completely hindered from filling up, and obstructing the tendency of the fundus to rise upwards to its natural situation. It has well been contended that, for retroversion of the gravid womb, a sound discre- tion indicates the propriety of leaving the case in nature's care, after this preliminary measure has been accomplished, lest, by any rude or too persevering attempts to replace the uterus, the ovum might suffer so much injury as to bring on an abortion. I admit that I am not prepared to decide as to the necessity for such great prudence, since I have on only one occasion put it to the test. On that occasion, I drew off the urine two successive days, the accumulation being very great; and then, finding that the malposition was not rectified,, I was com- pelled to replace the womb with my hand: no inconvenience whatever followed the operation, although the patient was near four months com- plete gone with child. In a subsequent pregnancy, the same person suff'ered a retroversion of the womb, nearly at the same period: and when I was called to see her, I immediately proceeded to restore it to the proper attitude. In this case also the pregnancy was not in the least interrupted. Having succeeded in drawing off the water, the patient, if necessary, should have a copious enema, in order to unload the rectum, which, if replete with fecal matters, might offer considerable obstacles to the success of our attempt. In the next place, we ought to endeavor to raise the fundus, the patient lying on her left side, by pressing the bas-fond of the womb, which can be felt through the pos- terior wall ofthe vagina, upwards, with the fingers, so as to move the whole mass in a direction parallel with the axis of the brim. The cervix uteri is tied to the more anterior parts of the pelvis by the vagina and the vesico-vaginal septum, so that if we carry the mass considerably upwards, it must be by tilting the fundus in that direc- tion. Attempts of this kind will not always succeed. Where they fail, a finger may be passed into the rectum, the forefinger of the left hand if the woman is on her left side, and of the right hand if she be upon her back. Before the finger has passed very far, it meets with the fundus uteri, which presses upon the canal of the intestine; in this situation, we have far more power to move the womb than when the effort is made only from the vagina. Pushing gently and steadily upwards, we find the mass gradually to recede, until at length the fundus, liberated from its restraint, suddenly emerges, with a sort of PREGNANCY. 249 jerk, from under the promontory from which instant the woman is cured. 489. I have sometimes failed of success, until I placed the patient in a more favorable attitude; one in which she could not bear down, and thus oppose the success of my measures. I have directed that she should turn on her face, then draw her knees up under her until the thighs were in a vertical position, giving to the pelvis the highest possible elevation: the cheek was to be placed on the bed without pillows, and the point of the thorax was also to be touching the bed. Lying in this posture, the power of mere gravitation might suffice, in time, to unhitch the fundus uteri from beneath the promontory ; since all tenesmus and bearing down are thus arrested. After waiting a short space, until the effects of the position were secured, I have pushed up the fundus very easily by acting either through the vagina or the rectum. 490. A pregnant woman, who has just recovered from a retrover- sion, ought to lie in bed two or three days, and should not, for a few days, be left more than six or eight hours without evacuating the bladder, either spontaneously or by the catheter; lest that organ, filling again, should unhappily a second time depress the fundus, and so cause us to lose all our trouble through want of a moderate precaution. The gravid womb, doubtless, becomes, in four months and a half, too large to admit of the occurrence of retroversion : but the accident may occur at any period short of it; it may take place not only in the non- gravid, but in the virgin uterus. 491. Case.—On the 22d of February, 1828, I was called to visit Elizabeth B., aged about twenty years. She had complained for several months past of dragging pain in the left side of the abdomen, with a sense of weight and great uneasiness within the pelvis. She has menstruated regularly. For the last three weeks she has been perse- cuted with constantly repeated and painful desire to go on the stool, and with symptoms of strangury, or dysury, amounting often to stilli- cidium urinas. After a careful inquiry into the history of her case, I informed her of the nature of my diagnosis; and she at length agreed to permit an examination by the Touch, as I assured her that I had no means of relief for her, if there were really a retroversion, short of the Touch. In this painful necessity she submitted, with a laud- able unwillingness, to the operation, and it was with no little difficulty that I at length carried the finger beyond a remarkable strong hymen, into the vagina. The os uteri was found near the symphysis of the pubis, and the fundus was discovered overturned into the Douglas's 17 250 PREGNANCY. cul-de-sac. After a long perseverance in endeavoring to raise the fundus, I was compelled to attempt it with the forefinger of the left hand passed into the rectum, by which method I pushed the uterus up; whereupon she immediately declared that she was fully relieved of the sense of weight aud pain that had so long been tormenting her. She continued well from that moment. I consider this a case of con- siderable interest, inasmuch as it further proves the possibility of a long-continued retroversion of the womb in the non-gravid and virgin state of that organ. I have seen many such cases since 1828. 492. There are some persons to be met with, in whom retroversion takes place so readily, that the least exertion of strength brings it on. In a single individual, I am sure that I have been called on to restore it to its position twelve or fifteen different times. So great, in that case, is the tendency of the womb to turn over, that it has several times occurred, notwithstanding the presence in the vagina of a very large globe pessary, and I did never regard her as exempt from the proba- bility of an attack, except when in a state of advanced pregnancy. I presume that, in her case, there was not only a great relaxation of the vagina and its connecting media, the recto-vaginal and vesico-vaginal septa, but there must also be supposed to exist a condition of the liga- menta rotunda et sacralia, which has allowed them to become elongated to such an extent, that the least pressure on the anterior face of the womb pushes it backwards and downwards. No one, I think, could suppose a case of retroversion without, at the same "time, implying that the round ligaments, which pass from the angles of the organ out of the abdominal canal, and abdominal rings, are lengthened—and even stretched. A permanent elongation or laxity of those ligaments would add a great facility to the disposition to oversetting of the organ. As there is reason to believe that there is a character of muscularity attached to the round ligaments, proceeding as they do from, and being composed of the same tissues as the womb, we may indulge, in any case, the hope that time, if not drugs and medicines, will bring them back to their natural tension and length, so as to obviate the evil propensity to the retroverted state of the uterus. 493. The accident of retroversion may be considered serious and dangerous just in proportion as it occurs at a more advanced period of pregnancy; for, according as the pregnancy is of an older date, is the necessity greater for a speedy reposition of the organ. I have, I think, pointed out sufficiently at length (225), the dangers to be appre- hended from a retroversion continued until the whole mass becomes so impacted into the excavation, as to render its extrication, without abortion, impossible. As I have met, hitherto, with only two exam- PREGNANCY. 251 pies in which it was impossible to replace the gravid organ, I do not feel it incumbent upon me, at this time, to do more than refer to the severer methods of extricating the woman: these are, first, the artifi- cial rupture of the amniotic sac, which, by allowing the water to escape, reduces the size of the womb so much as to enable the operator to succeed in restoring it to its proper position; or, lastly, the puncture of the womb itself, when it is found impossible to reposit or pass a bougie into the os uteri. 494. The Student ought early to become aware that some of these retroversions are rendered incurable by the formation of adhesive de- posits, that tie the fundus uteri close down to the back part of the pelvis, and that as these adhesive bands cannot be approached with the bistoury, nor otherwise broken up, the womb is liable to remain in a state of permanent retroversion. M. Amussat mentions two such cases in his essay on retroversion, and I have met with three, two of which were verified by the necroscopy. I shall publish one case, as drawn up by Dr. Yardley, and illustrate it by a cut copied from a drawing by Mr. Mcllvaine, who had the specimen before him, and which con- stitutes one of the most interesting preparations in the museum of the college. The following is the history ofthe case, as drawn up by Dr. Yardley himself, who allows me to publish it here. 495. Case.—" Mrs. N------ became my patient in the spring of 1840. I visited her on account of a diarrhoea, which had continued for some time, and which was attended with distressing pain in the left side. A regulated diet, saline frictions of the skin, which was cold and dry, together with small doses of mass, hydrargyri, opium, and ipecacuanha, soon cured the diarrhoea; but as the pain in the side and other symptoms of disease still continued, I was induced to inves- tigate the case more fully. I then learned that since her marriage, about three years previously, she had had two attacks of uterine he- morrhage, which were pronounced by her physician to be abortions, though nothing like an ovum had ever been detected, and he had never examined the state of the uterus. The first attack came on on New Year's day, 1838, after taking a very long walk, and though the hemorrhage was not profuse, it was attended by such excruciating pain in the side on being moved that it was necessary to bring her bed into the parlor, where she remained several weeks. The hemor- rhage and pain gradually subsided, and by the 1st of June she ap- peared to have regained her usual health. The second attack took place April 12th, 1839, and came on suddenly when making some unusual exertion while engaged at her toilet. The pain was so severe 252 PREGNANCY. as to cause fainting, and was attended by vomiting, diarrhoea, reten- tion of urine, tenesmus, severe bearing-down efforts, and slight uterine hemorrhage. These symptoms were mitigated by general treatment, without resorting to the catheter, or making a vaginal examination. She was confined to her chamber nearly three months under this attack, and was still suffering from its effects when I was consulted in her case. Her menses were irregular; her bowels frequently disor- dered ; she was unable to take her accustomed exercise on account of a bearing-down pain and distress in the pelvic region, which was increased by exertion of any kind. Her husband informed me that since her last attack, she had always suff'ered severely from sexual intercourse, I considered these symptoms sufficiently indicative of disease or displacement ofthe uterus to call for an examination ofthe state of the parts. I found the uterus low in the pelvis, hot and swollen, and so sensitive as to preclude further exploration. Rest in a recumbent position, bleeding, cupping over the sacrum, and general antiphlogistic treatment, in ten days produced so much relief that the patient declared herself better than she had been for more than a year. I then made a second examination, and found the engorgement, heat, and tenderness much diminished; but there was considerable prolap- sus, and the uterus and vagina were morbidly sensitive. I was desirous that the patient should remain longer in the recumbent position, but the weather being warm, and confinement very irksome, I introduced a gilt-ring pessary, and sent her into the country. Mrs. N------re- turned about the middle of September. She informed me that for three weeks after the introduction of the pessary, she felt unusually well; she was able to stand and walk without suffering, and the dis- tress in the pelvic region was much mitigated; but about that time, when using considerable exertion, she felt the instrument move, and it continued to trouble her until it came away. After the displace- ment of the instrument, her old symptoms returned, though for a time she was better than before its introduction. After keeping the patient quiet a few days, I made another examination; all morbid sensibility of the parts had now subsided, so as to admit of a full exploration, and, for the first time, I detected in the hollow ofthe sacrum a round, hard body, with a deep indentation between it and the lower part of the neck of the uterus. It was difficult to decide whether this was a tumor, or the fundus of the uterus bent down in that position ; but after a careful examination, I was disposed to regard it as the latter, though it was much lower and more prominent than I should have expected from the situation of the os tineas, which was not more ante- rior than is usual in simple prolapsus of an equal degree. After press- PREGNANCY. 253 ing up the uterus as far as I could, I introduced a gilt-globe pessary under the fundus, hoping it would gradually restore the organ to its proper position, and that, if it came away, the patient could replace it herself, which was important, as these repeated examinations were very disagreeable to her. The globe pessary was retained but a short time, and as it caused considerable pain and uneasiness during its retention, the patient was unwilling to have it again introduced. At the sug- gestion of Professor Horner, of the University of Pennsylvania, I next placed the patient on her knees in the bed, with her head and shoulders as low as possible, and introduced an instrument into the rectum, under the fundus of the uterus, and, by that means, assisted by its own gravi- tation, endeavored to dislodge it from its position. In this manner, I succeeded in pressing the uterus up much higher than before, and after again introducing a ring pessary, I requested the patient to remain quiet for a few days. This ring kept its position two weeks, and was productive of much relief; but it then came away, and the unpleasant symptoms returned. This process of pressing up the uterus, and introducing a pessary, was repeated several times; and it was found that a ring pessary was the only kind that was of any advantage, for, while a ring retained its proper position, the patient was comparatively comfortable. This relief, from the use of a ring pessary, appears re- markable, when, after death, it was discovered in what manner the uterus was bound down to the rectum; there is, however, no doubt of the fact, aud it may be explained, by supposing that the anterior wall of the rectum was pressed forward and upward, or the adhesions stretched. The difficulty of retaining the ring in its proper position, however, seemed to increase; rings of silver gilt, glass rings, ivory rings, rings of hard wood, such as ebony and lignum vitas, and rings of gum elastic, were all tried, but the gilt rings were found much the best. Discouraged by my want of success in the treatment of the case, I sought further counsel, and Professor Hodge, of the University of Pennsylvania, saw her with me, July 10th, 1841. On examination, he readily detected a retroflection; a displacement of the uterus with which he was familiar, and which he calls a retort uterus, from the fact that the uterus is bent on itself in the form of a retort. He pro- posed the introduction and persevering use of a pessary of a peculiar form, which he has successfully used in many cases of the kind; I had an instrument made after his pattern, and introduced it; but it was not of the proper size, and caused considerable discomfort, which the patient attributed to the form of the instrument, and, to my regret, was unwilling to have another one of the kind used. During the following five years, she pretty much abandoned medical treatment, 254 PREGNANCY. except that, whenever her sufferings became unusually severe, she applied to me, when, by pressing up the uterus and introducing a ring, she would be much relieved for a time. Several other physicians were consulted in the case, but nothing important or novel was suggested. Her symptoms gradually grew worse, and, in July, 1847,1 visited her, and found her confined principally to her bed; she appeared slightly emaciated; her brilliant color was gone, and she suffered severely from sickness of the stomach. She informed me that, after passing her monthly period about three weeks, she had had a slight show, which had returned every few days for the last two weeks; making about nine weeks from her last regular monthly period. On making an examination, I found the uterus occupying the same position it had heretofore done, and somewhat larger than before, but apparently not larger than an ordinary unimpregnated adult uterus. I declined adopting any active treatment without assistance, and suggested Pro- fessor Meigs, of the Jefferson Medical College, who saw her, with me, on the 17th of July. Dr. Meigs was sanguine, after examining the state of the parts, that the uterus could be restored to its proper posi- tion, notwithstanding the length of time it had been displaced. He came next day, prepared with an instrument to press up the fundus of the uterus, and with some small gum-elastic bottles, of the kind recommended by Hervez de Chegoin, in the hope that by gradual pressure in this manner we might succeed in restoring the organ to its proper position. The patient complained of much pain when the doctor attempted to press up the uterus, though but moderate force was used. I filled the bottles with curled hair, which I found to an- swer admirably on account of its elasticity, and introduced one of them carefully between the perineum and the fundus of the uterus. It gave no pain, and was retained without inconvenience, and appeared as though it would fulfil the indication. I kept her in her bed a few days, after which she rode out occasionally, and once walked several squares. On the evening of the 5th of August, after using much more exertion than she had done for several months, the ball was forced away, and she was attacked with severe bearing-down efforts, so that it was a considerable time before she could be removed to her chamber. After she had been carried to her bed, I made an examination, and found the uterus at the os externum, and the bearing-down pains so severe as to threaten its expulsion from the vagina. After administering an anodyne enema, and in some measure tranquillizing her system, I succeeded in pressing the uterus up to its former position, and intro- duced the gum-elastic ball at her own request, as she said she felt safer and more comfortable while it was in situ. The patient PREGNANCY. 255 was unable to leave her chamber, and seldom her bed, from this time; and she often passed whole days and nights in the most awk- ward positions, because the least motion increased the pain beyond endurance. Her stomach became so irritable that it was seldom anything would be retained in it even for a single hour. She became weak for want of nourishment. The most excruciating neuralgic pains pervaded every part of her abdomen, so as to preclude the possibility of any examination either externally or per vaginam; and, to increase the difficulty of diagnosis, she became tympanitic. The wise women of the neighborhood said she was in the family way; but of this we were not satisfied; and Dr. Meigs, who placed considerable reliance on the appearance of the nipple, examined her breast carefully, and there was not the slightest change of the areola. An anodyne enema was administered every evening, but her nights were generally sleepless, and she gradually grew worse till the 19th of August, when I was obliged to leave the city for a few days. My friend Dr. Jewell attended her for me, and has furnished me with the following notes of the case:" "My first visit to Mrs. N. was made on Thursday, August 19th, at the request of my friend Dr. Yardley, who was to be absent from the city for several days. Her condition, when I saw her, was anemic; countenance thin, pale, and sallow, expressive of long-continued and wasting disease; pulse sharp and frequent; ab- domen tympanitic and exceedingly tender to the touch; tongue clean and moist; stomach so exceedingly irritable as to reject all nourish- ment and medicine, craving only ice, which, however grateful for a moment, afforded no relief. All her suffering was directed to a most excruciating pain in the left iliac region, accompanied with extreme gastric distress, which symptoms had been in existence, and increas- ingly so, for several days. Fomentations of brandy and spices were applied to the abdomen, and various anti-emetics and sedatives were ineffectually tried for the vomiting. In the afternoon, the symptoms being more aggravated, twenty-five leeches were applied over the stomach, and an enema of forty drops of laudanum in a gill of warm flaxseed tea thrown into the rectum. In the course of the night, the gum-elastic ball pessary, which had been introduced by Dr. Yardley for the retroversion of the womb, came away during an effort to vomit, and was not replaced. Friday, 20th. Found her very weak and ex- hausted, with some slight relief from pain and vomiting; expressed herself to be easier, but dreaded the return of the severe suffering she had experienced the day before. Was troubled with flatulency and slight oppression at the praecordia. Directed the effervescing draught, with thin arrowroot, in small quantities, and to be frequently repeated. 256 PREGNANCY. The fomentations to be continued as yesterday. In the afternoon, was sent for in haste—that Mrs.----had convulsions. On my arrival at her bedside, I found her in a collapsed condition, insensible, extremi- ties cold, pulse and breathing scarcely perceptible, and her whole ap- pearance completely blanched. By the persevering help of stimulants and artificial heat, she gradually revived. I learned from the family that, previous to her insensibility, she had complained of an ago- nizing pain in her left side, and an increase of sickness at the stomach, and in a few moments after went into convulsions. So forcibly was I struck with her bloodless condition at this time, I remarked to her husband that she had all the appearance of one who had lost a great amount of blood from flooding. Being comfortably restored, before I left, I ordered her brandy and water; ice in small and repeated doses, with essence of beef; and to repeat the enema of laudanum and flax- seed tea if the pain returned, together with the following prescription in doses of twenty drops every hour: R.—Solut. sulph. morph. 3j; Hoff. anod. liq. 3ij- During the three following days, the vomiting continued with very little abatement. Every attempt to administer nourishment or medicine was indomitably resisted by the stomach, with the exception of the brandy and the morphine solution. On each successive day an anodyne injection was given, to subdue the attacks of pain in the left side. Her pulse, in the mean time, was feeble and frequent, her countenance blanched, and her whole condition so much exhausted as to afford but slight hope of her recovery. On Tuesday, 24th, however, there was an apparent amendment in her case; her pulse began to react, she was able to retain a little nourishment, the vomiting had in a great degree subsided, and her expression was, 'I feel comfortable.' Her bowels not having been open for several days, I ordered her a turpentine enema, to which they responded readily, though not freely. Wednesday, August 25th. Had passed any easy night, but without much sleep; upon the whole she had improved, was cheerful, had taken a cup of tea, and had eaten some calf's-foot jelly; the tenseness and tenderness of the abdomen had subsided. I could make considerable pressure without causing either pain or sick- ness, and for the first time I was able to detect a tumor in the left iliac region, upon which spot, however, she could not allow pressure with- out acute pain. I felt quite encouraged with her appearance and the improvement in her symptoms, as did also her friends. Feeble hope was given that she might be restored. She asked for a peach, which was allowed her, and I left her in good spirits. It was near 3| o'clock P. M., when I was summoned by a hasty messenger, that Mrs.---- was dying. On approaching her bedside, which was surrounded by PREGNANCY. 257 weeping friends, I found her lifeless. I learned that she continued as well and as cheerful as when I left her in the morning, up to 3 o'clock, when she was suddenly attacked with violent pain, followed by a con- vulsion, which in a few minutes ended in death." 496. Having inserted the foregoing account of Mrs. N----'s case, by Drs. Yardley and Jewell, it only remains for me now to say, that the necroscopic examination of the body of this unfortunate lady was made by Dr. Ellerslie Wallace, in presence of Dr. Jewell and the au- thor of this article, on Friday, August 27, 1847. Upon exposing the contents of the abdomen by a crucial dissection, and looking down- wards into the excavation of the pelvis, there was discovered a great quantity of coagulated blood and serum, which being removed, the uterus was observed to extend across the pelvis from front to rear, lying horizontal in the excavation, and covered by the left Fallopian tube, which was turned over from left to right quite across the pelvis coincidently with the transverse diameter. The tube was enormously enlarged, having been converted into a sac which contained a foetus of near three months, developed in a tubarian gestation. The uterus being measured, was a little more than four inches long, and at the broadest part three and three-quarter inches wide. The child-bear- ing Fallopian tube could be lifted up from where it lay upon the front surface ofthe womb—no inflammatory attachment having as yet been formed to bind them together. Upon lifting the tube-sac off the uterus, and then attempting to raise the fundus uteri out of its retroverted position, it was not possible to succeed, in consequence of the adhe- sive bands and bridles that bound it to the lower part of the sacrum. When these adhesions had been divided by the scalpel, Dr. Wallace could lift the fundus out of its bed, and reposit the womb. This I had been unable to effect during Mrs. N----'s lifetime, either with the hand or with Hervez de Chegoin's caoutchouc pessary. I was not surprised to find the fundus glued in this manner to the lower part of the sacrum, for I had, in June, announced to Dr. Yardley my belief that it was adherent—an opinion founded upon the firm resistance of the tumor against all my attempts to reposit it. I may remark here, that I believe the womb might have been got out of its false and ad- herent position by means of the caoutchouc pessary, or by slow and cautious proceeding with colpeurysis, had not the tubal pregnancy unhappily supervened. I suppose that the adhesions might have been gradually broken or absorbed under the elevating power of M. Braun's method. The rupture of the tube had occurred near its outer end, which, from its being turned over and laid upon the prostrate womb, was found nearer the right than the left ischium. Through the edges 258 PREGNANCY. of laceration in the tube sac, one of the feet of the embryon was pro- truding. The uterus and its appendages were removed, with consent of the friends. Upon laying the uterus open, it was found to be filled with a deciduous mass and with bloody slime. The cavity was some- Fig. 75. what enlarged, but the paries of the uterus was very thick, like that of a uterus contracted after delivery. The tube was now laid over to the left, its natural position, and opened; whereupon it disclosed the embryon, as in the figure, which was drawn by Mr. M'llvaine ad v i v u m. The deciduous membrane is seen in the cavity of the uterus, its edges being laid over on the cut surfaces. I regard the case as an • PREGNANCY. 259 interesting one, from its showing the presence of its decidua in utero in a tubal pregnancy, and more especially as presenting an example of adherent retroversion ; and, perhaps not less so, as exhibiting tubal pregnancy in a woman with adherent retroversio uteri. Since Dr. Braun's invention of the colpeurynter, described in a former page, I have used his instrument as a means of repositing the organ in the following case, and conceive that I have been the first person to make that application of it. 497. Case.—In the month of June, 1856, a medical gentleman, practising in one of the interior towns of Pennsylvania, came to me to say that he had a case of retroversion in a woman, past four months pregnant, which he had in vain attempted to relieve. Nothing that he had done had in the least changed the posture of the womb, and he had accompanied his patient to the city for my advice and aid. On proceeding to the hotel, I took my colpeurynter with me, and found that I could barely reach the os uteri, by pushing the index finger as far as it could possibly be thrust upwards behind the symphysis pubis. I am sure the point of the finger was three and one-eighth inches within the orificium vaginas; so that, as the symphysis is but one inch and a half long, the os was situated very far above the top of the symphy- sis, and close behind the anterior abdominal paries. The pelvis was quite full of a fluctuating mass, which was the womb, distended with something, but whether with an ovum, I dared not then say. I prevailed upon the woman to lie on the back near the foot of the bed, with the limbs flexed, and, upon introducing and gently distending the colpeu- rynter, she complained of some uneasiness. In a short time, addi- tional portions of water were thrown in, and I again desisted to let her rest. I soon afterwards allowed the sac to collapse, by letting the water escape into a bowl, and then repeated the injections, begging her to decide for me as to what amount she could, on trial, easily en- dure. It was not long before she, with a start, exclaimed: "What's that?" My reply was: "I suppose it is your cure;" and truly on withdrawing the colpeurynter from the vagina, I found, to my great satisfaction, that the uterus was completely reposited, the os being in its true normal position, and the fundus, that had long been turned over into the recto-vaginal cul-de-sac, being now above the plane of the superior strait. The woman was so overjoyed with this entire re- lief, as to signify her happiness, by the wildest expressions of delight to her husband, who stood by her couch. 498. I have made use of the colpeurysis in a great many cases of 260 pregnancy. retroversion of the womb, and I am free to say that I cannot now conceive of any such case that would not readily admit of repositing by the colpeurynter, excepting always those cases in which adhesions have taken place so as to confine the fundus low down in the cavity; and even in some of these, if the adhesions should not be very strong and old, repeated gentle and persevering colpeurysis might enable one either to elongate the adhesive bridles, or even break them, and force the fundus to rise up to its place. Mr. Gemrig, surgeons' instru- ment maker, in Eighth Street, Philadelphia, prepares a most conve- nient colpeurynter. It consists of a vulcanized rubber bag, which, when collapsed, is not much bigger than a black walnut. To the sac is attached a hose, or tube, of the same material, about fourteen to eighteen inches long. A small brass stop-cock is secured on the end of the hose, and fitted to receive the fistula of the syringe, by means of which water or air may be injected, and the bag distended at will. The great length of the hose permits one to use the apparatus in a way less shocking to the woman's delicacy, as the stop-cock can be brought out from beneath the bedclothes, and the sac filled and emp- tied by turns. 499. In my practice, I am in the habit of teaching the patient to perform the colpeurysis with her own hands, first showing her how to adjust the colpeurynter, and then teaching her how to force the air or the water into the caoutchouc bag. This I have done for such persons as, having a chronic retroversion with considerable hypertrophy, I did not choose to attempt to cure by one violent operation; and I do believe, that in the bad cases, it would be, in general, for the interest of the sick woman to first teach, and then trust her as to the mode and degree of the colpeurysis. I am very glad to have an opportu- nity to recommend the employment of the colpeurynter for the treat- ment of retroversion, particularly as such an application of the instru- ment appears to have wholly escaped the attention of its author, Dr. Braun, who, at p. 126, op cit., gives us a list of the affections for which he advises its employment, and which consist in cases No. 1, Metrorrhagia during dilatation of the cervix in labor; 2, bad presen- tations, as preparation for turning; 3, deformed pelvis; 4, bringing on, or hastening labor in eclampsia; 5, for sustaining the parts in hernia-intestino-vaginalis in pregnant women; 6, bringing on premature labor; and 7, as a substitute for the dangerous actions of secale in the dila- tative stages of parturition. It appears to me unnecessary hereto add anything on the subject of Braun's most useful instrument. I shall in subsequent pages have to speak of its various other applicabilities. PREGNANCY. 261 500. Extra Uterine Pregnancy.—I have met with four cases of extra-uterine pregnancy in the tube, all of which proved fatal about the third month, and I should expect the death of the patient to take place, at or before the third month, in any case; since it is improbable that the tube can ever furnish the material for a matrix for more than some ninety days, at which time the tube-sac must be- come so much thinned and extenuated by its expansion as to burst. The rupture of the tube will be attended with fatal hemorrhage, because, being the seat of gestation, it has become highly vascular in order to the carrying on of the gestation within its walls. I do not believe that a tubal pregnancy will ever be suspected until it has burst and begun to bleed. One of these cases I have just related, as drawn up by Dr. Yardley, under the head of retroversion. If a woman should experience the signs of pregnancy, such as change of the aureole, nausea, pica and malacia, growth of the breasts, extraor- dinary sensation within the pelvis, &c, and thereupon, when having attained to the middle of the second or to the third month, be seized with horrible pain in the hypogastrium and pelvis, turn pale, lose the pulse, and faint—I should suspect the rupture of a tube-sac of extra- uterine pregnancy. It is true that the above symptoms might be expressions of affections of the ureter, perforation of the bowel, or fatal typhlitis calculosa; but, in case they should continue and in- crease, with signs of concealed hemorrhage, so as to leave no doubt of imminent death, I think the diagnosis could not be other than a ruptured tube-sac of gestation. Such a diagnosis would not lead to any hopeful therapeutic or chirurgical intervention, for nothing is to be done in these melancholy cases beyond the adoption of mere pallia- tive measures. No man would be mad enough, under such diag- nostic, to perform a gastrotomy operation. 501. Case.—I had, some years ago, a young woman under my care who supposed herself to be pregnant some two or three months. One morning she took the broom to sweep her chamber-carpet, when sud- denly she felt agonizing pain in the left iliac and pelvic region, which extended through the belly. She fainted, and became mortal pale and pulseless; the agony was terrible. I supposed she had ruptured the sac of a tubal pregnancy. She expired in the course of a few hours, with all the symptoms of hemorrhage in the abdomen. I could not obtain permission to examine the body. 502. Case.—I saw another case, which I shall relate in this place as follows: Mrs.------, aged thirty-two, a healthy woman, mother of 262 PREGNANCY. four children, was in excellent health on Sunday, October 7th. At six o'clock in the morning, she was singing and playing with her children. At seven o'clock, her husband, who was sick up stairs, heard her ascending the staircase, and groaning heavily; when she entered his room, she appeared alarmingly ill. A physician, Dr. ■----, was sent for, and found her with a pulse one hundred and forty; in violent pain, extending from the top of the thorax on the right side, quite down to the iliac region. He attended her all day, applied a blister to the right side of the belly, gave a cathartic, &c. She passed a dreadful night, but was easier at eight o'clock next morning; the pulse then one hundred and twenty. He left her for a short time, but found her worse on returning to the house. I was sent for, and ar- rived at half past two o'clock. She appeared to be dying at the time of my arrival. As she had vomited very much, and had a most ex- cessive tympany, with violent pain in the whole belly, she got an enema, which brought off a great deal of stercoraceous matter, with- out sensible relief. In half an hour, she said: "Raise me up—my breath is leaving me." I raised her a little on the pillows, and she swooned and died. Twenty hours after death, I opened the abdomen, and found it filled with about thirty ounces of blood, and bloody serum. The whole pelvis was filled with coagula, while a great quantity of blood was among the bowels. This blood came from a ruptured left Fallopian tube, which contained a foetus of six or seven weeks. The ovarium was somewhat enlarged. The womb had a de- ciduous lining, and the canal of the cervix was filled with a claret- colored mucus or lymph. The womb was larger than a non-gravid womb, though not a great deal larger. 503. I have had under my care only two cases of ventral or abdominal pregnancy, though I have had opportunities to witness the examina- tion of bodies of persons perishing from this dreadful accident. I shall merely express some doubt that I feel as to the propriety of any gastrotomy operations in such cases save mere incisions for the easier escape of the contents of the suppurating sac and the remains of the foetus. I do not understand how any educated physician can suppose that ventral-pregnancy can depend on any other cause than rupture of the gravid womb, allowing the foetus to escape into the peritoneal sac—where it becomes subsequently invested with a special sac—the result of fibrinous excretions from the serous membranes. If a portion of the womb wall should through some arrest of develop- ment become as thin tissue paper—it would be very little vascular at such point—and if giving way slowly, the foetus and placenta might fall into the abominal cavity with little or no hemorrhage and without PREGNANCY. 263 violent constitutional disturbance. There is no other way for account- ing for the cases. I refer the Student to the records for samples of life not only continued long after the complete establishment of the extra- uterine pregnancy, but of good health enjoyed notwithstanding. The late distinguished incumbent of the chair of Midwifery in the Univer- sity of Pennsylvania, Prof. James, published in the "Eclectic Repertory" an account of a lady who carried out a normal pregnancy, notwith- standing she had in the abdomen an extra-uterine foetus, which she carried many years. 504. Signs of Pregnancy.—I have been, on several different occa- sions, both vexed and amused upon observing how prone are some medical practitioners to overlook the signs of pregnancy even in mar- ried women, their patients. One gentleman; of great experience, tapped a woman for ascites, but his trocar went into the gravid womb, and penetrated the shoulder of the foetus. She fell into labor, and recovered of the accident; the child had the mark of the trocar on his shoulder. She afterwards' suff'ered from strangulated hernia of a knuckle of intestine, that escaped through the trocar-opening in the linea alba. This hernia being reduced by Dr. Pancoast, she recovered happily. At a subsequent period, the protrusion again occurring, the gut was fatally strangulated. Professor Pancoast, who made the post- mortem examination, preserved the specimen in the Jefferson College Museum. Many instances of the strangest oversight have occurred within my range of observation, instances in which the size of the belly, the married state of the patient, and the obvious evidences of gestation, as well as its probability, ought not to have been overlooked, nor mistaken for diseases requiring troublesome, disgusting, or dan- gerous therapeutical prescription. The safest rule would be to sup- pose as pregnant every married woman, if of the proper age, with suspension of the catamenia, and not giving suck, and to treat her as gravid until convinced of the contrary. 505. Case.—Mrs. ------, aged thirty-six, multipara, resident in Philadelphia, was ill on the 15th of March, 1850, with diarrhoea, attended with very distressing tenesmus. That able physician, Dr. ------, attended to her during three days, and then left her in appa- rent good health. She was supposed to be, at the time, one hundred and twelve days gone with child. She had no doubts as to the preg- nancy. Ten days after the attack of diarrhoea, March 25th, she began to grow rapidly larger, and the belly soon became so enormous, and so painful from tension, as to induce her to send again for the doctor, 264 PREGNANCY. who found her, as he supposed, affected with a vast ascites, consisting of many quarts of fluid contained within the peritoneal sac. I know not on what day Dr.------first saw her again. The secretion of urine was nearly abolished. The reins and lower part of the abdomen were very painful, yet there was no pain produced by pressure or by palpation. No signs of pregnancy save that the cylindrical cervix was short as in a woman of seven months, and that the cone of the cer- vix, felt in the vaginal cul-de-sac, was expanded. The os uteri was well closed. Neither palpation nor auscultation disclosed the reliable evidences of a pregnancy. Still, the woman insisted that she was preg- nant and quick with child. She became affected with nausea and frequent vomiting. She grew thin, and got a haggard expression of the face. She was costive. There was not the least oedema of the limbs or face. Under these circumstances, Dr.-------announced his desire to tap the patient, which he looked on as the only hopeful means of arresting the vomiting, which now caused her to throw up the whole of the ingesta. The pain from abdominal tension was almost insupportable, and the emaciation extreme. On Monday, April 22d, I was called in consultation. She vomited everything—was in great distress from distension of the belly. Pulse frequent and energetic. Tongue clean. She was tolerant of pressure in every part of the abdomen. The vaginal touch revealed to us nothing to be de- pended upon, though made with great care. Protracted and anxious auscultation of all the parts of the abdomen, disclosed no foetal sounds, and long-continued palpation no foetal turbulency. The patient insisted upon the gravidity, which I could neither affirm nor deny. Upon con- sultation, it was agreed to defer for the present the idea of a tapping. She took citrate of magnesia, which purged her well and brought an end to the vomiting. She then took ascetic tincture of squills, combined with sweet nitre, for I fully believed in the existence of ascites having at least sixteen quarts for the collection, and I gave this as my opinion, concurring with Dr.------, physician in chief. I did not deny nor affirm the pregnancy. On Thursday, May 2d, at noon, Dr.------ was called to her in labor, which soon terminated in the birth of twins, of five and a half months, the first born being faintly alive for a few minutes, and the second quite dead. While Dr.------sat at the bed foot, a vast quantity of water (a great many quarts) gushed from the ruptured membranes;—" a very large bucket-full" was the doctor's expression. Soon after which, the twins were expelled, and then the placentas, united in one disk, were removed. To-day, May 3, 1850, I saw her at noon. The womb is firmly contracted in the lower part of the belly, though very large; being about five inches in trans- PREGNANCY. 265 verse by seven in longitudinal diameter. I do not think there is any, the least degree of effusion in the peritoneal sac, and the patient is in every respect comfortable. I do not suppose that I have ever been concerned with a more instructive case than this. Dr.------, an able and most experienced physician, who has had about 6000 labors, mis- took the developed belly for an ascitic tumor, an opinion in which I wholly concurred after the most careful observation, the employment of all the proper means of diagnosis, and serious reflection on the his- tory of the case. I never have met with a more fluctuating dropsy than this one, the waves being most distinctly and clearly perceptible, in whatever direction propagated by the percussions. It was dropsy ofthe ovum. My objection to the paracentesis depended upon two points; first, the risk, of peritonitis from the wound; and second that of interfering with the uterus, provided she was really pregnant. But for this hesitation she would have been tapped, and that with my consent, which I was on the point of yielding!! Let the perusal of this most interesting case serve as a memento for the Stu- dent in all instances of such sudden dropsies, complicated with averred gestation. Let the distress of this patient be referred to the same category of influences that occasion so much constitutional irri- tation from the too rapid growth of the womb, under hydatid gra- vidity, as treated of at length in 455. I was greatly shocked, this morning, to find how grave a mistake in diagnosis I had made, and equally relieved to find the patient delivered of her twins and her ascites by the same gush. I beg the Student not to forget this lesson, and I hope he will refer to it before he taps a female of whom it is possible to suppose that she is gravid. Let the Stu- dent also imagine, for a moment, how very disagreeable must be the reflections that follow the clearing up of so egregious an error as that of administering powerful emmenagogues to married women, who, nevertheless, would not miscarry; or who, now and then, are found to miscarry under such a diagnosis. The signs by which a woman knows herself to be pregnant are, the cessation of her regular menses and the subsequent enlargement of the abdomen; the movements of the foetus; certain constitutional or local disturbances or disorders, and modifications of the mammas. A married woman, who has been well regulated, suspects that she has conceived, if she fails to menstru- ate at the proper term; but this cannot be considered as conclusive evidence of conception, since so many and such various causes are found to obstruct and divert the regular course of the menstrual func- tion. A second failure, especially if it be not accompanied with any signs of depraved health, renders the suspicion still more valid; while 18 266 PREGNANCY. after a third and fourth omission, the change of form, and at last the perceptible motion of the embryo put all doubt to flight. I may say, however, with great confidence, that the audible or palpable move- ments of the foetus afford the only true and infallible signs of the existence of pregnancy. But, the audible are far more to be relied on than the palpable signs, at least after the sixth month. There are many accidental or correlative signs which establish a probability of the existence of pregnancy: among these I may mention nausea and vomiting; a gradual increase or development of the mammas; a change of the areolae of the breast, which become more protuberant or elevated, and acquire a dark brown hue, much to be relied upon, especially in first pregnancies. The nausea is mostly found to occur in the morning, and is attended in some individuals with a distressing heartburn and salivation or spitting of saliva. Some people are affected with gravel, or dysury, from the extension of irritation to the neck of the' bladder, or from pressure of the enlarging womb upon the posterior surface of that organ. An irritable state of the temper indi- cates it in some women, which is attributable to the general malaise that must attend the gastric embarrassments which the early stages of pregnancy are so commonly found to produce. Toothache, earache, styes on the eyelids, morph on the skin, a dark areole around the eyes, and strange, unaccountable longings or appetites are also signs of pregnancy, rather to be noted after pregnancy is fully ascertained, than to be depended upon as sure evidences of its existence. 506. By means of the Touch, pregnancy may be doubtfully ascer- tained, before quickening has taken place, but not surely. By the Touch we can readily learn that the womb is enlarged, altered in form, and contains something; but I do not see how any physician can absolutely aver, what that something is, unless he can perceive a spontaneous motion in it; so that even the ballottement, or tilting the embryo upon the point of the finger, does not furnish, to my mind, any sure evidence that the tilted body is an embryo. I ad- here, therefore, to the opinion I have already expressed, that we have no certain signs of pregnancy except those derived from the visible, palpable, or audible motions of the child. 507. Auscultation, either by means of the stethoscope or the direct application of the ear to the abdomen of the woman, enables us to perceive two very distinct sounds, one of which is the beating of the heart, and the other that which has been called the placental souffle, bruit de souffle, or bellows-like sound; the latter being occasionally attended with a sound like the cooing of a dove. Whenever we can distinctly hear the beating of the foetal heart, so as PREGNANCY. 267 even to count the number of its pulsations, all doubt must be at an end. The placental sound, or the souffle, is a very distinct sound, which has been supposed to indicate not only the presence of a foetus, but also that it lives; the rushing or blowing sound being said to always cease as soon as the foetus expires: it was said to be, in some way not yet sufficiently understood, connected with the movement of the blood in the placenta, and to cease, of course, with the cessation of that move- ment, which is itself dependent on the systole of the foetal heart. 508. Upon a more scrupulous inquiry as to the value of the bruit de souffle, in the diagnosis of pregnancy, it has at last been found that the earlier opinions of it were erroneous, and I believe that there are few well-informed physicians to be now met with who give it even the smallest portion of their confidence in the doubful discriminations that they are sometimes compelled to make. It is not to be doubted that the sound is produced by the rush of blood in vessels, and in my opinion, sustained by very long practice in obstetric auscultation, it depends upon the motion of blood in the iliacs and hypogastrics. I have certainly heard the same sound after delivery as before the child was born; and I have heard it, as dependent upon pressure by tumors within the abdomen. Hence I have not the least confidence in it as a means in obstetric diagnostication. The sounds of the foetal heart need never be mistaken. They can be detected at the fourth month, when the opportunity is good. M. Depaul has heard them much earlier. To look for them earlier than the fourth month is, however, in general, merely to lose one's time and find a disappointment. 509. It is perhaps, on some accounts, of less consequence to be able to ascertain the existence of pregnancy in the married than in the un- married woman. The lapse of twenty weeks, and sometimes of six- teen weeks, makes it surel}" known; and the married woman, who has no motive to keep it a profound and important secret, readily imparts a knowledge of her situation, or her suspicions relative thereto, to the physician, or her friends. Not so with the unmarried female, whose reputation depends upon the concealment of her misfortune or crime. I have frequently been sorely embarrassed by uncertainty as to the condition of a patient whose ruddy cheeks and embonpoint seemed quite incompatible with a suppression of the catamenia, and whose complaints of aches and pains might possibly be merely assumed as a means of deceivng the medical adviser. Physicians are frequently applied to by the unfortunate or guilty for relief from "obstruc- tion s," when the applicant has only a design to obtain some powerful deobstruent or emmenagogue, which may serve to procure an abortion, that she knows no honest or respectable medical practitioner could be 268 PREGNANCY. induced to procure for any pecuniary reward whatever. I hold it, therefore, to be a duty, in all cases, or ranks, to compare the com- plaints of amenorrhoea with the appearance ofthe patient, and if some evident malady does not accompany the supposed suppression, to withhold all medical aid, until time or necessity discloses the indica- tions that are to be fulfilled. In physic, nothing should be taken for granted. It is too much to expect that a female, who has it at heart to conceal her pregnancy, will confess it to a medical man. Ex- perience teaches us the very contrary. 510. Case.—I was requested some time since by a lady to visit a favorite servant, whose situation excited her apprehension, as she had failed to menstruate for the antecedent seven months, and was already considerably swollen with something like dropsy. Being directed to the young person's apartment, I found her in bed, covered up to the throat with bedclothes, but the face that peeped out from above them actually shone with ruddy health, or agitation, or both. The pulse was natural, the tongue clean, the respiration normal, and the entire physiognomical expression as healthful as possible. She informed me that she had a stoppage of the courses for the last seven months, and felt very bad, and was now alarmed at a swelling of the stomach, which had increased greatly of late. Suspecting that she had an im- portant secret, I asked some questions about pains in the stomach, and, upon permission obtained, placed my hand on the abdomen, being almost certain that I should feel the motions of a foetus; but, however long I held my hand on the abdomen, no movement of the child could be felt; so that, although I was certain she was pregnant, I was as yet unprepared to tell her so. I at length got permission to apply the ear against the side of the abdomen, and distinctly heard the placental souffle, and afterwards the stroke of the fcetal heart. Upon this assurance, I told her she was pregnant. "If I am," she replied, "I wish God may strike me dead!" and continued, with much temper and even passion, to declare that I maligned her and slandered her. I was obliged to leave her without the least assent, on her part, to my diagnosis, although she knew perfectly well that I spoke only a truth with which she had been long acquainted. She went out of town, and was confined in the country with a fine boy. Many examples of similar perverseness, in denying pregnancy, the signs of which were perfectly plain to me, and ought to have been obvious to the most careless observer, have fallen under my notice; so that I deem it a solemn duty, previously to the exhibition of any medicines, to ascer- tain that some signs of disordered health are present, in order that I PREGNANCY. 269 may not commit the unpardonable fault of provoking an abortion, instead of removing a morbid obstruction of the catamenia. Let me, however, warn the young beginner here, to take special care, in his diagnosis, that he shall first know the woman to be pregnant before he clare venture to say so. How could a gentleman commit a more unpardonable, or more insulting error? I might here abstain from any further enumeration of the signs of pregnancy; for 1 am accus- tomed myself to decline giving an opinion in any case, until I am sure that I cannot be mistaken, which I never can be when I hear the fcetal heart, clearly and distinctly repeating its beats in the womb. 511. Quickening is not a sign to be depended on by the m ed real atte ndant, though it may convince the p at i en t herself; for the woman may perceive it, when the physician cannot. Her convince- ment ought not to be equivalent to his own convincement. Even the sensible motions felt upon palpation of the abdomen may deceive both the woman and the doctor. Multitudes of such deceptive cases of "dans e de la ma trice" are met with in a long career of practice. I have seen a woman who had the sensible motions of a child in her belly, though she had given birth to a foetus at full term only six weeks before, and of whom several physicians who examined her had declared the motions to be caused by a ehild, yet her cervix uteri was an inch long in the vagina, and the abdomen so soft as to allow one to push his hand down so far as to feel the spinal column. She was not and could not be pregnant. Many of my patients having engaged their monthly nurses and called me in, were found, when I' arrived, to be troubled with tympanitis only. Tenues in auras evadit. —See certain cases in my " Letters to the Class," under the article Tympanitis. The toothache, the ephelis, the hordeolum, the nausea, salivation, pica, pouting of the navel, aud even milk in the breast, are merely inferential signs, and are by no means to be depended on. I repeat, that I can rely only on the heart's motion heard in ausculta- tion, and that sign cannot be detected until the fourth month. This is the rule; the exceptions, few in number, are those in which it has been found in the pregnant woman as early as three months and ten days, as in the instance now to be related from Depaul, "Traite Thcorique et Pratique d'Auscultation Medicale," p. 248, where he gives us the following account:— 512. Case.—" Madame T----, who has already borne several child- ren, had her courses on the 10th to 15th April. From the 17th to the 20th of same month, she cohabited with her husband; he then left Paris on a journey of a fortnight. Upon his return early in May, he 270 PREGNANCY. found his lady confined to bed with the early symptoms of a typhoid fever, which in a few days became perfectly well marked, and con- tinued twenty-four or twenty-five days. Her convalescence required a lapse of time nearly as long; and no sexual relation occurred until after her recovery. Nevertheless, upon the first of August following, as her courses had not reappeared, I was requested to see her with a view to determine whether this retention, which was very naturally attributed to the severe disease she had lately suffered, might require the employment of certain remedies for its cure. I confess that I was at first inclined to give up the idea of a pregnancy, begun previously to trie commencement of the typhoid fever. I was little inclined to suppose its existence computing it from the new sexual relations suc- ceeding her convalescence; but the examination per vaginam enabling me to detect a notable development of the volume ofthe uterus, I fell back upon the first opinion, of the propriety of which I became fully convinced, when, after having applied the stethoscope at various times upon the inferior region ofthe abdomen, I discovered the double pul- sations, which were repeated 140 times a minute, while the pulse of the mother was only seventy-six. I could not hear the souffle uteri n. Her confinement occurred in the following January." M. Depaul, if the above case is to be relied on, heard the double sounds 100 days, or three months and ten days after the fecundation had taken place. The pregnancy continued 174 days after the audition of these fcetal sounds. Probably few such early detections will be made by all the readers of this paragraph. Inasmuch as I have spoken at length on the signs of pregnancy in my "Letters," I shall beg to refer the Student, for further information, to that volume sub voce. PART III. THE THERAPEUTICS AND SURGERY OF MIDWIFERY. CHAPTER IX. LABOR. 513. In coming now to this third division of his subject, or Mid- wifery proper, the Student ought to understand that the practice of this art is one requiring not only a large amount of obstetrical or sci- entific information, but also a great deal of prudence and delicacy, as well as some knowledge of the world; without which he will scarcely attain to any considerable eminence or happiness in the practice of it. Even the foregoing imperfect statement of the Anatomy aud Phy- siology of Midwifisry, subjects which, to be well described, would require several volumes rather than a few short chapters in this one, might serve sufficiently to show him that a great variety of consider- ations must precede the study of Midwifery proper; and that those considerations relate not only to the structure and* functions of the living body, but also to every step in the development of that body, from the earliest dawn of its existence, up to the complete maturity of its powers and faculties. There have not been wanting very good writers to show that the whole of this study and practice ought to be confined to persons of the tender sex; asserting that the differences between the sexes ought not to warrant those impudicities that are supposed inseparable from the practice of the Art of Midwifery by men; and, in the world, at the present day, though it is admitted that the Surgeon-accoucheur is an indispensable person in society, he is by many looked upon with a sort of doubt and distrust, on account of the very peculiar nature of his pursuits. On this question, however, I think any man's mind may arrive at a satisfactory conclusion, if it be only considered that a person with a pure heart and righteous pur- 272 LABOR. poses may be safely confided in, as far as relates to the morals of an obstetrician's profession; and I will add that the objectors to the practice of Obstetrics by males, are perhaps of more impure minds than the accoucheur himself; who, if he be actuated by the laudable motives that ought to rule the life and conversation of every medical man, may retort upon his opponent ho n i soit qui mal ypense, or shame on him who evil thinks. In Midwifery there is much to dis- gust and nothing to demoralize a physician: the man who practises the art, sacrifices himself. It ought to be evident to the intelligent and ingenuous Student, that some fit preparation of the mind to the discipline of this Art is required as an introduction to the exercise of it; since, to go at once from the College into the very delicate posi- tions in which he is about to be placed, shows, to say the least, a great want of prudence and forethought. Many clever men have made shipwreck of their hopes by the want of a little reflection as to the course they should pursue; or by early abandoning themselves to professional habits, which, without the least intention on their part, have gradually assumed a tone of familiarity, that has been construed into impertinence, or downright insult. No woman can be placed in a sanitary condition compelling her to appeal to the aid of the ac- coucheur, without some sense of a mortified delicacy, and it is quite clear that the only reparation for, or the only means of obviating this unpleasing impression, consists in the exhibition to her-wards, of the most profound respect and sympathy, and that, too, proffered with a sincere conviction of the painful nature of her position, as well as the indispensable propriety and necessity of her submission to it. A female possessed of ordinary sensibility will be less affected by the sacrifice of feeling she is thus compelled to make, if she be treated as an object of respectful consideration, than if approached with a light and indifferent address; and while she finds her own pride less wounded, will be both more confiding in the wisdom of her physician, and more grateful for his counsel or service, as well as respectful to and considerate of his counsel and profession. The occurrences that befall in the course of an accoucheur's professional life are many times of a nature to require at his hands secrecy and good faith; for he cannot but become the depository of many informations in which are involved the reputation and even honor of persons, and the safety of important private interests. Let the Student, then, before he goes any farther, take a firm resolution to guard with good faith those secrets with which he may become acquainted as physician or Sur- geon-accoucheur. He ought beforehand to consider the meaning of the term professional secrets, and know that they are either accidental LABOR. 273 revelations, or homage due to his station as physician, and not to himself as person; for of the vast number of those which may be hereafter communicated to him, or discovered by him, not a tithe or hundredth part of them would ever be his but for his professional position. If a man, therefore, is dishonored who reveals a secret communicated by a friend, how far more base is he who takes advan- tage of his professional standing to make public, circumstances that have been intrusted, so to speak, not to himself alone, but to the sacred character of the Iatrist! He disgraces his calling in disgracing himself. It is not in regard to grave and serious matters only that he is called upon to be silent, prudently abstaining from acquiring for himself and his brethren the unenviable character of the babbler; even the most inconsiderable circumstances as to the sick are confi- dences that ought not to be disappointed and betrayed. This is a just and true remark, and it is a rule that ought to be followed in all cir- cumstances and ages. 514. The Caliph Al-Mamun, as we are informed by Abul-Pharajius in his history of the Dynasties, was a friend of science, and exhibited his patronage of learning by fostering many learned men, among whom were some of our own profession. Among others of his numerous medical favorites was John Ocularius, the oculist, whose duty it was to visit the Commander of the Faithful every day, and that in his most private apartment, alone. The Caliph gave him great honor, and for his services allowed him a monthly stipend of a thousand gold sequins. Upon one occasion, as the physician came out of his master's apartment, while passing through an anteroom, he was asked by one of the servants: "What is the Caliph doing?" "He is sleep- ing," was the incautious reply. Unhappily for the Doctor, this reply was overheard by the successor of Mohammed, whereupon the culprit was sent for, and brought before the chief of Islam. "What!" said he to the offender, "have I employed you as my physician and admit- ted you to my intimacy in order that you should report to my ser- vants as to my private occupations? Go out of my house!" The poor medico, in telling this story, to account for his fall, added the Caliph never afterwards would admit him into his presence, which was but the just punishment of a professional indiscretion. Let the Student reflect upon the punishment deserved by those who babble the con- cerns of families or individuals. John Ocularius was turned out of the court of Al-Mamun for merely saying that his master was asleep! suppose the young doctor should say: "My mistress has a sore leg!" 515. But in addition to the quality of discreetness above insisted upon, the Midwifery Student should firmly resolve to merit the appel- 274 LABOR. lation of Scholar, a title far more honorable than that of knight, noble- man, or minister of state, for it is to the Scholar that the world is in- debted for its preservation from its own violence and vices. It is to the Scholar that it is indebted for laws, for science, and for all the arts. The Scholar is the promoter of virtue, and decency, and good conduct, both by his precept and his example; for it is to him that mankind turn their eyes to see what is wisdom, what is virtue, and what is true liberty. All those who are not, by education, brought out of the bondage of ignorance are slaves indeed—slaves of lust, superstition, and ignorance. Hence, it is evident that the Scholar is the only real nobleman, and his nobility becomes more and more exalted in the ra- tio of his elevation in virtue and knowledge towards the fountain and source of all knowledge and all virtue. Let him aim, therefore, to become a Scholar indeed, not only that he may embellish his under- standing, with every ornament of learning, but that he may become able also to minister to those who may be committed to his care, tost, seurement, et sans douleur, as old Fournier says in his "Accoucheur Me'thodique." 516. The Student ought not to rest satisfied with the bare intention to make himself equal in skill and dexterity to the common midwives of the country. He ought to be resolved to become fully acquainted with the dynamics ofthe generation-sphere, by the irregular operation of which as Wigand says, the power of the uterus in labors is so often baffled, and its energies misdirected. If he studies well the the- rapeutics of midwifery, and practises them well, there will be no occasion to twit him with the reproach so commonly cast on the accoucheur, that when he is called in, " one or the other, mother or child, goes to the grave," to use the words of Wigand, which I cannot but quote in this place. "Gibt es keine gegend, keine stadt mehr, wo das Publi- kum es nicht anders weiss und gewohnt ist als dass, wo ein accoucheur sein hand anlegt, wenigstens eins von beiden, das Kind oder die Mut- ter darauf gehen miisse? Kennen, wir jetzt keine Geburtshelfer mehr, die, wo sie hinzugerufen werden, keine andere Indication zu machen im Stande sind, als augenblicklich mit Zange oder Faust, uber den unschuldigen Uterus herzufallen, und ihn, wie einem Dieb und Spitz- buben der das Kind gestohlen hat, zu mishandeln?" "Are there not any districts or cities to be found, in which the public generally sup- pose that where a physician is called in, one of the two, mother or child, must be sacrificed ? and are there no accoucheurs at the present day, who, being called to a case of labor, can discover no other indi- cation of treatment than that of instantly, with fists or tongs, falling upon the innocent womb to abuse and maltreat it as a thief or robber LABOR. 275 that has stolen the child ?" These words of Wigand are strong words; let them sink deep into the heart of the Student, for they were from the lips of as true and noble a Scholar as has in any age graced the annals of Medicine. Let the Student also enter upon his pursuit with a good resolution to add something to the value ofthe art he is about to practise during his future life; let him leave to the brethren and to the world some fruit or fruits of his observation, his reflections, or his experience. He is about to enter upon a course of life singularly ar- duous and toilsome, and involving sudden and most painful responsi- bilities to individuals, and to society at large. He is doomed to sacri- fice himself for his station. There are no vacations or holidays for him: and night itself is turned into day, for his occupations cease not with the setting sun; his task is never done. More labors occur at night than during the day, a circumstance that adds greatly to the onerous and distressing duties of the Accoucheur. 517. Labor is the process by which the contents of the gravid womb are expelled; and the word is highly expressive of the fatiguing, violent, and painful struggles and efforts of the woman to overcome the obstacles to her deliverance from the uterine burden. Labor should commence, as we have already seen, at or about the two hundred and eightieth day from the last show of the menses, or the one hundred and fortieth day after quickening; and it may, in general, be expected to terminate without any artificial power or assistance, after a few hours of travail—the time being greater or less, according to the amount of the power employed, or the resistance to be overcome. The average duration of labor has been stated at four hours; I should think it greater. There are many examples of women in labor who are completely delivered in ten minutes from the first perception of the signs of parturition; very numerous cases occur in which labor is protracted during twenty-four hours: while some of the patients are occupied three, four, and even five days, with continuous efforts to bring the child into the world. I have witnessed one labor of nine days' duration, and many of from three to five days. 518. The essential element of labor is the contraction of the mus- cular fibres of the womb, the end or object of which is the evacuation of the uterine cavity, so that, the whole of its contents being ejected, it may return again to the non-gravid state, when it will measure from two and a half to three inches in length, about an inch and a half in width, and half an inch or three-quarters of an inch in thickness; the organ being, before the commencement of the contractions, about twelve inches long by seven or eight inches in transverse diameter. As the os uteri is closed during pregnancy, it follows that the expul- 276 LABOR. sion of the contents of the organ cannot take place until the orifice becomes sufficiently opened to permit the child to pass out; and that there is also required a sufficient dilatation of the vagina, and of the vulva; in all which parts a greater or less degree of resistance or obstacle is found; which, taken in connection with the resistance afforded by the bony structures and the perineum, are generally the causes of a delay of several hours in the birth of the child, even where it presents itself most favorably to the openings through which it is destined to eff'ect its exit. 519. In a vast majority of cases, the powers of the womb alone are insufficient to eff'ect the delivery of the child, and its birth must be aided by the forces of the abdominal muscles, and the diaphragm, which are not only capable of making a direct expulsive effort, but, by presenting a point d'appui for the contracting womb, can assist it more efficiently to exert its own peculiar powers. The abdo- minal muscles and the diaphragm, acting alone, can push the point of the womb down low into the excavation, and hold or fix it there, while the fundus and body of the organ are propelling the ovum against the obstacles that stand in the way of its escape. Hence, although the essential element of labor consists in the uterine contrac- tions, there are collateral dynamic elements of the process that greatly avail in its completion, and that ought always to be well understood, in order that they may be either called into action, or restrained, as the obstetrician may please to direct. Perhaps the best idea of the dilating pains of labor is, that the presenting part of the child is pressed against the circle of the os uteri, which, by the contraction of the body and fundus, is drawn upwards over it, so as to strip the womb up over its head, its body and its legs, until the whole is ex- pelled from the cavity of the uterus. 520. Cause of Labor.—The cause of labor, or, I should rather say, the cause of the onset of labor, is not well understood, although it is quite probable that it is to be found only in the inability of the neck of the womb, in any given case, to bear further hypertrophy. In the beginning of pregnancy, the ovum inhabits and distends only the corpus and fundus of the womb. As the child increases in size, it requires a larger nidus than these parts can afford, so that the upper end of the cervix now becomes distended. Gradually, the whole of the neck is taken in to form the oviform nidus for the full-grown ovum. The os uteri still remains unexpanded; when the ovum has become too large to exist within the completely developed uterus, even the circle of the os uteri can no longer resist the distending LABOR. 211 pressure. It begins to yield; it opens a little, and, at length, its antagonism to the expulsive powers growing feebler and feebler, it is fully dilated. The whole cervix is now become a wide cylinder, through which the child is thrust by the contractions, which tend to approximate the fundus to the os uteri. This is labor. Labor begins from a necessity of the uterine constitution, and not from any ascer- tained degree of development of the child, which, whether large or small, is most likely to be born two hundred and eighty days after the last catamenial period of the mother; but may not be born until three hundred, or even more days have elapsed. The size of the child is not found to bear a proportion to the excess of the duration of the pregnancy. It does, in fact, frequently occur, that the womb begins its contractile effort long before the expiration of the two hundred and eighty days; or, on the other hand, it fails to commence its contraction for several days after the two hundred and eighty have elapsed; but, whenever it does begin, it is because it will admit of no further or longer-continued distension ; or because the cervix and os will no longer prevent the ovum from escaping, which it always tends to do when they cannot prevent it. 521. This is the theory by which Baudelocque endeavors to account for it, and which I have above explained. It seems clear that there is a contest or antagonization betwixt the fibres of the cervix and those of the fundus and body of the womb going on throughout every stage of the pregnancy; that, in the early months of pregnancy, the fibres of the body and fundus yield to, while those of the cervix resist the distending force, until about the seventh month, at which time they also begin to yield, and continue to yield until the end of the ninth month. These fibres of the cervix are the seats of a retentive, while those of the fundus and body are the seats of a contentive and expul- sive faculty or power. At the ninth month they are balanced, or antagonize each other exactly. At length, the development of the ovum going on, those of the fundus become the more powerful, and those of the cervix and os uteri are lessened, and finally so completely overcome as to allow the ovum to escape. The same force which con- verted the cylindrical into the conoidal cervix continues to operate until it has converted the conoidal neck into the wide cylinder whose diameter is at least 3.8 inches. When this change is once effected, the foetus comes forth into the vagina and then into life. This ex- planation is, perhaps, as good as any that could be offered; it is perhaps not unworthy of remark, that, in the development of the gravid uterus and its contents, we behold a wonderful adaptation of parts to the purposes they are destined to fulfil; since the growth of 278 LABOR. the child would, if continued indefinitely, make its delivery impos- sible, and therefore the Author of nature has by a simple law provided against such a fatal contingency: the womb, by that law, refusing to yield any further than is sufficient to allow the child to acquire a cer- tain degree of magnitude and vigor, essential for its respiratory life, but not too considerable to prevent its birth from taking place; and this perhaps is, after all, a sufficient solution of the problem. 522. Subsidence of the Womb.—The term of utero-gestation and the commencement of labor may be supposed, as has before been said, to be fixed, and rendered necessary in part, by the great disten- sion of the abdominal muscles and the intolerable pressure upon and displacement of the parts contained within the abdomen. I know not what influence upon the production or first excitement of labor-con- tractions may be exercised by the altered state of the abdominal mus- cles themselves; but it is, perhaps, not too much to infer that they do at length exert some considerable share of influence, by their constant or tonic contractile operation, in aiding the fundus and body to over- come the retentive effort of the os uteri, any yielding or relaxation of which tends to invite or provoke the contractile effort of the fundus. We see, at least, that in the last days of pregnancy the womb settles down with its apex in the excavation, and the woman seems much smaller than she was before this sinking downwards of the uterine globe was perceived. Now, it may be asked what can cause this set- tling or sinking downwards of the womb, if it be not the tenesmus ofthe abdominal muscles and diaphragm, which have pushed it downwards. Labor pains are caused by the contractions of the womb, and are first situated in the neck of the organ ; but it happens that when the womb is much sunken, it in one case feels very hard and firm, as if its fibres were in a state of contraction or condensation ; whereas in another case it is soft and flaccid, notwithstanding it may be very much de- pressed into the excavation ; no sign of actual labor being present in either example. The sinking downwards of the womb takes place, in some persons, several days before the first pains are felt. In such instances, the womb must be regarded as wholly passive in the matter; it is forced down by the muscular tenesmus, not by any intrinsic action or any power of its own. This is called the subsidence of the womb before labor comes on, and it is a sign of the approach of that crisis, which monthly nurses and experienced women are acquainted with— and which it is proper that the Student should also be able to appre- ciate. LABOR. 279 523. Discharges from the Genitalia.—As labor approaches, the secretions of the vagina and os uteri become augmented. They grow more viscid, and are often of a pink or even red color. In some cases there is a clear show of blood. The labia externa seem to be swollen or succulent with the increased circulation in their capillaries, and the mucous lining of the vulva retains its moistness notwith- standing the augmented vascular activity. They do not become harder, but, on the contrary, softer and more ductile: which prepares them well to yield to the distending force by which they are soon to open a way for the transit of the child. 524. Labor Pains.—The contractions of the womb take place at intervals which are longer at the beginning, and shorter as the labor advances. They last from fifteen to thirty or forty seconds, and, on many occasions, even longer. The intervals, at first, are from twelve to thirty minutes; but as the irritation becomes more intense, the pains are repeated every five, three, and two minutes, and even every minute; increasing in violence and duration until the organ is freed from its load. As to the duration and number of the pains, I said a little while ago that the average duration of a labor has been stated to be four hours. If this computation is a correct one, then it may be said that in the first hour the woman shall have a pain every twelve minutes, which would give five pains for the first hour. If she should, in the second hour, have a pain every six minutes, she would have ten pains in the second hour; pains in every five minutes in the third hour would amount to twelve pains; and if she should be affected with them every three minutes during the fourth and last hour, she would suffer the pains twenty times in that period. So that twenty, twelve, ten, and five pains would make up the sum of forty-seven pains for the labor. The whole duration of the whole of the labor pains, supposing each one to last only forty seconds, would, under this computation, be about fifteen minutes; so that, in a labor of four hours, the woman would be fifteen minutes under labor-throes, and more than three hours and a half without them. It is to be understood, how- ever, that much pain and distress may be sometimes experienced not- withstanding the womb is not actually contracting, or during the in- tervals ; though, generally speaking, the woman is comfortable except when under the power of the pains. This calculation refers, there- fore, only to the state a woman is in when under the influence of a labor pain, and not to the other causes of distress, from pressure, distension, and the distension of the textures in the pelvis. 525. There is a very singular passage in Saccombe's "Elemens de la 280 LABOR. Science des Accouchemens," p. 202. I was much tempted to trans- late the whole story as he relates it, not only as a case excellently cal- culated to give instruction to the young, but quite as much so to show forth the impudence and audacity of that singular and talented author. The case in question is the history of a labor which he had charge of, and which he observed, from beginning to end, without in the least interfering with the operations of nature. He was alone in the cham- ber with the young woman. "En cet etat des choses, je me suis mis en embuscade, l'ceil au guet, et bien resolu d'abandonner entierement la patient a la nature, comme si elle eut 6t6 seule au sein d'un bois. La, le compas dans l'ceil, la montre d'une main et le crayon de l'autre, voici le spectacle vraiment ravissant dont je fus temoins." M. Sac- combe goes on to say that, from ten o'clock exactly, to eleven A. M., the woman in labor had seven pains, which became greater and greater in succession, and followed each other in the order here expressed. From the 1st to the 2d pain 2d ' 3d 3d " 4th 4th ' 5th 5th < 6th 6th < 7 th Interval of Duration of pain 15 minutes 21 seconds. 14 " 27 it 10 " 27 (i 8 29 ii 7 ■ 32 ii 6 35 ii From eleven to twelve o'clock she had twelve pains, increasing pro- gressively and recurring as follows:— From the 7th to the 8tb pain 8th it 9th 9th ci 10th 10th ii 11th 11th ii 12th 12th ii 13th 13th it 14th 14th u 15th 15th ti 16th 16th K 17th 17th ii 18th 18th it 19th 6 minutes 36 seconds 6 40 ii 6 42 u 5 " 45 u 5 " 45 ti 5 47 u 5 " 49 it 5 55 ti 4 " 62 ii 4 " 70 u 4 " 87 u 4 " 93 u As the clock struck twelve, the waters of the amnios gushed forth, and, he says, "me baignerent de la tete aux pieds." At the 20th pain, the head passed the inferior strait. With the 21st pain the head was born. After a rest of five minutes, the 22d pain carried LABOR. 281 the right shoulder to the sacrum and the left to the pubis, and the 23d pain expelled the child; five minutes after which the placenta was thrust forth from the organs. 526. The pain felt in labor is owing to the sensibility of the resisting, and not to that of the expelling organs. Thus the sharp, agonizing, and dispiriting pains of the commencement of the process, which are called grinders, or grinding pains, are surely caused by the stretching of the parts that compose the cervix and os uteri and upper end of the vagina. Pains are rarely felt in the fundus and body of the organ; and nineteen out of twenty women, if asked where the pain is, will reply that it is at the lower part of the abdomen, and in the back— indicating, with their hands, a situation corresponding to the brim of the pelvis, and not higher than that—a point opposite to the plane of the os uteri. When the pains of dilatation are completed, and the fcetal presentation begins to press open the lower part of the vagina, the pain will, of course, be felt there, and is finally referred to the sacral region, the lower end of the rectum, and perineum. The last pains, which push out the perineum and put the labia on the stretch, will of course be felt in those parts chiefly. The sensation, under these circumstances, is represented as absolutely indescribable, and certainly as comparable to no other pain. The eff'ect of the pains on the bladder and rectum might easily be foreseen; but, even where they fail to excite the sympathetic action of those parts, the descent of the fcetal head, which sometimes fills up the pelvic canal as a cylinder is filled by its piston, must cause the evacuation of the entire contents of the lower rectum and bladder of urine. 527. The effects produced by the pains and efforts of labor upon the constitution are very striking. The woman is in the beginning anxious, irritable, and full of the most gloomy anticipations; but as the process goes on, and the expulsive efforts become more and more violent, she acquires courage and firmness and the most dogged resolution: the patient seems like one who has a task set which she is resolved to execute as rapidly as possible; and she therefore bears the great pains of expulsion far more submissively, or courageously, than the small or dilating pains. The actions of the woman indicate pretty clearly to the practised eye, the state of advancement of the process. Previously to the exit of the head from the os uteri, or its deep insertion into that circle, the voluntary efforts of the patient are confined to a violent grasping of things with her hands. She generally seizes the hand of a bystander, and squeezes it violently or endeavors to twist or wring it, not pull it. Such an action always indicates a grinder, or a pain of dilatation; but when an expulsive effort takes place, she not only 19 282 LABOR. grasps with all her force, but she p u 11 s at anything in her reach; so that an experienced accoucheur generally can decide, upon entering the chamber during a pain, that the dilation is or is not completed, by observing whether the patient merely squeezes or presses the hands of her assistants, or, on the contrary, whether she pulls them with great violence. The low position or situation of the presentation at length brings on a tenesmus or bearing-down sensation, which is a desire 10 thrust with all the forces of the abdominal muscles, whatever exists within the pelvis, beyond the limits of the body. Tenesmus is, in the beginning, controllable by the will, but when it has become exagge- rated by the presence of the presenting part in the ostium vaginas, no exhortation or fear is capable of inducing the woman to refrain from making the tenesmic effort, in certain cases; sometimes, however, the patient may be aroused from the all-absorbing tenesmic sense, and made to heed the urgent appeals of the surgeon to desist from efforts that endanger her. The urine and stool are generally expelled pretty soon after the commencement of the tenesmic pains of labor; but in some patients, the first signs of labor coincide with a disposition to go to the close stool. In addition to the signs derived from the woman's volun- tary actions, the practitioner can frequently decide upon the degree of forwardness of the labor, by attending to the nature of his patient's expressions and moans, and to her respiration : in the early stages, during the dilating pains, she either gives out her breath freely, with voice, or merely holds it, making use of no straining or bearing- down effort; and even if she be here requested to strain or bear down, as at stool, she will resist, or cannot obey the injunction. 528. Women cannot bear down, at the very beginning of labor. Bearing-down means an eff'ort to expel, by contracting the muscles of the belly; but when the womb is full, its fundus at the scrobicle, and the os at the plane of the strait, the recti muscles cannot expel, they can only hold or compress it: the same is true of the oblique and transversalis muscles. When, however, the fundus has descended low in the abdomen, having followed the os uteri, which has, by this time, been pressed down to the bottom of the excavation, then the abdo- minal muscles can exert a vast expulsive energy. So that, when the os uteri is nearly or quite opened, and the real expulsive pains begin,- the woman not only holds her breath, but makes use of the muscles of respiration, to fix the thorax firmly, and then, in the most forcible manner, contracts the muscles of the abdomen upon the womb. If she be now enjoined to desist from bearing down, and fails to obey the injunction, it is because the tenesmus "of labor, like that of dysentery, is irrepressible. The muscles that she employs in bearing down, after LABOR. 283 she has fixed the diaphragm and other muscles belonging to respira- tion, are the rectus abdominis, the external and internal obliqui, and the transversalis. Is it not clear that, while the fundus uteri is high up in the abdomen, the violent contraction of these muscles would have little effect in forcing the uterus downwards, but would rather compress the womb against the back part of the abdomen; while on the other hand, when the uterine globe has sunk low down in the belly, the operation of these abdominal muscles, as agents of expulsion, must become very great and cogent? I have ever found it useless to urge a woman to bear down upon a grinding pain, and always feel it incum- bent upon me to cause the nurses and bystanders to desist from v exhorting the patient to bear down in the early stages of labor; an exhortation which they very kindly, but very untimely, never fail to make. Such voluntary efforts cannot be beneficial in their influence on the labor, and may even become pernicious, in certain circumstances, where they not only tend to disorder the sanguine circulation, but very much to exhaust the strength. 529. I have placed here a cut, Fig. 76, which shows the state to which the cervix uteri must come before the full efficacy of the trueexpulsive, or bearing- Fig. 76. down pains can become manifest. This is a cross section of the pelvis, with the womb and a part of the already dilated vagina. It seems that the cervix uteri has become almost cylindrical, from being a cone, as it was be- fore labor began. The bag of waters is seen bulging out from the fully dilated orifice. The waters are nearly ready to give way— and, in fact, there are many labors in which, as soon as the crevasse in the membranes takes place, the child's head rushes rapidly through the orifice, and descends to the very bottom of the excavation, or is even expelled by the same single pain. 530. Constitutional Effects of the Pains.—Even leaving out of the question the exciting effects of the pangs and agonies of travail, we should naturally expect that the muscular exertions of the parturient subject would, as in any violent exercise, greatly accelerate the circu- lation of the blood, and augment its momentum; and we accordingly find the pulse to become more and more elevated as the efforts prove to be greater and greater. The heart beats with increased violence, and the pulsations amount to one hundred and upwards in the minute; 284 LABOR. even one hundred and twenty beats are not uncommon, as in a person running very fast. The respiration becomes hurried in proportion, and of course the heat ofthe body tends to be developed pari passu with the augmentation of the circulation and respiration; so that fever would soon become intense, were it not that the most profuse dia- phoresis, chiefly from the upper part of the body and head, comes on to prevent the occurrence of what would, otherwise, become a dangerous fever, and in a few instances does become so. I have already taken occasion to remark upon this excited state of the vascular system, that it is not to be deprecated except in those instances in which it goes beyond the just bounds: it is, however, always worthy of close observation, in order that any tendency to excess may be checked, by a free use of cooling drinks; by ventila- tion; by lightening the bedclothes; by making the patient comforta- ble in her bed—appeasing her anxiety of mind by assurances of care and protection, by removing wet sheets and heated pillows; by an enema or purge; and, lastly and chiefly, by the use of the lancet. 531. The state of the mind is worthy of a large share of the ac- coucheur's regard. The most cheering and satisfactory assurances that the state and prospects of the labor will admit of, should be given, with a due observance of the truth. A woman will be more comforted and composed by being made certain that she shall be delivered in six hours, than by a promise which she does not fully believe, that half an hour more shall put a period to her anguish. No promises should be made, that may not be implicitly relied upon by the physician him- self, as well as by the patient. One of the golden verses of Pythagoras says, y detaining portions of blood. A complete, clean delivery ought always to be effected, if possible. If the woman finds, the next day, that portions of membrane are hanging out ofthe vulva, she becomes alarmed, or at least thinks her medical man careless or ignorant. Notwithstanding that the placenta may be carefully rolled as above directed, we sometimes find that where the membranes have been very much broken by the child, or where they are extremely delicate, the cord or rope we have formed by twisting them is break- ing, so that a considerable remnant of them is about to be left in the uterus, which we cannot get possession of without passing up the hand at least into the vagina. My custom, when I find the mem- branes breaking, is to cease pulling until I have wrapped round my rope of membranes a small rag, which enables me to spin them still more, and thus draw them entirely away: they are so slippery that 324 CONDUCT OF A LABOR. the rope cannot be twisted with the fingers, but when a dry rag is wrapped round them, we can twine them, and pull them as much as we may think needful. Unhappily, the placenta does not always come away so soon; we may wait half an hour or an hour, for the expul- sion of the after-birth, and yet upon examination, repeated from time to time, discover that it has not come within reach of the fingers. Frictions upon the abdomen powerfully excite the peristaltic fibres of the alimentary canal, but their effects upon the womb are far more de- cided ; it may be said, that when made upon the hypogastrium, they generally compel the womb to recommence its contraction—some wombs are so excitable, that a touch brings on the after-pains; fric- tions ought, therefore, to be instituted. The consent of parts also, causes the womb to act as soon as the woman makes a strong bearing- down effort, to which she should be urgently prompted, if needful. When a contraction has been procured by frictions, or in any other way, it may be rendered permanent by pressure; therefore, let an as- sistant be properly taught to apply the palm of the hand over the uterine globe, and not take it off until told to do so. Such assistant, however, ought to be one worthy of the trust; an ignorant one might, by pressing at an inconvenient moment, indent the soft and relaxed fundus uteri, and cause the beginning of an inversion of the organ. I have no doubt that some of the cases of inversion recited in the books were brought about in this way. In all those patients who habitually flood in labor, these precautions ought to be observed. When the hand is removed, a bandage should be ready to occupy its place. If the os uteri be very much closed, it is probable that the placenta will require a long time to come away ; and I know no ob- jection to a patient waiting for the spontaneous movement of the organ, where no hemorrhage, or other unusual appearance, is observed. Some writers have been disposed to assign a fixed period, up to which the accoucheur ought to wait, before he resorts to compulsory measures for the delivery. But there can be. or ought to be, no fixed rule on the subject except this one rule, namely, the placenta must be got away, as there is no security while it is left. I have never gone away from a patient leaving the placenta undelivered; never. I think I have never waited for its spontaneous extrusion more than an hour and a half, for I have always supposed that if it would not take place in one hour, there was little prospect of its taking place in twenty- four hours. I cheerfully admit, however, that cases may and do oc- cur, in which a longer delay might be advisable. I have not met with such cases. I wish to be understood as speaking, in this place, of the placenta retained in utero, and not of cases where it is partly ex- CONDUCT OF A LABOR. 325 pelled into the vagina; for, when in the vagina, I think there can be no necessity for waiting at all; it ought to be removed at once. Ruysch, the celebrated Dutch anatomist, zealously inculcated the doctrine, that as the expulsion of the placenta is a natural office, it ought not to be interfered with except upon the occurrence of symptoms making such intervention indispensable; and his authority having been deemed unquestionable, was yielded to by several physicians of eminence, who nevertheless found, after losing not a few patients from hemorrhage, inflammation, &c, that experience is the best teacher; and they there- fore reverted to the custom of securing the expulsion of the secun- dines by artificial measures, wherever the powers of nature were in- competent to that end. 603. Hour-glass Contraction, or Adherent Placenta.—As to placenta retained by what is called hour-glass contraction, I am con- fident in asserting that it is always an adherent one. Where the connection of the placenta to the uterine surface has, by force of some certain inflammatory action, become preternaturally firm, the substance of the placenta acts as an antagonist to the contraction of that part of the uterus on which it sits—in fact, the placenta may be said to splint the womb, and keep its superficies extended. Now, when all the parts of the womb-fibres, except those of the placento- uterine region, are left without antagonism, they contract as usual, but the antagonized portion remains extended and splinted by the after- birth, so as to be incapable of contracting like the rest, which, by their contraction, shut the placenta up in a cell or cavity, which is the upper cavity of the before-mentioned hour-glass. I have never seen an hour-glass contraction without adherence of the after-birth; and I take it for granted, that, as soon as an hour-glass contraction is discovered, there is at the same time discerned the indication to deliver, there being no reasonable hope that a spontaneous delivery will ever take place. I freely, therefore, advise the reader to deliver at once in all cases where an hour-glass contraction can be clearly made out. The operation, which may be performed so as to give no great pain, requires explanation of the necessity for it, and assurances of great carefulness and tenderness in the performance. Half the hand should be insinuated into the ostium vaginas as far as the thumb, which, being next buried in the palm, permits us to get the whole hand within the pelvis. From thence, either the whole hand, or half the hand, or sometimes the index finger alone, may be made to enter the cavity of the womb to detach and seize upon the placenta, which, when fairly severed of its unnatural connection to the uterine wall, may be removed by the hand, 326 CONDUCT OF A LABOR. or left to be expelled by the contractility of the organ. It is a safe and proper conduct, however, to bring it away in withdrawing the hand, so as to let the uterus contract as much and as soon as possible. (698). 604. A placenta may weigh from a pound to a pound and a half. Let the Student reflect that such a mass, if within the uterine cavity, must distend it considerably; and if he cannot touch it by passing the finger up to the os tineas, the fundus of the womb must, of course, be high up within the abdomen. Therefore, in any case of retained pla- centa, he will find the fundus fully as high up as the navel. It will require, then, in order to get it, that the hand should be introduced: the finger cannot reach far enough. From the dilated state of the vulva and vagina, after delivery, no difficulty stands in the way ofthe introduction of the hand into those parts. As it passes up, it is guided by the forefinger, gliding along the cord while that is tightened by the other hand. The accoucheur must expect to find instances in which the os and cervix uteri actually gripe the cord; so that he is necessitated to introduce only one finger at first, then a second, and a third, which gradually conquer the resistance of the circular fibres of the os and cervix uteri, so as to make way for the whole hand, which at length is found to have entered into the cavity of the womb. But the pressure required in this operation has put the vagina, even the womb itself, on the stretch; so that were he not to resist its rise by pressing the abdomen with the other hand, the fundus would be pushed up to the scrobiculus cordis, and his arm pass inwards as far as the elbow. He ought not to allow any help, but with his own left hand on the fundus, force the womb downwards, towards his right hand. Let the operator always stop the womb from rising, by counter- acting it with one hand placed over the top of the fundus to push it downwards towards the hand which is within. 605. When the last portions of the child quit the uterine cavity, expelled by the muscles of the organ, it generally happens that the placenta is completely detached from the uterine wall by that same contraction. This, however, is far from being always the case. When the womb fails to displace the placenta by force of the last expulsive effort, it does not follow that we are to expect an hour-glass con- traction. On the contrary, the hour-glass is a rare event, while the continued normal adherence, total or partial, is a common one, a partial being more common than a total adherence. Yet it is probably true that an hour-glass would ultimately shut the placenta in its upper cell, in all cases where the placenta should fail to quit the surface after a few contractions. If, in such a case, there be no flooding or other symptoms indicating our intervention, we ought to wait for one CONDUCT OF A LABOR. '327 hour at least. It is not wise to wait longer, and my multiplied experiences teach me that it is not rash then to proceed to the delivery of the secundines. The cord furnishes a most convenient means of pulling out the placenta, which should never be used for that purpose without careful reflection on all the circumstances. If the after-birth is still attached, and the uterus firm, to pull at the cord is to endanger the breaking it off even with the surface, which is an embarrassing and rather disgraceful accident; but if the womb be not firmly con- tracted, it might be so flaccid as to be turned inside out, like a wet bladder. I have seen a womb that was turned inside out by a midwife in this way, a case of great interest, that will form the subject of a future page (701). To any individual who has seen one at full term, nothing would seem easier than to invert a relaxed uterus. Wherefore, no man of discretion ought to draw by the umbilical cord, without having first ascertained that the womb is well contracted; and even then, the force he may venture to employ by its means is an exceedingly limited one. 606. Womb after Delivery.—When the placenta is delivered a hand should be placed on the patient's hypogastrium, for the purpose of ascertaining whether the uterine globe is firm. If one forgets to do this, he will incur the hazard of leaving his patient with an inverted womb: this lately happened here to a friend of mine, who did not discover the accident until five weeks after the event. The woman suff'ered the greatest distress, and the greatest weakness from loss of blood, but recovered at last. The uterus ought, to feel through the integuments, about as large as the fist; but there is great diversity in regard to the magnitude of the organ immediately subsequent to delivery. The smaller it is, the better for the patient, who, with a well contracted uterine globe, may be pronounced beyond the reach of danger from effusions of blood. In feeling for the globe of the womb, whether before or after the delivery of the placenta, we should always endeavor to ascertain that the fundus has not fallen in making a deep concavity like that in the bottom of a junk bottle; such an indenta- tion is the first beginnings of inversion of the womb, and it may readily be detected where the belly is loose, thin, and flabby. If, in any case, such an indentation should be discovered, the rule of prac- tice ought to be to introduce the hand and take the placenta bodily away, or pushing the incipient inversion of the fundus back to its place, forbid the woman to make even the least expulsive effort. After the extraction of the after-birth, great care should be invariably used to make sure that the proper pyriform shape of the organ is preserved. 328" CONDUCT OF A LABOR. 607. After-pains.—The pains which women suffer, whether before or after delivery, depend upon one and the same cause, namely, the muscular action of the womb. The organ, after delivery, grows alter- nately small and large for some hours; expanding to double the size of the fist when the pains are off, and reducing itself to the smallest size when they return. Every interval, or period of expansion, permits a small quantity of blood to accumulate in the cavity, which is forced out by the returning pains. The woman feels the gush of warm fluid issuing from the vulva, and is apt to say that she is flood- ing or flowing. An inspection of the countenance and an examina- tion of the pulse are perhaps sufficient to indicate the course of the practitioner. If the face is not pale, and the pulse not weak or small, he will feel sure she is not bleeding too freely; but if they indicate the existence of too considerable a discharge, the amount of it ought to be ascertained with precision. There are few nurses who are com- petent to decide upon the case; as whether it amounts to what might be denominated hemorrhage or not. Case.—I was called in haste to attend a woman whom I found just delivered of a child; I received the after-birth, which came off spon- taneously, and observed that the sanguine discharge was very great, but the woman, although feeble, was not sunken. The uterus con- tracted well, and I left her in a comfortable and usual state. In about two hours I was summoned again, and found her very faint, with extremely feeble, slow pulse. Placing one hand upon the hypo- gastrium, I found the womb not dilated, and then inquired of the nurse as to the amount of the lochia. She assured me that it was not greater than it should be. She had examined carefully into the circumstances, and found all right. Distrusting her account, I determined to learn for myself whether a large effusion had taken place, and found an immense quantity of coagula lying upon the bed, which the nurse had either not seen at all, or disregarded. This case, which many years ago caused me great trouble and anxiety, has influenced me ever since, and now I always feel un- willing to take information at second hand upon the important subject of profuse uterine discharges. I think it the duty of the Student early to resolve to learn accurately whatever may have an injurious or dangerous tendency for the patient committed to his charge. It may be stated as an axiom in obstetrics, which has almost no exception, that a well-contracted uterus cannot bleed; and all obstetricians habitually feel secure when they find the organ hard CONDUCT OF A LABOR. 329 and small. Nevertheless, the state of contraction may speedily be followed by so absolute a relaxation of the contractile fibres of the uterus, that the gentlest infusion of blood into its cavity shall distend it again, if that fluid be prevented from escaping at the os tineas or at the vulva;—but if a coagulum should fill the vagina, or stop the mouth of the womb; or if the napkin should be too strictly pressed against the genital fissure, preventing the escape of fluid therefrom, the blood which flows into the womb will gradually distend it to that degree, that without losing a spoonful externally, the woman may effuse enough blood into the uterine cavity to expand it so as to cause fatal syncope. 608. Case.—I was called, about three years ago, into the country, to assist a practitioner in a difficult labor. When I arrived, the child had just been delivered with forceps. The placenta was adherent. After waiting some time for its spontaneous extrusion, I removed it, and the womb contracted well. In the course of half an hour, my attention was attracted by a sort of gurgling sound from the bed, which caused me to draw near the woman, whom I found already quite fainted away when I approached her. She was very pale, and the pulse could not be felt at the wrist. The discharge was incon- siderable ; but on placing the hand on the hypogastrium, the womb was found enormously distended, and full of blood. Two fingers were now carried into the os uteri, which was completely tamponed with a very firm clot. This I broke up and brought away, when out rushed a large quantity of grumes, mixed with fluid blood, whereupon the womb returned to its proper dimensions. She had no return of the symptoms. I could cite many examples from my case-book, of vio- lent hemorrhages, both concealed and open, which have fallen under my notice in females where the uterus had contracted perfectly well after the delivery of the placenta. One case is so remarkable that I cannot resist the inclination to publish it here. 609. Case.—Mrs. S. was delivered of her first child after an easy labor. She had a very good getting up, and on the fifteenth day walked down stairs. Some words of an unpleasant character passed between her and her husband. She became violently excited with anger; then burst into tears, and ran up stairs, where she threw herself on the bed. She was shortly afterwards found in an apparently dying state. When I reached the house, there was no pulse—great coldness, and the greatest degree of paleness. I found the womb filled with blood, and reaching above the umbilicus. Dr. Dewees was so kind as to visit 22 330 CONDUCT OF A LABOR. this patient with me, and assist me with his valuable, counsel. She recovered, but suff'ered a long time under the symptoms produced by this excessive sanguine discharge. This case will show the Student that even where the uterus has contracted so much as to sink down below the superior strait, it may be afterwards enormously distended by influent blood; and the reflection arising from it, though an uu- pleasant one, is a very just one, that, even where we succeed in getting a good contraction, we can have no sense of absolute security against concealed or open hemorrhage, in a patient whom we may have put to bed ever so comfortable or apparently safe: therefore it is our duty always to remain within call for at least one hour after the delivery. If a whole hour passes without any such accident we may feel quite at liberty to go away. I advise every student to mark and observe this as a rule of conduct. I have observed it for half a century. 610. The influence of position in determining the momentum of blood in the vessels is well known to the profession; but there are few cases wherein it is of more consequence to pay a profound regard to this influence, than in parturient women. (581.) A uterus may be a good deal relaxed or atonic, and yet not bleed if the woman lie still, with the head low; whereas, upon sitting up suddenly, such is the rush of blood down the column of the aorta, the iliacs, the hypogastrics, and the uterine and spermatic arteries, that the resistance afforded by a feeble contraction is instantly overthrown, and volumes of blood escape into the womb and vagina with almost unrestrained impetuosity. The vessels of the brain under such circumstances become rapidly drained, and the patient falls back in a state of syncope, which now and then proves immediately fatal. I may be excused for stating here that I have never met with but one of these sudden and fatal hemorrhages in my own practice. It is, perhaps, due to the special attention I have always considered it a duty to pay to this point, that I have hitherto avoided so serious a misfortune. Surely, I have, in a multitude of persons, by a prompt attention to the state of the womb, put aside the stroke of death by proceeding without delay to empty the organ by turning out with my fingers the masses of coagula with which it was filled. If you leave your patient soon after her deliverance, and are hastily recalled to see her with an announcement perhaps that she is dying* y°ur nrst duty on reaching her bedside is to examine the hypogaster to ascertain if the uterus be firmly contracted or not, and, if you find that the uterine globe is not too large, too much distended or expanded, then do not rest satisfied until by a vaginal examination you shall have learned that there is or is not a clot-tampon in the vagina. CONDUCT OF A LABOR. 331 611. Case.—In conversation with my late venerable friend Profes- sor James, upon this very subject, he informed me that he delivered a lady a few years before, after an easy natural labor. The uterus con- tracted well, and all things seemed as favorable as possible. As the accouchement took place early in the morning, he was, subsequent to the event, invited to breakfast down stairs, whither he proceeded, after having given strict caution to the lady on the subject of getting up. While the persons at breakfast were conversing cheerfully, and ex- changing felicitations upon the fortunate issue of affairs in the lying- in room, the nurse was heard screaming from the top of the stairs, ''Doctor, doctor, for God's sake come up!" He hastened to the apart- ment, and the lady was lying across the bed quite dead. It was found that, soon after the doctor went below, the lady said to the nurse, "I want to get up." "But you must not get up, madam; the doctor gave a very strict charge against it," replied the nurse. "I do not care what the doctor says," rejoined the patient; and thereupon arose, and throwing her feet out of the bed. she sat on the side a few moments, reeled, and fell back in a fatal fainting fit. The remarks of Dr. James, as he related the occurrence to me, made upon my mind a deep im- pression of the vast consequence of careful and well-timed instruction of the nurses; who, if they could have the dangers of mismanagement fully exposed to them, would surely avoid some accidents that every now and then are attended with shocking results. Though large dis- charges are not apt to occur when the womb has once contracted pretty firmly—there are precautions which ought always to be observed : for example:— 612. Case.—I left a woman half an hour after the birth of her child. She was as well as could be desired. I gave the usual directions. In a short time her husband came running to me, in the street, where he met me, and said his wife was dying. Upon hastening to his house, I found her, in fact, pulseless, pale, and completely delirious, with a con- stant mutteriug of incoherent phrases. Upon inquiry, the following occurrences were found to have taken place. She felt some desire to pass the urine. The nurse told her to get up. "But the doctor says I must not get up." "Oh, never mind what the doctor says; it won't hurt you;, get up." A chamber-pot was placed in the bed, and Mrs. F. was lifted upon it, in a sitting posture. She fainted in the woman's arms, was held up a short while, and when laid down, the vessel was discovered to be half full of blood. She had nearly died; and did suffer long and severely in consequence of this imprudent disregard of orders. When I left her, the uterus was well contracted; but the 332 CONDUCT OF A LABOR. change of momentum in the arterial columns produced the hemorrhage, than which I have scarcely seen one more dangerous. 613. Case.—It is of the highest consequence to secure a firm con- traction of the womb after delivery, in all those women who have before suffered severely from flooding soon after the birth of the child, A lady in three successive labors, of which the first occurred on the 30th of December, 1819, and the last on the 28th of September, 1824, which were rapid and easy, was brought almost to the gates of death by enormous discharges, which commenced about five minutes after the birth of the foetus. I saw her lie pulseless, and as near as possible to dissolution in those labors. In two subsequent confinements, she took one scruple of ergot, just as the fcetal head began to emerge. This was given to her, not for the purpose of aiding in the expulsion of the child, or placenta, which had never occasioned any embarrass- ment in antecedent labors; but to save her from those dangerous losses, by constringing the womb permanently; and I am pleased to say that, in both instances, she experienced none beyond the ordinary amount of effusion. I could cite numerous examples of similar re- sults. I scarcely ever omit such a precaution for any patient, of whom I am informed that she floods after delivery. 614. Sitting up too Soon.—As regards the danger of sitting up soon after delivery, there are some important suggestions for the Stu- dent that ought not to be here omitted. Certain women are met with who pass through the conflict of parturition unscathed, and who are quite as competent to the performance of their daily toil on the following day as the Chief's wife who so much excited the astonishment of Hearne on his Northern Journey. I have found that many of my patients, and some in the class of what are called the " upper ten thousand," were completely destitute of all symptoms of indisposition as the halest Potawattomie or Ottowa woman. Such people might get up ; and I have seen very elegant women get up and "be about" on the third day without pretence of after indisposition. Still, it is a safe rule to advise the keeping of the bed for many days, since to leave the bed is to go forth a la chasse for some malady. Hemorrhages, chill, prolapsions, and an evil train attend those imprudent women who leave the lying- in couch too early. A rest of nine days is a short rest after nine months of fatigue crowned by the exhausting conflict of a labor. 615. Heart-Clot.—It is well known that the coagulability of the blood becomes greater in proportion as any hemorrhage progresses— CONDUCT OF A LABOR. 333 therefore a woman who has lost during her labor forty or eighty ounces of blood has the rest of it more coagulable than it was before the flooding commenced. Again, fainting consists in the too little intensity of the pressure of the blood in the brain capillaries—it is encephalic anaemia—and a woman just gone through a flooding, ex- periences a sensation of faintness from lessened vascular tension of her encephalon. If she suddenly assume an erect position, the tension becomes instantly much lessened in consequence of the gravitation of the blood. But—and this is the danger—if she faint badly while her blood is become thin and highly coagulable from hemorrhage— the scarcely moving current nearly stops in the heart, and when she comes out of the deliquium, if ever, she sometimes does so with a clot in the auricle and ventricle—she has got a false polypus in the heart —and she will surely die. Many women have died soon, almost im- mediately after giving birth to the child, or speedily after the delivery of the placenta. Some of them have perished suddenly upon rising up in bed, within a day or two, or more, after a labor attended with hemorrhage, from which, however, they were then so far recovered as to give no apparent cause for anxiety about them. It used to be con- sidered as an unaccountable circumstance, that some women should suddenly expire, either soon after the birth of the child, or not long after the delivery of the secundines, or within a few days subsequent to their being layed. I had noticed, on various occasions, the total want of any means of explaining such disasters, and remained as much in the dark as my compeers, until I discovered that the incident depends, most commonly, on the sudden coagulation of the blood that occupies) for the time, the right auricle of the heart, and, in some of the cases, even that which is in the ventricle and the pulmonary artery. A per- son who should suddenly have these cavities filled with a strong, firm clot, could hardly be expected to survive the accident, and would perish with symptoms of asphyxia; for, to choke up the way of the blood either in the heart or in the pulmonary artery, would have nearly the same effect on the life, and give rise to nearly the same symptoms as would attend a ligation of the vena cava or the arteria pulmonalis. My first publication on this subject, and which I consider to have made the rationale extensively known in the United States, appeared in the "Medical Examiner," No. 51, for March, 1849, now thirteen years ago. Since that time, I have both seen and heard much of this sudden heart-clot, so that my views having been confirmed by my own obser- vation and that of other physicians, I shall seize the present occasion to explain them to the student. As the life of the blood is intimately connected with that of the vessels in which it circulates, it is reasonable 334 CONDUCT OF A LABOR. to infer that the health and vitality of the former should bear a certain ratio to those of the latter. It is beyond cavil, that the blood of an animal slowly bled to death becomes more and more coagulable as the hemorrhage proceeds, and that the last ounce that is extravasated will coagulate in a shorter time than the first ounce would. Hence the co- agulability of the blood remaining in the vessels after profuse hemor- rhage is considerably augmented, and sometimes to so great a degree, that care is to be taken to avoid bringingon a fainting fit, which increases the already dangerous tendency to heart-clot. Copious hemorrhages produce weakness not of the blood only, but of all the organisms, whose forces, indeed, depend on the crasis of the blood, forces which are lessened by the blood's weakness, while its strength is equally de- pendent on the living solids it inhabits. The blood is weak when the vessels are weak, strong when they are in tone, and dying when they are likewise dying. It draws its life from the living solid of the endangium, which is the only tissue to which it has any relation of contact. To withhold from the blood this vascular life-force, is to cause the blood to die by coagulation; for when the nervous mass no longer influences the blood through its endangium, it must die—its coagulation is its death. If a woman loses, by flooding, a very great quantity of blood, the vessels soon become as full as they were pre- vious to the accident, but the blood has become hydrasmical or watery, and incapable of taking up in the lungs, and delivering over to the body, a suitable sum of oxygen. Hence the propensity to faint after hemorrhages; and hence the danger of rising up from a recumbent position. If the patient have become ever so hydrasmical, and yet keep the head low, she will hardly faint, for, while she is down, the encephalon contains its full proportion of the watery blood, which, poor though it be, is still equal to the wants of the economy, if the woman but keeps her head as low, or lower than the trunk. But, if she rises up and sits, or stands on the feet, then the encephalon be- comes anasmical, and the lessened tension of the brain allows her to fall down in a fainting fit. In an ordinary state of health, a fainting fit may be brought on by various causes, as mental emotion, a sudden nausea, &c, and it is not a dangerous incident, because the blood is strong, and speedily restores the suspended innervations. But where the blood is so weak that it is necessary to keep the head as low as the trunk to avoid fainting, it is very dangerous to faint badly, because the blood, already excessively reduced in strength, and prone to coagu- lation, is likely to become concrete if it but come to a stop in the auricle. Let a woman, who has lost by flooding, say 150 ounces, bring on a bad fainting, by sitting or standing up, and she will seem CONDUCT OF A LABOR. 335 quite exanimate. All motion of the muscles is suspended. It is a question whether she is breathing or no, and the pulses of the heart have almost ceased, while the radial artery has wholly ceased to beat. If now, this dangerously coagulable blood continues to ooze rather than flow into the right ventricle to slowly fill it, lingering as if doubt- ful whether to move or rest, it may die there, in the heart, because the heart being scarcely alive and most of the vessels quite still, they are without nervous force to be inducted into the blood. The blood dies in the heart's auricle by coagulating there, just as it would in a cup or vase. If the woman in such a state should now be aroused by any means, the heart will recommence its pulsatory motion but cannot expel the clot that has been moulded by its cavity. The auricle, the ventricle and the pulmonary artery, filled with an immovable coagu- lum, which stops off the pulmonic circulation, causes the woman to experience what is called want of breath. She breathes, indeed, and breathes violently, with greater and still greater effort, but can get no oxygen out of the circumambient air, because the lesser circulation is cut off" by the clot, which acts as effectually as any ligature, and she must die. There is not, in the whole field of medical experience, a more pitiable sight than that presented by some of these heart-clot cases. The distress is truly inexpressible, and the gestures as well as the voice are fit to melt a heart of adamant. Those are to be esteemed the most fortunate in whom the clot, when it does come, is so great and strong as to preclude the possibility of any further movement of the heart, for such persons die on the spot; but in such as form a smaller clot, the efforts of the heart to dislodge or expel it from its cavities are terrible indeed; small quantities of blood only can be poured into the auricle, to pass onwards between the clot and the walls, into the pulmonary circulation. The diaphragm redoubles its exertion to pour over the scanty rill a copious flood of oxygen, which the hydrasmical stream can no longer take up and carry forwards, so that the tissues and the whole brain and cord are left in fatal destitu- tion of the life-giving reagent. Should an instance occur so threaten- ing as to lead to the greatest apprehensions of a fatal result, it may be still possible, by wise precautions, to indulge hopes of a recovery; which will depend upon the size of the clot formed during the state of fainting. A clot that should quite fill the whole cavities must pre- clude the possibility of any recovery; whereas, a smaller one would not prevent the blood of the cavae from entering into, and being ex- pelled from the heart, but with difficulty and imperfection depending on the magnitude of the clot. In the case of the Princess Charlotte, whose death within a few hours after the birth of the child cast a deep 336 CONDUCT OF A LABOR. gloom over the whole British empire, there is reason to believe that a clot in the heart brought her existence to an almost instant close. We have a clear relation of the circumstances attending that deplorable occurrence in a letter from one of the physicians who was summoned to Osborne House at the time of her lying-in; and I shall make use of the present opportunity to lay it before the Student, that he may consider whether or no her death should be accounted for by the supposition of a sudden heart-clot. Dr. Sims's letter to the late Dr. Joseph Clarke, of Dublin, was originally printed in a " Short Sketch of Dr. Clarke's Life," by his son-in-law, Dr. Robert Collins, Master of the Dublin Lying-in Hospital, and author of an important work on Midwifery. Dr. Collins says it is the only authentic account of the case that has been published. I copy the letter from Dr. Collins's short sketch, &c. The letter is as follows:— "London, November 15, 1817. 616. "My dear Sir: I do not wonder at'your wishing to have a correct statement of the labor of Her Royal Highness, Princess Char- lotte, the fatal issue of which has involved the whole nation in distress. You must excuse my being very concise, as I have been and am very much hurried. I take the opportunity of writing this in a lying-in chamber. "Her Royal Highness's labor commenced by the discharge of the liquor amnii about 7 o'clock on Monday evening, and pains followed soon after; they continued through the night and a great part of the next day, sharp, short, but very ineffectual. Towards the evening, Sir Richard Croft began to suspect that the labor might not terminate without artificial assistance, and a message was dispatched for me. I arrived at 2 on Wednesday morning. The labor was now advancing more favorably, and both Dr. Baillie and myself concurred in the opinion that it would not be advisable to inform Her Royal Highness of my arrival. From this time to the end of the labor, the progress was uniform, though very slow, the patient in good spirits, pulse calm, and there never was room to entertain a question about the use of instruments. About six in the afternoon, the discharges became of a green color, which led to a suspicion that the child might be dead; still, the giving assistance was quite out of the question, as the pains now became more effectual, and the labor proceeded regularly, though slowly. The child was born, without artificial assistance, at 9 o'clock in the evening. Attempts were for a good while made to reanimate it by inflating the lungs, friction, hot bath, &c, but without eff'ect; the heart could not be made to beat even once. Soon after the delivery, Sir Richard Croft discovered that the uterus was contracted in the CONDUCT OF A LABOR. 337 middle, in the hour-glass form, and, as some hemorrhage commenced, it was agreed that the placenta should be brought away by introduc- ing the hand. This was done about half an hour after the delivery of the child, with more ease and less loss of blood than usual. Her Royal Highness continued well for about two hours; she then complained of being sick at stomach, and of noise in her ears; began to be talkative, and her pulse became frequent, but I understand she was very quiet after this, and her pulse calm. About half past 12 o'clock, she com- plained of severe pain at her chest, became extremely restless, with a rapid, irregular, and weak pulse. At this time I saw her for the first time, and saw immediately that she must die. It has been said we were all gone to bed, but that is not a fact. Dr. Croft did not leave the room, Dr. Baillie retired about eleven, and I went to my bedchamber and laid down in my clothes at twelve. By dissection, some bloody fluid (two ounces) was found in the pericardium, supposed to be thrown out in articulo mortis. The brain and other organs all sound except the right ovarium, which was distended into a cyst, the size of a hen's egg; the hour-glass contraction of the uterus still visible; a consider- able quantity of blood in the cavity of the uterus; but those present differ about the quantity, so much as from 12 ounces to a pound and a half; the uterus extending as high as the navel. The cause of Her Royal Highness's death is certainly somewhat obscure; the symptoms were such as attend death from hemorrhage, but the loss of blood did not appear to be sufficient to account for a fatal issue. It is possible that the effusion into the pericardium took place earlier than what was supposed, and it does not seem to me to be quite certain that this might not be the cause. As far as I can judge, the labor could not have been better managed. That I did not see Her Royal Highness more early was awkward; and it would have been better that I should have been introduced before the labor was expected; and it should have been understood that, when the labor came on, I should be sent to, without waiting to know whether a consultation was necessary or not. I thought so at the time, but I could not propose such an arrangement to Croft. But this is entirely entre nous. " I am glad to hear that your son is well, and, with all my family, wish to be remembered to him; we were happy to hear that he was agreeably married. " I remain, my dear Doctor, "Ever yours, most truly, "JNO. SIMS. " P. S. This letter is confidential, as, perhaps, I might be blamed for writing any particulars without the permission of Prince Leopold." 338 CONDUCT OF A LABOR. 617. I believe that few persons die with scarlet-fever, or smallpox, or consumption, who are not hurried to the grave by means of coagula formed in the heart, late in the progress of the cases, in consequence of the debilitation or lessening of that inducted-life that passes from the vessel to the living blood. I have many times, in the closing scenes of pulmonary consumption, and other lingering, and some acute maladies, perceived, from the running and fluttering pulse, and the augmented respiratory distress, that the last fatal blow was struck by the formation of a heart-clot of greater or less size. But these coagu- lations, that ordinarily take place in the last days of lingering chro- nical disorders, are different from the sudden and blasting power of the same accident in our midwifery practice. I cannot doubt that the lady whose case I have related as having been under Dr. James's care, must have died from the coagulation of the blood in her heart. A mere deliquium is recovered from very soon after the body is placed in a horizontal posture. I should think that*a fainting fit could hardly prove fatal per se; but, if a heart-clot should be formed during the deliquium, it seems unlikely that the blood could again move in its circle. No examination was made of the dead body of Dr. James's patient. No one knew anything of sudden heart-clot. She did not die with hemorrhage. What was it that destroyed her life? what could have destroyed it so suddenly save a deliquium, during which the heart filled with a solid clot, that precluded the possibility of re- establishing the circulation, the oxygenation, and the innervation of the unfortunate lady? Bichat has taught us the important truth, that man cannot die save by the cessation of life or power in the lungs, or in the heart, or in the brain. By lungs, he means oxygenation of the living mass. By heart, he means the sanguine circulation; and by brain, he means the nervous mass, particularly the nervous mass of the medulla oblongata, in which essentially resides the innervative force of the respiration, and so, the oxygenating force. Man must, therefore, die by the brain, the heart, or the lungs. It is to the last degree improbable that Dr. James's patient died solely because her brain ceased to evolve nervous force; but, if it did not wholly cease to do so, it must have continued to be the cause of some motion, every- where within. But if, as I,suppose, the heart became instantly filled with an immovable clot, so that it could no longer receive nor dis- charge any blood, the nervous mass would die as soon as the last remaining atoms of oxygen in its capillaries should have become exhausted: for the function of the capillaries is to take the oxygen out of the blood, which is thus converted into venous or black blood. Dr. James's patient died by the heart, as do all those who have the CONDUCT OF A LABOR. 339 misfortune to form a heart-clot of considerable size. I have had the unhappiness to witness several fatal terminations of puerperal eclamp- sia. In the paroxysms of this sort of convulsion, the patient's face ordinarily grows darker and darker, and the tongue and lips blacker and blacker, as the paroxysm goes on, until the pulse almost ceases to be felt; the respiration becomes nearly suspended, and at last the patient lies still. This scene, at the greatest height of the struggle betwixt life and death, is one of almost complete asphyxiation; the innervations have become so reduced that the physician is led to look with an anxious eye to see whether or not life has become wholly extinct. If death does not supervene, there comes a slow recuperation of the forces. Now, if the patient rises upon her elbow, or attempts to escape from the bed (and it is sometimes very difficult to hold her down); if she stares wildly about her and breathes with difficulty or violence, she will surely die; and that, because, during the extremest intensity of the late asphyxiation, a soft clot has filled the right auri- cle, ventricle, and pulmonary artery. I have not seen such a patient, so struggling and so breathing, escape from the fatal termination. Indeed, it would be difficult, & priori, to imagine a condition more likely to lead to the heart-clot than that of a woman in a violent eclampsia, especially if an unmeasured use of venesection should have been employed. 618. Case.—A lady was confined, and with a natural labor, giving birth to a healthy child at term. She had lost a good deal of blood with the expulsion of the placenta, which left her weak and pallid. The physician directed her to be kept quiet, so that she had a good day and following night. On the following morning the physician found her in all respects as well as could be wished. Very soon after he had withdrawn from her chamber, she became alarmingly ill and i he was sent for, and returned, having been absent about one hour. The pulse was now extremely frequent, weak, and small, and it con- tinued so until her death, which took place on the 18th or 19th day. It was upon the 18th day that I was invited to the consultation, and at once formed the opinion that she had a heart-clot, as the cause of all her dreadful symptoms, and which acting as a tampon of the heart, deranged the circulation, respiration, and innervations of the dying lady. After her decease, which occurred the next morning, a white, fibrinous coagulum was found in the right auricle, nearly filling it and projecting through the tricuspid valve into the right ventricle; the tail of the clot was whipped into cords by the threshing action of the chordas tendineae of the ventricle. The pleura of the right cavity 340 CONDUCT OF A LABOR. contained a large quantity of serum. When the physician left his patient's chamber on the morning of the attack, she was well enough; when he returned, after an absence of only one hour, he found her alarmingly ill. She had lost blood in the labor. He had no sooner gone than the nurse took her up, and sat her upon a vessel in bed to pass the urine. She fainted; the blood coagulated in her heart. She did not die outright, but carried on an imperfect circulation outside of the clot, and betwixt it and the walls of the heart. The red matter of the blood was gradually squeezed out from the clot and hurried into the pulmonary artery, together with numerous fragments of the remaining mass of immovable fibrine. Such concrete elements ofthe blood could not possibly pass through the pulmonic capillaries; whence there arose pulmonary obstructions, pneumonia, pleuritis, and hydro- thorax, as the last consequences of the heart-clot. So that she died about the 19th day. 619. Towards the end of the year 1848, a primipara gave birth to her child. She was a tall, slender, and very delicate woman. The placenta was not removed. She lost a good deal of blood; probably a large quantity. Between forty and fifty hours after the birth of the child, I was called in, and removed the placenta from the grasp of the cervix, which alone detained it. It was so putrid that the stench of it could not be removed from my hand, by any means that I could employ, for full twenty-four hours. She was pale, and her pulse was somewhat frequent, but not enough so to annoy me. The next day I found her co m for table ; the milk had come, and she was doing well, though very pale. On the seventh day she was put into a chair and set before the fire. Immediately she fell sick, was put to bed very ill, and I being hastily called, told her friends that she had formed a heart-clot, because she had been imprudently taken out of bed, set up, and thus made to faint. In that fainting fit the blood lost the vital induction, and coagulated as it died. She died, as any woman may be expected to do who is so treated, under such circumstances of debility and exhaustion. 620. The state of fainting is one that I consider to be dependent always upon anasmia of the encephalon; for whenever the vascular tension of the parts contained within the skull is suddenly and con- siderably diminished from what cause soever, faintness comes on, and the individual seeks for or falls into an horizontal posture, in order to restore the plenitude of the brain-capillaries. I can form no conception of a fainting fit occurring during the existence of an encephalic hyper- asmia. To raise a woman up, who within a few days past has sus- tained a great loss of blood, is almost inevitably to bring on a deli- CONDUCT OF A LABOR. 341 quium animi. Now, if the opinion be a sound one, and I believe that it is so, that precedent losses of blood increase the tendency of that fluid to coagulate, it follows that, to take a woman under such circum- stances out of her bed, and make her sit up, is to expose her to the risk of forming a heart-clot that shall instantly manifest its presence by a wild feeling of suffocation and all the distressing manifestations of an insupportable asphyxia. Often, very often, such a heart-clot is immediately fatal—the patient dying as suddenly as if a grape-shot, instead of a clot, were lodged in one of the pulmonary auricles or ven- tricles. Monthly nurses, and the ordinary companions of the sick, like the public at large, know nothing of these things ; which yet are so plain and so undeniable, that at least every Student of Medicine ought to be concisely acquainted with them. Let me recommend the perusal of the following interesting case to the Student. The facts as they occurred were intensely interesting to me—and I wish that I were possessed of some art of picture-writing by means of which to repro- duce the scene before the mind of the reader ; and that he might see it in all its force as I did at the time of its occurrence. 621. Case.—A lady, the mother of four children, after having been considerably excited by certain circumstances in her domestic rela- tions, was attacked with symptoms of labor in the afternoon. She sat all night in an arm-chair, and did not sleep even for a moment. At 5 A. M. she placed herself upon the bed, and the child was born in half an hour. The placenta came off well, and nothing was left in the womb, which was found firmly condensed. In the course of an hour after this, she was seized with a copious hemorrhage. The vagina and womb contained large coagula that were turned out by the physician, upon which the hemorrhage ceased, and she was pretty well, although she had lost by estimate some thirty ounces. The accoucheur re- mained near his patient from half past six, when the hemorrhage ceased, until after 10 A. M., and then bade her good morning, and left her very well. At midday, and throughout the following night, she continued very well. At half past nine on the next morning, at his visit, he found her as well as could be wished, having no pain nor any appreciable indisposition save those symptoms appertaining to a healthy accouchee. The pulse was about 75; she was quite well. The physician took his leave of her at 10 in the morning. Being summoned to her, he came to her chamber again at 1 o'clock, and found her apparently nigh unto death: the pulse 164, feeble and thread-like; the hands cold; but the respiration, repeated, with long iutervals, seemed to depend solely on the exertion oft the will. The 342 CONDUCT OF A LABOR. respiratory acts were performed with great violence, and without rhythm; she had lost no more blood, and there was no coagulum either in the womb or vagina. The physician—it was Dr. Yardley—re- quested me to visit with him, and I arrived at 3 P. M. She supposed herself to be moribund; and still breathing solely by her will, and without organic rhythm, asked me, a stranger, in words broken by the occasional forced aspirations, "Sir,—do you—think—I shall be— alive—in half an hour?" It would be difficult to conceive of a greater physical distress than that which was now endured by the dying lady. Every respiratory act was attended with an agonized sense, and with pain at the end of the sternum, as in angina pectoris. I auscultated the heart and the lungs, and sought by percussion to discover the state of the lungs and pericardium. I could detect nothing to explain the curious phenomena, I examined the abdomen, and employed the Touch to explore the pelvis. I was informed that she sat up in bed to make water, soon after the Doctor had left her at 10 o'clock, and that she was immediately thereupon seized with this illness. At once, I perceived that the deliquium had allowed a clot to form in the heart, and that it must prove as fatal as it would if it were a bullet instead of a coagulum lodged there. Indeed, I could not come to any other conclusion, for I said, at 10 o'clock she had 75 pulsations, at 1 o'clock, 165 pulsations. There is no pathological principle could bring about so sudden and great a change in the pulse, the respiration, and tem- perature, except some mechanical obstruction, such as a clot or tampon filling up the heart. Such a clot, occupying the auricle, ventricle, and pulmonary artery, can never be taken away. Its influence on the circulation is equal to that which would be exerted by ligation of the cava, leaving only a small aperture for the transmission of a very little blood to the lungs. This lady is not dead already because she still urges a very little blood onwards to the lungs, and which finds its way betwixt the coagulum and the walls of the heart; but the quantity thus propelled is insufficient to take up an amount of oxygen equal to the demands of the nervous system, and hence, she makes these violent and voluntary efforts to breathe and to obviate the asphyxiation. Her instinct, not her knowledge, teaches her that the more perfectly she can oxygenate, even the small stream that still remains to her, the less will she perceive the sensations arising from her cyanosis, or approaching complete state of asphyxia. I thought it might be possible to restore the organic rhythm of her respiration, at least for a short time; and that, if that could be done, she would be greatly comforted by it. Hence, I stood before her and asked her to look at me, and exactly imitate the acts of respiration I was about to CONDUCT OF A LABOR. 343 perform before her. Accordingly, she fixed her eyes upon me, while I, by a forced aspiration, inhaled perhaps 150 cube-inches of air, which she did in like manner; I then repeated the aspiration, which she also did for more than a minute, when I ceased; she now breathed with rhythm, and without the intervention of her will; in short, she was greatly comforted, and had not from that time until her death any more of the purely voluntary respirations that constituted the most shocking spectacle of the whole scene of her sufferings. 622. Let the Student consider what must be the result of such a mechanical obstruction in the heart, as this I have here supposed. The systemic auricle and ventricle and the aorta are unaffected, at least directly; nothing prevents the easy outflowing of their blood; nothing prevents the circulation from flowing in on the cosliac and the mesen- teric arteries; but the capillaries in which they terminate can no longer deliver over all the blood they receive, because the clot in the heart is equivalent to a ligation of the inferior cava. It is to be ex- pected, therefore, if the patient should survive for a few hours or days, that the aqueous elements of the blood must largely escape, by exos- mose or otherwise, from the mesenteric and intestinal capillaries, and fill the peritoneum with water. In one of the cases I have herein related, the pleura was filled, because, I suppose, the minute fragments of the concreted blood had been driven into the lung capillaries, and so caused the hydrothorax through a pulmonary obstruction, by what are now denoted as emboli. Here, when the fibrinous clot was unbroken, the effusion fell into the peritoneal sac; and the clot must have acted as a complete tampon, since not only were the right pulmonic cavities quite full, but the clot also extended far within the pulmonary artery itself. Twenty-four hours after her death, which took place some thirty hours subsequent to the occurrence of the accident, I found both the right auricle and ventricle, as well as the pulmonary artery, filled with a whitish-yellow, chicken-fat colored coagulum. One might well feel surprised to find that such an obstruction should not have proved instantly fatal. Let the Stu- dent here observe that the clot was not one of those dark enthanasial coagula, that are commonly met with in the heart, when examined after death from ordinary causes. Had it been even a firm but dark clot, I should havevconcluded that it was formed during the moribund state of the subject. On the contrary, whenever the clot consists chiefly of the fibrinous portion, and is of a yellowish, chicken-fat hue, it must be assumed to have been formed a considerable time before the death struggle of the patient. Its whitish-yellow tint proves that the red matter had been long before completely pressed out of and separated from the fibrine. These coagula have been called false 344 CONDUCT OF A LABOR. polypi of the heart. I have had so considerable an experience in these matters, that I could relate, in this place, many other instances of per- sons in whom heart-clot was suddenly formed, but I must abstain for want of space from such remarks in the present volume. Besides, I am content with having, in the foregoing, called the attention and ex- cited the reflection of the Student, as to the case, and with having put him upon his guard against the most real and perhaps only danger connected with deliquium animi. After having read these remarks, I venture to hope that, in all cases of dangerous uterine or other hemorrhage, he will not be so blind to the circumstances, as to allow his patient to be taken out of the horizontal posture, until he shall have become well assured that a deliquium animi cannot come on to arrest the movement of the blood in the pulmonic heart, so as fatally and instantly to fill the cavities with this heart clot. Several authors have spoken of heart-clot; but I am not aware that any one has here- tofore set the case in such a light as that in which I have attempted to place it. There is a very clever resum^of the subject now before me in a pamphlet which was an inaugural dissertation de Poly pis Cordis, &c. &c, presented at Halle in 1821, by Dr. John Valentine Deegen, of Croppenstadt, near Halberstadt. I have a just right to claim the merit of being the first writer to call the attention of the Medical Profession to these sudden concretions of the concrescible elements of the blood in the heart and great vessels. In an argument upon the subject, at the Phila. College of Physicians, I maintained this doctrine, and my speech was published in the " Trans, of the Phila. Col. of Physicians," in the number for------ 18—. Though what is called polypus of the heart was known before my publication, it is true that the now widely spread theory of Emboli was not at all known. That idea has been greatly enlarged and improved, so that I now consider the doctrine of vascular emboli, as not only fully es- tablished and received, but I have yet no shadow of doubt that my opinions set forth at the Philadelphia College concerning the true nature of tubercle, as resulting from emboli in the pulmonary capil- laries will be finally adopted everywhere in the learned world. M. Virchow has carried off the palm—but it ought to be true that pal- mam qui meruit ferat. 623. Tampon Never.—I repeat the opinion already expressed, that the blood that issues from the placental surface of the womb after delivery at Term, ought to be -permitted to flow freely out from the vagina. After it is effused, it is of no use to the woman. What is the reason that a woman does not bleed to death after the CONDUCT OF A LABOR. 345 placenta is detached ? It is not because a coagulum is formed, by which the effusion is arrested. She is saved by the condensation ofthe uterine tissue which, by its coacervation, is not only sufficiently diminished in volume to close the small orifices of the vessels on the placental surface, but even to close the largest sinuses that may be opened dufHng the Caesarean section, or in extensive lacerations ofthe womb. I saw, in a Caesarean operation, the scalpel open the uterus immediately over the placenta—an incision large enough to permit me to extract the child with sufficient facility. The cut was, of course, through the most vascular part of the organ. I need not say, that the blood bubbled up from the incised surfaces very rapidly ; but it wholly ceased to flow as soon as the placenta was removed from the womb, so as to permit that organ to contract. The condensation of the womb, in contracting, shut up the cut vessels as completely as if ligatures had been applied to them. I repeat again, that a very firm clot, shutting the mouth of the womb, may serve as a tampon which shall wholly prevent the escape of blood from the cavity, which expands as it con- tinues to receive the effusion, until the womb becomes fully as large as at the sixth month; and the larger the womb, the more capacious its vessels. Such clots should be broken up, and removed. They are as dangerous as, but not more so than the artificial tampon, when used after delivery at term. I have never used a tampon after delivery at term; but I have seen them used, which came ver}7 near causing the patient to sink, by detaining the effusion within the cavity. The principle is false, and the practice dangerous, which resorts to such a mode of arresting uterine hemorrhage, at term: he who resorts to it, does so under the ignorant presumption that uterine, like chirurgical, hemorrhage is to be arrested by coagulation of the outflowing blood. If it should be said here, that women very commonly do discharge utero-morphous clots after delivery, I admit the fact; but I insist that but for a sufficient degree of irritability in such uteri, the clots would become so large as to require for their formation a wasteful, and even dangerous or fatal extravasation of the vital fluid. Strong uteri never permit them; weaker ones allow pretty large ones to be formed, and very feeble wombs fill until the woman faints or dies. 624. Turn out the Clot.—I should feel happy if I could impress upon the mind of the Student, in such a manner as to make it ever present to him when the occasion demands, that the only certain mode of arresting uterine hemorrhage is to empty the womb and cause it to contract. If a woman have alarming discharges of blood before the delivery of the child, let him take away the child if he can. If she 2'd 346 CONDUCT OF A LABOR. bleed before the after-birth is withdrawn, let him withdraw it. If she bleed after delivery, let him introduce his fingers into the uterus and break to pieces the firm coagula that he will find in it, or in the vagina; and then by frictions of the hypogaster, or by cold, by pres- sure, by ergot, and by all the means in his power, let him compel the womb to contract; then, and not until then, will his patrent be safe. He should always turn out the clot, if the patient is sickened by it. The weakening eff'ect of a sudden removal of pressure or support from the contents of the abdomen, is noticed not only in labors, but in tap- ping the abdomen for dropsy. It is always deemed necessary, in tap- ping very distended persons, to pass a broad roller round the abdomen, so as to constrict it in proportion as the water flows off". In cases of paracentesis, where this precaution is not observed, the patient is very apt to faint, and evidently from the same cause I have mentioned, namely, the want of pressure on the contained organs. I had occa- sion, more than two years ago, to verify this principle in a case. A young woman, excessively distended with ascites, was tapped; the water flowed off" very rapidly; in proportion as it escaped, I tightened the bandage, and she made no complaint of faintness. In -order to test the effect of relaxing it, I withdrew all pressure for a very short time, the water still flowing, and she immediately began to grow sick and faint; which symptoms ceased as soon as I renewed the pressure with the bandage. It is with the greatest confidence, both as to its neces- sity and efficacy, that I therefore recommend, that a bandage should be early placed around the abdomen of such patients as are prone to fainting after delivery, as the compression, all things being thus ready prepared, may be applied soon after the birth, and without disturbing the patient. 625. The Binder.—It is well worth the Student's while to bestow some sober thought upon the subject of the binder for a newly de- livered woman. As a general precaution, it is doubtless a laudable one to bind up the weakened and exhausted abdominal region. But, it is questionable as to how long it should be used. Dr. White, of Manchester, "Treatise on the Management of Pregnant and Lying-in Women," says very properly, at p. 116, "Much mischief is often done by binding the belly too tight. If there be any occasion for support, a thin napkin pinned very slightly around the waist, is all that is absolutely necessary, and the sooner this is disused the better." Cer- tainly after the first days of the confinement, it is not to be held necessary as a preventive of syncope or hemorrhage; nor has it any special usefulness beyond the doubtful one of restoring the woman's CONDUCT OF A LABOR. 347 shape. But as to this, I think that Asdrubali is very correct in his assertion, that it cannot at all restore the figure, whose restoration depends upon the vital contraction of the muscular and other tissues that have been relaxed by the gestation. I fear that much of the too general complaint of prolapsus and retroversion of the womb among American 'women may be attributed to the use of bandages worn so tight, and so long, as to drive the recovering uterus to the bottom of the pelvis, or even overset it backwards into the hollow of the sacrum. Dr. A. F. Hohl, "Lehrbuch der Geburtshiilfe," 8vo., Leipzig, 1855, says, at p. 1113, "The application of a binder for the abdomen, with a view to preserve the shape, to obviate the sense of emptiness in the belly, or to prevent fainting or flooding after delivery, we have by experience found to be unnecessary as long as the woman lies in bed." 626. Diet.—The diet of a woman recently delivered, ought to be very light, and of easy digestion. Tea, bread, gruel, vegetable jellies, and panada suffice, and are the safest materials during the three or four first days of the accouchement. Circumstances may demand a more liberal allowance; but for persons who have small lochial evacuations, or who are of an excitable constitution, the simplest ele- ments of nutrition only should be prescribed. For a surgical patient, both before and after the completion of the operation, a regimen is deemed of vital importance; and yet the shock to the constitution, and the irritative influences of the wound, in severe or capital opera- tions, being not greater than those developed by many instances of labor, are not dietetic precautions equally proper, then, in both cases? In addition to these considerations, it ought to be remembered that, during the months of gestation, the fluxional determinations have been towards the uterus; but now the wave of vital fluids is marching towards another set of organs, and great disturbances are, many times, occasioned by this mutation of directions. The effort of the constitution produces fever, which commences simultaneously with the irritation of the mammary glands; but, happily, when those glands are enabled to throw off'an abundant secretion, the whole con- stitution is relieved by the evacuation, and the fever undergoes a crisis, as well marked as that of a bilious remittent, or any other febrile disorder that goes off by a profuse diaphoresis or diarrhoea. Let the body, then, be prepared for this fever, by a correct course of diet; and when that crisis has been completed, much of the hazard of an accouchement will be already over-passed, and a reasonable indul- gence in stronger food becomes safe and proper. 348 CONDUCT OF A LABOR. 627. Suckling.—The child should be put to the breast as soon as the mother has recovered sufficiently from her fatigue and exhaustion. This is a natural course—it is, therefore, the best one; for by the act of suckling, the new determinations, about to arise, are directed to, and restrained within their proper bounds: the vital wave ought to come hitherto, but no farther. Such a course is useful for the child, which generally procures, from the earliest lactation, some saline fluids that have a favorable influence on its digestive tube; and for which ought not to be substituted that pernicious compound, molasses and water, which every child in the country is doomed to swallow, at the cost of a sour stomach and flatulent bowels, displayed in the almost univer- sally resulting symptoms of colic, green stools, and vomiting. The antediluvian mothers had no molasses and water for their children, who lived nevertheless, a thousand years. Certainly nothing can be more conformable to the dictates of nature, than an early application of the infant to the mother's breast. If we could suppose a woman in a state of nature, to be delivered alone, under the shade of some primeval forest, and unsuspected observe her conduct, we should witness the instinctive movements and promptings of nature, that would far better guide us in the management of such affairs, than the crude conceptions of those who are ever ready to boast of the excel- lence of art or skill over the sure suggestions of instinct. Such a mother would soon be aroused from the weakness and languor that succeed the pangs and throes of childbirth, by the cries of her help- less offspring. She would take it, as soon as a little returning strength should permit, into her arms, aud the newly-born child would probably not nestle a moment on the maternal bosom, without finding the source of its future aliment; the very anatomical struc- ture, both of the maternal arms and breast, and the instinctive mo- tions of the child's head, would bring its lips speedily in contact with the nipple. But we, wiser than our great instructress, often keep the new-born child away from its natural resting-place, and deprive it of the most appropriate nutriment for two or three days, in order to eschew sore nipples, or to propitiate some other imaginary evil; while we allow the breast to till almost to bursting, and actually to inflame from distension, before we admit that preparation to be complete, which our presumptuous interference, in this manner, vitiates and troubles. The child ought to be put to the breast as soon as the mother is strong enough to take it. 628. Medicine.—It is a good custom to give an aperient medicine on the third day, or about seventy hours after delivery; while in most CONDUCT OF A LABOR. 349 cases, it is safest to defer the administration, at least up to this period. Disturbances of vital action in the abdominal viscera, occasioned by medicines administered too early, are observed to result in symp- toms of congestion, and of peritoneal fever in not a few instances, particularly where an epidemic tendency to the latter malady exists. It should be well understood in the lying-in apartment, that no medi- cines are to be given to the mother or the child, without the sanction or advice of the medical attendant. In our part of the country, it is exceedingly common for the nurse to take upon herself the function of prescriber, and administer a dose of severe cathartic medicine, upon her own responsibility; which, however great and important she may deem it, remains, after all, with the physician. He it is who bears the burden, and undergoes all the trouble and anxiety and responsibility of the management. He ought, therefore, always to direct that no interference with his rights should be suff'ered to take place. There are many reasons why he should be the sole director of the case; for it is not a matter of indifference what particular article is selected, any more than it is of little consequence at what moment the medicine (if any) should be administered. Castor oil is the article in most request for this period of the confinement; and in a dose of less than half an ounce operates sufficiently well. Where the castor oil is particularly disagreeable, a proper quantity of magnesia and rhubarb; of infusion of senna; of Epsom salts; of Seidlitz powders, may be substituted; but, in general, the oil is to be preferred, because of the great certainty and moderation with which it operates on the bowels. 629. Lochia.—The lochial discharges grow' gradually less abun- dant, and of a paler color. The tone of the womb itself must deter- mine, in a great measure, the duration and amount of the discharge. It disappears in the third week, and sometimes earlier. Not a few women continue to have a show in the fifth week; and, in fact, the Jewish women had their purification at the fortieth day, which proba- bly might be founded on observations as well suited to the inhabitants of this country as those of the Holy Land. 630. Etherization.—In speaking of the various points in the Conduct of a labor, I cannot well eschew to say something upon the employment of those anaesthetic agents whose recent irruption into the domain of Medicine and Surgery has been so sudden, violent, and overbearing. To avoid altogether any notice of these agents would have been more consonant with my taste as well as with my views of medical duty; but as I feel that those who may please to have 350 CONDUCT OF A LABOR. this book will surely expect to find a record of my opinions on anaesthesia as an obstetric resource, I feel constrained to overcome my reluctance to say anything concerning it. In Philadelphia, the use of ether and chloroform in Surgery and Midwifery has made no great progress, notwithstanding the very numerous reports upon the benefits derived from those agents in Europe and in parts of the United States. Some of our surgeons in this metropolis have applied the ether inhalation in their surgical cases—and some per- sons in labor have likewise been rendered insensible to their pain by breathing the vapor of chloroform or ether. I am not able to say in how many instances this recourse has been had here ; but I should suppose that not fewer than some thousands of women have been subjected to it on account of labor; and I believe the practice does not become much more common and general in our community; and that not a great many more women in labor will have been etherized in 1862 than in 1850-51. I do not feel inclined at all to deny that there may be instances of severe suffering for women in labor, that ought to be mitigated or even wholly obviated by casting the woman into the pro- found anaesthesia of etherization. But what I do desire to say is this, viz: that, having carefully studied the reports upon etherization and chloroformization, whether those of this country or-those produced in Europe, I remain as yet unconvinced—either of the necessity for the method, or of its propriety as an ordinary practice. 1st. As to its ne- cessity in ordinary cases of parturition ; the average duration of labor is four hours, and I have shown at 517 that the number of labor pains is about fifty; and that they last, each about thirty seconds, so that the parturient 'woman really suff'ers from labor pains about twenty-five minutes and no more—and these twenty-five minutes are distributed among the four hours of a labor of mean duration. It has never been pretended that the motive for the anaesthetic practice has any connection with the other pains of women in labor, but only with the suffering from contraction or labor-pains; for, though we may well suppose that women suffer from painful sensations inde- pendent of those arising from the actually contracting womb, yet we find them in general, easy, complacent, and but too happy when the pain is off. Hence the ether is exhibited for the pain, and for no other motive. I contend, that it is to an exaggerated notion of the nature of labor-pains we owe the too frequent use of ether in our art; for if the mean of labor-pain be only twenty-five minutes in all, there can be no necessity in the average of cases for its exhibition. I should find the objection to it less and the inducement greater, were the twenty-five minutes of pain to be always twenty-five consecutive CONDUCT OF A LABOR. 351 minutes. When they are distributed through two hundred and forty minutes, or four hours, I look upon the exhibition as unnecessary and uncalled for. 2d. The representations that have been made by the friends of anaesthesia, of the harrowing distress endured by women in childbirth, do not consist with the general state of facts in the case; and it is quite true that a lying-in room is, for the most of the labor, a scene of cheerfulness and gayety, instead of the shrieks and anguish and despair that have been so forcibly portrayed. Few women lose their health or their lives in labor, and the dread of future sufferings is insufficient to prevent the increase of the family. As to the neces- sity of the Letheon practice, the birth ofthe past myriads of the race shows that it is not necessary. The propriety of resorting to the use of chloroform and ether as means of obviating the pain and hazards of labor is a question to be settled by an estimate of the safeness as well as necessity of it. It were well, before making up his mind upon this point, were the Student to make himself aware that the encepha- lon is a compound organ, or a compound bulbous nervous mass, part of which (the hemispheres) are devoted to the offices of intellection; part, the cerebellum, to the duty of co-ordinating or regulating the movement of the force which is generated perhaps by the whole nerv- ous mass: a part, the tubercula quadrigemina, to the faculty of seeing or vision; and a part, the medulla oblongata, to the important office of governing or giving origin to the act of respiration. Thus we have the brain of intellection, and those of co-ordination of force, of vision, and of respiration. They might be denominated the thinking, co-ordinating, seeing, and breathing bulbs of the nervous mass. Now, it appears from very numerous reports contained in the " Comptes Rendus" of the French Institute, and from papers in various journals containing accounts of experiments made both in men and in animals, that to breathe for a few minutes the vapor of ether or of chloroform and various volatile liquids, is to cast the subject into an insensibility called anaesthesia, so profound that the cautery, whether actual or po- tential, the bistoury, the ligation, or the forceps are equally incapable of exciting any sense of pain. Nay, more, that the patient, in some instances, looks upon the incision of his flesh without feeling the knife. Very soon after ceasing to inhale the vapor, the insensibility disap- pears, and the individual, upon recovering the use of his faculties, is with difficulty persuaded to admit that he has been subjected to a severe operation; while the mother is incredulous as to her having borne a child during her sleep. Such are the facts. The Student ought to know them. Half an ounce to an ounce of ether poured upon a sponge, and held to the mouth and nose, or a drachm to two or three 352 CONDUCT OF A LABOR. drachms of chloroform administered in the same way, bring on the insensibility in from three to ten minutes, less or more. The insensi- bility once produced, may be maintained according to the pleasure of the physician, by repeating the application of the moistened sponge from time to time upon any manifest signs of returning consciousness. The statements show that the power of these anaesthetics is capable of abolishing the sensibility, without greatly interfering with the motor power of the subject—or it may abolish the motor power, and allow the sensitive power to be acute, as in health. The inhalation may pro- duce anassthesia ofthe thinking brain, yet leave the co-ordinating, the breathing, and the seeing brains intact—or it may put a temporary end to the power of the cerebellum and tubercula quadrigemina, without influencing the other parts of the encephalon. In short, there is no ascertained law of progression in the activity or power of the anae- sthetic agent, chloroform, and no man knows, when he begins to ad- minister the article, upon what part of the brain it will proceed to exert its first benumbing power. M. Flourens has shown that all the other parts of the brain may be safely suspended of their forces, provided the medulla oblongata remain unattacked by the agent; and that, as long as the medulla oblongata retains its energy, it is capable of recall- ing the other bulbs to life and activity through its own force, provided the further inhalation of the letheon be arrested. Hence he calls the medulla oblongata the vital tie (1 e n oeud vi tal), since it binds the rest of the encephalon and nervous system into one with its "silver cord." Now I have to suggest to the Student the propriety of asking what would be his feelings, provided in any such case, this silver cord should be loosened; and I ask him whether, if the anassthesia should proceed at first, or secondarily, to attack and overthrow the power of the medulla oblongata, his patient would not be instantly deprived of life! For if to breathe is to live, to be deprived of the uses of the medulla oblongata is to die—since on that noeud vital depends the whole business of the oxygenation of the body. Many, and but too many examples of the power of these tremendous agents to over- throw, almost instantly, the force resident in the medulla oblongata, are spread upon the records of medicine in the last few years. I do not well understand how those persons can recover their composure or their complacency, who, by an unnecessary and inappropriate re- sort to so dangerous a process, have seen the victims of this extraor- dinary power struck lifeless before their eyes. It behooves not me to enter into the lists with the surgeons who cast their patients into the deep insensibility of etherization before performing their operations— suum cuique tribuito is a proper law for me in this place. CONDUCT OF A LABOR. 353 But I cannot avoid the feeling of astonishment which seizes upon me when I read the details of cases of midwifery that have been treated during the long profound Drunkenness of etherization. To be insensible from whiskey, and gin, and brandy, and wine, and beer, and ether, and chloroform, is to be what in the world is called Dead- drunk. No reasoning—no argumentation is strong enough to point out the millionth part of a split hair's difference between them—except that the volatility of one of the agents, or its diffusibility as a stimu- lant narcotic, enables it sooner to produce its intoxicating eff'ect, which is sooner recovered from in one case than in any other of the use of an intoxicating drug. 631. I showed, in the first part of this section, why I deemed the use of etherization in Midwifery unnecessary; in the second part, I have endeavored to show why it is improper. I have by no means said what I am inclined to say as to the doubtful nature of any pro- cesses, that the physician sets up, to contravene the operation of those natural and physiological forces that the Divinity has ordained us to enjoy or to suffer. The question is often propounded as to the Benefi- cence that ordained woman to the sorrow and pain of them that travail in childbirth. It ought to be taken for granted, without any, the least, disposition to what is called canting, that some economical connec- tion exists betwixt the power and the pain of labors. While, there- fore, we may assume the privilege to control, check, and diminish the pains of labor whenever they become so great as to be properly deemed pathological, I deny that we have the professional right, in order wholly to prevent or obviate these physiological states, to place the lives of women on the hazard of that progress of anassthesia, whose laws are not, and probably can never be ascertained, so as to be truly fore- known. Notwithstanding I have expressed the above opinions in regard to etherization in Midwifery, which might suffice to expose my sentiments upon that topic, still, my respect for eminent brethren who think differently, calls upon me to acknowledge their equal rights, and probably superior claims to the confidence of the Student. Professor Simpson, ofthe University of Edinburgh, it is well known, is amonar the most distinguished and able advocates of anassthesia in CD O our art. I will not, therefore, refrain from laying before the reader the following letter from that eminent gentleman, with my answer to his communication. Letter from Professor Simpson. Edinbukgh, January 23, 1848. 632. Dear Sir: By private letters from America, brought by the last steamer, I hear that in most of the cities of the Union, your 354 CONDUCT OF A LABOR. chemists had failed in preparing proper chloroform; and that, conse- quently, most experiments tried with it had been unsuccessful. In Great Britain, and on the continent of Europe, chloroform has every- where entirely, or nearly entirely, superseded the use of sulphuric ether, as an anaesthetic agent. The want of success which has attended its employment in America is, perhaps, owing in a great measure to an error of my own, viz: to my not stating, in my origi- nal account of it, the proper method of purifying it. This and other omissions were owing to the haste with which my first paper was drawn up. I will feel, therefore, deeply obliged by your taking any measures that you may deem fit, to circulate amongst American medical men the formula which I inclose for the preparation of chloroform. It is the formula used by Messrs. Duncan and Flockhart, our Edinburgh druggists, who have already manufactured enormous quantities of it. They always now are able to produce it as heavy as 1500 in specific gravity. Their first distillation of it is made in two large wooden barrels, with a third similar barrel as a receiver. They throw hot steam into the first two barrels, which serves to afford both sufficient heat and water for the process. They employ sixty pounds of chlo- ride of lime at each distillation, and have been able to manufacture three hundred ounces of chloroform a day. Each ounce of the chlo- ride yields, in the long run, about half an ounce of chloroform: con- sequently, to obtain three hundred ounces (as above), about six hun- dred ounces of bleaching powder are required. At first, they could only make ten or twenty ounces per diem, then they rose to sixty, and latterly, enlarging their barrels, they can make, as I have said, three hundred ounces in the twenty-four hours. Various other chemical houses in Edinburgh, Liverpool, Glasgow, York, London, &c, are busy manufacturing it in great quantities. They keep their formulas as secrets. But none of them make so good an article as Duncan and Flockhart, whose formula I append. The statements which I have already made may show you to what an extent the chloroform is used in this country; and our chemists tell me that the demand for it steadily increases with them. In Surgery, its use is quite general, for operations, painful diag- nosis, &c. My friend, Mr. Andrew Wood, has just been telling me of a beautiful application of it. A boy fell from a height, and severely injured his thigh. It was so painful that he shrieked when Dr. Wood tried to handle the limb, and would not allow of a proper examination. Dr. W. immediately chloroformed him—at once ascertained that the femur was fractured—kept him anaesthetic till he sent for his splints-- CONDUCT OF A LABOR. 355 and did not allow his patient to awake till his limb was all properly set, bandaged, and adjusted. In Medicine, its effects are being extensively tried as an anodyne, an anaesthetic, a diffusible stimulant, &c. Its antispasmodic powers in colic, asthma, &c, are everywhere recognized. In Midwifery, most or all of my brethren in Edinburgh employ it constantly. The ladies themselves insist on not being doomed to suffer, when suffering is so totally unnecessary. In London, Dublin, &c, it every day gains converts to its obstetric employment, and I have no doubt that those who most bitterly oppose it now, will be yet, in ten or twenty years hence, amazed at their own professional cruelty. They allow their medical prejudices to smother and over- rule the common dictates of their profession, and of humanity. No accidents have as yet happened under its use, though several hundred thousand must have already been under the influence of chloroform. Its use here has been a common amusement in drawing- room parties, for the last two or three months. I never now apply it with anything but a silk handkerchief. In surgical cases and operations, the quantity given is not in general measured. We all judge more by the effects than the quantity. Gene- rally, I believe, we pour two or three drachms on the handkerchief at once, and more in a minute, if no sufficient eff'ect is produced, and we stop when sonorous respiration begins. Not unfrequently spasms, rigidity, &c, come on, but they disappear as the effect increases, and none of us care for them any more than for hysteric symptoms; nor do they leave any bad eff'ect. But the mere appearance of them is enough to terrify a beginner. I shall be glad to hear how the cause of anaesthesia gets on among you, and I remain, with great respect, Very faithfully yours, J. Y. SIMPSON. To Professor Meigs. The following is the Formula for Chloroform, communicated by Professor Simpson:— "Take of Chloride of Lime, in powder 4 pounds. Water . . . 12 " Rectified Spirits . . 12 fluidounces. 1 Dumas? "The chloride of lime and water being first well mixed together, the spirit is added. Heat is then applied to the still (which ought not to be more than a third full), but as soon as the upper part of the still 356 CONDUCT OF A LABOR. becomes warm, the heat is withdrawn, and the action allowed to go on of itself. In a short time the distillation commences, and whenever it begins to go on slowly, the heat is again applied. The fluid which passes over, separates into two layers, the lower of which is Chloro- form. This, after having been separated from the weak spirit forming the upper layer, is purified by being mixed with half its measure of strong sulphuric acid, added gradually. The mixture, when cool, is poured into a leaden retort, and distilled from as much carbonate of baryta by weight, as there is of sulphuric acid by measure. The pro- duct should be allowed to stand over quicklime for a day or two, and repeatedly shaken, and then re-distilled from the lime." Reply to Prof. Simpson's Letter. Philadelphia, Feb. 18th, 1848. 633. Dear Sir: I have to acknowledge the favor of your letter of Jan. 23d, which I received yesterday. The chemists in this country have produced very perfect chloro- form, of the specific gravity of 1450, as I am informed, and which is much employed in dentistry operations, and to a considerable extent also in surgery. I presume you will, ere this date, have received copies of Prof. Warren's pamphlet on "Etherization," which may inform you, very fully, as to the use of the anassthetic agent in the Massachusetts General Hospital, and in Boston. That eminent gentleman is more reserved as to the obstetric employment of the agent; much more so, I understand, than either Dr. Channing or Dr. Hornans, and other practitioners, who make use of it very commonly. In New York, as I learn, the surgical application of chloroform is common, while its obstetrical use has not as yet acquired a general vogue. In Philadelphia, we have the Pennsylvania Hospital, with more than two hundred beds. A very considerable amount of surgical practice, which renders that house a favorite clinical study for medical students of the United States, has not, as yet, furnished a single ex- ample of the exhibition of chloroform or ether as anassthetic agents. The Surgical Staff' of the institution have not become convinced of the propriety of such a recourse in the operations performed there. In the Jefferson College, to which I am attached, as Professor of Midwifery, etc., there is a Medical and Surgical Clinic held on the Wednesday and Saturday of each week. The resort of surgical cases there is very great, and a Clinical day rarely passes without some sur- CONDUCT OF A LABOR. 357 gical operations before the classes. The clinical professors (in surgery), Drs. Mutter and Pancoast, almost invariably employ the chloroform, and the successful exhibition of the article has entirely confirmed them in their opinion of its great value. Some of the operations have been of the gravest character, and no serious event has occurred to check the career of the remedy. As to its employment in Midwifery here, notwithstanding a few cases have been mentioned and reported, I think it has not yet begun to find favor with accoucheurs. I have not exhibited it in any case; nor do I, at present, know of any intention in that way, entertained by the leading practitioners of obstetrical medicine and surgery, in this city. I have not yielded to several solicitations as to its exhibition, addressed to me by my patients in labor. As to the extension of the anaesthesia in the Southern and Western States, I am not at present enabled to give you information. I believe the practice is slowly gaining converts, and that it will become more and more common ere long. You may perhaps feel surprised at this admission on my part, seeing that I am still a recusant; and I ought, therefore, to be allowed to explain myself, lest I should continue to appear unreasonable in your eyes. Having carefully read the "Comptes Rendus" of the Royal Academy of Medicine of Paris, which contained full reports of the copious dis- cussions on the question of the Letheon, a few months since, and having also seen the English and American Reports in the Journals, and particularly having read your own pamphlet of "Remarks," &c, I may not properly be accused of ignorance of the power, effects, or motives, in relation to chloroformization in surgery, or obstetricy. The copy of your own pamphlet, for which I now beg leave to thank you, would necessarily have put me au niveau on the subject. Not being myself engaged in the practice of surgery, proper, I prefer to avoid any expression of opinion as to the propriety of the practice; and I do this upon the principle, suum cuique tribuito. It would be an impertinence in me, were I to interfere with the conduct of the surgeons. But, in Midwifery, to which a long and extensive practice has enured me, and rendered me a familiar dispassionate witness of its various forms and phenomena, I am less liable to misconceptions. And here, allow me to say, I have been accustomed to look upon the sensation of pain in labor as a physiological relation of the power, or force; and notwithstanding I have seen so many women in the throes 358 CONDUCT OF A LABOR. of labor, I have always regarded a labor-pain as a most desirable, salutary, and conservative manifestation of life-force. I have found that women, provided they were sustained by cheering counsel and promises, and carefully freed from the distressing element of terror, could in general be made to endure, without great complaint, those labor-pains which the friends of the anassthesia desire so earnestly to abolish and nullify for all the fair daughters of Eve. Perhaps, dear sir, I am cruel in taking so dispassionate a view of the case; and it is even possible that I may make one of the number of those "amazed" converts of whom you speak in your worthy letter to me. But, for the present, regarding the pain of a Natural labor as a state not, by all possible means, and always, to be eschewed and obviated, I cannot bring myself to the conviction that of the two, whether labor-pain or insensibility, insensibility is to be preferred. If I could believe that chloroformal insensibility is sleep indeed, the most considerable of my objections would vanish. Chloroform is not a soporific; and I see in the anaesthesia it superinduces a state of the nervous system in no wise differing from the anaesthetic results of alcoholic potations, save in the suddenness and transitiveness of its influence. I freely admit, for I know it, that many thousands of persons are daily subjected to its power. Yet I feel that no law of succession of its action on the several distinct parts of the brain has been, or can be hereafter ascertained, seeing that the succession is contingent. Many grave objections would perhaps vanish, could the law of the succession of influences on the parts ofthe brain be clearly made out, and its provisions insured. There are, indubitably, certain cases in which the intellectual hemispheres are totally hebetized, and deprived of power by it, while the co-ordinating lobes remain perfectly unaf- fected. In others, the motor cords of the cerebro-spinal nerves are deprived of power, whilst the sensitive cords enjoy a full activity, and vice versa. In some instances, the seeing brain enables the patient to look upon the application of a cautery that he does not feel while it sears him, or of a bistoury, whose edge gives him no pain. In others, the influ- ence of the agent upon the sources of the pneumogastric and phrenic nerves is dangerously, or at least alarmingly, made manifest by modi- fications of the respiratory force. It appears to me, therefore, quite certain, that there is no known law of succession of the ether-influences on the several parts of the brain. It is known that the continued aspiration of the vapor brings at last the medulla oblongata fully under its anassthetic power, and the consequent cessation of respiration CONDUCT OF A LABOR. 359 which determines the cessation of the oxygenation of the blood, and thereby of the brain, is death. M. Flourens' experiments, and others, especially those by the younger Mr. Wakley, of the "Lancet," prove very conclusively that the aspiration of ether or chloroform, continued but a little longer than the period required for hebetizing the hemi- spheres, the cerebellum, the tubercula quadrigemina, and the cord, overthrows the medulla oblongata, and produces thereby sudden death. I fully believe with M. Flourens, that the medulla oblongata is the noeud vital, and that, though later brought under the power of chloro- formization, it is always reducible under it. Hence, I fear that, in all cases of chloroformal anaesthesia, there remains but one irrevocable step more, to the grave. I readily hear, before your voice can reach me across the Atlantic, the triumphant reply that an hundred thousand have taken it without accident! I am a witness that it is attended with alarming accidents, however rarely. But should I exhibit the remedy for pain to a thou- sand patients in labor, merely to prevent the physiological pain, and for no other motive—and if I should in consequence destroy only one of them, I should feel disposed to clothe me in sackcloth, and cast ashes on my head for the remainder of my days. What sufficient motive have I to risk the life or the death of one in a thousand, in a questionable attempt to abrogate one of the general health conditions of man ? As to the uses of chloroform in the medical or therapeutical treat- ment of pain, the question changes. There is no reasonable therapeia of health. Hygienical processes are good and valid. The sick need a physician, not that they are well. To be in natural labor, is the culminating point of the female somatic forces. There is, in natural labor, no element of disease—and, therefore, the good old writers have said nothing truer nor wiser than their old saying, that " a med- dlesome midwifery is bad." Is chloroformization meddlesome ? Your countryman, old Thomas Rainald, in the " Woman's Booke, or The Byrthe of Mankynde," at fol. liii., says, " Very many be the perilles, daungers, and thronges, which chaunce to women in theyr labour." These are the cases requiring our therapeutical and chirur- gical intervention. You will, my dear sir, think me a hopeless recu- sant, if I decline the anassthesia here also. I pray you, therefore, allow me to state my reasons for such recusancy. If I were amputating a limb, or extirpating a tumor, I should see all the steps of my incisions, ligations, &c. But if I apply my forceps in a right occipito-posterior position (fourth of Baudelocque), I know that I thrust the blade of the male branch far upwards betwixt the 360 CONDUCT OF A LABOR. face ofthe child and the upper third ofthe vagina, which, in this case, is already greatly expanded, and that the extremity of the blade is separated from the peritoneum only by the mucous and condensed cellular coat of the tube. Now, no man can absolutely know the pre- cise degree of inclination his patient will give to the plane of her superior strait, while in pain ; an inclination to be modified by every movement of her body and limbs. Under such absolute uncertainty, the best guide of the accoucheur is the reply of the patient to his interrogatory, " Does it hurt you ?" The patient's reply, " Yes," or " No," is worth a thousand dogmas and precepts, as to planes and axes, and curves of Carus. I cannot therefore deem myself justified in casting away my safest and most trustworthy diagnosis, for the questionable equivalent of ten minutes' exemption from a pain, which, even in this case, is a physiological pain. Having thus, in my own defence, and not as attacking your opinion, set forth the motives that have hitherto served to restrain me from the administration of chloroform, I desist from giving you any farther trouble in this line of thought. I have, Sir, a far more pleasing duty to perform, in saying that your name is as well known, perhaps, in America as in your native land, and to congratulate you on the exten- sion of your fame. I had the pleasure to read your interesting letter to my class, consisting of several hundred young gentlemen, who list- ened to your words with the same respect they would have paid to you, had they been pronounced by your own lips. They will disperse themselves in a few days hence, over all the States of the Union, and thus will have it in their power to report the latest dates of your opinions as to chloroform. I shall also allow it to be published on the first proximo, in a medical journal of extensive circulation. You will herein perceive the readiness with which I assist in disseminating your views. It is not without regret that I find myself opposed to your opinions in the case. That difference ought not, however, in the least degree, to affect those sentiments of respectful consideration and real esteem with which I am, dear sir, very faithfully, your obedient servant, CH. D. MEIGS. Professor Simpson, &c. 634. Having reprinted the foregoing in this new edition, in order that the reader might see what I said and thought, in a Journal, in 1848, I have now to state that I adhere, in 1862, to these opinions, and consider them sound and just, and recommend them with a clear conscience to my readers. CONDUCT OF A LABOR. 361 635. Since the date of my letter to Prof. Simpson, I have been induced by many motives to administer ether (never have I given, nor will I ever give any person chloroform), in a considerable number of cases: many of the women were delighted with its operation after they had recovered from the intoxication, but about an equal number appeared to have been disgusted with, or indifferent to its effects. I have certainly observed, in most of the experiments, that it lessened the frequency and power of the pains; and, in some of them, I was obliged to lay it aside wholly, until the motor powers of the womb, recovering from the stupefying influence of the intoxication or dead- drunkenness of the woman, allowed the labor to proceed, or to be terminated by a forceps operation. I have lost two children in labor because of the anaesthesia, as I fully believe; and some of my patients have had affections and post-partum symptoms, the remembrance of which makes me well content to remain among the opponents of the practice. I say these things, not with any feeling of disrespect, nor with a desire to disparage those of my medical brethren who habitu- ally employ anaesthetics in Midwifery, but in order that I may speak the truth as it appears to me, and let that truth pass for as much as it is worth, and no more. I shall only repeat that I sincerely regret the introduction of anaesthetics into Midwifery; not because they are not useful and laudable in some rare cases, but from a conviction that the use of them has become a great abuse, which I believe will become greater until the day—no distant one—shall arrive, when mankind, and the profession also, shall have been convinced that the doctors have made a mistake on this point, in this part of the nineteenth cen- tury. In Nov. 1862, I remain unconvinced of the propriety of using ether in all labor cases, indiscriminately. Since 1852, I have allowed several of my patients to take ether, on account of pain that seemed excessive. All my experience leads me to hold to the opinions expressed in my letter to Dr. Simpson. I am still quite convinced that the discovery of anaesthesia in midwifery, has done more harm than good, and I believe its use will decline, and not increase. I think it is declining already. Now, in Nov. 1862, having declined for the short remainder of my life the business of a physician, and regarding that circumstance as liberating me from many of the mental bonds that qualify more or less every medical man engaged in the active pursuits of the Profession, I distinctly express my regret for the introduction of the anassthetic methods into the practice of midwifery. I consider that notwithstanding there may be some instances in which parturient women should be benefited by the use of ether, yet such cases are extremely rare; whereas the mischiefs arising from the lavish and 24 362 FACE PRESENTATIONS. indiscriminate use of anassthesia, so tempting as it is, are very numer- ous and serious. So far as I am now informed the use of anassthesia in midwifery has made no progress in this country since my last note on the subject in Sept. 1856. (See 371.) CHAPTER XI. FACE PRESENTATIONS. 636. In cases in which the usual dip of the occipito-frontal diameter fails to take place, but, on the contrary, is reversed, so as to allow the chin to depart far from the breast, the head may be actually turned over backwards, permitting the child's face to fall down into the pelvis. In face presentations, as delineated in Fig. 78, annexed, the chin is on one side, and the top of the forehead upon the other • side of the pelvis. The face seems to be looking directly down- wards into the excavation of the lower basin. This could not be the case without complete departure of the chin from the breast (see the figure), and an absolute overset of the head backwards, as in a person who should be looking upwards at an object directly overhead. These are what are denominated Face Presentations: a sort of labors that are now thought to be less unnatural and dangerous, than in former times. I am clearly of opinion that face cases may well be included among the natural labors, except where some failure in the powers of the woman should cause us to convert them into preternatural ones, feeling obliged to turn and deliver by the feet; to restore the vertex by some serious operation ; or to extract with the forceps, or other instrument. The fcetal head being an oval, five inches long, from the vertex to the chin, and more than three and a half inches wide at the widest part, it ought to make no difference, as far as the mere head is concerned, whether the chin or the vertex advances first in labor, be- cause, in either case, the same circumferences of the head are presented FACE PRESENTATIONS. 363 to the planes through which they are to be transmitted. The foramen magnum of the occipital bone being nearly equidistant from the vertex and chin, and situated on one side of the ovoid, the peculiar difficulties and hazards of these labors are attributable, rather to the nature of the articulation by which the neck and head are conjoined, than to the form of the head itself when advancing with the face downwards. The nature of this articulation is such, that extension of the head cannot take place so well as flexion; hence the requisite extension dip of the occipito-frontal diameter is not effected in face cases without difficulty, and the consumption of much time. 637. Let the reader figure to himself the state of the spinal column of a child, urged on in labor by powerful uterine contractions, directed to its expulsion with the face in advance. The inferior-posterior part of the head is pressed against the back of its neck, or betwixt its sca- pulas, which could not be the case without bending the cervical spine backwards, like a bow, while the dorsal and lumbar vertebrae are curved in the opposite direction, causing thus a double antero-posterior curve, on which, in consequence of the elasticity of the two arches, much of the expulsive force is vainly expended; so that, though the power may be as great as in a common labor, it produces much less effect than in a common labor—a great part of every pain being ex- pended in reproducing the greatest amount of curvature; for the elasticity of the two curves is such that they are straightened, at least, in some measure, as soon as the pain subsides, while the rest of the pain is used in pushing the face onwards. 638. A child in utero ought to be in a state of universal flexion, as I have already remarked. It cannot be in extension, as supposed by the old authors, whose rude cuts, accompanying their crude descrip- tions of labors, are calculated to excite a smile of pity in any modern obstetrician. In this state of flexion, the chin approaches or even touches the breast. Such a flexion in a head labor always gives us a vertex position. But if the chin, instead of approaching, depart from the breast, there is a tendency towards the face presentation. Let the Student consider that when the chin departs from the breast, it does so by slow degrees, and not suddenly nor wholly, at once. Hence he should in face presentations, whose whole progress he has opportunity to supervise, expect to touch at first the top of the fore- head as the lowest point, or presenting point. As the labor goes on, the head continues to turn over more and more completely until it is at last quite overset backwards; as may be seen in the annexed draw- ing (Fig. 79), in which, in addition to a face presentation, there is a prolapsion of the left foot. If, in such a labor as this, the foot were 364 FACE PRESENTATIONS. thrust back into the womb during the absence of a pain, we should have a very bad case of face labor, with the chin to the sacrum, and the forehead to the pubis. 639. When the face presents, the head does not enter the ex c a v a- tion with the fronto-mental diameter FiS- 79- parallel to the plane of the strait. On the contrary, the frontal extremity of that line is lowest at first, but the mental extremity of it comes at length to be lowest, at least as regards the successive planes through which it passes in the lower part of the pelvis, as may be seen on reference to the neat figure which is annexed. The direc- tion taken by the face, as it proceeds, in such a labor, is worthy of the closest attention of the practitioner. Should the chin enter the superior strait near to the acetabulum, it will after- wards rotate toward the arch of the pubis, and, escaping under that arch, will rise upwards over the Fig. 80. pudendum, so as to allow the under aspect of the chin and the throat to be applied to the arch, and to the front of the symphysis, while the remainder of the head is evolving itself from the os ex- ternum. In such a birth, the part that first emerges is the chin ; then the mouth, the nose, the forehead, the crown; and, last of all, the vertex, which escapes over the fourchette, whereupon the flexion of the head immediately becomes complete again. This is the most favorable direction for the face to take, and it will generally be found that a well-formed pelvis is capable of transmitting a child of moderate size almost as speedily and safely, in such a labor, as if it were a vertex presentation. Let it be remembered that the symphysis of the pubis is only one inch and a half long, and, of course, if the chin should escape under the arch, the neck is so long that the throat can apply itself against the inside of the symphysis, allowing the chin, nay, the FACE PRESENTATIONS. 365 whole head to be born, before any part of the thorax of the infant begins to plunge into the excavation. 640. Figure 81 may serve to show how the chin, in a favorable case, comes, at last, to the symphysis pubis, slides down behind it, and at length begins to. emerge underneath the crown of the pubal arch. Look at the figure; reflect that the occipito-mental diameter is five inches, and the pelvis only four and a half; and that, as soon as the chin begins to come forward under the arch, the five inch mento-occi- pital diameter is coming, with its mental extremity, out beneath the arch. ' Fig- 81. Fig. 82, 641. The next figure (Fig. 82) shows how the chin rises upwards in front of the pubis as soon as it begins to escape beyond the arch, and thus allows the head to roll out of the excavation. The three outline heads show the three successive positions of the cranium after the chin has once come under the arch. 642. A very contrary state of things from the foregoing obtains where the chin, instead of revolving towards the front, turns towards the back part of the pelvis. Here the forehead must appear first; then the nose; next the mouth; and lastly, the chin, escaping from the edge of the perineum, retreats towards the point of the coccyx, allowing the crown of the head to pass out under the arch; and finally, the vertex emerges, which concludes the delivery of the head. I say that the forehead appears first, not that it is born first, for the part first born is the chin. When the chin has escaped, and begun to retreat behind the perineum, the mouth becomes delivered, then the nose and eyes, top of the forehead, crown, and, lastly, the vertex. This must be the case, considering that the occipito-mental diameter is fully five inches long, and that there is no antero-posterior, oblique, 366 FACE PRESENTATIONS. or transverse line of such length in any part of the lower excavation. It is impossible then to see-saw a FiS- 83- diameter of more than five inches within the excavation. Therefore, if the mental extremity of the occi- pito-mental diameter descends first, it must escape first, and the occipital extremity last. But, while the chin is sweeping, slowly and painfully, down the curve of the sacrum, and especially, when it is goWso low as the edge of the perineum, the breast of the child is also entering the pel- vis, where the space it should occupy is already taken up by the perpen- dicular diameter of the head. Imagine the painful distension of the parts within the pelvis, and the enormous extension of the os exter- num, required for the exit of the child, in such a case! 643. Figure 83 shows the difficulty that is produced by a rotation of the chin backwards, in so clear a light, that I hope it may greatly assist in teaching the young Student how extremely important a mat- ter it is to give all possible aid and assistance to nature, in her attempts to turn it towards the front of the pelvis. 644. The cause of face presentations is not perfectly well understood; it is, however, probable that they are more commonly occasioned by an obliquity of the womb than by any other cause. For example, let the womb, at the onset of labor, be so oblique as to throw its fundus far down to the left side, the child presenting by the head, and the vertex to the right side of the pelvis: the direction of the expulsive force operating on the infant will propel its head against the edge or brim of the pelvis, and either cause the head to glance upwards into the iliac fossa, so as to let a shoulder fall into the opening, or it will be turned over, so as to let the face fall into the opening, and thus produce a face presentation, in which the chin is near to the left aceta- bulum, and the forehead to the right sacro-iliac junction. It is easy to set this in a clear light, especially if it be accompanied with de- monstrations on the phantome. 645. Two Positions onl y.—In my opinion, it would be right to admit, in a systematic arrangement, only two original positions of face-presentations: viz., one with the chin to the right, and one with it to the left in the pelvis; it being always understood, that the position is not necessarily exactly transverse, but that the chin may be variously FACE PRESENTATIONS. 367 addressed, sometimes, and indeed most generally being so far back as to be near the sacro-iliac symphysis, and sometimes more anteriorly, or near the body ofthe pubis: Velpeau prefers to have only two positions. By admitting these two positions only, the Student's mind is relieved from the burden of unnecessary artificial distinctions; and should he in practice rest upon them, it will be easier for him to comprehend the practical doctrines relative to the case. Thus, in all face cases, the great doctrine is to bring the chin to the pubic arch, because the chin, being the mental extremity of the five inch long mento-occipital diameter, may escape by gliding an inch downwards behind the symphysis pubis; whereas, if it be directed backwards to. the sacrum, it must slide five inches down the sacrum and coccyx, and from three to three and a half inches over the extended perineum, before it can be born; but, five inches and three inches make eight inches. The child's neck is not eight inches long. Therefore, before the chin can slide down the sacrum, and off' the anterior edge of the extended perineum, a good part of the child's thorax must be pressed or jammed into the exca- vation along with the head, the vertical diameter of which alone is more than three and a half inches. (See Figure 83.) If we should adopt four positions, we must have a doctrine for each ; but with the two only, there is a necessity for only one doctrine—namely, to bring the chin to the arch of the pubis, if practicable; if not, let th'e fore- head come, and do our best with it. 646. Face presentations are accidents; and, perhaps, they are so un- likely to happen, in consequence of the normal law of foetal flexion, that they ought to be regarded as examples of preternatural labor. Yet, when we come to reflect that the female can generally expel the child with but little more difficulty, in this case, than in vertex posi- tions, it seems altogether proper to regard them as natural cases. But I have said that they are accidents, and I believe that they are accidents generally caused by deviations of the axis of the womb. I beg leave to repeat that, if a female have a very great right lateral obliquity ofthe womb, and the vertex present towards the left side of the pelvis, it may be impelled against the brim in such a manner as to glance above it, and allow the forehead to fall into the opening, which state could not exist long without being followed either by the descent of the face, or the inducing of a shoulder presentation. It should never be forgotten that, from the chin to the vertex is a distance of five inches, which none ofthe diameters of the straits will take in, in the living subject: therefore, if the vertex should rise above the brim, and let the fore- head fall into the opening; the chin would gradually come down. Let not the Student then expect to find the face looking full down 368 FACE PRESENTATIONS. into the excavation, at the beginning of these cases: but rather, let him expect to find it coming more and more completely down as the labor draws to its close; hence, all face cases are at first cases of fore- head presentation, and, whenever the chin departs from the breast in a labor, let him take heed lest it lead to a face presentation, I pro- pose to the American Student to adopt Dewees's recommendation, to have only two face presentations, and to let the first be that in which the forehead is to the left, and the chin to the right side of the pelvis —while the second position is that in which the forehead is to the right, and the chin to the left side of the pelvis. Let this be the deci- sion; and let the Student, though he finds the chin disposed to address itself to a point in rear of the transverse diameter, still consider it as a first position, or a second position, as the case may be. Suppose a case of face presentation to be caused by a right lateral obliquity of the womb, the point of the head being repelled above the edge of the strait: the womb, in its oblique state, leans to the right and for- wards, and not directly towards the right; whence, if the accident occur in the manner supposed, the chin could not fail to be placed to the right, and a little forwards: the same thing is true of cases caused by left lateral obliquity—m utatis mutandi s—as before stated. This furnishes a striking manifestation of the wisdom which, in giving form to the pelvis, even provided us herein a remedy for the accidents that might occur to thwart or prevent the parturient act* Should the chin be towards the posterior part of the pelvis and not susceptible of being directed towards the front of the pubis, the most serious mischiefs might be expected to occur; whereas, when the chin advances towards the pubis, little embarrassment is, in general, to be apprehended. 647. If we could know, antecedently to the descent of the present- ing parts, what they are, it might be supposed that we could easily restore them when wrongly placed, to their proper situation; but, while the presenting part of the child is above the brim, it is very rare, if not indeed impossible, to have such a good degree of dilatation as to admit of the hand being introduced, in order to effect the needful changes. The womb opens as the part comes down, and only as it does come down. Hence, when a face case is ascertained to exist, it is mostly (I say not universally) too late to return it into the abdomen or superior basin ; and as to attempting to bring down the vertex, after the head has once sunk well into the excavation, I regard it as a rash, if not an impossible operation; rash, since it could not be done without very great violence; and generally impossible, since we cannot turn or see-saw a diameter of full five inches in a pelvis furnishing less than FACE PRESENTATIONS. 369 that space. Where it is possible to push the whole mass back, and bring down the vertex, let it be done, if deemed really necessary; but the opportunity to do this good action will rarely occur in practice. Viardel tells us that, in Sept. 1669, he was called to Madame Nissole, who had been already two days in labor with a face presentation. He made use of a compress, with which thrusting upwards with the fingers, he pushed the face, i. e. the head, back again; and so enabled him, after he had raised it up, to slide his hand along the face until he got hold of the vertex, which he pulled downwards, and thus restored the chin to the breast, placing the head in extension. Viardel boasts of this case—but it is doubtful whether he could have pushed the head back if it were already out of the womb at the time of his arrival; and if it were not yet in the vagina, he did an imprudent act of meddlesome midwifery in his operation. He relates the case at p. 110 of his " Obs. sur la Prat, des Ace." Dead, and half putrid children, in whose tissues there is scarcely any resiliency or resisting power left, are not so unapt to come face foremost as living children, in whom departure of the chin from the breast occasions such a great extension of the head as to be painful, whence the living child in- stinctively opposes the wrong tendency, by acting with all its strength, to get the chin back, or the head flexed again. 648. Let me repeat that it is not to be expected that, at the very beginning of a labor, the face of the child shall be found looking directly downwards. When the examination is made early in a labor, the os uteri being dilated very.little, the accoucheur ordinarily rests content with ascertaining that the head presents, and does not endeavor to complete the diagnosis as to position. Hence, there is almost always an early mistake in the diagnosis and prognosis, for it is the forehead that is first felt; and the face itself does not appear in the excavation for some time after the commencement of the parturient throes. The head turns over only by degrees, and allows first one eye to be felt, and then the other, the nose, the mouth, and the chin. In order to exemplify these processes, I shall cite some cases from my record-book. 649. Case.—On the 5th day of February, 1830, I was called to at- tend Mrs.----, in labor with her second child. When I reached her house, it was half past six o'clock in the morning. She told me that she had had pain for a day or two, but was seized with regular labor- pains at four o'clock this morning. Upon making examination per vao-inam. I found the os uteri from one inch and a half to two inches in diameter, with the edges thin and ductile, and the very tense mem- 370 FACE PRESENTATIONS. branes protruding through them during the pains. I could, at first, just feel the even smooth surface of the fcetal cranium, which seemed to be resting or lodged upon the top ofthe symphysis pubis, and not in the least degree engaged, or entered into the superior strait; this was all that I learned from this first examination, and was all that I wished to learn. As the pains were regular and good, I expected soon to find the head engaged within the passage; but I observed that the uterus was very large, as if distended with an undue amount or excess of liquor amnii. At nine o'clock A. M., the pains, although regular and of increasing severity, had not caused the head to engage in the slightest degree; it remained exactly as at the first Touching. These circumstances led me to suspect that the womb was unprovided with a proper degree of energy, on account of its being distended be- yond its just dimensions. I deemed it, on this hypothesis, advisable to rupture the ovum, in the expectation that, as soon as the womb should condense itself a little by the flowing off of the waters, it would acquire such vigor as to compel the head to engage in the strait, and thence pass speedily into the excavation, as I had repeatedly observed to be the case in other persons. Upon rupturing the ovum there came off' a very great quantity of water; I should think nearly two quarts in all: but the head did not advance until three or four pains had acted upon it; after which it came slowly down, and I felt a suture; but as yet no fontanel was distinguishable. The examination induced me to suppose it was a vertex presentation of the first posi- tion, in which opinion I was most egregiously mistaken, in conse- quence of the very careless manner in which I made the investigation. At eleven o'clock I made a more careful inquiry, and was distressed to find that the left side of the os frontis was in the middle of the ex- cavation, and that, by passing the finger very strongly up towards the left sacro-iliac junction, I could feel the edge of the left orbit and root of the nose, beyond which it was impossible for me to reach, in the then state of the organs of generation. It seemed, on account of the advanced state of the labor, too late to turn, even if that could have been considered the best resource; and I was the more averse to such a proceeding, considering that I had before delivered her of a large child, and also that the waters were now drained off, and the uterine contractions powerful. As she had by this time become heated, and very much disquieted with her pains, from which the suffering was severe, I gave her thirty drops of laudanum, and soon afterwards took twelve ounces of blood from the arm. She also got an enema of flax- seed tea and olive oil. The head was now fairly engaged, and the face was becoming more and more the presenting part, notwithstand- FACE PRESENTATIONS. 371 ing my repeated endeavors to push it up, by forcibly pressing against the ossa malarum during each pain; and I became thoroughly con- vinced that it was impossible to force up the face and bring down the vertex by the employment of any legitimate force, or by mere dex- terity. The pains had become so dreadfully severe, and the poor woman suffered such agonies, that I really entertained serious appre- hensions that the womb might rupture itself or the vagina in its vain efforts to carry on the parturient processes, lashed as it was into a rage of excitement by the obstacles to delivery. At my request, Dr. James, at that time Professor of Midwifery in the University of Pennsylva- nia, was invited to see the patient, and arrived at two o'clock in the afternoon; and after having examined the case, left me with encou- ragement to hope that the vertex might come down after some further efforts of the womb. Dr. J. was to return to me at half past four o'clock. In the mean time, I provided myself with the long right hand blade of Davis's oblique forceps; and when the professor re- turned, at four o'clock, it was found to be vain any longer to expect the descent of the vertex. I therefore introduced the blade above mentioned behind the right ramus of the pubis, got it upon the left parietal bone, and, using it as a vectis, drew down with it during the pains. The head advanced very much by this aid, and began to press upon the perineum; but there it stopped, and seemed no longer affected by the vectis. I next attempted, with my Baudelocque for- ceps, to introduce the male blade behind the left obturator foramen. I was foiled, but Dr. James succeeded in adjusting it. Every attempt to adjust the female blade, whether made by Dr. James or by me, proved fruitless. They could not be made to lock; nevertheless, I rashly attempted to deliver with them by securing the joint with one hand, and by this means the head again advanced, but soon stopped. The forceps were now abandoned, after vainly attempting to make them lock. I next resorted to the oblique vectis again, and with it caused the head to advance so much, as to put the perineum in a state of tension. The chin turned to the pubic arch, and then emerged from the genital fissure; and as the successive portions of the face came forth, the chin rose up to the mons veneris, and allowed the fourchette to slip backwards off the vertex, which immediately retired towards the coccyx. This child was born, but the cord, which was tight around its neck did not pulsate; the infant, however, began at length to gasp, and after having been well dashed with brandy, cried lustily. It was born at half past six o'clock P. M., so that the labor was found to have continued about fourteen or fifteen hours. At the time I last put on the vectis, the child's chin was in the left sacro-iliac 372 FACE PRESENTATIONS. corner of the pelvis. Both Dr. James and I expected that the rota- tion would inevitably carry the chin to the sacrum, to be consequently delivered at the perineum. I have every reason, therefore, to suppose that the vectis was the chief means of giving the head so favorable a rotation, a result attributable to the admirable curve of Dr. Davis's oblique blade. The perineum was not hurt; the placenta came off in twenty minutes, and the mother found herself very comfortable, con- sidering her great fatigue. The face was one enormous suggillation, carried to the extent of producing numerous blebs or vesications on the eyelids and cheeks. The mouth was excessively swelled, and the left eye completely closed. The face was, on account of this state, di- rected to be frequently bathed with cream. This infant was carefully weighed on the evening of its birth, and was found to weigh nine pounds and three-quarters. On the sixteenth day after delivery, the woman was down stairs to dinner, and had no subsequent indisposi- tion. In giving the details of this case, I am liable, as I well know, to the charge of having, in an important matter, anticipated my sub- ject : but although I have not yet come to the formal consideration of instrumental cases, I feel pretty well Fig. 84. assured no evil will happen to any Student for having, by reading the foregoing relation, in some degree anticipated the regular and formal consideration of obstetric operations. The cut Fig. 84, repeated from 374, which represents the fcetal head, in a face labor, thrown back to that degree as to press the occipital bone against the interscapular space, suf- fices to show how well founded were my fears lest the forehead, instead of the chin, should rotate to the front, to prevent which is the chief doctrine of this obstetric topic; and I would again urge the Student to take the first opportunity that may present itself, of testing the doctrine, by trying to deliver on the machine, or phantome, with the chin backwards, in a face presentation. By so doing, he will at once have a demonstration of the point of practice to be adopted, and never afterwards be in the least danger of making a mistake, or com- mitting a blunder in this matter. 650. Seeing the great and merited reputation of the late Professor Dewees, of Philadelphia, and the general recourse to, and reliance on FACE PRESENTATIONS. 373 his obstetric precepts, I feel constrained to warn the Student of one error in his " System of Midwifery," 2d edition, 1828. He is speak- ing, at p. 328, of the instrumental delivery in a face-labor. "Should the forceps be determined on, we must apply them over the ears; that is, one blade behind the pubis, and the other before the sacrum; they must be so applied that the concave edges must look towards the hind head, which must be brought under the arch of the pubis and not the chin, as directed by Smellie." This operation would inevitably, if successful, bring the top of the forehead and the crown of the head under the arch, and the chin to the sacrum and coccyx, as in Fig. 84. To deliver it, would imply that the child's throat should stretch to a length beyond eight inches, or that the thorax and head should both be in the excavation together. I should not have noticed this lapsus of my celebrated townsman, but as evidence of my respect for his great reputation, and because I know that it was a lapsus pen- nas, and not a precept that he would follow in practice. When such authorities happen to fall into even a small error, it is proper to point out the error, lest an accidental error with the authority of a great name should mislead the early beginner, or Student. I should think no long disquisition would be required to convince the Student who will carefully examine the Fig. 84, that, in a face presentation with the forehead to the pubis, and the chin to the sacrum, it must happen that a considerable part of the child's thorax shall be jammed, together with the cranium, into the pelvis. The same cut shows that if the occipito-mental diameter be reversed, so that the mental extre- mity of it, instead of the occipital extremity, enters the pelvis first, it must leave it first, for it cannot be reversed within the excavation. Further, let the Student examine the drawing, to see how the chin must in these unfortunate presentations slide down the posterior sur- face of the pelvis, from the promontorium to the point of the coccyx, and so over the perineum, until it escapes from the vulva, over the fourchette. In examining Fig. 80, he will readily perceive how easy it is in that case for the mental extremity of the oblique diameter to begin to escape, since it has only a slide of one inch along the sym- physis pubis to make before it emerges; whereas, in the reverse posi- tion, it slides seven or even eight inches, over bone and resisting tissue, before it can begin to be born. 651. Case.—A case of a different kind occurred to me on Wednes- day, the 17th of February, 1830. Mrs. M. was in labor with her seventh child, having been taken at four o'clock A.M. with the pains, which continued to increase up to the time when I arrived, which was 374 FACE PRESENTATIONS. about half past six o'clock. The pains were strong; the waters gone off'; and the head pretty low down in the pelvis. At my first exami- nation, I mistook the presentation, thinking that it was a vertex case; but, as the pains seemed to have no good eff'ect, I examined again, and could feel the root of the nose directly behind the symphysis pubis, and the superciliary edges of the orbits upon each side of the symphysis of the bone. Upon this discovery, I endeavored to turn the forehead towards the left, by raising the os frontis, and pushing it in the proper direction ; but as soon as each pain came on, it forced the presenting part back again into its former position. I next endea- vored, by simply pushing up the forehead during the absence of a pain, and sustaining it while the pain was active, to cause the vertex to descend along the curve of the sacrum, and on to the perineum: but I could not succeed here any better than in my attempts at rota- tion : the pains drove it back, maugre all my wishes to the contrary. As the chin was so far departed from the breast, I had good reason to fear that the head must turn quite over in extension, and thus give me a face case to manage; for, as I could feel the superciliary ridges on each side of the symphysis pubis, there was some likelihood of a complete overset of the head, provided the cranium was not too large. The patient, who had met with no such difficulties in her former labors, and to whom I was a stranger, now became greatly alarmed and distressed; so much so, indeed, that I judged it most prudent to explain to her the true situation of affairs, and encourage her to look for relief after a reasonable time. I told her that she could be deli- vered by her own unassisted efforts, but that it would take a good deal of time and much pain; but that I could speedily deliver her with the help of an instrument, which would add neither to the hazard or pain of her condition. She clapped her hands, trembled violently, and uttered exclamations indicative of the greatest dismay, and even terror, but at last agreed to be guided by my opinion. I introduced the right-hand long blade of Davis's oblique forceps, with which I caused the head to make a considerable advance; but it again stopped, and I applied the Baudelocque forceps; with the aid derived from this instrument, I drew the head downwards so as greatly to extend the perineum; upon observing which, I deemed it prudent to remove the forceps, lest I might rupture the perineum, which was about to under- go, unavoidably, a very great distension, and which I was not inclined to augment too rapidly. After removing the forceps, I reapplied the vectis, as beforej and it very greatly assisted me to bring the head on- wards as far as was requisite. As soon as I withdrew the vectis, a pain came on, by which the head was expelled, the vertex passing out FACE PRESENTATIONS. 375 over the fourchette, upon which it immediately completed its act of extension, and allowed the crown, forehead, nose and chin successively to escape under the pubic arch. The child was born alive, and the after-birth followed in ten minutes. Upon the infant's forehead was an enormous black suggillation, which disappeared in the course of a few days, and was followed by no inconvenience. Of the above case it is proper to remark that the mother was very well formed, and the pelvis large; the child of medium size; and although it did not be- come actually a face presentation, but was rather a case of presenta- tion of the forehead, it still serves to illustrate my observations on the difficulty of converting face presentations into those of the vertex. I think that, but for the aid of the instruments, k must have at last brought the face from behind the top of the symphysis pubis to look fully down into the excavation; for the difficulty of bringing down the vertex, although not insuperable, was exceedingly great. Per- haps the labor would have been easier, had I turned the head quite over! In some small heads, I have pulled the chin down and let the vertex rise; but this can be well done only where they are small. In the course of my practice, I have met with a considerable number of cases like the one whose relation I have just given, but it seems unne- cessary to cite them here, as I presume this one may suffice to explain the nature of the mechanism of such a labor. 652. Case.—I find in my case-book, another example of face pre- sentation, which I shall not deny myself the privilege of laying before my reader in this place, because it offers good encouragement to those who may happen to meet with such untoward sorts of labor in the commencement of their practice. October 11, 1830. Mrs. C. W., aged twenty-six, was in labor with her first child. I was called at twelve o'clock at night. She had been poorly throughout the day, but kept about until bedtime. At ten P. M., had a violent pain, and large discharge of waters. She lay on her left side. Upon Touch- ing, I could not reach the os uteri, nor feel any part of the child. Upon causing her to turn on the back, I was enabled, by pushing the finger very far upwards and backwards, to hook the anterior lip of the os uteri, and draw it, by means of the finger, downwards and for- wards, into the centre of the plane of the upper strait: I could then touch the child's cranium, but I could not touch a sufficient portion of it to learn what part of the cranium it was. Not long afterwards I felt, in the left anterior part of the upper strait, a ridge or edge, which I soon made out to be the superciliary edge of the orbit of the left eye, the globe of which soon came within my reach. I could not 376 FACE PRESENTATIONS. touch the anterior fontanel. Here, then, was a crfse which, like that just now related, was to become a face presentation at last, if I should prove unable to prevent it by failing to restore to the head its lost flexion. I vainly tried to do this by pushing up the forehead, and holding it up during a pain. It always came back to its place, in spite of whatever efforts I could make. I next introduced the whole hand, except the thumb, took hold of the vertex by a fair purchase, but could not turn it downwards; and at length, becoming convinced of the impossibility of succeeding, resolved to abandon such irritating interference. As the head sank lower and lower, there was an obvious tendency of the chin towards the left sacro-iliac junction. I opposed this movement of the head by pressing the finger on the left side of the nose, which kept it from turning to the left, and at last brought it to the obturator foramen. The face came more and more down into the excavation and began to swell very much. The lips became ex- cessively tumid, and the whole face at last felt like a tense bladder. By the force of the pains alone, the chin was afterwards slowly brought to the os externum, and applied itself to the top of the pubic arch, under which little by little it emerged, and then rose up towards the mons, permitting the front of the throat to take its place under the arch, and thus allowing the vertex to escape last from before the fourchette. (See Fig. 82, p. 365.) The placenta came off in six minutes. The infant was very weak, and its face greatly swollen, and black with the suggillation. It soon cried loudly, and I found that on the 14th, that is three days after its birth, it was in fine health, and without any swelling of the face. The mother had a very favorable getting up. The net weight of the infant was nine and a half pounds. The mother was a large and very powerful woman. 653. Madame Boivin informs us, in her " Me"moires sur l'Art des Accouchemens," page 276, that, out of seventy-four cases of face pre- sentations, fifty-eight children were born naturally. Of these, forty- one were delivered without any assistance, and seventeen, by restoring the vertex to the centre of the excavation ; a success almost incredible. Fourteen cases required the turning and delivery by the feet, while only two were extracted by the forceps, and in one of the latter cases the mother had convulsions. " Thus," says the learned lady, "although presenting by the face, the child may be born alive and naturally, provided the head be not too large, if the parts of the mother are well formed, the pains strong and good, the woman resolute and healthy, and no accident occur during the course of the labor." 654. Madame Lachapelle, whose vast experience, gained while at the head of the Maternite Hospital at Paris, gives her valid claim to FACE PRESENTATIONS. 377 speak as with authority, and whose thorough knowledge of the theory of midwifery must confirm those claims as rights, gives us only two sorts of face presentations: one in which the forehead is to the left, and the chin to the right of the pelvis, and the other in which the forehead is to the right and the chin to the left. She says she never met with Baudelocque's first and second positions. Dr. Dewees, who asserts that his list comprises near nine thousand labors, also informs us that he never met with them. It will be remembered by the reader, that the second case which I related in this chapter, that of Mrs. M., was one in which I felt the root of the nose behind and above the symphysis, and the two orbits on each side of it; and he will admit that, although the vertex was at last restored so as to escape first, yet this was a real example of a face case of the rarest occurrence. Smellie gives us at least four examples of the face presenting in Baudelocque's first or second position; and assuredly no English or American student of Midwifery will be disposed to call in question the accuracy or candor of that admirable author, notwithstanding that Madame Lachapelle tells us she finds no very evident examples of such face positions in any good collection of cases. 655. For my own part, I do not perceive the great importance of dwelling with much emphasis upon all the possible positions of the face. It cannot be doubted that they are each possible, inasmuch as, where the child's head is not disproportionately large, the mass of the head is observed to rotate upon the cervical axis, as I before remarked, sometimes threatening to carry the chin towards the sacrum, and sometimes flattering the accoucheur with the prospect of its speedy arrival at the pubis." The more important and useful knowledge is that which teaches us the nature of the accident, and the appropriate indications of treatment. But we have already seen that the accident consists in an excessive departure of the chin from the breast, or failure of flexion; that is the first principle: and that the chief indi- cation founded upon it is to restore the flexion by pushing up the forehead, and bringing down the vertex; and where that cannot be done, the next indication is to rotate the chin to the front, so that flexion may take place as soon as possible after the chin has emerged. I am not capable at present of stating the number of face cases I have had occasion to treat. The number has been considerable. The result, as to its influence on my opinion, is that they are rarely for- midable when the great precept of bringing the chin to the pubis is understood and can be fulfilled. Certainly, I have not been, in a majority of my cases, called upon to use any extraordinary measures of relief. 25 378 PELVIC PRESENTATIONS. 656. I have a word of counsel for the Student as to the care of his own reputation in the conduct of such cases. There can rarely be met a more disagreeable spectacle than that of a new-born child's face, after a bad face-labor. It is frightfully suggillated, and often covered with blebs filled with yellow or bloody serum: the lips are completely in a state of ectropy, the eyes closed by infiltration of the palpebras, and the nose enormously swollen. Bystanders cannot comprehend why these appearances should exist in a neonatus that has been tenderly treated—and are therefore too apt to assign as the probable cause the rudeness and brutality of the medical man. As soon as the young beginner has surely made his diagnosis, let him announce the proba- bility of a swollen and blistered face, notwithstanding the gentleness of the treatment which he is about to administer. In this way he may save and augment not only his own credit, but that of his art, a pleasing duty for every true scholar. As I shall have occasion to revert to the consideration of face-positions when I come to treat of the various uses of the forceps, I shall close the present chapter, in order to take up the consideration of those labors in which the child presents the breech, knees, or feet, when descending. (See 759.) CHAPTER XII. OX PRESENTATIONS OF THE PELVIC EXTREMITY OF THE F(ETUS. 657. As the length of the gravid uterus, at full term, does not exceed twelve inches, and as a well-grown foetus is nineteen or twenty inches in length, it is evident, as I have already said (159), that it must, while in utero, be folded up in a very compact form, and that it will be an oval body, one of the extremities of which ought to be directed towards the orifice of the womb, and the other to the fundus. The most natural position of the foetus is certainly that in which the head points down- wards ; so that the vertex, or some other part of the head, may, in labor, advance first. But it happens that about one in every forty-five or fifty cases presents the other extremity of the ovoid to the os uteri; and, in doing so, it is a matter of mere chance whether the breech, or the knees, or the feet, prove to be the presenting part. In strictness, PELVIC PRESENTATIONS. 379 the breech ought to descend first in these labors, but if the feet happen to be near when the membranes give way, they are quite likely to prolapse into the opening, and pass, soon afterwards, out at the vulva; so that, supposing the breech presentation to be, after that of the vertex, the most natural, we may properly include, in the account of the presentations of the pelvic extremity, those of the knees and feet, and regard them as mere accidents of the pelvic presentations, and all to be included under the head of natural labors, agreeably to the doctrine expressed in a former page of this work (165)—a doctrine that announces two essential presentations of the foetus, one a cephalic, and the other a pelvic presentation; each of them is, liable to the accidents appurtenant to their form. 658. Causes of Pelvic Presentations.—The causes which pro- duce these presentations must be purely accidental. The most natural presentation is that of the head, which is turned towards the os uteri from the earliest period of pregnancy. The insertion of the navel- string is nearer to the pelvis than to the head of the child, the head therefore hangs downwards; but when the cord, by the growth of the ovum, has become of a very considerable length, the child ceases to be dependent from it, for the cord is not unfrequently from twenty to thirty inches long. It seems very probable that while the foetus is yet small, it may change its position in the uterus; but if it happen to turn as late as the fifth month, it will be apt to retain the attitude it may then acquire till the end of the pregnancy, as its length does not admit of its changing again very readily after that period. It is not to be doubted, however, that the attitude may, by certain extra- ordinary or violent movements of the mother, be reversed, at a later period, so that the head, which was originally at the os uteri, may be afterwards brought to the fundus, and vice versa. Prof. Paul Dubois, of Paris, has an article in the " Mem. de l'Acad. Royale de Med.," in which he endeavors to show that the child does turn its head downwards in consequence of a certain instinct at about the seventh month, but I am far from being convinced by his arguments. It is not an easy matter to determine why the breech presentation occurs about once in forty-five or fifty labors, and it is far less easy to say what is the reason that certain women are prone to this sort of labor to such a degree as to.bring all their children so. I knew a woman whose children, four in number, were all born with the breech pre- sentation, and it is by no means very rare to meet with persons who have been similarly situated in more than one of their labors. Dr. 380 PELVIC PRESENTATIONS. Collins, of Dublin, in his "Practical Midwifery," informs us that one woman who was delivered at the Dublin Lying-in Hospital had pre- ternatural presentations in every one of her labors, and she had given birth to nine children. While that gentleman was master of the Dub- lin Hospital, sixteen thousand four hundred and fourteen women were delivered, of whom three hundred and sixty-nine had presentations of the breech, feet, or knees; making rather more than one such labor in every forty-five cases. Out of 54,723 labors stated by Boer, Bland, Merriman, Boivin, Lachapelle, and Nasg&le, there were 1694 cases of breech, feet, or knee presentations, which give us one pelvic presenta- tion in thirty-two and one-fifth cases nearly. It is commonly assumed that about one in forty-eight, or more generally two in 100 cases will prove to be pelvic presentations. 659. Some persons will not agree with me in regarding the pelvic as a natural labor; yet notwithstanding the breech presentation is met with only once in forty-five or fifty labors, I am not inclined to regard it as a preternatural case, for I cannot discover any reason for classi- fying it along with that sort of births, in the mere fact that the head does not present. The breech composes one end of the foetal ovoid; and a breech labor requires, for its complete success, no greater dila- tation than that demanded for the passage of a head presentation; it may be effected without any aid, and is, perhaps, not really fraught with greater danger for the mother than the other, the common vertex presentation. It is, however, far more dangerous for the child than the vertex case ; and as the object of parturition is the safe birth of the infant, it might be absolutely proper to include, in the class of preternatural labors, all those in which the child is exposed to unusual hazard. Still, many breech presentations terminate favorably with great celerity and without any artificial aid, whence I look upon them as not really preternatural. In former times these presentations of the pelvic extremity of the foetus were regarded as much more serious events than they are at the present day. The ancient Romans used to call all those persons that were born by the pelvic presentation Agrippas, as is seen in the following passage from Pliny, lib. vii. cap. viii.; and all such labors were regarded as not natural. " In pedes procedere nascentem contra hatura est, quo argumento eos appellavere Agrippas utaegre partos; qualiter M. Agrippam ferunt genitum unico prope* felicitatis exemplo in omnibus ad hunc modum genitis." If the birth of Marcus Agrippa were really the only instance of a safe de- livery of the child in a breech presentation, we should not have occa- sion for surprise at Pliny's opinion as to the preternatural character of PELVIC PRESENTATIONS. 381 such labors; but doubtless, thousands of Roman children must have been safely born so, and that without any assistance in the birth. That sprightly and most delightful old book—the first Midwifery book ever printed in England—I mean the " Byrthe of Mankynde," by Thomas Rainald, Lond., 1565, at fol. liii., has the following: "Agayne, when it proceedeth not in due tyme, or after due fashion, as when it commeth forth with both feete, or both knees together, or els with one foote onlye, or with both feete downwards, and both handes upwardes, other els (the whiche is most perillous) sidelong, arselong, or backlong, other els (having two at a byrth) both proceade with theyr feete fyrst, or one with his feete, and the other with his head, by those and dyvers other wayes the woman sustayneth great dolour, payne, and anguishe," Thomas Rainald would be very much surprised and comforted could he see what facilities modern science has provided for the obviation of all these terrible occurrences. 660. The danger to the child, here depends on its liability to as- phyxia, from several causes: first, from the compression of the cord, which is pressed betwixt the child and the parts from which it is es- caping; second, from the detachment of the placenta before the head is born, by which the uterine life of the child is destroyed before its birth; thirdly, the compression of the placenta itself betwixt the uterine parietes and the head ofthe infant; or fourthly, the constriction of the placental superficies of the womb, during the time that the child's head, still remaining in the vagina and lingering there, ceases to dis- tend the uterus, which closely contracts on the after-birth, and even though still retaining its connection with it, yet suspends all the utero-placental operations, on which the foetus depends for existence antecedently to the establishment of its respiration. The last named cause is, I presume, the one chiefly to be feared; and I have long deemed the pressure upon the umbilical cord, in breech cases, a matter of small moment as to the child's security, in comparison with the as- phyxiating influence of the compression, detachment, or constriction of the placenta by the reduction of the superficial content of the pla- cental seat. It is probable that that seat, which is eight inches in diameter before the commencement of the labor, is diminished to a diameter of four or even perhaps three inches by the time the head is driven out of the womb into the vagina in breech cases. Under such a reduction, no valid placento-uterine intercommunion can be sup- posed possible. Very often it must happen that the whole placenta is off long before the head gets even out of the womb and into the vagina. 382 PELVIC PRESENTATIONS. 661. The breech may descend into the excavation, and it may even pass through the vulva, without the least danger of compressing the cord; but when the body of the child has sunk so low as to bring its navel down into the bony pelvis, there is little danger that the arteries of the cord shall be completely obstructed for a period long enough to give the child a fatal asphyxia. Such an event is far more likely to occur where the feet present than where the breech advances; because in the latter case, the thighs, and generally the legs, are extended along the front of the body in such a manner as to protect the cord from pressure, its vessels being fully guarded by its position betwixt the thighs, during all the time the body is escaping; thus enabling the infant better to bear the temporary pressure on the cord for the short time it must be compressed by the head only, while that part stops in the excavation; longer pressure by the head would easily extinguish the remains of a life that was already about to expire from preceding obstruction of the cord circulation. In general, the danger for the child is not great until the head has sunk down into the exca- vation, because it commonly does not take a great deal of time for the whole of the body to pass through the dilated canal of the vagina; but the head, being subject to arrest while in the passage, may there fatally compress the cord betwixt itself and the bony sides of the pelvis. W^ know that the prolapsion of the cord, in an ordinary vertex labor, is very apt to occasion the death of the foetus; aud it is therefore easy to perceive that such compression of the cord, between the fcetal head and the pelvis, is here the real cause of the loss of the infant. From this we might naturally suppose that those children that are lost in breech and footling cases are lost from the same cause, to wit, a compression of the cord. But I believe upon evidence, that the placenta is often detached as soon as the breech or even the head leaves the uterine cavity: and if so, then the child is rather lost from the suspension of the placento-fcetal circulation by the afore-mentioned detachment, than from the compression of the cord only. 662. Fatalities in Breech Cases.—I think it probable that more than one child in every five that presents by the breech, or feet, or knees, perishes in the birth. Certainly, if we may judge from what Pliny says about the Agrippas, in the passage quoted but a little while ago, the highly civilized people of Rome, and probably the ancients in general, looked upon these labors as replete with danger, and hence, if four out of five children born in this manner escape with life, such a success is as much as we ought to expect—all the world over. In PELVIC PRESENTATIONS. 383 large lying-in hospitals, perhaps, the proportion of fatal cases is rather less unfavorable, in consequence of the prompt attention always paid in such establishments to the parturient female, and to the greater skill and dexterity acquired by abundant opportunities of practice. Of Dr. Collins's cases, 369 in number, of breech, feet, and knee pre- sentations, 234 were born alive, and 135 were born dead—some of which were putrid, premature, &c. In Dr. Cazeaux's "Traite' Theo- rique et Pratique de l'Art des Accouchemens," a work published in Paris in 1840, and which is said to enjoy the very highest favor in France, there are the following remarks upon the subject ofthe danger to the foetus in pelvic presentations. I translate it, as containing a late novelty upon the subject. " Delivery by the pelvic extremity is very dangerous for the child. The statistical results furnished by Madame Lachapelle prove that, out of eight hundred and four pre- sentations of the pelvic extremity of the foetus, one hundred and two children were born feeble, and one hundred and fifteen were born dead. The proportion of dead children to the whole number is one- seventh; whereas, in 20,698 vertex positions, there were only 668 dead born ; which is one in thirty, or about one-thirtieth. As to the prognostics of the several sorts of pelvic presentations, it has been remarked that, when the breech comes down first, the number of dead born is about one to eight and a half, which is about an eighth and a sixteenth. In footling cases, one out of six and a half die, a sixth and more; and lastly, for the knee cases, one out of four and a half." M. Cazeaux goes on to say that the above is not a fair representation of the dangers to the child in these cases; for these results do not exclude those cases of dead born that are not properly assignable to the presentations as causes of the death; the statements ought to ex- clude putrid foetuses and deformed children; and he states, as the opinion of M. P. Dubois, that, setting aside all the cases in which the children appear to have been lost from causes not connected with the presentation, M. P. Dubois has arrived at this result, that in labors with footling presentations, there dies one child out of eleven, whilst in presentations of the head there dies one out of every fifty. It is plain that the difference is frightful.—P. 359. 663. Diagnosis.—It is a question whether the nature of the pre- sentation can be discovered by reference only to the movements of the foetus in the latter stages of gestation. Some persons have foretold that the child was improperly placed, judging it so to be by feeling a greater degree of motion in the pelvic region than in the upper part 384 PELVIC PRESENTATIONS. of the uterus. It seems not difficult to believe that, if the motions of the child should be chiefly felt towards the cervix uteri, they ought to be accounted for by referring them to the presence of the feet in that quarter. However, I feel assured that those patients whom I have attended, and whose labors were accompanied with this presentation, were in general utterly unsuspicious of it in pregnancy ; and they are, commonly, ignorant of it until the child is born. It is not rare, indeed, for women to fear that the child is to be born double, as it is called, when the vertex really does present; and many patients are quite convinced the child is wrongly placed, until labor comes on to prove their fears ill founded. There may be some certainty obtained by a diagnosis derived from the stethoscope applied to different parts of the uterine region ; for, if the child's head be directed towards the fundus uteri, there will be heard, in consequence, a pulsation of its heart at a higher level than if the head occupy its more natural position—pro- bably near the navel; but there will always remain some liability to wrong impressions, if they be derived from auscultation alone. The surest way is that of the Touch, which is scarcely to be confided in except at the commencement of labor, or at a period when the pre- sentation can be touched with the tip of the finger. 664. When the breech can be reached per vaginam, it ought to be recognized by its mass filling up the pelvis; by its softness, and its fleshy feel, so different from that of the fcetal head; by the tubera ischii; by the point of the coccyx, the anus, and the organs of genera- tion, male or female; by the spines of the sacrum, and by the sulcus found between the nates and the thighs, which tend upward from the presenting part; I may add, also, by the meconium, which is often discharged at a pretty early stage of labor, and comes away with the waters on the hand of the accoucheur; but let not the young accou- cheur be deceived by this symptom, since it is possible for portions of the meconium to come away even in the best vertex position. It is also to be observed that the form of the bag of waters is commonly not so much like a segment of a sphere in the presentations of other parts than the head. In breech presentations, it is more like an intes- tine in shape, sometimes descending to the very orifice of the vagina, and yet not very considerably dilating that passage. Notwithstanding we ought to be able clearly to distinguish betwixt the breech and the head presentations by the first touch, it is, I think, not very uncom- mon for us to make a great mistake, if I may judge from the instances of mistakes that have come under my knowledge; but I am sure that such errors are the results of mere carelessness, and they could PELVIC PRESENTATIONS. 385 therefore always be avoided. Let it not be here understood that, when the true nature of the presentation is known, it ought to be communicated to the patient; on the contrary, it should be carefully concealed from her, as not calculated to promote her easy deliverance, since she attaches to the circumstance the idea of greater suffering or danger, which, by depressing the powers of her mind, would be very apt to affect, in an injurious manner, the pains or the voluntary efforts that she ought to have in their greatest vigor. While the nature of the case, then, is carefully concealed from the patient, it should be formally announced to her husband, or to some responsible person, and all the hazards of such a situation for the infant should be ex- plained, in order that, if any untoward incident should cause the infant to be still-born, no unjust imputations might lie against the candor, the skill, or dexterity of the accoucheur. 665. Not to bring down the Feet.—When the breech is found to be the presenting part, it is very natural to suppose that, could the feet be brought down, they would give us the command of the child, so that we could very greatly assist in its delivery; and this is quite true; nevertheless it is bad practice to bring the feet into the vagina, except for some very well understood and sufficient cause. When the child descends d o u b 1 e, as it is called, the parts yield very slowly for its advance, and this tediousness is a necessary consequence of its bulk, and the yielding nature of its substance. Unlike the head, which is hard and firm, this part, when urged downwards by the pains, gives way before them, and is compressed so much that each pain is half lost in compressing the yielding mass before the part becomes firm or condensed enough to make it act as a dilater. This slowness is greatly to be deprecated; and all proper means to obviate it may be safely resorted to, such as a venesection, or the administration of a clyster or a dose of castor oil, &c.; yet this very slowness, and the great size of the breech, serve as means for the child's security, at the last moments of labor. By their means the os uteri, vagina, and vulva are so completely opened, become so absolutely cylindrical, and are so entirely deprived of the power of resisting, that when the head comes to take the place of the body in the excavation, a very little force of the woman's straining serves to extricate it; or at least the complete dilatation enables the accoucheur to employ his hand or his forceps to extract the head in time to save the child from an asphyxia, which is almost sure to affect children that are not born very soon after the escape of the shoulders, during the whole time the head is passing the 386 PELVIC PRESENTATIONS. vagina; for the placenta would be now so completely squeezed by, or even separated from, the womb, that the utero-placental functions must cease to be performed. 666. The Breech to descend -without help.—The impatience, which can scarcely be avoided when witnessing the throes of the mother or the perils of the child, also exposes us to the danger of doing it a great harm by pulling strongly by the breech, shoulders, &c, in order to get both mother and infant the more speedily released; but if any one will take the time to reflect that the spinal marrow may be greatly injured by a violent extension of the neck, it will be evi- dent to him that no very great amount of extracting force ought to be applied. It is best, therefore, as a general rule, to permit the breech to descend, and not in any mauner to interfere with the feet until they are spontaneously born: an extracting force has also an invariable tendency to slip the arms upwards, so as greatly to embarrass the last and most important act of the breech labor. The child is wholly ex- pelled by the uterine contraction, being pushed out of the womb in consequence of the approach of the fundus to the cervix of that organ : in that natural process, if the arms happen to be resting on the sides of the abdomen of the child, they ought to descend pari passu with the parts on which they rest; but if the child be pulled out, then, as the fundus uteri does not press with a proper power upon the head, the arms will naturally slip up over or alongside of the head, where they sometimes are so firmly fixed as to make it a very difficult matter to bring them down again. Hence the soundest discretion teaches us to let the womb push forth the breech as we let it push forth the head, in vertex labors, without laying hold of it to drag it downwards as soon as the least purchase can be had on the presenting part. The legs, in a breech presentation, may be turned upwards on the child's belly, or they may be flexed on the thighs, so as to bring the feet very near the nates. If the breech engages in the pelvis, or begins to pass the circle of the os uteri, the feet disappear, rising as the nates descend. There is no danger of injury to the hip or knee-joint, if the child be trusted to the natural powers employed for its birth or expulsion ; but whenever much force is employed by putting the fingers in the groin, we do incur the hazard of breaking or dislocating the thigh. 667. Positions of the Breech.—The breech may have one of four positions: 1st, the child's back to the left acetabulum of the mo- PELVIC PRESENTATIONS. 387 ther; 2d, to the right acetabulum ; 3d, to the pubis ; 4th, to the pro- montory. These several positions are easily discriminated in practice by the Touch, which ought not to mislead any attentive or considerate practitioner, since by the Touch it is easy to learn where are the coccyx, the tubera ischii, the genitalia, the sulcus betwixt the thighs, the sacrum, &c. &c. As the escape of the breech occasions a great distension, the perineum requires a most careful support by pressing a soft napkin against it, for the purpose, first, of resisting its too rapid advance, and second, in F]S- 85, order to give to its movement that curvilinear direction which ushers it into the world in a course coinciding with the line of Carus's curve. Figure 85 exhibits to the Student the appearance of bending which is acquired by the pelvic ex- tremity of the trunk while passing outwards in a breech labor. It is manifest that the perineum may be here subjected to a great degree of dis- tension. As soon as the body is so far born as to permit the navel-string to be reached, it is to be drawn downwards a little, so as to free it from the danger of being broken off, or the other danger of a too early detachment of the pla- centa. It is easy to draw a considerable Fig. 86. loop of it downwards, by pulling at the yielding portion, as in Fig. 86. As soon as the feet are delivered and extended, they, as well as the body, should be wrapped in a napkin, in order that the skin may not suffer any injury, and also for the purpose of enabling the accou- cheur to hold it more firmly, which he could not otherwise do on account of the viscous nature of the substances that ad- here to it soon after it emerges. 668. First Position.—In the first position of the breech, the child's left hip should rotate to the left towards the pu- bis so as to allow the sacrum to glide down along the left ischium, and the right hip to fall into the hollow of the sacrum. Fig. 87 shows this. pelvic presentation in situ before rotation, while Fig. 85, above, 388 PELVIC PRESENTATIONS. exhibits the appearance after the rotation has taken place. But after the hips are fully delivered, they reco- ver the obliquity of their former situa- tion, and the body continues to descend so, until the shoulders, entering into the pelvis in an oblique direction, come to rotate as did the hips; the left shoul- der advancing to the pubis, as the hip did, and the right one falling back into the hollow of the sacrum. In Fig. 86, or second position, the right shoulder has come to the pubis and the left to the sacrum. When the shoulders do not come down well, a finger should be passed up so far as to reach above the one that is nearest, to depress it by drawing it downwards with the finger, which commonly suffices to cause the arm to escape. But if the arm does not descend readily, let the finger be slid along its upper surface to a spot as near as may be to the bend of the elbow, and then the elbow may be drawn downwards with considerable force, and without any danger of fracturing the os humeri. One arm having escaped, there will be little difficulty or delay in getting the other down, especially if care be taken to move the body, rotating it in a line of direction opposite to or away from that part where the arm is detained. As soon as the arms are delivered, an examina- tion should be made in order to learn how the head is situated. If the face is found in the hollow of the sacrum, and the chin well down to- wards the fourchette, it is well. The child's body ought now to be raised, upwards on the practitioner's arm, to a height sufficient to enable the longest axis of the head to become parallel with the axis of the vagina, and the patient should be urgently exhorted to bear down and force the child's head out of the passage; for at this time the head is not in the womb, but in the vagina, and for its expulsion there is required rather the effort of the abdominal muscles than that of the uterus, which doubtless does, in many instances, partially close its orifice above the vertex, in this stage of a footling or breech case. If the patient therefore does not make a very great effort of bearing down, or expulsion, the head must remain in the passage; during all which time the child is exposed to the risk of perishing by asplwxia. It is true that the pressure of the head upon the parts tends to produce a violent tenesmus, which compels the woman to strain very much; but it is also true that in some instances she will not make the smallest PELVIC PRESENTATIONS. 389 effort, unless urged or commanded in the most earnest or even vehe- ment manner by the physician. Should the Student make the grave mistake of waiting for a pain, he might lose the child. Let him not forget what I have above said, viz., that the child's head is out of the womb and in the vagina, and that the action ofthe womb has nothing further to do with it; for the expulsion of the head is now to be effected by a tenesmic, and not by a womb contraction. Some aid may be given at this critical moment by drawing the child down- wards; but the attendant should always carefully reflect, while em- ploying anyextractive force, that the child's neck will not bear a great deal of pulling, without the most destructive effects on the spinal mar- row. Certain it is that the infant in the birth will not safely bear more force applied to its neck than one after the birth, a reflection that ought to regulate the physician always, who should remember that the infant will not safely bear a more violent pull by the neck in this situation, than it would if dressed and lying in its mother's arms. Such a reflection would be a very Useful one for the occasion. If all his exhortations should fail of causing the woman to assist him by bearing down, let him endeavor to preserve the child from suffocation by passing two of his fingers upwards until they reach the two maxil- lary bones, and cover the nose; by doing this, the backs of the fingers, pressing the perineum backwards, serve to keep an open communi- cation with the air, and the child can breathe very well until the tenesmus comes on. I have kept a child alive in this way, breathing and sometimes crying, for twenty or twenty-five minutes before the birth of the head, and thereby saved many a life that must have been lost but for this care. At last the head descends and escapes from the vulva very suddenly, after which, the placenta having been duly at- tended to, the delivery is complete; whereupon the patient may be put to bed. 669. Second Position.—The rule for managing this case is the same as that for the first position. Here the sacrum of the child is to the right acetabulum of the mother; the right hip to her left aceta- bulum, and the left one to her right sacro-iliac symphysis. As the presenting part descends, the right hip comes to the pubis, and the left falls into the curve of the sacrum. 670. Third Position.—Here the sacrum of the child lies behind the pubal symphysis—its right trochanter to the left ischium, and its left trochanter to the right ischial plane. In any such case, there will be rotation, converting it into one of the first or one of the second 390 PELVIC PRESENTATIONS. position, as accident may determine. It requires no further observa- tion in this place. 671. Case.—A few years ago, I was engaged to attend a young woman in her first childbirth. When she fell in labor, I discovered that the breech presented. Her residence was about three-fourths of a mile from my house. I was very much inclined to send for my for- ceps, for fear that when the head should come at last to occupy the vagina, I might be unable speedily to deliver it: but as she was ex- ceedingly delicate and timid, and her friends anxious, I deferred send- ing for them lest needless alarm should be the consequence of bringing them to the house. The labor proceeded favorably until the shoulders were free, and then, notwithstanding the head took the most favorable position, I found no exhortation or entreaties sufficient to make the woman bear down, and the child soon became threatened with asphyxia, which I obviated by admitting the air freely to its mouth and nostrils, by pressing off' the perineum, as before explained. The child cried from within the vagina, and I felt a hope that the forceps, which I now sent for, would arrive in time for its succor. The instru- ments were placed in my hands in the shortest time possible. In two minutes after I received them they were applied, and the head with- drawn, but it was too late to resuscitate the child. I have never since failed to order my forceps to be placed within my reach in any case of footling or breech labor, and I feel well assured that the consequence of this care has been the saving of several lives that must have been lost but for this precaution. I have lost but few children in pelvic presentation of late years. It is my invariable custom to order a forceps to be got in readiness as soon as I ascertain that the presenta- tion is not one of the head; and I feel well assured that such a pre- caution, if generally observed, would preserve many a life that would be lost, either by delay in the delivery of the head, or by pernicious attempts to extract by pulling at the neck, to which the temptation is so strong in moments of great anxiety for both parent and off'spring. It is so unpleasant an event in the practice of Midwifery to lose a child in the operation, that the accoucheur ought to take all the pre- cautions possible to free himself from reproach, which he shall scarcely escape, in consequence of the utter ignorance of the nature of parturi- tion even in what is called educated or good society. 672. Case.—On the 11th of September, 1848,1 visited a primipara lady in labor, at 7 A. M. She had been in sharp pain from 10 P. M., nine hours. The os uteri was not so large as the end of a finger. PELVIC PRESENTATIONS. 391 Upon ausculting and examining by palpation, I determined a pelvic presentation. At 12 M., I thought the labor would continue until morning, so slow was the dilatation; but at 5 the membranes gave way, and all the liquor amnii came off, the os uteri being still rigid and irritable. The bands of the upper os uteri were more tense and unyielding than those of the os tineas proper. The child was still in health, as ascertained by the regular action of the heart. I had an- nounced all the hazard for the child early in the day. My forceps was at hand; at 8 P. M. the head was thrust into the vagina, and, as I failed to deliver it with my hands, I applied the forceps and speedily drew out the head. The child was quite dead. There was no motion of the heart. When I drew down the feet, I found there was no vital tension in the limbs. Now I feel sure that this child perished by asphyxia from the unmitigated pressure of its placenta against the head consequent to the discharge of the waters. It perished of course before the operation. How could I, by any careful obstetrical measure, have saved it? I regretted, upon finding it dead, that I had not repeated my auscultations, after the rupture of the ovum. Had I done so, I should have been able to announce the lbss of the child long before the midwifery opera- tion became possible. I do not suppose that I am blamed by its friends, but a young accoucheur would feel less uncomfortable in such a case for having announced his prognosis. Hence, let ttie Stu- dent remember to auscult often towards the close of pelvic labors. 673. Fourth Position.—In those cases in which the sacrum of the child is directed towards the mother's back, it is highly desirable so to conduct the labor as to effect a complete rotation of the child before the head begins to get fairly into the excavation. If this change does not take place spontaneously, or by the skilful interfer- ence of the accoucheur, it must happen, at the last and most important stage, that the chin will be to the pubis, and then there will be some difficulty in obtaining the requisite dip of the head or its due flexion. It is exceedingly dangerous for the child to be so situated, but happily there is a method by which it may be hopefully assisted. As soon as the shoulders are fairly freed from the vulva, the edge of the peri- neum tends to compress the neck of the child, and force it upwards against the arch of the pubis. In some cases, the perineum is so strong or elastic as to exert a considerable power in this way; and it is clear that, if it be not counteracted, the chin may be lodged upon the top of the symphysis of the pubis, which will wholly prevent the flexion of the head from taking place. For, if the perineum should 392 PELVIC PRESENTATIONS. press strongly on the nucha, it would push the front of the neck or throat hard against the symphysis, so as to prevent the chin from coming down. Under such circumstances, the child speedily perishes. The indication is to push the perineum back again, or carry the child far back towards the coccyx, and afford space enough to let the chin descend, either spontaneously, or by pulling it down, after introducing the fore and middle fingers of the right hand into the mouth. As soon as the chin is well brought down, the woman should use all her power to assist in the expulsion of the head. I have found that the best attitude for the mother, in this kind of delivery, is that which is advised for forceps operations, to wit, that in which she is placed on her back with her hips brought quite over the edge of the bed, the feet being supported by two assistants; so that, when the shoulders are delivered, the child may be supported almost in a vertical posture, as if standing, by the left hand of the accoucheur, while his right hand aids in the delivery of the head. I am sure that much greater com- mand of the labor may be had in this position of the patient than in any other that can be devised. But, as I have already observed, we should always endeavor to manage the case so as to get the face into the hollow of the sacrum, instead of letting the chin come to the pubis. If, therefore, the breech sink into the excavation in this unfavorable manner, we should, by pressure with two or three fingers, endeavor to force that hip which is nearest the front towards the symphysis, and if we succeed in effecting its delivery in that position, we should, with a proper degree of force, continue to turn the forward hip more and more round, so as to bring the child's spine at least as far in front as the ramus of the ischium or pubis; so that, when the shoulders begin to enter, they may enter obliquely, and that, after they have passed down, the head may also enter obliquely, or at least transversely. For example, let the sacrum be towards the mother's back, the child's right hip will be on the right ischium of the mother. We might try to get the right hip towards the ramus of the ischium, then towards the ramus of the pubis, and, as it advances, cause it to emerge just under the arch. When fully emerged, the hip should be turned more and more round to the left of the mother, so as to let the right shoulder enter the brim at the left acetabulum, afterwards to escape under the arch, in doing which the child's chin will enter near the left sacro- iliac symphysis, or at least near the left ischial plane, and at last slide into the hollow of the sacrum, as in the second position of the breech. Where, in consequence of the grasping force of the womb holding the child's body tight during a pain, this desirable rotation cannot be gently PELVIC PRESENTATIONS. 393 effected, we ought to watch for an opportunity, during the absence of a pain, to push the child's body upwards again as far as we conveniently can, and then draw it downwards, endeavoring, while pulling it down- wards, to twist or rotate it in the manner that is required, and above recommended. If, on the other hand, we endeavor to bring the left hip to the pubis, we shall also get the left shoulder there; and at last, compelling the face to enter at the right sacroiliac symphysis, we shall terminate the labor as in the first position of the breech. 674. Case.—I shall here relate a case taken from my record book, which may serve to show the Student what a great rotation may be effected by the hand of the practitioner, in cases of the fourth position. Tuesday, Oct. 5th, 1830. Mrs. J., a young woman in her first preg- nancy, sent for me at eight o'clock P. M. The waters had come off'at five o'clock P.M. The os uteri, at my arrival, was almost completely opened. I touched the breech and feet; the toes were towards the left acetabulum. At a quarter before nine o'clock, I disengaged the right foot, and then the left one. At nine, the arms were both delivered, the left one escaping first along the perineum, and the right one under the pubis. I could not effect any further rotation, and was, sorry to find the chin immediately behind the symphysis pubis. I then turned the child's body on its axis, and pulling the chin well downwards pressed the face with two fingers, on its right side, and with great ease turned it into the hollow of the sacrum. I next made a channel by passing up two fingers to the superior maxilla, so as to admit air freely to the nose, and the infant breathed; there was a total cessation of pulsation in the cord. The child breathed and cried at least twenty minutes before the head was extracted, which I could not eff'ect until I carried its body upwards towards the mother's abdomen, and rolled her over on her right side, which gave me far better power to aid her with my right hand. The infant was born living, and did well. Let the Student remark that I turned the woman on her right side at the close of this labor. I wish that, in any case where he encounters delay or difficulty, yet not to such an extent as to demand the forceps, he would, at the last moment, turn his patient upon her right side, so as to enable him to make use of his right hand in assisting to make the head roll out under the crown of the arch. The fingers of the right hand are stronger and more apt than those of the left, and in these cases, where expedition in the operation is so essential to safety, it is desirable to obtain even this not inconsiderable facility and ad- vantage. 26 394 PELVIC PRESENTATIONS. 675. Case.—On Thursday, July 14th, 1836, Mrs.------was seized with labor pains, which came on with a rupture of the membranes. At six o'clock, I made an examination, and found the left foot in the vagina, accompanied by the umbilical cord, which pulsated. The toes were directed to the pubis. I could reach the breech of the child, but the right foot was so high up that I could not touch it. In a short time the left foot came quite down; and in order to rotate the body I drew moderately upon the foot, which caused the left hip rapidly to approach the pubis. I could not even yet get at the right foot, where- fore I permitted the child to descend with that limb pressed upwards against the belly; the left hip came under the centre of the arch, and, as soon as I could command it, I turned it more and more round, so that when the arms were delivered I found the face in the sacrum, soon after which the head was expelled. I immediately ascertained that there was a second child; pains came on, and in fifteen minutes after the first one was born, I broke the membranes of the second, which presented the nates and the right foot. The foot prolapsed, but the other limb was pressed against the child's belly, so that I could not get it; the sacrum was to the right acetabulum. When the shoulders were delivered, I found the child's face rather transversely directed towards the left ischium. I brought it into the hollow of the sacrum, soon after which it was also expelled. Both children were well. It is so easy a matter, in general, to cause the body to rotate during its transit through the pelvis, that it very rarely happens, if the physician is called early, that the face at last is found towards the pubis. 676. With regard to the presentations of the feet and knees, I do not feel that it is necessary for me to enlarge upon them before I close this chapter, inasmuch *!as the footling case is a mere accident happen- ing in a pelvic presentation, and which, moreover, can never prevent it from being at last a pelvic presentation—for all footling and knee cases are certainly breech presentations. I may remark, however, that the knee presentation is found to be embarrassing from the tendency there is to a sort of arrest, in consequence of the knees abutting against the sides or parietes of the pelvis, which is sufficient to prevent the descent of the child's nates, so that they, being thereby thrust over to the opposite side, cannot enter the excavation. Hence, where the knee presents it is advisable to convert it into a footling case, which can be done by pushing the whole presentation upwards, during the absence of pain, in order to gain space enough to bring down the feet. The Student will perceive, if he refers to the axis of the womb and that of the vagina, that in a knee case, in which the preternatural labor. 395 child's back is towards the left front of the mother, the thighs would be very greatly extended, or bent backwards, before they could emerge from the external organs; an extension that must be very difficult to eff'ect where the legs are bent up on the back of the thighs—for in such circumstances the rectus femoris, and indeed the whole quadriceps muscle must be put excessively on the stretch. It is a good rule, there- fore, in knee presentations, to get the feet down as soon as it can be prudently done; whereas, in the well defined breech cases, the feet ought not to be brought down, except for some valid and well-understood cause. In order to distinguish the feet from the hands, for which they are sometimes mistaken, it is only necessary to give attention to the sensations imparted by the operation of Touching. The even range of the ends of the toes, and their shortness, compared with the length of the fingers; the closeness of the great toe to the one next to it, in contrast with the wide separation of the thumb from the forefinger; the ankle and the heel, are marks that might be supposed sufficiently prominent to guard us against even the danger of mistake; yet very great attention is in some instances required to enable us to aver positively that the presenting part is, or is not, the foot. As the foot- ling is but a deviation from the breech presentation, its positions are like the original four—namely, the heels to the left acetabulum; the heels to the right acetabulum; the heels to the pubis; and lastly the heels to the sacrum. As the treatment is precisely the same as in presentations of the nates, I shall not detain the reader by any further remarks upon the management of them. CHAPTER XIII. OF PRETERNATURAL LABOR. 677. Any labor that cannot be brought to a safe conclusion by the natural powers of the system might properly be denominated a pre- ternatural labor; and, as the causes that might prevent the accom- plishment of the parturition, save by the intervention of our art, are very numerous, it follows that there are a great many kinds of pre- ternatural labor. 678. Causes.—A labor may be accidentally changed from a natural to a preternatural one; or it may possess a preternatural character 396 preternatural labor. from the very beginning, and be unavoidably so. Thus, a woman may have brought her child almost into the world without any appearance of disorder, or danger, or uncommon distress, and be then suddenly attacked with convulsions, apoplexy, hemorrhage or laceration of the womb, &c. &c, either of which occurrences completely changes the character of the labor. Or she may, in consequence of disease or accident, be found incapable of bringing her child into the light with- out surgical aid ; as, where the passages are closed by stricture, or by some fibrous tumor, or by a deformity of the bones of the pelvis. Lastly, the labor may be preternatural because there presents at the strait some portion of the child which cannot pass through it, but must be put aside in order to let some other part advance, before the labor can be brought to a close. For example, if the arm or shoulder should present, it is necessary to put them out of the way and bring the head back to the opening, or else the feet must be brought there, the child being for that purpose turned quite over; for have we not learned that one or the other of the extremities of the fcetal ovoid must advance, in order to admit of the escape of the child? It ap- pears from the above that the causes which constitute preternatural labor are very various; and it is reasonable to infer that the medical and obstetric treatment of the several cases will be founded upon the peculiar and distinguishing character of each individual example of the labors. The subject, therefore, embraces so wide a field of dis- cussion and detail, that it will be requisite to treat it according to the nature of the several causes that happen to interfere with the usual process of childbirth; whence I shall endeavor to describe the different sorts of preternatural labor according to the circumstances that make them what they are, and point out the modes of treatment most suita- ble to their several natures. 679. Shoulder Presentation.—Perhaps it matters not which kind of preternatural labor is here first treated of, for as there is no natural order or method of their occurrence; each one might be the subject of a separate monograph. Yet I have chosen to commence with the account of presentations of the shoulder, in which the operation of Turning is generally considered to be inevitable as a part of the treatment; and since that operation is not unfrequently resorted to in other kinds of preternatural labor, I deem it of some advantage to take an early opportunity of describing it in this connection. I have already said that, in order to constitute a natural labor, one of the extremities of the fcetal ovoid ought to present at the opening; and I have treated of the pelvic presentations as being natural; and I have PRETERNATURAL labor. 397 supposed that the knee and footling cases are but accidents or devia- tions of the natural pelvic presentation. In presentations of the head, there is also, I said, a liability to deviations, by which the head glances off from the brim of the pelvis, whereupon it is either turned upwards into the venter of the ilium, or rises above the top of the pubis. In a case where the direction of the uterus is very oblique, so as to allow the fundus to fall far down into the right flank of the patient, the child, if pressed by the contractions of the fundus, might be pushed towards the left side of the brim of the pelvis in such a manner as to make it doubtful whether the head would enter the strait, or slide up- wards on the left side of the womb. For the most part, it fortunately happens, even in the very greatest lateral obliquity ofthe womb, that the head is not deflected, but enters the strait; but in a few examples it is found to rise upwards, instead of engaging. "When this takes place, it must almost inevitably happen for the shoulder to fall into the cavity from which the head was turned away, and as the shoulder is a projecting part, it is very likely to maintain the position in which it is once ensconced. The shoulder, therefore, when the head glances off, descends or engages in the superior strait, and is pushed downwards by the uterine contractions as far as it can possibly be urged, and there it stops. The strait being now jammed full of a mass, composed of the shoulder, arm, neck, throat, and part of the thorax of the child; so that no additional portions of the child can be pressed into it, a total arrest of the progress takes place, and the woman, after vain struggles, protracted according to the strength of her constitution, sinks at last, without the possibility of rescue from death except by the skilful aid of the obstetrician, or by the happy event of what is called a spontaneous evolution. There can scarcely be any need for me to enlarge upon the impracticability of delivery here except by art; for even could the shoulder be pushed down as low as the vulva, it would happen, at last, that the head would be again brought to the strait from which it had been turned off, but it would be accompanied by the child's body, either of which, alone, is sufficient to fill the plane and the excavation, so that the two together could by no means pass through. The remedy is either to push the shoulder out ofthe way, and to bring the child's feet down so as to deliver it footling, or to restore the head to its proper place. There is, even where any operation is impracti- cable, an exceptional escape from death under these circumstances by the very rare occurrence of what is called spontaneous evolution of the foetus, to be hereafter described. I ought to remark that while the shoulder presentation is a deviation or accident occurring in an original head presentation, so it may happen that, instead of the shoul- 398 PRETERNATURAL LABOR. der, the hand or elbow may come down; but in fact they are mere circumstances of a shoulder case; and when they are advanced to a certain degree, it is the shoulder, after all, that fills the strait and the excavation, and which constitutes the presentation. The hand and arm are merely prolapsed, and their prolapsion adds nothing to the difficulty of the case; indeed, their prolapsion serves as a means of guiding us in our diagnosis, and does not at all oppose the successful treatment of the labor. In the management of a pelvic presentation, I should, in general, prefer that the feet should not prolapse; in a shoulder presentation, it would be rather a favorable circumstance for the arm to prolapse. 680. Case.—Some months since I was in attendance in a labor case, in which, though the os uteri was very much dilated, and completely dilatable and distended with the bag of waters, I could not with the index finger touch the presentation. The patient was very much flexed, which relaxed the abdominal integuments. Upon placing my hand over the right iliacus muscle, I distinctly felt the orbicular mass of the child's head under my palm. Introducing the fingers, again, I waited until a pain came on. As soon as the bag of waters became tense from the pain, I pressed with my left hand, the head out of the right iliac fossa towards the chasm of the superior strait. I then ruptured the ovum, and exhorting the woman to " bear, down, bear down," I had the pleasure to perceive the head driven quite into the ex- cavation, and to find it born after a few minutes. Doubtless, I prevented the shoulder from coming to the os uteri by pushing the head to it. 681. Two Shoulder Presentations.—Two Positions for each Shoulder.—As there are two shoulders, a right and a left one, there must be a set of positions for each shoulder; but in determining what is the position of the shoulder, it is also necessary to determine the situation of the child's head. In speaking of natural labor with the vertex in the first posi- tion, I endeavored to explain the causes which give a greater number of first positions. The same reasons operate to produce, in shoulder presentations, a greater proportion of instances in which the head is to the left side of the pelvis, than those in which it is to the right side. Now if the right shoulder presents at the strait and the head is to the left, as in Fig. 88, the face of the child, and its toes and feet, will look towards PRETERNATURAL LABOR. 399 the mother's back; but if the same shoulder presents, and the head is to the right side of the pelvis, the face and front of the child must look towards the mother's front: so of the left shoulder in the first position, the face will look in front, and in the second position it will look towards the mother's back. By speaking, therefore, of the positions ofthe two shoulders separately, we get a better and less complex idea of this sort of labor than we should have were we to enumerate a set of positions without such a divisiou. I think that the form of the foetus, and the capacity of the womb, are such as to make it unneces- sary to establish more than two positions for each shoulder: for exam- ple, for the right shoulder a first position, or that in which the head is to the left, looking backwards, and a second, in which the head is to the right, and looking front: for the left shoulder a first position, wherein the head is to the left, looking front, and a second, in which it is to the right, looking towards the back of the mother. This will, I think, be quite sufficient; and gives us four positions for the shoulders, hand, or elbow. It is not to be denied that the head might be in front, looking to the left, or looking to the right side of the mother, giving us in the former case a right shoulder, and in the latter a left one, in the strait; but it is needless to enumerate such a position, as the con- tractions of the womb and abdominal muscles would soon turn it into one of the attitudes I have before pointed out. 682. Diagnosis.—The signs by which a shoulder at the strait may be diagnosed are, 1. The want of the regular form of the bag of waters, which, in all preternatural presentations, is without that proper convex shape that we notice in favorable instances of natural labor: whenever the membranes pass down into the vagina, shaped almost like an intes- tine, or in a cylindrical form, there is good reason to think there is something untoward in the posture of the infant. 2. The spinous process of the scapula being present; the clavicle; the round-shaped shoulder; the axilla; the ribs; the arm, distinguishable by its size from the thigh, are evidences that a shoulder presents; but should the attend- ant retain any doubts, let him never omit to remove those doubts by the introduction of half his hand into the vagina, whereby he will be able freely to examine the nature of the presenting part, and learn its true position: no person is excusable for mistaking the diagnosis who knows he can command so infallible a method of making a cor- rect one. The diagnosis can always be made in good time—that is, as soon as the dictation will admit; and until then nothing can be done to aid the labor. 400 PRETERNATURAL LABOR. 683. Turning.—Having ascertained that a shoulder is at the strait, there remains but one determination for the practitioner, and that is to put it away and bring another part of the child to present. This neces- sity, aud the hazard in which, consequently, both the mother and child are involved, should be plainly and seriously laid before those who have the best right to know her case; namely, her husband or parents, or such near relative or friend as may seem to be, for the time, in loco parentis for her. The necessity for interference ought also to be explained to the sufferer herself, but in the gentlest and most cheering manner possible. If it be within the bounds of possibility to do so in good time, a medical brother ought to be invited, in order that his counsel may be taken, and particularly that the friends, and the patient also, may have no doubt left in their minds as to the propriety of the operation, nor claim the least right afterwards to find fault with the physician, should any untoward event follow the plan he had recom- mended. The act of turning to deliver by the feet is fraught with danger, for there is danger of uterine laceration, or of fatal contusions of the parts of the mother, and of failure to succeed in effecting the version, and great danger of destroying the life of the child in the act of turning. In early times, our ancestors, who did not understand the mechanism of labor, used to wait, after pushing the shoulder back into the body, in hopes the head might descend. For example, here is the doctrine of Thomas Rainald, to be found at fol. lxv. of his " Woman's Booke :" "And yf so be that it appears and comes forth first the shoul- ders, as in the XI figure, then muste ye fayre and softlye thruste it backe again by the shoulders till suche tyme as the head come for- warde." It may be that those old practitioners of the days of Queen Elizabeth may have sometimes succeeded, by pushing up the present- ing shoulder, in getting the head at last to come to the strait again; but such au event appears'to me in any case most improbable. 684. But no operation can be performed while the os uteri is so closed as to refuse admittance to the hand. It cannot and must not be forced. The mouth of the womb must be dilated or dilatable before any operation is lawful; it must be dilated or sufficiently yielding to allow the hand to pass upwards into the uterine cavity; of this degree of dilatability the obstetrician is the only judge. He must never run the risk of tearing or inflaming such an important organ, since its laceration by his hand would be much increased by the following birth of the child, and place the woman in danger of sudden death; or he might contuse the parts so much as to establish a highly dangerous inflammation in them. So important is it to judge aright concerning the time to be chosen for the exploration of the womb, that it is PRETERNATURAL LABOR. 401 thought to be the most responsible duty of the physician in the whole case. If he proceed too soon, the most lamentable consequences are apt to ensue; and if he defer the procedure too long, the difficulties and dangers are greatly enhanced by the delay, while the patient also suff'ers useless and pernicious pain. The bladder and rectum should be evacuated before the operation. The position should be carefully ascertained; this can be done by the introduction of the hand, if necessary, into the vagina; and if it be certain that the left shoulder presents with the head on the left side of the womb, then he must make choice of that hand which can most conveniently be employed in the operation. The rule is to use that hand whose palm, when open in the cavity of the womb, would look towards the face or breast or belly of the child, which, in this instance, would be the right hand; for it is clear that if the left hand were used, it would not apply the palm to the front of the infant, whether it were carried up before or behind the child's body. Although some accoucheurs prefer the late- ral decubitus, the best position for the patient is that on the back, with the end of the sacrum brought quite over the edge of the bed, the feet and knees being properly supported by assistants, one holding each limb, which should be properly flexed. The woman ought to be carefully covered with a sheet or a light blanket, according to the season of the year, and some thick cloths should be placed on the floor, under the foot of the bed, to receive any discharges of water or blood that might accompany the operation. Everything being fully prepared, the operator's right arm should be bared to the elbow, and well anointed with lard, while a sufficient quantity of the same mate- rial should be applied to the external parts. During a pain, two fin- gers, and then three, should be passed into the vagina, to be followed by the little finger, and afterwards by the thumb, strongly flexed into the palm. The hand, having gained possession of the vagina, may then rest until the pain is gone off, after which the presenting part must be pushed upwards and leftwards, the fingers and whole hand following the receding shoulder into the cavity of the womb. The shoulder being moved somewhat to the left as it mounts upwards, when the hand is fairly introduced, it ought to be opened and glided along the breast or abdomen towards the feet or knees of the foetus, which will be looked for towards the right and posterior portion of the cavity. In searching for the feet, the contractions of the womb are excited, and pains are produced, especially if the waters are much drained off'. During these contractions, it is absolutely necessary to open the hand, lest the uterus, from the violence of its own action, might be torn on the knuckles; and the hand ought never to move 402 PRETERNATURAL LABOR. except the organ be in a state of relaxation. At length, after more or less research, one or both feet, or a knee is found; and, whether it be one or the other, it should be taken hold of; for it is nearly a mat- ter of indiff'erence whether it be one foot or both, or one knee that is used as the point on which to act in turning the child. Dr. Collins, p. 69, remarks, on this point, that "it is quite sufficient to bringdown one foot," and I find that Dr. Simpson, of Edinburgh, is of the same opinion—deeming it far more injurious to make persevering attempts at exploration, than to deliver by one foot only. I say nearly a mat- ter of indiff'erence, because, the object being to turn the child as soon as practicable, with proper caution it may be effected in either of these ways; it is always desirable to get the hand out of the uterus as soon as may be, and it is far better to turn by one foot or by a knee, than to incur the risk of laceration or contusions of the organ, by a tedious search after the other foot, which, if it be not originally near its fellow, is very hard to be found by any search for it. The inexperienced student can have little notion of the extreme difficulty there is to move the hand about while it is compressed betwixt the womb and the child; a short experiment of this difficulty would suffice to convince him of the propriety of the foregoing directions. If he should use the knee as a point of traction, it would be very easy, when the version is nearly complete, to draw the foot down. If he use only one foot to turn by, he will have nearly all the proposed advantage of the breech present- ation combined with the greater facility enjoyed in manipulating in the footling case—that is to say, he will have the abundant dilatation, and the power of traction by the limb. It sometimes happens that a foot is met with close to the orifice; so that, even without carrying the hand within the uterus, the foot can be hooked down by means of one or two fingers, as has been done by Dr. Robert Lee, of London, and as I also have done. Having found the foot, if a pain should come on immediately, and prove severe, the foot should be let go, and caught again after the pain is gone off, according to the discretion of the operator. During all the time he is passing his hand up and exploring for the child, either his own unoccupied hand or that of an assistant should be applied to the abdomen, in order, by pressing the womb downwards, to keep the os uteri below the strait; and when he is ready to turn the child, his own hand only should be used by the operator to press on the outside of the abdomen, so as to favor the version by pushing the breech of the child downwards, while he also draws it downwards by the feet or knees. If the hand ought not to move during a pain, ft would, a fortiori, be the height of rashness to attempt to turn the child with the womb in a state of contraction. PRETERNATURAL LABOR. 403 The time for turning ought to be taken as soon as the pain has gone off. Then the womb feels yielding and soft as a wet bladder, and the part held in the hand may be drawn towards the os uteri slowly and gently, but firmly, and, if possible, brought quite into the vagina, or even to the vulva. External pressure with the free hand favors this version very considerably, and ought never to be neglected. It is easy to ascertain, by external taxis, if the version be complete, and by noticing how far the child is drawn downwards, and judging of its length as compared with the length of the uterus, as well as by noting the eff'ect of the next pain, which propels it if it be turned, but does not move it if it be still transversely fixed in utero. 685. Which foot? The Student should remember that the child, from the extremity of the buttock to the crown of the head is be- tween eleven and twelve inches in length. Hence his hand placed on the abdomen will inform him whether the uterus is of this length or not. If he find the buttock at the os uteri, and the uterus not so long as it should be under the circumstances, he will know that the version is not yet completed, and take his measures accordingly. Wherever it is possible to make choice of a foot to pull on, we should select that which is nearest the front of the pelvis. In the present case, it would be the right foot, in drawing upon which one, the right hip would come under the pubic arch, and favor very decidedly our wish to bring the vertex at last to the pubis, and carry the face to the hollow of the sacrum: whereas, should we draw down upon the left foot, the child's face would, at last, be very sure to come to the pubis. Under all cir- cumstances, the practitioner is only called upon to do that which he can do, and not that which he Would but cannot do; therefore, when he can only find the most unfavorable foot, let him draw by it and meet the consequences. As soon as the turning is completed, the case has become a footling one, and must be treated as if it were originally so; that is, it should be left to the expulsive powers alone, if they are sufficient, for it is always bad and almost always unnecessary to draw out the body; it should be expelled by the pains. The arms must receive such assistance as they may need; and the head, being properly situated in the vagina, ought to be expelled by the womb with such aid, from slight traction, as the obstetrician may adventure with safety to make. In going about to perform this operation, the medical attendant ought to reflect upon all the dangers incident to it, and clearly understand, beforehand, that what is most desired in it is, not speed but safety; festina lente ought to be the motto. As to the difficulties of it, they are so great, in a womb long drained of its waters and lashed into fury by a long period of unavailing irritation 404 PRETERNATURAL LABOR. suffered previously to the operation, that nothing but practical expe- rience of them can make them known, unless indeed the fact be under- stood that it cannot in some instances be effected at all, and that we are obliged to extract the child double, after having removed the tho- racic viscera, as well as those of the abdomen, by the crotchet and per- forator; upon doing which, the foetal remains may be drawn forth. I have, after having had my hand in the womb, found it so completely benumbed by the pressure, as to be unable to feel with it or to close it; in such a case, the other hand ought to be made use of, however ill adapted either for the exploration or seizing the feet, &c. The child being delivered, and the placenta taken away, the mother must be drawn up into her bed, so as to enable her to stretch out her feet, and be bandaged and put to bed properly. A grain of opium, or a dose of laudanum, containing twenty or forty drops, is very soothing and calming after such high excitement and fatigue, and ought not to be withheld from her. A cup of tea or gruel may next be presented to her, and a short sleep, if she can take it, is followed by a comfortable state for the before exhausted woman. There is very little difficulty in this operation if the waters are not gone off; they should, therefore, be alv/ays left whole, if possible, until the moment for interference is at hand. Could we, indeed, always have the privilege of rupturing the ovum at the time of carrying the hand into the womb, we should avoid much difficulty, and a large moiety of the danger. Unfortu- nately, however, turning is rarely determined on until the waters are lost, and then the danger is necessarily greater. 686. There are many ignorant persons, who are generally the more presumptuous the more they lack knowledge, into whose hands women are so unhappy as to fall on the occasion of their childbirth. If, in a shoulder presentation, the hand happens to prolapse, finding a very convenient handle, they, make use of it to pull the child away by, and I have seen a case in which an unfortunate woman had been so treated; the arm was wholly withdrawn, and the acromion process of the scapula was actually under the pubic arch, so violent were the tractions that had been made on the hand and arm. This was done, too, with a rigid os uteri, which, after yielding a reluctant passage for the arm aud point of the shoulder, was now grasping the parts above it with a strength like that of a rope, and which afterwards resisted for a long time all attempts to pass the hand along betwixt its circle and the child. To one unaccustomed to the incidents of the lying-in chamber, it would be, perhaps, vain to attempt to convey an idea of the resistance sometimes met with in the circle of the os uteri. Dr. Collins, in speaking of one of his cases in the Dublin Hospital, PRETERNATURAL LABOR. 405 says, at p. 67: "The mouth of the womb was absolutely as firm as a piece of thick leather, and embraced the arm of the child as tightly as a ligature could be applied without cutting the part." There can- not happen anything but evil from pulling at the hand and arm. Such force cannot pull down the child, which is too large to pass doubled. The arm is not in the way; for the hand of a practitioner and the arm of a foetus at term can never equal in size a circle suffi- ciently large for the head to pass through it. The lack of space is not in the faulty construction of the pelvis, but in the rigid constric- tion of the os uteri and vagina, which, if too rigid to admit the hand, is also too much so to allow the child to escape. That rigidity can be overcome. It cannot be needful to excise the arm, or twist it off at the shoulder-joint, a horrid practice, which seems to have received a salutary check from a judicial investigation that was had a few years since in France: a practitioner there, finding it impossible for him to deliver in an arm presentation, cut it off at the shoulder-joint, and nevertheless the child was born alive. The obstetrician was justly prosecuted on a charge'for maiming. 687. Undilated Os Uteri.—If an os uteri will not admit the hand of the accoucheur, it is because it is not dilated or dilatable. Let the proper measures, then, for effecting the requisite change in the uterine tension be resorted to. These are bleeding, the warm bath, anti- monials, emollient enemata, followed by enemata of laudanum; and patience, though last, is not the least of the resources for such an occasion. Women in labor bear venesection remarkably well; and they demand, in some instances, very plentiful bleeding in order to get the full benefit of the remedy. A patient bled ad deliquium animi will be more capable of undergoing safely the operation of turning than one left to the unmitigated provocations and stimulus of useless labor pains. It will have been seen that, in a preceding sec- tion (369), I have strongly expressed my dissent as to the anassthetic practice in Midwifery. If there could be a case to render a complete anassthesia by ether or chloroform a desirable condition for the patient and the practitioner, this is the case par excellence; certainly, a complete anassthesia might have the eff'ect to abolish the voluntary power of the mother, and, thus taking away the injurious force of the abdominal muscles and diaphragm, leave her to the sole influences of the uterine powers, which are not wholly annulled even by very deep anassthetic insensibility. Professor Simpson and other distinguished gentlemen warmly advocate the induction of anassthesia in these cases; let the Student give heed to the opinions of these meritorious 406 PRETERNATURAL LABOR. men, but let him be the sole judge of his own duty in any and in every case. 688. Warm Bath.—The warm bath is a safe and easy remedy for the obstinate constriction of the orifice, as it is for all spasms and other congenerous disorders. Tartar emetic, in doses of the eighth or sixteenth part of a grain, repeated every thirty or forty minutes, con- duces very powerfully to the reduction of the spasm or rigidity, and may be very safely resorted to in the management of our case. Much reliance is also to be placed on the power of the belladonna ointment applied to the cervix uteri, in which it often most speedily induces a complete local anassthesia. Copious enemata of infusion of flaxseed, with a portion of castor oil to render it somewhat more aperient, should be had recourse to, and they may be followed by anodyne enemata, composed of an ounce of flaxseed tea or clear-starch, with from forty to sixty or eighty drops of laudanum. We should also not forget that patience ought to work her perfect work, and no more; the accoucheur must be the sole judge of how far patience ought to go. I should think that there can never be the least use in attempt- ing to return the arm. The arm must be returned by the version of the child: it goes upwards into the womb as the head rises and the breech descends. It would always be prudent to secure it by a noose, for the purpose of preventing' its going too high within the cavity, where its presence might cause some embarrassment in the delivery of the head. P. Cosgreave, Esq., in the "Lancet" of 1828-9, p. 298, informs us that he has at no time lost a child in an arm presentation. His method is to push up the arm during the absence of the pain, and return it into the womb and hold it there; after which the sponta- neous evolution takes place, and the infant is born by the spontaneous powers of the womb. Mr. C. must certainly be regarded as a very lucky practitioner, to have met only with cases in which he could restore the arm to the cavity in this way, or in other words turn the child without searching for the feet. I am not aware of the number of his cases. I cannot, therefore, judge of the comparative success. 689. The Arm not to be Amputated.—Some persons have im- agined that in the conduct of some of these dreadful cases of shoulder presentation, great facility in delivering the woman is obtained by amputating the arm, or wrenching or twisting it off by sheer brute force. Indeed, I am aware of an instance in which the doctor tore off in utero the arm of a child which was afterwards born alive, with the end of the humerus projecting below the ragged and torn edges of the PRETERNATURAL LABOR. 407 wound. The arm was hidden, but afterwards discovered. The people interested, were made to believe that the lost arm had been destroyed by absorption. Such a course of proceeding is to the last degree un- justifiable. Unjustifiable before the outraged family, and equally so as bringing unmerited discredit upon the whole profession of physic. If in any case it were deemed necessary to remove the prolapsed arm, it ought not to be done without any antecedent announcement of the purpose, and its motives. For my own part, I cannot understand what are the motives that should leave an accoucheur to do so barbar- ous an act. The extirpation cannot be deemed needful to provide space within a pelvis, since the arm of a foetus can never fill up a pelvis so as to prevent the introduction of the accoucheur's hand for exploration and version. Whenever it is done, it is done with a view to make space within soft parts, but those soft parts will dilate in due time and under wise treatment. My clear opinion is that the amputa- tion of the arm in shoulder presentations is a mala-praxis, and that it ought to be discountenanced and protested against. 690. Spontaneous Evolution of the Foetus.—It has happened that the operator, being unable to turn the child, has abandoned any further and useless attempts to deliver. In such instances, the woman has sometimes delivered herself by what is called spontaneous evolution of the foetus. It is very important for the Student to understand clearly what is meant by spontaneous evolution of the child; and it will not be difficult for him to do so, if he will bear in mind the facts: 1st, that there is a superior strait; and, 2d, that the child's head and its body cannot be within the plane of that strait at the same time. Now when the shoulder is presenting, and the arm, fallen down, allows the shoulder to be thrust or drawn quite out under- neath the triangular ligament of the pubis, it happens that the side of the child's neck lies against the inner aspect of the symphysis of the pubis. But, if the side of the neck is pressed against the wall of the symphysis, the head of the child will lie upon, and even project over and beyond the horizontal part of the pubal bone, making a hard or- bicular tumor that may be felt there with a hand laid on the hypo- gaster. Now, things being situated as above, let the Student conceive that the trunk of the child's body, still contained in the womb, is thrust by the continued contractions more and more downwards, the head still resting upon or above the brim. The eff'ect of this downward thrusting force will be to push the shoulder farther and farther out beyond the crown of the arch, and the head more and more over the top of the bone, leaving a space in which to thrust the trunk of the 408 PRETERNATURAL LABOR. child. If it be a left shoulder case in the second position, the third rib will come out at the vulva, then the fourth, fifth, sixth, seventh, and so on until all the left side of the thorax is pushed out; after which follow the left flank, the left ischium, and trochanter; upon the escape of which the left thigh and leg are delivered, followed imme- diately by the right thigh and leg, then the right arm, whereupon nothing remains but the head, which is speedily born. Such is a spontaneous evolution. It diff'ers from Version or Turning in this— that in turning, the head goes up to the fundus, while the buttock comes into the passage. Here the head is held close to the plane of the strait by the shoulder which has got under the arch, and even pro- jects beyond it, so that the head is, as it were, tied fast to the brim so that it cannot rise. 691. Here I repeat the figure of the double-headed foetus, which I already have given at 214. Let the Student see in this figure a case in which evolution was indispensable. FiS- 89- For example, suppose the right head to have presented, and to be delivered. That head would be held close to the vulva, out- side by the left head and body—the left head and body could not possibly be in the plane of the strait at the same time. It would be impossible to deliver by Turn- ing—for the delivered head ties the unde- livered one to the plane of the superior strait. Of course, then, it only remains that the undelivered head shall be forced over the horizontal ramus of the pubis to allow the trunk to descend by evolution, as I have described that process in the shoulder case. As soon as the trunk is born, the remaining head may be brought away. Dr. Pfeiffer, who showed me the specimen, delivered the woman, as I found upon inquiry, by compelling the evolu- tion of the body of the foetus. Here is a repetition of the figure of Dr. Rohrer's case, given at 224. Let the Student observe that such a vast fluctuating tumor on the vertex of the child could never be the really presenting part; that it must necessarily deviate, and go up in the iliac fossa, allowing the true head to present, and making that, of course, a face presentation. I say, of course, for the head would be of course in extension. Well—the labor going on—the head is born PRETERNATURAL LABOR. 409 in face presentation—giving the face the appearance of suggillation— of which I have made a good representation in the figure; but the head being born, the tumor, larger than the head, remains above the Fig. 90. strait in the same way as the second head of the double-headed foe- tus of Dr. Pfeiff'er's did. Here, then, is a case in which evolution is indispensable, and Dr. Rohrer informed me that this was what he brought about—after doing which he was enabled, with very violent force of traction, to pull away the caput succedaneum—as you see it in the figure. 692. Case.—I was called, some time since, by a friend of mine to assist him in a case of difficult and alarming labor. The woman, small, feeble, and highly nervous, was the mother of several children. The doctor, finding the labor very slow, had administered a dose of ergot, which had brought on a most violent ergotism ; to that degree, indeed, that I had great reason to fear she might speedily die from the mere excess of pain and irritation, if not from laceration of the womb, which appeared to me imminent. I have rarely witnessed a wilder expression of agony than hers. Lfound the left shoulder down, in the second position. The indication was to turn and deliver by the feet—which I was requested to attempt. Protesting beforehand that I deemed success impossible, I reluctantly consented to make an at- 27 410 PRETERNATURAL LABOR. tempt. With great difficulty I passed my right hand through the os uteri; but it was completely pinioned and held fast and immovable by the muscular contraction, and I was but too happy to extract it with- out having caused a laceration of the cervix. The waters had long gone off. The child was dead. I concluded it was impossible to turn, and I felt equally convinced that she would die before evolution could take place spontaneously. I opened the thorax at the axilla, and broke up the tissues within both pleural cavities. Then, by means of the crotchet, I drew down rib after rib, the flank, the hip, and the buttock, so that I got the left thigh and leg down; then the other ex- tremity, which completed the evolution. The arms came down, and I delivered the head. The woman recovered happily. I relate the case, in order that the Student, reading it, may have a clearer idea of what is meant by evolution in contradistinction to turning of the child. 693. Hemorrhagic Labor.—Labors are also rendered preterna- tural by the occurrence of hemorrhage from the womb; for, although it is very common, and not unfavorable for the parturient woman to have an issue of blood during some part of the process of childbirth, it is not either safe or natural for her to lose so much blood as to give to the flow the character or qualification of hemorrhagic. In general, the quantity lost antecedently to the birth of the child does not exceed an ounce, and it is commonly even less than that. The occurrence, therefore, of a show of blood need not, and does not excite any alarm or even surprise, unless it goes beyond the ordinary amount. But where the effusion becomes excessive, great alarm is felt, and there is more or less real danger according to the cause of the hemorrage. 694. Hemorrhage before Delivery.—I have already (393) ex- pressed my opinion of the mode of connection between the placenta and the womb; and the Student will have seen that I do not admit that any very large vessels pass from each to the other, inter- changeably. Hence, when blood escapes from the uterus, it may be, perhaps, in consequence of a hemorrhagic nisus or sanguine determination, like that which sometimes causes the efl'usion of blood from the Schneiderian membrane, in those cases of epistaxis that come on spontaneously, or in the floodings of ordinary pure menorrhagia. We often see very copious outpourings of blood in epistaxis, where we can have no reason to suspect any rupture of ves- sels or solution of continuity in the membrane. The same thing takes place in the pulmonary hemorrhage, and in hasmatemesis. But as the PRETERNATURAL LABOR. 411 womb, from its very constitution, is prone to the hemorrhagic affec- tion, it is more liable than any of the organs to losses of blood, with- out the suspicion of rupture of its tissues. Nevertheless, there is reason for believing that, in some cases of profuse bleeding, the deli- cate tissue of the uterine veins has been ruptured. The gravid womb, a vacuum plenum, is filled with the ovum, which is really- connected with the containing organ only at the placental superficies. All other points of the ovum, except the placental portion thereof, adhere so slightly as to be readily capable of detachment. The pla- centa itself may commonly be separated with great facility from the surface on which it sits. When the chorion is detached from the womb, very little or even no blood escapes; but when the placenta is torn offj the womb generally, not always, bleeds freely. The separa- tion leaves exposed many patulous openings that lead directly into the large veins and sinuses of the uterus. Hence, large eff'usions of blood in labor indicate that the placental surface of the womb is ex- posed by the separation of the after-birth from it. If the after-birth is torn oft', or in any manner separated from its place, the womb still remaining undiminished in size, it is evident that the blood may con- tinue to flow for an indefinite period, and that the woman may be brought into great danger thereby—for the bleeding orifices may, for an indefinite term, continue to have the same degree of aperture as that which first allowed them to bleed. Supposing the superficial con- tent of the gravid uterus to be two hundred inches, and that of the non-gravid womb to be only three inches, then it is evident that the great desideratum in uterine hemorrhages, before delivery, is to empty the organ as soon as practicable, in order to reduce its superficial con- tent, as nearly as may be, to the smallest number of square inches, or the non-gravid superficies. In treating cases of alarming hemorrhage, therefore, we should ever keep in view the fact that, if the womb be allowed to contract or condense itself, its own muscular fibres will, by their contraction, lessen the calibre of all the bloodvessels that are distributed on or in the organ, and in proportion to this condensation or contraction will be the certainty of arresting the sanguine effusion. It is not the orifice only1 that is closed, but the whole tractus ofthe vessel that is constringed. If a labor should commence ever so favor- ably, with the child presenting the vertex in the first position, and the pains should propel the child downwards so as to give reason to think the process about to terminate in the most happy manner, it might yet happen that hemorrhage should commence, and continue so abund- antly as to make it absolutely necessary to deliver the child, in order to let the womb contract speedily. This delivery by artificial means 412 PRETERNATURAL LABOR. converts the labor, which commenced naturally, into a preternatural one. We should hardly be inclined to call that a preternatural labor which, though accompanied with a great effusion of blood, should terminate well, without any assistance on the part of the accoucheur. 695. Post-partum Hemorrhage.—There may also be a very copious and dangerous effusion of blood between the time of the birth of the child, and the delivery of the after-birth; and even after the after-birth has been discharged, the flow of blood may be so consider- able as to involve the woman in the greatest danger. In the man- agement of all these kinds of bleeding, the same indication is to be kept always in view; to wit, the condensatian or contraction of the womb; for when that organ is fully contracted and condensed, the blood cannot flow so abundantly as to endanger the patient, except in some very rare, and almost unheard of cases. 696. Placenta Praevia or unavoidable Hemorrhage.—Among the diverse causes of flooding in pregnant women, there is a dangerous one, that consists in the implantation of the after-birth upon or very near to the inner orifice of the womb; and which, after having been originally formed there, must become, in whole or in part, detached from the womb surface upon which it continued to be developed up to the time of the appearance of the flooding. A child could not be born until such an obstruction should be taken out of its way ; there- fore this detachment of the placenta will unavoidably take place, sooner or later, according to a variety of circumstances; but it is generally supposed most likely to occur at or about the seventh month of the pregnancy because it is about that time that great changes do take place in the form and capacity of the cervical portion of the uterus. Upon entering into the hollow of the womb, the ovarian ovule which has been fecundated in the canal of a Fallopian tube, may attach itself to any portion of the inner wall of the womb, on which it chances to rest and stick fast. It is at that point that conception takes place; the fecundation having been effected some days beforehand in the Fallopian tube as above said. In a great majority of the cases, the affix- ation or conception takes place on some portion of the fundus; not unfrequently, however, the ovum settles itself on the corpus uteri: it is rare to find that it was settled and affixed on the upper orifice of the canal of the cervix; when it does so, the placenta grows upon that spot; the child is developed above it or beyond it, so that the placenta is found to be on the track, prasvia, in the way by which the child is to come forth. It is in the way, or, as the case is technically expressed, PRETERNATURAL LABOR. 413 it is placenta prasvia. And since it must be got out of the way before the child can pass, it must be detached or torn off' from its base the womb-surface whereon it grew; and the bloodvessels, whose open mouths it stopped, as the palm of a hand pressed down upon them would stop them, after it is torn off those opened mouths unavoid- ably pour out their blood, as they would do if the palm of the hand, which had stopped them, should be lifted up and so, let the blood run. The truth is, that Noortwyck, and Dr. Robert Lee after him, were both correct in their description and delineation of the open orifices of vessels that are always to be found on the inner surface of the gravid womb well advanced in the pregnancy; and all Professor Simpson's arguments on the mechanism of placenta prasvia floodings, can have not the least power to change the convictions on that matter, which must exist for whoever has repeatedly seen them, as I have. I wish the Student to understand, that a full-sized placenta is a cake consist- ing of a mass of bloodvessels, enclosed in a copious areolar tissue, which lies upon the inner face of the womb; it is as large as the inside of a common dinner plate. If such a cake were lying flat on the surface of a dinner plate which had been drilled so as to have many holes in it, one might set the plate in water without fear of its leaking in through the holes, so long as the cake should lie close and flat upon the disk. But, if an edge of the cake should be lifted up, and expose two or twenty of the holes, the water outside of the plate would hasten to flow in. It is just so with the placenta; which, as long as it lies close and flat on the womb wall prevents the outflow of the blood; but when once separated from the womb wall, it leaves the blood- mouths gaping wide open, and pouring into the womb great torrents of blood. Now the Student can readily understand; that if a placenta big enough to fill up the inner part of a dinner plate is lying very safely upon its base in the womb, the placental surface and the womb surface on which it sits are of the very same size. Very well; let the womb be suddenly dilated, or slowly, so as to treble or quadruple its size, it follows that, as the placenta cannot stretch so much, it must be torn off, or detached in whole or in part; and the holes in the womb surface, which it always stopped before, have now nothing to stop them, and so the hemorrhage begins to be seen. As the womb surface, set all over as it is with holes, grows larger, the holes them- selves must continually grow larger along with it: and the hemor- rhage must grow more violent and dangerous the greater the dilatation, and the nearer the moment at which the dilatation is become great enough to suffer the child to pass along the track to be born. Hence, the nearer the woman is to the completion of the preparations for her 414 PRETERNATURAL LABOR. delivery, the more violent the hemorrhage, and the more imminent the prospect of flooding to death. The Student has already learned, that the neck of the womb does not very greatly change its cylindrical to assume a conical or funnel shape, until some time after the com- mencement of the pregnancy, and that it is commonly supposed, that no considerable change does take place in its shape until the seventh month, equal to seven-ninths of the whole time of the pregnancy. Whether this notion is true or not, certain it is, that these unavoida- ble hemorrhages do not in general come on until about the seventh month, at which period they are very apt to begin in all cases of im- plantation. Nevertheless, it does happen, that they attack as early as the sixth, and even in the fifth, or not earlier than the eighth, or even so late as the ninth, at the full term of utero-gestation. It is quite true that a pregnant woman, with her placenta seated upon the very fundus uteri, may be seized with hemorrhage upon the accidental de- tachment of it, from a blow, or any other accidental cause ; but every such instance is an example of accidental hemorrhage, whereas the implantation of the after-birth directly over the os inevitably brings on a flooding; which, as it cannot be avoided, is therefore called the unavoidable hemorrhage. It is the office of the physician, then, to discriminate betwixt the case arising from an accidental cause and that which is unavoidable from placenta prasvia. Though this diagnosis cannot be absolutely made, save by the operation called Touching, it is almost an invariable suspicion that arises that the after-birth is in the way; and the greatest anxiety to learn the truth immediately follows the suspicion. If I should be hurriedly called in to a woman recently attacked and rapidly reduced to great weakness by flooding, I could draw no other inference than to a placenta prasvia; and should feel myself derelict of the plainest duty, were I to fail of asking permission to verify the facts. This I should do by Touching, which would ena- ble me to say that the placenta is or is not to be felt at the os, or within it. If it should be felt, then I should certainly communicate the alarming fact to the patient's friends, and, in addition, inform them that it would probably be my duty, when the fitting time should arrive, to turn the child and deliver by the feet, or in case of a breech presentation, to draw down the feet and deliver. From these remarks let the Student gather, that my instruction for him is this, videlicet: in placenta prasvia the indication is to turn and deliver by the feet. This doctrine has long been adopted in midwifery, and I consider that it is, at the present day, universally received and acted upon by all well instructed physicians, saving a very small party, who have proposed a singular heterodoxy in this matter, which I PRETERNATURAL LABOR. 415 shall presently examine. As every swallow does not make a summer, so every such hemorrhage does not make a labor: far otherwise; the occurrence, unless of a most violent character, is most likely to prove transitory, all the symptoms disappearing soon after the first gush ; but it is sure to return, sooner or later, for the cause is the unavoida- ble cause. Suppose the woman to have finished her eighth month, which is seven-ninths of the whole course, she has two other ninths to go through with, or two entire months, upon any day in which she might fear a» return of the flooding. If in the first gush she should lose twenty ounces, and ten ounces at the next, and eight or sixteen at the third, and so on to the end, she would be too much reduced, by the end of her time, to safely encounter the last greatest flooding of all; greatest, I say, because the greater the portion separated, the greater the number of exposed mouths, and the more rapid and copi- ous the effusion ; so that, if she should not perish undelivered, there would be great risk of her dying within a few minutes after the birth of the child. It appears to me, that when called in to such a case, we have pretty sure means of judging correctly as to the greatness or slightness of the detachment, because it is not to be doubted, that where a very considerable portion of the after-birth has been torn away from its basement, or seat on the womb, the hemorrhage will be very considerable, and vice versl And that out of this judg- ment will arise the plain indication of the course to be pursued. If the flooding should, upon due reflection, be deemed so great as seriously to threaten a fatal conclusion, we ought at once to take mea- sures for ridding the womb of its entire contents, in order that, as soon as it should become quite empty, it might so contract and condense all its texture as to quite shut up all the bleeding holes in its inner wall, and so stop the outflowing of the vital stream. On the other hand, when the slightness ofthe show, and its progressive diminution should encourage us to use measures for its entire suppression, we might hope that by prudent cares, the woman might happily reach to her full term, and then, being in all respects prepared and ready for the task, get through her labor rapidly and with little loss. Indeed, it has sometimes happened in these placenta prasvia labors, that the woman has been delivered after a labor of only a few minutes' dura- tion ; the child's head pushing before it the whole placenta, which rested on its head like a low Scotch bonnet. 697. When called to superintend one of these cases, the first ques- tion after having inquired concerning the amount and the constitutional eff'ects of the losses is as to the stage of the gestation. If the woman is at full term, we shall be held bound not to quit her house until the 416 PRETERNATURAL LABOR. danger is wholly past. This we ought certainly to do, even though we can have no assurance that by our constant presence a happy suc- cess would surely crown our fidelity and skill. To show how neces- sary is such a precaution, I may say that many years ago we had here in Philadelphia three physicians—the celebrated Professor Dewees, Dr. Eberle, and Dr. Jno. Ruan—each of whom had a considerable share of the obstetric practice of the place. Dr. Eberle had under his care a lady in Market Street, whose residence was about two and a half squares from his own house. Dr. Ruan lived in a house about a square and a half off', and Dr. Dewees was distant three squares. After Dr. Eberle had made the diagnosis of placenta prasvia, the flood- ing having been suspended, he engaged the husband of the lady to send off three messengers as soon as the attack should come on again; one for Dr. Ruan, who was nearest, one for himself, and one for Prof. Dewees; hoping, in this way, to secure the prompt attendance of at least one of the three. Now, the Student, who will doubtless applaud so much and such wise precaution, need not "be exceedingly surprised to learn that the hemorrhage which came on not long afterwards, was so violent as to prove fatal before they could assemble at her bedside, and I wish him to observe that I relate this history in order to illus- trate the necessity there is of the utmost watchfulness and the very best considered precaution in all such cases. As one of the chief sources of danger consists in the liability of the woman to be so much reduced by reiterated attacks of hemorrhage between the seventh and the ninth month as to be quite unequal to the last and most dangerous conflict which, unavoidably, she is doomed to encounter in the labor, it is a thing of the most serious import so to conduct the affair as to obviate, if possible, the successions of attacks. Hence he would be a most imprudent person who should allow the patient to work, to walk, to run, to ride, or do any act provocative of new eruptions of blood from the old and now stopped openings, or to open new ones by any- thing that might disturb the repose of the placenta upon its uterine disk. It is a great merit, and one that ought to be boldly claimed, when a physician successfully conducts such a case from the first una- voidable eruption of the flooding to the happy conclusion of it in a safe delivery without renewed and dangerous losses. To this good end it is proper for her to pass, as far as possible, the whole remainder of her gestation in a low recumbent posture; to live with a regulated diet; to be well advised as to her dress, bed coverings, the urine and stool, and indeed to be governed by rules of living prescribed by the attend- ing physician. 698. I have already said that those unavoidable floodings that come PRETERNATURAL LABOR. 417 on in the early months do in general soon stop, and this is so true that I suppose the Student will seldom reach the bedside of the patient thus flooding until after it shall have ceased in a great measure. Upon inquiry he will probably learn that the flooding came on suddenly, and that the woman suddenly lost a very large quantity, perhaps while using the night vase. Let him not suppose that the half pint or even the pint of blood which is shown to him in the chamber vessel could have issued from the veins in some three or ten seconds. It was not so, and could not be so; but the flow had been going on unperceived for some time, and the product had been slowly accumulating within the vagina, where it was retained by the sphincter until, half a pound or even a pound being collected, it gushed forth of a sudden upon some movement made by the patient, particularly by the movement of sitting down to make water. It is a very great consolation to a beginner to know these things, for the knowledge teaches him that it might be possible for the half pint or pint of blood to have required an hour or even four hours to accumulate in the vagina, and that the flooding might have stopped three or four hours prior to the sudden and startling discharge of these accumulated vaginal contents. If, however, the bleeding should be going on at the time of the Student's arrival, he will be tempted to do something to stop it; and what shall that something be? Many people, under such circumstances, are tempted to resort to the use of the Tampon or plug, made of sponge or of bits of old linen, &c. Such a proceeding is not only uncalled for, but it is very dangerous. It is well known that blood driven forth from the living vessels among the tissues has not only an infiltrating power, but a great dissection or laceration-power, as is manifested in labial thrombus, in dissecting aneurism, and in apoplectic lacerations of the brain. Hence, to fill the vagina with a tampon is, 1st, to shut the windows of diagnosis: and, 2d, to expose the patient to the great risk and evil of having all the blood that she continues, notwithstand- ing the Tampon, to lose, driven back upon the placenta in force suffi- cient to infiltrate the utero-placental connecting tissue, or with a dis- secting force so great as to wholly separate the after-birth from the womb. This to do is a stupidity that is hard to be conceived of, and yet it is an every-day stupidity among even the learned! I warn the Student to be wise in time. Very well, then; if he may not do this, what can he do? He can remember that if a person is lying down flat on the back without a pillow for the head, the blood of his circulation will not redden his foot so much as it would should he stand up on his feet; and that, the lower the head the paler the feet will be. The same thing that is true of the vessels of the foot is true 418 PRETERNATURAL LABOR. of the uterine vessels, which are less turgid the lower the recumbency; and if the Student will but make a practical application of the import- ant truth for the case in question, by taking away all the pillows and bolsters, and even by putting a big family Bible under the foot of each lower bed-post, he will have done all and the very best that can be accomplished by means of decubitus. It is probable, indeed, that this is all that is really called for by the circumstances; yet, it might be well enough to spread a thickly folded towel, wrung very hard out of cool water, over the hypogastrium and groins, and to give small draughts of iced lemonade, or vinegar and water—or exhibit five-grain doses of alum with a little grated nutmeg mixed in a teaspoonful of honey or syrup; to set the doors and windows wide open; to lighten the bed-covers; to exclude strong lights: to forbid talking or sudden movements by the attendants; and lastly, to insist that the patient shall not quit the recumbent position for any occasion whatever until allowed by the physician to do so. Should necessity demand it, let the foot of the bed be raised more and more, and when the flow has ceased let it be gradually lowered again, because the object of this decubitus has been fully accomplished. Such is the Treatment that I now advise the Student to institute, and at the age of seventy years, with fifty-two years of hard earned experience, and a great deal of reading and reflection, I am profoundly convinced that such a method is the very best that I do know for the case in its phase as stated. Certainly, it is meanwhile a matter of great interest to promote, by all reasonable measures, the highest activity of the haematosis; to which end, the woman should use a nourishing diet and a portion of wine to "cheer but not inebriate." I have not the least doubt concerning the consummate power of iron by hydrogen as a reinforcement for the hasmatosis, and should therefore desire that the sick woman should take six grains of iron by hydrogen per day, two grains being for one dose, to be taken soon after each daily meal___ And this is all I have to say in the present aspect of the case. 699. Treatment of Placenta Prasvia, the Woman being either in Imminent Danger or in Actual Labor.—The question of safety in labors, with unavoidable hemorrhage is very much a ques- tion of time—for if a woman with centrical implantation of the after- birth could, as some have done, expel the child in one or two pains she would not have time to die, inasmuch as the involution power of the womb would shrink the bleeding surface so speedily after the ex- pulsion, as to put an end to the flooding at once and so, to all the danger and alarm. On the other hand, where a woman continues in labor for four and twenty hours, she will probably die either before or very soon PRETERNATURAL LABOR. 419 after its conclusion. Therefore, one ofthe prime indications of treat- ment is to get her out of the trouble as soon as possible with due regard to prudence. In any such case a physician ought to deliver by the feet if they should spontaneously present—and if the head, or any other part should present, his duty is to turn and deliver by the feet. Hence when the Student asks one what he is to do in his case of placenta prasvia, I invariably reply turn and deliver by the feet, for if the child does not present by the pelvic pole, the indication of treatment is cer- tainly to turn and deliver, so that I am almost ready to say that the word placenta prasvia is not merely a denotative but a connotative word, meaning at the same time a placenta on the orifice, and the necessity for turning and delivery by the feet; certain it is that the enunciation of the word never fails to awaken in my mind this com- pound idea. However, turning cannot be attempted until the os is sufficiently (not dilated) dilatable to allow the hand to pass inwards to take the feet. I trust the Student will never dare to force an u n- dilatable os, and I am equally confident that no wise prudent man will set himself down patiently to wait for dilatation. It is not dilatation that he is to expect, but dilatability, two ideas that are as widely sundered as the poles. Let him therefore Touch from time to time, so that he may know when the precious moment of dilatability is come: this is a thing that no man can do, who stupidly resorting to the tampon shuts out all the light of diagnosis. I was on the very point of losing a most interesting woman in such a labor by this very piece of stupidity, but I have been better educated since that early day, and at the present day we are all far better off as to our resources than our fathers were, for we are in possession of the colpeurynter and the knowledge of its uses, which enables us to make the womb dilatable, and to so dilate it in about four hours, as to admit of the passing a hand in search of the feet. Let every person, therefore, who is liable to be called upon in a case of implanta- tion be sure that his colpeurynter is not only at hand, but in good order. This colpeurynter may be filled with cool, not iced, water, which greatly serves a haemostatic indication. The sac when filled should be kept full about as long as the duration of a very long labor pain, and no longer—a mode of using it far preferable to that which is commonly adopted—and which is to fill the colpeurynter with air or water and leave it so i n si tu indefinitely. In this advice I am speaking empirically, and not schematically. I hope the Student will think well of it and act upon it. Attention should be paid to the state of the bladder, and while the woman is in the labor the urine should be taken away by the catheter: she should not be permitted 420 PRETERNATURAL LABOR. to rise for any purpose, nor to make any uncalled for muscular effort. As for the flowing blood, 1 e t i t fl o w, since it cannot be safely stopped by methods other than those I have pointed out. When dilatability is almost attained, the patient should be adjusted in a proper situation for the turning. She should be upon her back with the hips near the foot or side of the bed, and conveniently supported by a woman on each side to steady the bent knees, and keep the feet from slipping. The question as to which hand the accoucheur ought to use is settled by the fact, that as the placenta lies betwixt his hand and the foetal head, he cannot touch a fontanel so as to learn which hand is to be preferred: but, as he knows that afirstposition is far more pro- bable than a second, he'will of course choose the left hand, whose palm will, in a first position, correspond with the child's front surface. The time being fully arrived, let him take the time of a labor pain for the dilation of the sphincter-vagina, or ostium vaginas, where the only difficulty exists, since the hand once passed through that outer firm ring meets with no further vaginal resistance. (208.) Having accom- plished this object, the fingers may be used by insinuating them one by one between the inner wall of the dilating womb and the placenta, and keeping the dorsum of the fingers against the wall, slip them upwards, detaching as he does so enough of the attached after-birth to allow him to carry the finger points higher up than the edge or mar- gin of the placenta. It is a very desirable thing to get the hand quite above the margin ofthe placenta and outside of the chorion or ovum, without breaking into the amniotic sac. By carefully effecting this part of the operation the waters may be preserved, and so the child be more easily, speedily, and safely turned, than if all the waters should be expelled and the womb allowed to contract about the foetus hold- ing it as if in the folds of an anaconda. As soon as a foot can be found let it be laid hold of, and if no pain comes on to prohibit it let it be drawn down to the os, and into the vagina. If both feet should be found together they should together be grasped and brought down; but it would be wrong to lose any time in searching for a second foot, since the child can be as well, if not perhaps better delivered by one foot than by both. It can hardly be necessary to say that no sensible man would continue the effort to turn if a pain should come on while he was trying to make the version, since not only must he wait, but he would probably kill the foetus and burst the womb if he should per- severe : no, let him stop at once if caught by a pain and wait to renew his attempt the very moment the pain is nearly gone off". A pair of Davis's forceps ought to be in readiness for the delivery of the head in case of its suffering any delay within the vagina, for the most ur- PRETERNATURAL LABOR. 421 gent call ever exists for a speedy delivery not of the child only but of the after-birth. The woman is threatened with sudden death from flooding, and it is not the first lost quart that kills her, but the last fluid-ounce; the physician may save that most precious ounce if he should have a proper forceps at hand, and he could not perhaps save it if unprovided with so great a power. I conceive that in the treat- ment of placenta prasvia cases one of the most invaluable precautions that could be taken is that which is connected with the decubitus of the patient. So firm is my reliance upon this portion of the method, that I should consider myself derelict of duty in omitting a most care- ful consideration of it. It was a great many years ago that being called to assist a young practitioner in such a case, I found the woman nearly dead with the flooding, so that I feared she would ex- pire soon after the child should be born. As the doctor requested me to deliver his patient for him, I made him raise the foot of the bed, after taking away the pillows so that her body was inclined some 15°, which enabled me to lift, so to speak, the child from out her womb. How could she faint and die while I kept her encephalon in this way replenished with blood ? She happily recovered, which she could not have done under any other mode of treatment. 700. I have not hitherto called the Student's attention to a method of treatment for placenta praevia that has attracted a good deal of notice, and which has been proposed and advocated by Drs. Rad- ford and Simpson chiefly. This method consists in what is supposed to be a detaching of the whole placenta from its place on the womb, with a view to put an end to the unavoidable hemorrhage. The friends of this measure, having been educated in Mr. Hunter's country, have seemed to be, hitherto, unable to free themselves from the bonds which Mr. Hunter's great power laid upon them. They are yet in bonds to his famous Hunterian dogma of the placental structure, and they therefore continue to believe that the placenta consists of two distinct products, one called the feeta 1 portion, and the other the uterine or maternal portion ofthe placenta. Now, inasmuch as the progress of discovery in these matters has made it clearly known, that the uterus furnishes no portion of the placenta, and that that body is a fleshy vascular excrescence formed upon the exterior surface of the chorion, any hypothesis of practice or rnethodus medendi that is based upon the exploded notion of Mr. Hunter should be considered as dissipated with that very explosion. The antiquated idea of Mr. Hunter concerning the two portions, fcetal and maternal, led him and his followers to the delusive idea that torrents of blood passing from the mother's vessels into the maternal portion to fill 422 PRETERNATURAL LABOR. its cells, may, and do escape, from within those maternal cells, as soon as the after-birth or any portion of it happens to be detached from the womb, and thus the false doctrine grew up that in uterine hemor- rhage the blood does not escape from open mouths of the womb-wall, but from open mouths of the detached placenta wall, so that when Drs. Radford or Simpson find a woman bleeding with placenta prasvia, they suppose, singularly enough, that the blood is pouring out of the placenta and that if the entire connection between it and the uterus could be put an end to, the flooding would immediately stop, because the blood no longer passing from the uterine vessels into the cells of the maternal portion, the source of the hemorrhage would no longer exist. And this is a notion that those gentlemen maintain, wholly regardless of the fact, that the superficial content of the womb may remain undiminished; nay, more—that it must become subsequently greatly augmented as to its cervical portion, by the inevitable dilata- tions that must precede the delivery of the child. Moved by their antiquated notions concerning the constitution of the placenta, they have persuaded many practitioners to adopt the method which they hypothecated, and which consists in separating the whole placenta from its place on the womb, by means of the fingers inserted within the os for that purpose; but this is a thing impossible to be done in the vast majority of the cases, because the state of the os uteri renders the greater part of the implanted placenta unassailable by even the tactus eruditus of the womb—erudite digitus. Every instructed phy- sician knows that the placenta is a branchia, or aerating organ, and serves as substitute for the lungs during the whole term of fcetal life. To greatly lessen its function by pressure on it or on the cord is to endanger the child's life; while wholly to suppress it, is to certainly destroy that life; but, notwithstanding all this truth, they have suc- ceeded through their great abilities and distinguished professional station, in disseminating a doctrine so absurd and so pernicious. Our journalistic medicine is loaded with cases moreover claiming the most triumphant success for this practical application of the exploded Hunterian dogma! Let the Student employ his faculties of analysis to explain the mystery of this impossible success, and he will surely find that if it be true that a foetus depends for its aeration or oxygena- tion upon its placenta alone—that death by asphyxia is the inevitable consequence of absence of oxygen, it is also true that the placenta has not been so completely removed as is supposed in all those cases in which the child was afterwards born living. This I say, notwith- standing I have found a child coming into the world and pushing the detached placenta of its unborn twin, or butting it forth with its head. PRETERNATURAL LABOR. 423 This is true, but not truer than that I made great haste, as soon as it was born, to get its twin brother out of its great danger, by hurryino- it into the world. I Have said, already, that the question of danger in placenta prasvia is a question of time, and that a woman, who could in such a circumstance, get through with the labor in a pain or two, would not have time to die; whereas, she would hardly escape with life if in a lingering labor with rigidity of the cervix—or torpor of the uterus. Now, let the Student observe that in the rapid cases, Messrs. Radford and Simpson would find no sufficient motive for the employment of their method, while, in the case of rigidity of the os, they could by no means effect the object with a finger, because, a finger, which, at most, is three inches long, cannot reach so far upwards in the womb as to detach the whole of a placenta, eight inches in diameter, and which, moreover, is rarely implanted centrically—but much oftener only partially upon the os, and which, when not centri- cally implanted would have some segment, at least, of its circumference far beyond the doctor's finger-points: if the Student should here say, "Oh! but he introduced his hand to feel the after-birth," I should be compelled to think that he must have been a very bad practitioner, that he did not then make use of that introduced hand to seek and seize the foot, and so, carry out the only real scientific indication in the case, which I have already stated to be—turning and delivery by the feet. I hope none of the several thousands of American physicians whom I have had the honor and the pleasure to instruct at Jefferson College, will suffer such illogical lapsus as that of Messrs. Radford and Simpson and those they have misled, and I also hope that these remarks will be received in the spirit in which they are offered, viz: in a spirit which hates no man, envies no man, and desires solely that useful truth may everywhere take the ground from under the feet of every mischievous error, such as this one most assuredly is proved to be. Lastly, let no man suppose me to be so bold, not to say so impu- dent, as to call in question the perfect good faith with which Messrs. Radford, Simpson and others, have stated their experience; it will ever be far from me to do so, though I can find in the mystery of their success no other solution than the error of their observations, since I know, not believe, that a child deprived for many consecutive hours of all its sources of aeration must of necessity die, and since I know equally well that when the os is not very greatly dilated and practicable for speedy delivery, no man can, or will ever be able to detach an unassailable implanted placenta—unassailable, I say, be- cause it lies far beyond his finger points. There ought to be a public recantation made of so considerable and so mischievous an error—an 424 PRETERNATURAL LABOR. error that assuredly will not long withstand the light of the nineteenth century. 701. Turning in Placenta Praevia.—Although I have, already, at 474 of this volume, made mention of Braun's colpeurynter, and spoken of the applications I have made of it in the case of very obsti- nate retroversions of the womb, it becomes necessary to show, in this place, the great advantages derivable from its employment in placenta prasvia. No person will ever be able to persuade me that it is either good physiology or sound practice to proceed in curing or rather in trying to cure placenta prasvia by detaching the whole placenta, with an incomprehensible notion that to do so, is certainly to arrest the hemorrhage, and that on the erroneous assumption that the blood in this condition runs out of the uterine vessels into certain hypothetical cells of the placenta, and from those cells into the womb or vagina. I utterly deny the doctrine and sincerely hope that the American Student will reject it, which he cannot but do if he will but receive proper views as to the structure and functions ofthe human placenta. With these opinions I adhere to the long settled practice of Turning and delivering by the feet in all cases of placenta prasvia in which the indication is presented of emptying the womb as soon as it can be safely done. In saying so, I am not forgetful of the fact that I have in placenta prasvia delivered by means of the forceps, a case that might occur a few times in one's practice of half a century. Nor am I oblivious of the undeniable truth that some women have had vigor enough to thrust the presenting part of the child upon the placenta prasvia and push it rapidly before it, so as to expel the foetus by a labor so rapid as to prevent the loss of any considerable quantity of blood. Unhappily, these rapid labors are very uncommon, and the woman is compelled to suffer dangerous and sometimes fatal losses of the vital fluid, before the os becomes sufficiently open to allow a hand to pass within it. Should the Student find himself in charge of a case of placenta prasvia, with excessive flooding and a slow dilating os, he would be sure to reflect that turning is the indication which is to be fulfilled as soon as the os will permit, and he will think that if any measure could be taken to get the os open enough to allow the hand to pass upwards in search of the feet, such measures ought to be resorted to. He has just the thing he wants in Braun's colpeurynter. (Vide Fig. 74, p. 240.) If a colpeurynter should be placed within the vagina, he might fill it with water at 60°, or 50°, or 45°, and he might gently go on with the injection of water into the vulcanized rubber bag until the woman complains of the distension. I have thrown PRETERNATURAL LABOR. 425 cold water into the sac in such quantity as to make it expand to the size of the child's head; and in doing so I have felt quite sure that I was not only aiding in the process of dilatation, but I was applying a salutary therapeutic means (cold) for the checking of the flooding. If a head is above the os uteri striving to dilate or force it open, a colpeurynter below the os, and made as large as the head, could not but materially assist the dilatation. Indeed, so effective is the method that, if a woman be seized with the flooding, without any dilatation, a colpeurysis, continued about four hours, generally opens the os uteri enough to allow the hand to pass within and explore for the feet. Such a dilatation, effected within four hours, with the double advantages of being an admirable cold application, would save a large proportion of blood that must be inevitably lost in a case where the dilatation might require twelve or fifteen hours before the hand could pass upwards to Turn. I believe few cases of placenta praevia will, hence- forth, be treated by European or American accoucheurs, without the use of colpeurysis; and I trust every Student will, on going into practice, be provided with a set of well constructed instruments of the kind. 702. Concealed Hemorrhage.—There is another kind of hemor- rhage that is met with in parturient women; I mean the concealed hemorrhage. It may take place from the placental surface, and con- tinue to a dangerous extent, without detaching the circumference of the after-birth from its connection with the womb. In this case, the whole placenta is separated from the womb, with the exception of its rim; and the distensible material admits of so large a quantity of blood being effused betwixt itself and the womb, as to make it take the appearance of a bag filled with blood, and depressed into the uterine cavity. I have never met with a clear sample of this kind of bleeding; but the phenomena that accompany excessive loss of blood would give to an intelligent physician, intimation sufficiently clear to engage him to proceed aright in lessening the bleeding superficies, either by merely discharging the liquor amnii, or by turning, or by delivering with the forceps. The symptoms, under such circumstances, would be weak- ness: dull pain in the womb; suddenly increased size and tension of the organ; frequency and smallness of the pulse; paleness; yawning and sighing: and syncope. The occurrence of such phenomena, in a pregnant woman, if alarmingly great, would, I think, be a full warrant for opening the ovum and an expeditious delivery; the latter always, however, to be held in reserve until the womb is dilatable. Such a case invariably deserves to be profoundly considered before proceeding 28 426 PRETERNATURAL LABOR. to the employment of an extreme measure. The ergotic action might, with great prospect of advantage, be resorted to, in case the hemor- rhagic symptoms should not abate upon the discharge of the liquor of the amnios. I do know that there are people, who, on perceiving that the blood is flowing in these cases, which might happen after some hours had elapsed since the first commencement of the hemorrhage, would make haste to use the tampon; but, this so manifestly seems to be wrong, that it is surprising any person should overlook the fact that, if the flooding comes from detachment of a placenta seated on the fundus uteri, it is in vain to place a tampon on the vagina, which is from 9 to 12 inches distant from the bleeding point; and that there is space enough between the margin of the placenta and the os to receive more blood than would suffice to kill the woman by its waste. The placenta is usually seated on some part of the fundus uteri, and when blood flows in consequence of its being partially or wholly detached, it may be that many hours, or even days should pass before it could force its way to the os by dissecting off enough of the chorion to afford a track for its escape. To attempt to suppress one of these floodings then by the Tamponade would be like damming a running stream, whose backed waters must accumulate and at last overcome all obstructions. What then is first to be done in the case? The Student should adopt the method of Louise Bourgeois, which is to break open the ovum—let the woQib grow smaller by contracting— and as soon as practicable take away the entire product of the preg- nancy, so that the uterus may return to its non gravid state. I will now show how I lately proceeded in a 703. Case—In February, 1854, Mrs. S---- C----, of ---- St., being pregnant near seven months, descended the stairs to dine, being conducted to the saloon by a gentleman who was the guest. At the foot of the last step a favorite dog laid asleep, and she not perceiving it, stepped upon the animal, which made a great howling as if badly hurt—the lady, who was nearly thrown to the floor, was greatly agi- tated—but recovering, took her place at the table and thought no more of it. Three days later, she was suddenly seized with flooding, so that a large quantity of fluid and clotted blood fell from her on the carpet, and wetted her dress excessively. She got to bed and sent me an urgent message. I found her in labor—but flowing considerably. As soon as the os became about 1J inches in diameter, I ruptured the membranes, and not long afterwards the foetus was expelled dead. I found that nearly the whole uterine face of the placenta was invested with a dense coagulum of a dark almost black hue, and in some places PRETERNATURAL LABOR. 427 more than half an inch thick. Only a very small part of the pla- cental surface was red or fresh. Hence, I supposed that hemorrhage commenced soon after the accidental mishap above mentioned, and, that three days elapsed before the concealed hemorrhage became open or manifest flooding, else the uterine face of the placenta could not have been so dark colored, nor overspread with red clots of blood. 704. Hemorrhage, following the Birth ofthe Child.—The hemorrhages that take place between the delivery of the child and the expulsion of the placenta, are frequently met with, and are so violent as to excite great alarm in the patient herself, or her friends who hap- pen to witness the distressing symptoms that accompany the accident. I think that, in a great majority of labors, the placenta is partially detached by the time the child's head has emerged from the vagina, and that the complete separation frequently takes place still earlier. In such women as have feeble pains, with long intervals, the effusion of blood is sometimes very great, so that a large quantity frequently is found to be expelled immediately after the child is born, being evi- dently the result of hemorrhage taking place in the intervals between the pains, yet detained behind or above the presenting part until the delivery of the child is completed, whereupon it rushes forth with great violence. If this is a correct statement, then it may, a fortiori, happen, that the effusion may go on rapidly as soon as the body of the child has escaped. The womb, in some instances, is perfectly pas- sive for a good while after the great eff'ort it has made, and the pla- cental superficies being exposed, a torrent of blood issues and sud- denly fills and distends the cavity, and the woman faints and dies with- out any one perceiving that she has flooded at all. I believe that this blood would always flow out of the vagina, were it not that a firm clot occasionally happens to stop the os uteri, or vagina, like a tam- pon, so that none can escape; and if the womb be deprived of its ir- ritability, its fibres will offer no resistance to the fluid poured into the cavity, which, being sealed up by a coagulum at the os uteri and in the vagina, must fill up more and more, and with a rapidity that aug- ments as the placental surface grows larger and larger. A careful practitioner ought not to allow such an event to take place, in his presence. He will frequently place his hand upon the hypogastrium of his patient, and ascertain whether the womb be properly con- tracted, and enforce its contraction, if necessary, by frictions, and by gently pressing the womb with his fingers applied to the lower part of the abdomen. The irritability of the organ is readily excited into effort by this means; and when the womb becomes properly con- 428 PRETERNATURAL LABOR. densed, there is little danger of any effusion taking place. It should be an invariable custom to place, after the child is born, the hand on the mother's abdomen, to make sure ofthe contraction of the uterus. This custom will always give prompt information of the existence or non-existence of a tonic contraction; and he who fails of attention to this point will, sooner or later, have reason to regret the neglect of so salutary a pre- caution. But when flooding comes on, whether after delivery or an- tecedently to it, the same universal principle of practice is applicable, namely, to empty the cavity as speedily as possible consistently with prudence. Let the placenta be taken away, and, after its removal, let pressure be made on the hypogastrium by the hand, or by a compress and bandage, the pressure being continued until the signs of hemorrhage have completely ceased. After having removed the placenta, or after having turned out from the cavity of the womb a pound of coagula, more or less, the woman cannot be deemed safe until the lapse of an hour or more shall have given assurance that no repetition of the hemorrhage can take place. I have, on a great many different occa- sions, found myself compelled to turn out the clot again and again, to prevent the patient from falling into fatal syncope. Let the Student, therefore, take heed, that, while he may have saved his patient from fatal hemorrhage at ten o'clock, she fall not in the same hazard again at half-past ten or eleven, or at half-past eleven, being careful not to quit her apartment till he can clearly pronounce her safe. Where the flooding returns again and again, let the Student feel for the pulsating aorta above the fundus uteri, and, pressing the vessel with the ends of his fingers, endeavor so to check or lessen the circulation in that great artery, as to hinder the excess of circulation in the branches below, and so of the uterine arteries. In this way, some lives have been preserved. It happens that the womb is incapable, sometimes, of separating the placenta wholly from its surface; but if it be half detached, there may flow a great quantity of blood, while the uterus continues unable to expel the after-birth. The duty of the medical attendant here is to separate it entirely, by introducing his hand, and gently detaching it with his fingers; taking every possible care not to leave any portion behind, which, by keeping up a continued irritation, would tend to maintain a hemorrhagic nisus, or even dispose the patient to metritis. He will separate the placenta, then, in order to let the uterus contract for the suppression of the hemorrhage, which it will do as soon as it can thrust the secundines forth from its cavity: but let it be always remembered that the hand is not to be introduced unless real need for it exists. The greatest care should be taken, in PRETERNATURAL LABOR. 429 this case, to keep the patient quiet, and strict order should be given not to lift her head from the pillows, until all the appearances of danger are gone. Indeed, she ought to have no pillows. Any attempt to sit up in bed, or even to turn, for a woman excessively reduced by hemorrhage, is dangerous; since any muscular effort, by occasioning faintness or exhaustion, invites a renewal of the hemorrhage and debility, which are both to be deprecated. 705. Hour-glass Contraction.—I have met with several exam- ples of the hour-glass contraction of the womb; of which incident, although I have spoken of it at 603, I desire to add something in this connection. Hour-glass contraction depends either upon the con- traction ofthe womb at the upper limit of its cervical portion, so that the after-birth is contained, as it were, in a separate cell, or the-con- traction may take place so as merely to include the placenta still retaining its original connection with the uterus. The finger may pass up to the constricted point, and find the cord closely embraced by it. If no bleeding comes on, it is commonly deemed proper to wait an hour, to see whether the co-ordinate action of the muscular fibres will not overcome the horizontal constriction; but, if an hour elapses without the least change in the case, we have reason to infer that two, or even four hours may not suffice to remove the difficulty, and we are always justified in taking away the secundines in that time, even should we not be prompted to do so earlier. It is, in gene- ral, not difficult to overcome the stricture, by introducing, first, the hand into the vagina, and then inserting one, then more fingers along- side ofthe cord, until a sufficient portion of the hand is introduced to command the placenta. But I can truly say that I have never yet met with an hour-glass contraction in which I was not compelled to separate the placenta with my hand. I cannot well conceive of an hour-glass contraction, independently of a preternatural adherence of the after-birth to the womb. I suppose that when the after-birth is so firmly attached that the contractions of the womb cannot slide it off, the substance of the placenta acts as a soft splint, counter-extend- ing the utero-placental superficies. The rest of the womb, having nothing to antagonize it, contracts as usual, leaving the placenta shut up in an upper pouch : it usually contracts at the upper extremity of the cervix. Sometimes, as where the placenta is situated upon the side of the womb, and cannot be displaced by its contractions in consequence of the preternatural adherence, the pouch in which it is contained is on the side of the womb, and the fingers, in dilating the constricted part, must be conducted to the right, or to the left, or to 430 PRETERNATURAL LABOR. the front, or backwards into the chamber containing the after-birth, as the case may be. If this explanation be just, there is no very well- founded reason to hope for the spontaneous expulsion of the after- birth—for the adhesion will not give way after the birth of the child, if it would not do so just before that event. Hence, the indication in hour-glass womb is, perhaps, to deliver at once, and I now heartily and warmly advise the Student to introduce his hand and separate the placenta, as soon as he can clearly determine that the real hour-glass contraction does exist. He will be compelled to do so sooner or later, —and the sooner it is attempted, the easier will it be effected. What can be more disagreeable, or even distressing, than to be compelled to carry the hand and half of the fore-arm inside of the body of a patient already weakened and exhausted by the labor, and, above all, to be obliged to remove from the womb, while she is agonized, the adhering mass, which sometimes is so firmly united as tp be apparently confounded with the texture of the womb. I am sure that, in per- forming this painful office, one is occasionally obliged, by a sense of duty to the patient, to continue the eff'ort to get off" the placenta, even when far from certain that he is not either leaving portions of the lobules still united to the uterus, or perhaps injuring the uterine tissue itself; all that can be expected of any practitioner, under such cir- cumstances, is that he should faithfully do his duty according to his ability. If he cannot get off the whole after-birth, he must leave portions of its lobules. Let him, however, always try to get every vestige of it off. To leave an ounce adhering is better than to leave a pound, and he can and ought to protect his own credit against any untoward results by a full and candid statement of the difficulty he has met with, and of the impracticable nature of the case. I have taken away a great many such, and all of the women save two have recovered, even where I was certain that my utmost care and desire to succeed in removing the whole had been in vain. The Student will learn that he will rarely, in practice, meet with these vexatious adhesions in cases that go on regularly and with a proper celerity; but if he have a labor that gives him great trouble and long detention from irregular action and feebleness of the pains, he may justly fear that the after-birth will not come off easily. I doubt not that a very firm adhesion of the after-birth is capable of greatly impairing the regularity and strength of the uterine contractions. Such an after- birth, by preventing that part of the womb in which it is situated from contracting in due proportion with the other parts of the organ, is probably the cause of most of the difficulty we have to contend with throughout the whole parturient process in such a case. When PRETERNATURAL LABOR. 431 the placenta adheres with such preternatural force, the uterine surface on which it rests is, to a certain extent, splinted or counter-extended during the contractile efforts of the rest of the organ. If one could suppose a placenta converted into bone, and retaining such preter- natural union with the womb, it is clear that so much of the organ as should be united to it could not contract, and that all the rest of the womb might contract, shutting the ossified placenta within a cell. But, in fact, when the adhesion is so strong that the uterus cannot abolish it by its contraction, the same result is virtually attained as if the ossification above supposed should really exist. 706. Hemorrhage following Delivery of the After-birth.— The application of a compress, made by folding one or two napkins, and securing them upon the lower part of the abdomen by the com- mon bandage, is a precaution that ought never to be overlooked where there is a great disposition to hemorrhage. Such a pressure not only prevents the womb from filling again, but it tends to secure a firm tonic contraction of the organ. Besides this compress, we shall find that the sacchar. saturni, combined with opium, in doses of three or five grains of the former, with from half a grain to a grain of the latter, repeated in an hour, offers us a very useful resource in the styptic influence ofthe acetate of lead. In like manner, infusion of red rose- buds, with elixir of vitriol; powders composed of five or ten grains of sulphate of alumina, with a few grains of nutmeg repeated every half hour or every hour together with the application of cloths pressed out of cold vinegar and water to the pubes—all these are measures that must be sometimes resorted to, when the flow of blood continues after the delivery of the secundines has taken place. Violent and dangerous eff'usions of blood sometimes come on immediately after the delivery of the placenta, and at a time when the labor is supposed to have been terminated in the most successful and fortunate manner. If half an hour elapses after the delivery of the after-birth, without any flooding, we shall rarely meet with it, and may, for the most part, con- sider the patient safe. Nevertheless, it does sometimes come on many hours later; or even many days are passed, without any apparent tendency to the accident, before the female is attacked. The causes of this bleeding are to be sought for in the relaxed state of the womb, arising from loss of power in its muscular element. The cases are almost invariably connected, too, with an excited and impetuous cir- culation, by which the blood is propelled with such power and momentum into the uterine vessels as to force open their extremities, when they are not sufficiently supported and constringed by the mus- 432 PRETERNATURAL LABOR. cular contractility of the uterus. Such an attack ought to be foreseen in the state of the pulse, and obviated by the use of such measures as may serve to abate the violence of the blood's motion; and the patient ought not to be abandoned by the physician, until he has become fully satisfied that the danger is past. Let the patient lie in a truly horizontal posture; let blood be taken from the arm if required; let cool drinks be given, and cold water applied to the face and fore- head ; and let great care be taken to ascertain, from time to time, by the touch externally, whether the womb is firmly condensed or not. It is not good, I am sure, to allow the napkins that are usually applied to the vulva, to be too firmly pressed to the parts; they act, when so pressed, as a sort of tampon, which enforces the coagulation of the blood in the vagina; and that itself is a dangerous tampon. The blood which cannot escape accumulates within the womb and consti- tutes a concealed hemorrhage, that is likely to increase with frightful rapidity aud that may sink the patient irrecoverably by the time it is discovered. When blood has once escaped from its vessels, it is of no further service, and therefore the sooner it is got rid of, the better for the sufferer. If the Student should find the hemorrhage not to be stayed by his treatment, let him press his fingers, gathered into a cone, firmly down upon the aorta, near the umbilicus. If the patient should not be troubled with extraordinary obesity, he will be able to feel the throb of the aorta with the points of the fingers. Let him compress the tube according to his judgment, in such a way as to check the downward rush ofthe torrent. This will operate usefully in two ways: first, by lessening the force with which the blood reaches the bleeding orifices, which will then have an opportunity to close themselves more or less completely; and second, by causing a greater determination of blood to the encephalon, whereby the tendency to deliquium will be lessened. Many lives have apparently been saved by thus compressing the aorta. I have always governed myself as much as possible by the rule acted on and enforced in his lectures by the late Professor James, which was, " Don't leave your patient for one hour after the termination of the labor." The pressure of business upon a medical man in a large practice will sometimes make it impossible to stay so long near the lying-in woman, but when under the necessity of leaving her, he ought always make arrangements for his recall in case of need. Leaving a newly-delivered woman a few minutes after the deliverance, he exposes himself to the shock of hearing, upon his return to his house after one or two hours, that " Mrs. B. wants him immediately, as soon as possible —has sent again and again—they think she is dying!" I have many times been saluted with such messages, and it would be difficult to PRETERNATURAL LABOR. 433 express the emotions they excite. It is true that most of the cases are neither fatal nor even dangerous; yet occasionally a woman is found to sink and die, almost without warning, from effusion of blood which either flows out upon the bed,or is retained within the vagina and womb, distending them enormously, without giving rise to the least suspicion in the friends or nurse that the woman is bleeding. In case of being summoned in this sudden manner to return to the patient, it is obvi- ously the first duty of the physician to make sure of the state of the womb; and accordingly as soon as he reaches the bedside, he should place his hand on the hypogastrium in order to learn whether the or- gan is too much distended ; if it be found too large, his course is plain —he must break up the clots which fill it and press them out. This is to be done in every such case. If the womb be not too much distended— and yet there are those signs of weakness which show that the patient has lost too much blood, while no great external or open flooding has taken place—he should still act as if there were really a hemorrhage. Let him then introduce one or two fingers into the vagina, and he will be almost sure to find that the tube is filled to distension with a very solid clot—a clot as large, perhaps, as a child's head, and extending g.** '» this line, was made for either; therefore, when the chdd » fed other- wise than at the breast, it is fed by a succedaneum; every succedaneum Hy comparison, infinitely inferior in value and adapt.veness to the ' eneri al food which the Author of Nature supplied for ,t and socon- ftructed ts organs and parts as to fit them to recede it and be deveh oped by H I shall not take the trouble, in this volume to repeat he analyst and the observations upon milk which I have already prmted nano her work, nor indeed does it require any argument to show hatInasmuch as the proportion of oil, casein, albumen, and water m he mTk of the different mammiferous creatures vanes according to heirtnus, so the young of each genus is adapted to the reception^ of he or of 'aliment devoted to its generical nature. It ,s true that a LZ child who has lost its mother must be fed, and ,t »better for t Lheldw^th cow's milk or goat's mi.k than not at .11; but I hoi ,t V to be a sacred duty for all those persons whose crcumstances adm.t of GS4 HISTORY AND DISEASES it, to provide the new-born child with the milk of a human nurse, and not to expose it to the hazards—I should say the dangerous risks—of distressing illness and impending death, that threaten the great majo- rity of those children that are brought up on the spoon or b i b e r o n . The neonatus comes into the world full of instinctive desires; it will take food soon after its birth, and will satisfy its instinctive cravings to absolute satiety. But I beg the Student to remark that, while the Divine Author of Nature has ordained that children shall be born, he has also ordained that the plenary abundance of their food shall not, as a general rule, be provided for them until the third day after birth. It is not necessary, therefore, to feed the child as soon as it is washed and dressed; I look upon it as a direct flying in the face of Providence, as acting in direct contravention to the law of nature, which is but the command of God, to fill the stomach of the new-born infant with mix- tures of saccharine matter, of gruel, or of the milk of quadrupeds; surely, He who made it knows better its true wants than those who, ignoring his wisdom and foresight, make haste to test its digestive powers by these detestable mixtures, instead of waiting the fulness of his own time. I have warned the Student, however, that hereafter he will encounter much trouble and vexation in consequence of the early and improper feeding of infants under his care, and I exhort him by careful consideration to inform his mind as to the medical duty in such cases. He will never err, he will never go astray as a physician who ascertains clearly the physiological laws of the function or functions placed under his surveillance; and he who in his hygienical ordinances is the best expositor of nature's laws, will be the safest and most suc- cessful physician; and it is certain that no human sagacity or skill can ever equal the perfection of those operations that are instituted and effected in accordance with the generical nature of the subject of them. It is a mistake, and it is a grave mistake, to suppose that the neonatus is in danger of starvation because it is kept until the third day on the supply furnished it from the mother's breast alone; for there is always, after the birth of the child, to be found some small quantity of mammary secretion, which, though it be not properly deserving to be called milk, yet it is possessed in a measure of the properties of that fluid. The earliest secretions of the milk gland are loaded with a great abundance of colostrum grains, which are to be seen thickly strewn over the field of the microscope, mixed with vesicles and oil- globules, floating in the serum-lactis. Probably the imbibition of this colostrum by the child has some economical relation to its conserva- tion. The colostrum disappears in the course of a fortnight, or at most in three weeks, after the child's birth ; I cannot imagine that it OF THE YOUNG CHILD. 685 is a mere excremental matter, for the breast is not an excrementitial, it is a recrementitial organ, and all that it produces is designed for the advantage of the new-born child. With these views I am quite clear in advising the Student to direct his patient to take the nursling to the breast at the earliest convenient moment. I have many times seen a child drawing vigorously at the breast within a quarter of an hour after its birth, and I believe to take the child to the breast is the most natural thing for the mother to do. To illustrate this opinion, let me invite the Student to consider the circumstances that might have attended the apparition of the first-born of mankind. The common mother of mankind had perceived the strange sensations and modifications of her form, dependent upon an advanced stage of her first gestation. She resided, perhaps, in some warm sunny valley of the Caucasus, bounded by an amphitheatre of lofty mountains, and enriched with a varied landscape, tinted with every hue and form of tree and flower and grassy mead. A transparent fountain arose, per- haps near the bower, in which Adam had left her sleeping at the up- rising of the morning. He may have climbed some lofty distant cliff to gather for his bride its Alpine blossoms, or return, loaded with fruits for the object of his tender care. In the mean time, she is seized with the pangs of the first human travail-the terrible fulfil- ment of the curse on her early disobedience; alone, unaided, in a purely natural state. With that inherent health and strength which we may conceive of as appertaining to a creature which had issued perfect from the hands of its Maker, she advances through the un- known conflict, and, at the moment of its consummation, becomes Lensible from the keenness of her anguish In a few moments she is recalled to her senses by the voice of the new-born child and raisin, her languid head and inclining her bending body feebly sup- "orte! upon tht elbow, she perceives the helpless ^ ^ lving upon the grassy floor of the bower near her. It is not necessary topfint indeed! it is impossible to imagine, the intenseness of the cradle, its lace woui 5 first-born, until his mother experience breast for the pours the nch —,.ream of bfo o t tfj ^ ^ :rr"epaeat, Z^^ •*• •»» ** » «" *— « 6^6 HISTORY AND DISEASES the earliest possible period after its birth. Every human direction and counsel in contravention of this most evident law of nature must be erroneous, save when it is founded upon views relative to the actual state of the mother or child, as setting aside, for the moment, the operation of those natural laws. Hence some information should be given to the inexperienced mother or nurse in regard to the alimen- tation of the neonatus. I believe that pure instinct is more unerring than reason, and a better guide in all those cases in which instinct is designed to preside. I therefore look upon it as a tyrannical thing on the part of any physician to prescribe precise intervals between the applications of the child to the breast. I have no idea that any physician can be competent to decide upon the degree of activity of the digestive powers of any young child. The principles of conduct here, are principles to be derived from a knowledge of the wrants of the child: a child may want the breast again in two hours, or it may not want it again in six hours. It is therefore preposterous on the part of the physician to say, as I have heard him say, that the child must be applied to the breast every three hours, or every four hours, according to his unerring wisdom. I advise the Student to direct the child to be fed when it is hungry, and allow it to be governed, as to the quantity it takes, by its instinct, which is superior in this matter to his reason. It is probable that the child within the month, whose stomach can scarcely be supposed to hold, when perfectly satiated, more than two or three fluidounces of milk, will be able to digest and discharge the major part of this quantity into the duodenum, in the course of some three hours after its assumption ; but it is probable that the feeling of hunger will begin to return long before the organ becomes completely empty. There are but few new-born infants that are incapable of rejecting a part of the ingested milk ; the stomach in this way relieves itself of any excess, which the appetite might induce it to swallow. I have no doubt that a considerable portion of the in- gested milk passes as milk and not as chyme through the pylorus. These considerations, together with observation of the facts, have in- duced me, in general, to say that the child might be applied to the breast about once in three hours ; but I am far from prescribing three hour intervals as an absolute rule of conduct, and I have no objection to see the child again applied to the breast within two hours after having thoroughly satiated its desire for food, for I repeat, I rely upon its instinct, which was provided for it before the invention of Physic and Surgery. The dental formula of animals is the index to their nature, especially to the nature of their alimentation. The state of its mouth is sufficient to make it apparent that the child should be fed OF THE YOUNG CHILD. 687 upon fluid aliment, up to the time at least of the establishment of its dental apparatus; and nothing could be more stupid than the conduct of those that feed young babies with bits of fat ham, minced chicken, and other articles of food for which the child does not become fitted until the period when nature announces it to be so, by the establish- ment of an apparatus for mastication. As a general rule, the child ought to be nursed at the breast until it is twelve months old; if the twelve months should happen to elapse about the beginning of June, it ought to be kept at the breast until the autumnal equinox, since experience declares that in the United States very few children can be severed just at the outbursting of the summer heats, without becoming subject to some degree of digestive derangement, which, when once begun, is not readily removed while the child is nourished artificially, but which either does not attack, or is readily overcome, if the supply be of the kind of food which is natural to it. 920. Weaning.—As to the nursing of the child, notwithstanding I deem it a sacred duty on the part of the parent to fulfil this obliga- tion, yet it is questionable whether the obligation is not really set aside where the inducement thereto arises from a dangerous condition of the maternal health. If a man marry a wife having a hereditary claim and expectation to perish with pulmonary consumption, it would be better, both for her and the infant, to dispense with the giving of suck. It is probable that the infant has already caught a touch of the taint or the diathesis, almost in the act of conception, and if not then, within the course of the uterine gestation. The sooner all influences of the mother's life over it shall pass away, the greater is the hope of its escaping the terrible fate before it; and on her part, it may be said that the rudest and strongest health is oftentimes much diminished and shaken by twelve months of lactation; but, for a person having in the lungs the invisible seeds of a tuberculosis, to subject such a one to the exhausting processes of the long lactation, is to nurture and call them into a fatal activity. I do not mean, in these remarks, to recommend that the lying-in woman should at once begin to throw back upon her constitution the fluxional movement towards the mammary glands, which can only be normally counter- acted by the proper physiological action of the gland. Her own safety exi^ently demands that she should favor this fluxional move- ment for a few weeks; but after four or six weeks she ought to let her milk slowly dry away, and provide for her child a wet-nurse of unquestionable qualifications for the end in view. I can conceive that by proceeding in this manner, a family might cast out of its stock 6^S HISTORY AND DISEASES even the tuberculous diathesis, in the course of a few generations. It is melancholy to contemplate the misery which is in store for those who, preferring the enjoyment of their natural and praiseworthy sen- timents, turn a deaf ear to the warning voice of experience and pru- dence. Counsel, however, is to be given by the physician, who is to be all things to all sorts of people; and it must happen that he shall have to counsel those whose circumstances forbid them to defray the extra expense of wet-nursing. Under such circumstances, the child must be fed; milk is its food, and the best succedaneum for its mothers milk is the milk of the cow—indeed, there is none other easily to be had in the United States; and it would be in vain in this country to recommend either the use of asses' or of goats' milk, which, in various countries in Europe, is abundantly provided for those who may find occasion to employ it. With regard to the artificial alimentation of the child, if the Student should reflect a moment, he will come to the conclusion that the act of digestion is much assisted by the admixture, with the food that is ingested, of a due proportion of saliva. The saliva, though not so essential in the digestive evolution as the liquor gastricus, is an indispensable agent in the act. A child that draws its milk from its mother's breast by the suction power of its mouth may be almost said to masticate it, and in doing so it causes a stream of saliva to pass into the mouth, which is swallowed along with the milk. The proper excitant of the salivary glands is first, perhaps, the pre- sence of alimentary matters in the mouth, and secondly, still more powerfully the motion of the tongue and cheeks and jaws, in eating. Now, a child that is fed from a spoon may be almost said to have the food poured down its throat without swallowing it, and the same is true of the infant that takes its aliment from the edge of a bowl or cup. It is far more convenient and proper, in all cases of artificial alimentation, to simulate as closely as possible the natural functions, and I believe that the child will digest its gill or half pint of food more safely and successfully, if it be taken through the b i b e r o n than if taken out of a spoon or cup. Let the Student give ample attention to these considerations, and judge for himself whether the remarks be well founded or not, and thereupon base his professional counsel. Without going here into a comparison of the different kinds of food, I beg to request the attention of the Student to the opinions which I have expressed upon this subject in my work upon " Certain Diseases of Children." 921. Of the Navel.—The navel being dressed in the manner heretofore described, it is usually left thereafter to the care of the OF THE YOUNG CHILD. 689 monthly nurse or attendant, and the physician is rarely called upon to interfere, except when it becomes the seat of some diseased action. The remainder of the umbilical cord, left after the severance of the child, soon begins to dry ; the water of the Whartonian jelly contained in it escaping through the inorganic pores or crevices in the amniotic coat. The vein usually contains a small coagulum of blood, and the arteries become collapsed and entirely desiccated. In the course of from four to seven days, the cord has become so dry and thin as to resemble a piece of transparent yellow horn ; the absorbents at the line of the demarcation early commence to cast off the slough, by estab- lishing a crack or fissure all around its root: this fissure, growing deeper and broader from day to day, allows the desiccated vestige to fall away, leaving a small spot of raw surface, often not bigger than the head of a pin; for most of the wound becomes incarned or cicatrized as the process goes on. While the child is in the womb, and even at the moment of its birth, the navel protrudes, often to the length of half an inch; but the two arteries, whose cut ends are at- tached near the surface of the new-formed cicatrix, act as cut arteries always do, by retracting, and thus serve to draw the navel inwards and downwards in the direction of the urachus. The remainder of the vein, which becomes a cord passing along the edge of the falciform liaament of the liver, is also, but in a less degree, retracted. These vessels serve in this way to draw the navel inwards, and to make the dimple of the umbilicus; but the deepest pit of the dimple will look downwards towards the bladder, for the retractility of the arteries is ereatest When the retraction thus effected is perfect, the tissues are drawn strongly inwards towards the inner aspect of the belly, and the vacuity in the linea alba, constituting the umbilical ring, becomes perfectly closed; but if this retraction be incomplete, then a plug of tissues contained within the circle of the umbilical ring prevents its absolute closure, and leaves the child liable to be affected with exom- phalos or pouting of the navel. It is clear that, in order to aid this ^ion and complete it, a proper compress should be adjusted over the umbilicus and retained by the belly-band, whose use ought to be ontinued as long as its use is indicated. If the child is quie , and little given to crying and straining with tenesmus and if the dimple ofits navel be perfectly well-formed, the belly-band may be left off at the end of the month; but the least disposition to protrusion, or a wintry season, furnishes motives for its longer continuance. qoo Of the Meconium.-The meconium of the child is a dark viscous, green, diffluent matter, which is contained in its colon and 690 HISTORY AND DISEASES rectum at the period of birth. The quantity is sometimes very great, and the first alvine discharges consist wholly of this material. Three or four of the first evacuations serve in general to carry it all off; occasionally, it is so adhesive as not to quit the surfaces of the bowels : perhaps it is lodged in the cells of the colon, so that the bright bile- tinted stool of such a child, seen upon its napkin, induces a belief that the meconium is all purged off, whereas subsequent dejections show that no inconsiderable quantities have been detained in the intestine. When the meconimm comes off freely, and seems to be entirely dis- charged, giving place to excretions of a healthy hue and consistence, no medical precautions can be deemed necessary; but if the child is uneasy, crying, fretful; affected with griping pains, which are betrayed by its voice and by the frequent flexion and extension of its lower ex- tremities, with an appearance of passionate impatience, and especially if some portions of the meconium seem to linger upon the napkins one after another, we should have reason to suppose that the surfaces are still vexed and irritated by this excreted matter, which ought to be removed by small portions of castor oil or some other convenient aperient. 923. Purging.—Children that feed many times a day will generally be found to require several alvine dejections per diem. A child that satisfies its instinctive desire for food generally does so by filling the stomach until it is quite distended, and it will often happen that some portions of the ingested milk will pass off through the pylorus into the intestinal canal too early to have been subjected to the influence of the gastric liquor. Such portions of milk will, therefore, appear upon the napkins in broken or granulated coagula of a white color. Most children, after filling the stomach to distension, enjoy the happy faculty of regurgitating the excess, so that the stomach soon becomes relieved of its over-fulness, retaining less than it has received, and subjecting it perfectly to the gastric digestion. A child that in this manner rejects the superfluity, and completes the digestion of what remains, will have small residue of its digestions, and therefore will have fewer alvine discharges, which shall also be smaller in quantity than those of the child a portion of whose undigested milk passes into the duodenum and jejunum. Without being able to speak positively from careful observation, I venture to state that the neonatus in per- fect health has three or four changes of its napkin daily, and I con- ceive that this is not too great a number; at the same time, I presume that a child might be very well, having only one dejection per day, provided it is known to have the faculty of regurgitating the super- OF THE YOUNG CHILD. 691 fluous ingesta, and provided also it has the appearance of enjoying a complete health. I beg to inform the Student that he will meet with a good many children which shall have eight, ten, sixteen, twenty dejections per diem, and that he will often be called upon by anxious parents to prescribe for such seeming diarrhoea. The case to which I allude is not a diarrhoea; it is a case in which a child, nourished at a free and abundant breast, fills its stomach again and again with a gastromorphous clot of milk, a major part of which, being comminuted by the contractions of the organ, is driven off undissolved through the pylorus, because the child has not the power to get rid of it by regur- gitation. When I am called upon to give counsel in such cases, I do not always take for granted that the child is sick because the nurse or mother tells me it is so, nor do I admit that it has a diarrhoea because it has twenty stools per day. Under such circumstances I have often said, let it alone, do not interfere with the case at all, except by regulating the amount of its food; do not give it such frequent opportunities to suck, and judge carefully when it shall have got what is necessary for it, and then put it away. If you give medi- cine to stop its diarrhoea—which is not diarrhoea, but a result of reple- tion—you will make the child sick, for if the child continues to live in the same way, so as to require twenty napkins per day, and you prevent the action of its bowels, by means of some astringent or narcotic medicines, you will make it really ill—it is a case for hygiene, not for therapeia. It has twenty evacuations daily; well, be it so. Examine the dejections, and you will find that they consist almost wholly of the whey of milk. The child keeps the curd and digests it —but the whey is more than it can keep, and so it passes off by the bowels in the form of what you call diarrhoea. But it is not diarrhoea, it is whey. I do not fear that I shall mislead the Student by the above observations, because, if he be a man of sense, he will judge for himself, and not from a book; he will inquire what is the nature of these dejections which are accused of being diarrhoea, and if he should find they are such as I have above described, he will perhaps remember my words, and act in accordance with the indications that I have pointed out. If the stools consist of masses of slime—if they are altogether bilious-if they give evidence of an excessive acid saburra then he will inquire into the particular wants of the case, and prescribe accordingly. The mucous, the bilious, or the acid saburra may require only a teaspoonful of castor oil, a small quantity of rhubarb a portion of magnesia, a half grain of calomel, or calomel with chalk.' Perhaps he will be enabled to fulfil the therapeutical indication by prescribing a portion of lime-water and milk, or a little 692 HISTORY AND DISEASES soda or potash mixed with water alone, or mixed in infusion of chamo- mile or some other bitter or aromatic garden herb. Possibly, he may find the fault to consist in a hyperneuric condition of the muscular apparatus either of the small or of the large intestine, and he will correct such an hyperneuria by means of an anodyne draught. An anodyne draught for the new-born infant should consist of half a drop of laudanum in a teaspoonful of water. To give half a drop of lauda- num, let him direct the nurse to put two teaspoonfuls of water into a cup, and add one drop of laudanum thereto, which, being perfectly mixed and compounded, permits him to give, in one teaspoonful of the mixture, just half a drop—the other should be thrown away. 924. Costiveness.—Sometimes the new-born child, instead of being troubled with too many dejections, is affected with costiveness. This costiveness is overcome either by a suppository of molasses candy, of a bit of castile soap, or a camel's-hair pencil dipped in castor oil, and thrust just within the grasp of the sphincter muscle. It may be remedied by an enema of tepid water, or water quickened with a modi- cum of salt, or molasses, or castor oil; or the child may take a teaspoon- ful of a weak infusion of rhubarb, or a little magnesia, or a little rhubarb roasted in a saucer until it is slightly browned, or, what is better than all, a pinch of pure precipitated sulphur mixed in water sweetened with honey or honey of roses. Small portions of sulphur, mixed with honey water, appear to me to operate upon the neonatus more kindly than any other therapeutic agent, in this peculiar case; and the use of it continued for a few days, often serves to remove an habitual dis- position to costiveness. The Student should judge, however, in the cases committed to his care, as to the cause of the constipation. He knows, or he ought to know, that the bile furnished by the liver is the natural eccoprotic, and that, if that bile should be in just quantity and of due quality, it should take the place of all rhubarb, senna, and pur- gative drug. If therefore, upon inquiry into his case, he discovers a deficiency in the quantity of the bile, or such modifications of its tint and other qualities as seem to call for his therapeutical intervention, let him judge as to the precise nature of that intervention. Let him ask himself what is the source of the blood that gives rise to the se- cretion of bile, or from which the bile is secerned, in the eliminating apparatus of it, the liver. He will see that the whole of this blood came from the aorta, through the cosliac and two mesenteric arteries; that the chief torrent of it, after being passed through the capillary circulation of the intestinal tube, hath been collected again by the radicles of the great portal vein, which lets it into the liver to be dis- OF THE YOUNG CHILD. 693 tributed through the hepatic branches of the vena portas to the capil- lary tufts in the acini, whence it is carried off again by the nascent radicles of the hepatic veins, which are to discharge it into the cava— and so his question is answered, for he will scarcely believe that the hepatic artery is the secreting tube, but only the nutritious artery of the liver. When, then, he finds a child disordered as to the action of its bowels and liver, I hope that he will cast his eyes upon this great system of what the ancients called the mesaraic circulation, so that, inspecting the whole field of it, he may discern in what point of it the pathogenic principle resides. I should think that he could not but look upon a hyperasmic condition ofthe capillary system of any large portions of the alimentary tube as matters important for the perform- ance of the secerning functions of the liver; and see that retardation in the movements of the great intestinal portal system, or of the great hepatic portal system, cannot but be regarded as giving rise to suffi- cient causes for those modifications of the functions of the liver which he desires to cure. Under these views, it will not always be for him in- evitable to administer mercurial remedies for slight derangements of the bile. He will-rather provoke the peristaltic fibre to greater or to renewed action, with a view to remove those embarrassments of the portal or mesaraic circulation which he shall accuse of causing the bilious disorder, and he shall find that a teaspoonful of castor oil, or a pinch of rhubarb, or a modicum of magnesia, or an innocent dose of precipitated sulphur, is quite as effectual, and abundantly more safe than the vaunted power of the mercurial dose in these affections. It appears to me that in the United States there is an indissoluble alliance between the word liver and the idea calomel, and that the notion of the alterative power of calomel springs spontaneously at the least suggestion of an hepatic or bilious derangement. I do not deny that calomel is a purgative, nor that it produces the most distressing nausea when taken into the stomach; nor that it may therefore, upon proper occasions, be rightfully administered, even to young children; but an examination of the circulation and of the in- nervation in those parts which stand before the gate of the liver, and which serve, as it were, as propyla, admitting the torrents of circula- tion into it, out of which the bile is to be taken by it, ought clearly to point to states of those parts, I mean the mesentery, the mesocolon and the alimentary canal itself, as often the seats of those pathogenical influences which are discoverable only in their effects in modifying he bue I beg the Student to get the baby through the month without'mercury if possible; since, though I deem mercury an ad- mtbleremedy'l consider it a most desirable thing for the young 694 HISTORY AND DISEASES child to avoid its too dangerous and powerful influences—influences capable of making such a profound impression upon the constitution as shall be felt in long after years. For my own part, notwithstanding I have long been laboriously engaged in the practice of my art, I feel very confident that I do not employ one hundred nor even fifty grains of calomel in the course of twelve months ; and that my patients are not the worse off on that account; while I myself am preserved from an intolerable anxiety which its administration always excites in my mind. 925. Ofthe Gum.—Children coming into the world—issuing from the soft and unctuous waters by which they have been surrounded—are first washed clean, and then exposed to the stimulating eff'ects of the atmospheric air; and are, then,covered with clothes, all of which things serves to irritate the tender and sensitive outer covering of the body, the derm. Moreover, the first copious indraughts of atmospheric air, changing the blood and converting it into tenfold more oxygeniferous streams, must have the effect almost of an intoxicating inhalation, like nitrous oxide, upon the child. The corpus mucosum of the skin be- comes instantly reddened after birth, and, in many children, so red as to present the appearance of engorgement or inflammation ; and there are not a few of them, indeed, in whom, in this first burst of dermal circulation, the hyperasmia is so considerable as to be followed, in the course of a few days, by desquamation, like that which succeeds to an attack of measles or scarlatina. We should not be surprised, there- fore, to observe slight inflammations and eruptions of the superficial tissues. There are few children, indeed, who fail, in the first three or five days after their birth, to be attacked with a slight papular erup- tion which is called red gum—a case in which a central papule is environed by a red aureole. It requires no particular treatment, since, like a vaccination, it tends to cure itself. Common custom and usage, however, prescribe the administration of weak aromatic infu- sions, which are supposed to possess a diaphoretic quality. Infusion of catmint, infusion of fennel or anise, infusion of saffron, &c. &c, are commonly resorted to, and as they do not much harm, it is not always, perhaps, the province of the physician to object to their exhibition. This red gum, or strophulus intertinctus, diff'ers from the other sort, strophulus albidus, which exhibits a larger papule, more nearly resembling the blister of varicella, though much smaller than the varicella. It is not surrounded by a red aureole, like the strophulus intertinctus. In children affected with either form of these eruptions, it is highly important that the skin should OF THE YOUNG CHILD. 695 be frequently powdered with some proper fecula, and there is none preferable to that of the arrow-root. The application of the fecula, under such circumstances, appears to me to possess a remarkable power to appease the hyperaemic and hyperneuric condition resulting in this form of eruption. 926. Sore Mouth or Aphthas.—In the course of a few days after the birth of the child, it is common to find it a little more sleepy than ordinary, and to hear the nurses say, " It is sleeping for the sore mouth;" and soon after, upon examining the interior of the lips, the gums, and the tongue, they are found to be overspread with very minute white flakes, that look like small curds of milk. These are aphthae, or the thrush, or the child's sore-mouth. The white deposit consists of a small quantity of excretion, albuminous,, or, possibly, fibrine of the blood, which is held in contact with the surfaces from which it exudes, by a delicate film of epithelium, so that, with the finger covered by a bit of rag, the white speck cannot be wiped away. In a short time—that is, in the course of a day or two—the pellicle of epithelium gives way and the crust falls off, leaving sometimes a minute sore, and sometimes a renewed surface of epithelium, from which the white crust has fallen away. Of course, this malady is the result of inflammation of the corpus mucosum of the interior of the mouth and lips, and it is to all intents and purposes a true stomatitis, or mouth-inflammation. In nine cases out of ten it cures itself, and it is, probably, in its nature very like the strophulus inter- tinctus, or strophulus albidus, of which I have just spoken, which are affections of the mucous body of the derm, whereas this is an affection of the mucous body of the mucous membrane. It is usual in this case to accuse the child as laboring under an acid saburra, and to furnish it, in consequence of that accusation, with a dose of physic, which for the most part it does not really want. But, inasmuch as this mild stomatitis may rise to a considerable hei-ht, becoming, in fact, a general and extensive inflammation ofthe tissues within the mouth, extending backwards into the fauces, and from the isthmus faucium into the throat, it is worthy of attention on such occasions, and should be treated in conformity with its nature. The custom, among physicians and nurses in this part of the country is to attack the local malady by means of portions of borax and powdered sugar, of which a pinch is frequently to be put upon the ton-ue of the child, and is supposed to have sovereign power as a rem°edy for the malady. There is little objection to the use of the biborate of soda; and it answers a good purpose, being a substitute 696 HISTORY AND DISEASES for-severer and useless remedies: now and then, when the stomatitis rises to a great and dangerous height, it is useful to wash the mouth of the child with a mixture of lime-water and fine Peruvian bark in powder; or to touch the irritated surfaces with a camel's-hair pencil, dipped in a weak solution of nitrate of silver, of a strength ranging from one grain to two or three grains to the ounce of distilled water; or a solution of sulphate of copper in combination with sulphate of quinia. Two grains of the former and half a dozen of the latter, in an ounce of water, furnish a mixture Which may be efficaciously applied by delicate contacts of the camel's-hair pencil to the affected parts. If fever arise, or saburra or disorder connected therewith, let the Student bethink himself of the efficacy of his doses of calomel or magnesia, or aperitive medicine of whatever kind. There is another kind of sore mouth which looks like this, and which is called muguet, and which is, I think, not so often met with in this country, as by some European practitioners. It is supposed to be a vegetable sub- stance attaching itself to the interior of the mouth, and sporiferous in its nature, so as to be capable of greatly extending itself when once planted there. It differs from aphthae or thrush by being un- covered, or having no investment of the stomal epithelium. I am not familiar with it, and refer the Student to the authorities for further information. 927. Icterus.—The neonatus is very liable, in the course of a few days after its birth, to be affected with a yellowness ofthe whole skin and eyes, and to have the urine so stained with bile as to impress its color upon the napkins when dried from the urinary discharges. The icterus of the young child doubtless depends upon the regurgitation of bile from the pori biliarii into the returning branches of the hepatic vessels, whereby the whole mass of the blood becomes stained with its yellow coloring material, which begins to appear first upon the color- less adnata, and next upon the whole dermal surface. Such a state of the skin does not imply a primary disease of the liver itself, since there are certain irritations affecting the duodenum, producing some degree of engorgement round about the ductus communis choledo- chus, and passing up along that tube, which might well suffice to detain the secreted bile in the pori biliarii, and cause its regurgitation in the manner above indicated. A dose of purgative medicine, freeing the stomach and duodenum, and jejunum from some certain saburra, and relieving them thereby of a troublesome hyperasmia, seems to me likely to set the gates of the bile wide open, so that, the regurgitation no longer being effected, the constitution soon eliminates the coloring OF THE YOUNG CHILD. 697 matter of the bile from the blood, leaving the skin to recover its healthful hue and softness. My clinical experience, which must have furnished me with numerous examples of these early hepatic derange- ments, as they are supposed to be, has left with me no painful impres- sion of the dangerousness or the troublesomeness of the affection, which is transitory, disappearing in the course of a very few days. In those cases in which the inspection of the dejections shows that the bile escapes freely through the ductus communis into the duodenum, I am always willing to wait for the result of such outflowing of the liquid and the spontaneous return of the liver to its normal functional rate. Whenever, on the contrary, I discover whitish or clay-colored stools, or stools tinted faintly with a whitish-yellow bile, I am willing to administer to my patient some doses consisting of the sixth part of a grain of calomel, repeated three or four times a day, and followed by a convenient quantity of castor oil or magnesia, or other approved aperient. 928. Coryza.—Many young children suffer severely, soon after birth, from attacks of coryza, commonly, by nurses and old women, called snuffles, and when the attacks are severe, morbid snuffles. Some children, indeed, appear to me to have come into the world giving evidences, with the very first acts of respiration, of the presence of this malady. I do not mean to say that they have coryza before they are born; but rather that they are born with certain tendencies which allow coryza to declare itself immediately after birth. Coryza or snuffles is inflammation of the mucous membrane of the nostrils and air-passages of the head in general, occasioning a great abun- dance of mucus to be excreted from them; which, filling up the air- passages and obstructing them, causes the child to breathe with difficulty, making a rattling or snuffling noise with every respiratory movement. Many of the cases, being very slight, and going off after a few days, scarcely serve to attract the attention of the physician, and the wise women content themselves with the usual remedy, which consists, in this country at least, in the application of a little grease or tallow to the bridge of the nose. While it is perfectly true that coryza is in many cases a matter apparently of small moment yet it is proper for the Student, when he observes its existence in the little nursling, not to pass it by idly and without notice for it is capable of producing the greatest annoyance in the lying-in room, by interrupting the sleep of the baby, and thereby interferino- with the repose of its parent, a circumstance always to be deprecated. But more than this, coryza may kill the child, outnght- 45 698 HISTORY AND DISEASES a thing to be deplored, in itself considered, and perhaps still more to be deplored on account of its possible influence on the health of the mother, who, in the early days of her lying-in, is easily moved by slight pathogenical causes, which, when they but begin to operate, may have results the most disastrous. Let the Student, therefore, not idly neglect a case of coryza in the neonatus; but he should extend his watchful care both over it and its hyperaesthetic parent. A lying-in woman is not like anybody else, and things may kill her, which, under other circumstances, might pass by her as the idle wind. I wish the Student to remember that the new-born child has no reason, but only instinct; that it is a purely instinctive creature, and impli- citly obeys the provocations of its instinctive nature. It has an instinct to breathe, for which purpose it is supplied with only two respiratory stigmata, to wit, its two nostrils. It has another aperture, its mouth, which its instinct teaches it to use as an agent of its alimentation, not as an agent of its respiration. I wish the Student to understand that, if one should stop the nostrils of a new-born child with two plugs of cotton or lint, so that no air can enter into those respiratory stigmata, the infant will surely die within from one to three days, because its instinct teaches it to breathe through its respiratory passages, and not through its mouth. I am sure that the subject of such an experiment would persistingly close its mouth or its isthmus faucium, and perish under vain attempts to continue its respiration through the closed up nostrils. When children die from coryza, as they not unfrequently do, they die in the manner just pointed out; and I adjure the Student, who shall read this passage, to give his careful and candid attention to the doctrines set forth in it, and looking upon the child that is seriously ill with coryza, see how, after making repeated attempts to aspire air through the nostrils, it suddenly starts forward, throwing out its hands with an appearance of agonized distress, and then, opening its mouth widely, suddenly makes a full and complete aspiration of air, which, dispelling for a moment the sense of suffocation, permits again the renewal of its vain attempts to breathe through the natural openings. If it had reason to guide it, as a man has, it might breathe by the mouth with perfect facility throughout the most dreadful attack of coryza, even coryza maligna; but it has only instinct for its guide, and that instinct teaches it to breathe through the nasal openings. I will take this occasion to remark that loss of life from coryza is to be observed sometimes in children many months old, and that a child even over two years of age may be lost in this way, as I have learned by disastrous clinical experience; and if the Student who reads these passages-should find any hesitancy in his mind to admit the truth OF THE YOUNG CHILD. 699 of my explanation, I believe that all doubt would vanish from him if he would please to make the following experiment. Let him com- press the alas nasi together with his thumb and finger, and then make half a dozen consecutive attempts to breathe, keeping his mouth shut at the same time; he will find that the effort to send down the diaphragm and expand the thorax will produce within the whole chest a feeling of deep distress, amounting almost to pain. But let him repeat the attempts five or six times consecutively; and then, while making the last attempts, suddenly open the mouth and permit the air to rush in a torrent into the air-passages, he will have the sensations which I attribute to the young infant, when, after its repeated attempts , to breathe through the nostril, it starts forward, throwing its hands wildly abroad, and fills its lungs with air through the opened mouth. If the Student, after experiencing these sensations, will reflect upon the effect of such efforts, repeated through two or three consecutive days by a tender infant, just born into the world, he will agree with me that stopping of its nasal passages is a thing greatly to be depre- cated. I do not mean him to understand that in ordinary cases of coryza the child takes no air through its respiratory stigmata, for it does get that small portion on which it subsists in that way, up to the period, at least, in which the apertures having become totally ob- structed, compel it at last to make the sudden and convulsive aspira- tions through the mouth which I have attempted to describe. But the difficult and interrupted aspiration of air through nostrils only partially obstructed is sufficient to diminish the amount of oxygen breathed upon the blood, and the torpid and imperfect innervation produced by imperfectly oxygenized blood in the vessels ofthe brain is followed by various derangements in the action of the organs whose force depends upon the regular supply of the vis nervosa. A young child, then, laboring under a considerable coryza, will have carboniferous blood in the systemic circulation; it will be pale, Ian- guid, and unhappy, and is always exposed, in consequence, to attacks of pulmonary or cerebral or abdominal disorder. I look upon a child, whose nostrils are half stopped up, whether by mucus, or by sub- mucous infiltration, as in a state analogous to that of an infant labor- ing under a moderate degree of pseudo-membranous laryngitis: for the one or the other equally prevents the aeration of the blood with its normal amount of oxygen, and all the consequences of such a state must result I ask the student whether the constitutional disturbance arisino- from such a degree of disorder as exists in the Schneidenan surface in a case of coryza could possibly be so disastrous, were it not for the accidental interruption occasioned by it to the oxygenating 700 HISTORY AND DISEASES OF THE YOUNG CHILD. power of the respiration. I should think that an inflammation ten times more violent would be incapable of producing so great an amount of constitutional disorder through any other means than those above alluded to; for the reaction of the heart and arteries, and the distress of the nervous system occasioned by the perception of it would in comparison be nothing—I was going to say less than nothing—were it not for the accidental interruption to the oxygena- tion. Therefore, I repeat that the slightest attack of coryza is worthy to be regarded. But the question arises what shall we do for the cure of this case; how shall we free the Schneiderian membrane from its hyperasmia and hyperneuria; how shall we prevent its follicles from furnishing this excessive amount of mucus, or how shall we take away the submucous infiltration, which causes the cavities to collapse and at last to close them ? Will the vulgar remedy, greasing the nose, have this effect? Certainly the Student cannot rely upon such a therapia as that. Will he purge the child ? Will he give it a warm bath? Will he apply a leech within the margin of each nostril? Will he give it diaphoretic remedies? Will he regulate the tempera- ture of its apartment? Will he cause the aperture of the nostril to be kept free from the scales and incrustations produced at the orifice by the desiccation of the mucus that falls upon the very margin of the nostrils, and sometimes forms tampons or plugs running far back into the cavities ofthe bead? It is well if he will do all these things; but experience, the best of teachers, will show him that such remedies have little power over the disorder, and that the coryza goes on not- withstanding all his attempts. Will he produce a useful therapeutical impression upon the ftiucous passages by touching them with a deli- cate camel's-hail pencil, dipped in proper solutions of nitrate of silver or other metallic salts? Even these things fail, and often fail, but there is a treatment which experience, the best of teachers, has taught me never fails. I scarcely dare, in a formal work, pretending to a character of science, to say what this treatment is, and yet I must, with undoubting confidence recommend the Student to adopt it. When a new-born child is seized with a coryza that attracts my attention, I invariably direct a skull-cap made of flannel, to be so constructed as accurately and perfectly to fit the form of the cranium. I direct this cap to be fastened upon its head, and to be left there for three days and nights, and I always feel sure that within about that time the coryza will have totally disappeared. I mean to say that the cap should fit the head closely, not loosely, for I desire that the air of the apartment should not be allowed to touch the scalp. If the Student will try my method and fail, he can but be disappointed, which, I am CYANOSIS NEONATORUM. 701 confident, he will not be; if he adopts all or any of the other reme- dies that I have hinted at above, he will surely meet with disappoint- ment many times—by my method perhaps never. It is hardly worth while to reason upon this subject, but let him read Dr. Den- man's account of coryza, and the accounts contained in the treatises on the diseases of children, in order to learn how he can, if he can in a better manner than that I have pointed out, and more effectually, counteract the pernicious existence and tendency of this troublesome malady. CHAPTER XXIV. CYANOSIS NEONATORUM. 999 In the month of November, 1832, now thirty years ago, during the prevalence of Asiatic cholera here, I had charge of the case of Mrs. Taylor of North Fourth Street, No. 503. She was seized with symp- toms of the epidemic, being at the time about seven and a half months advanced in her gestation. The attack was violent, and led to the pre- mature expulsion of the child, which was born living, though very feeble It soon began to turn blue, in consequence of its being affected with cyanosis, commonly at that time called blue disease, and as its hue grew darker and darker, its lessening respiration, and the coming on of convulsions, caused me to think it could not long survive; in- deed, it came apparently to the point of death. 930 Case of Cyanosis.-The young mother, who was still ill with her cholera, could not be insensible to the danger of the chi d and I perceived that the complication of a moral ^With te ^rr, tations might render the cure of her own malady more difficult, if no Tmplible. It became, then, in view of the mother's position, a matterTgreat moment to rescue the child from apparently imminent TaT These reflections, which I made at the time, gave me great pain, fowhile I deemed the state of the child one of partial asphyxia from he mixture of its venous with its arterial blood, the mixture being d^bv iniection through the foramen ovale ofthe auricular septum, made by injection tuiug obv ating that S IreAe* upo"he structnr'e of the fcetal heart, and the ron* of the'total circulation, and I said, if I bring the septnm aunenlarum 702 CYANOSIS NEONATORUM. into a horizontal position, will not the blood in the left auricle press the valve of Botalli down upon the foramen ovale, and thus save the child, by compelling all the blood of the right auricle to pass by the iter ad ventriculum, and so to the lungs, to be aerated? Having practised Midwifery for many years, I had, on many occasions, wit- nessed the fatal termination of cyanosis neonatorum, both in the pre- mature and the mature child. I had seen children at five, and at five and a half, at six, and at seven months, vainly attempting to carry on respiratory life, and observed them to perish with the signs of cyanosis, whether from too large a foramen ovale, or from imperfect develop- ment of the respiratory machinery of the lungs, or atelectasis. In the case now under consideration, I placed the child, which seemed nearly dead, upon a pillow, on its right side, the head and trunk being inclined upwards about twenty or thirty degrees. Upon placing it down in this manner it became quiet—began to breathe more natu- rally ; to acquire a better hue of the face, hands, and feet; until, in a very short time, it was quite well again, and did well, having no further returns of the attack of cyanosis neonati. I shall not conceal the satisfaction I derived from the successful result of my reflections, thus put into practice in the case; for I thought, and I still think, that the child would have inevitably died, had I not thus closed the valve. In very many instances, during a long obstetric experience, I had never made such a reflection upon the means of saving the blue child, of which I had seen many cut off. I believed, and I still believe, that I was the first to invent the treatment; and the first case in which I put it in practice, was thus eminently successful. I am not now aware that any other person had before suggested it, though in his account of cyanosis, M. Gintrac gives, in case 5th, an account of Dr. - Wm. Hunter's patient, ast. 8, who obtained relief from a paroxysm, by lying still upon his left side, which always relieved him. After his death, the ventricular septum was found to be wanting, or rather per- forated near the base of the heart, so that the aorta received the injec- tion of the right, as well as of the left ventricle.—Vide " Gintrac," p. 33. Six years later, in my " Philad. Pract. of Mid.," edit. 1838,1 pub- lished some remarks on cyanosis, or blue disease, which being written in much haste, I did not at the time remember the circumstances of the above case, which occurred in Nov. 1832, in Fourth Street above Poplar, No. 503, in a child of Mr. Taylor, a builder, formerly of this city. Since the date of my first application of this method, thirty years ago, I have had numerous occasions to put it in practice, and not a few opportunities of examining the state of the heart after death; in some of which, after vainly applying the treatment, I had CYANOSIS NEONATORUM. 703 come to the conclusion that other causes, not patency of the foramen ovale, must exist, so to contravene the curative tendency of the method. My publications—and my explanations to friends—with the lectures on the subject that I have now delivered to many hundred Students of Medicine, have rendered this treatment of mine a popular one—to such an extent that in various States of the Union, the treatment is become familiar to the profession. Many monthly nurses have become acquainted with it, and I presume it is so divulgated throughout the laud, that children suffering from the malady will very generally have the advantage of its application, if it be really advantageous, and this the more probably, since no reasonable objection can be found to the putting of it in practice. I make these remarks, founding them upon letters I have received from gentlemen in the different States of the Union ; from conversations, and from statements made to me by Medi- cal Students on their arrival here, in the autumn, of cases treated by their instructors. This explanation will show that I am warranted to say, that my invention has become extensively known, and is to a con- siderable extent understood aud practised in this country; the more especially as it has been reported by many hundred Medical Students, that are now settled in the North, the South, the East, and the West. The following is extracted from a letter to me dated Pittsburg, Dec. 7, 1838, from Dr. W. F. Irwin. 931. Case.—"The second item of information derived from your work is that in which you lay down the only rational explanation and mode of treatment for that formidable disease of infants, called ' morbus cosru- leus.' During a practice of twenty-five years, I have had about twelve cases. In one family I lost two cases in succession, with an interval of two years. In this family there appeared to be a singular tendency to the disease. From the mother's account, I should conclude that out of six deaths in her family, five must have died of morbus cceruleus. In deference to authority, I have generally pursued the plan recom- mended by the late Dr. Hosack, which may be seen in the Appendix to "Thomas's Practice;" and I must say that I was never satisfied with it, as it appeared to me to have no sort of adaptation to the then received pathology of the disease. In some cases, I have thought that a tepid salt-bath produced a beneficial change in the color of the skin, and in the respiration. In two cases, a tablespoonful of blood drawn from the cord seemed to have a good effect. In a case that occurred in August last—the child, which had been well for five or six days, suddenly changed color-had laborious and interrupted respiration at long intervals. I was sent for immediately, and ordered a warm salt- 704 CYANOSIS NEONATORUM. bath, in which the change of color from blue to the healthy tint was remarkably rapid. The attending physician came into the room while I was engaged, gave some powders, and the infant died. In October last, I had a strongly-marked case in the afternoon at about six o'clock. As soon as the nurse announced the condition of the child, I had the washing suspended, and ordered the child to be placed on its right side, and to be left undisturbed until the following morning. At my visit next day, I found the infant healthy in every particular, and it has continued so until the present time. I have been so pleased with what 1 deem your philosophical mode of treatment, and its success in the above case, that I could not refrain from communicating the result." 932. Case.—On the 22d September, 1856,1 superintended the birth of a well grown male child at term. It was badly cyanosed from the moment of its birth. The cyanosis did not arise from atelectasis of the lungs, for the infant cried aloud. It depended on open foramen ovale. I placed it on the right side, and it was left so for seven hours. When laid down it was blue as indigo, and when taken up was perfectly well, and is so now, which is Sept. 26th. 933. Case.—I have before me a letter from Paul F. Eve, M. D., then Prof, of Surgery in the Medical College of Georgia, dated Augusta, Feb. 2, 1848. In this letter, Dr. Eve informs me that he was in at- tendance 22d Nov., 1847, upon Mrs. C, then affected with premature labor of an uncertain date of gestation. The child, a male, which was born after an easy travail, weighed between five and a half and six pounds. The testes were not yet in the scrotum. The respiration was at first carried on by sighs repeated once in five minutes. The child was once supposed to be dead, and given up as lost; but by breathing into the lungs it revived; and then, upon being laid upon its right side, where it was kept during four days, it perfectly reco- vered, and was healthy at the date of the letter. It was not dressed for three days. Every motion, for some time after its birth, would produce the cyanosis. Dr. Eve is inclined to believe it was six and a half months in the womb. 934. Case.—Feb. 11, 1848. Mr. S. C.'s son, ast. 11 weeks. Very stout and healthy since his birth. Was vaccinated on the 3d instant, and has now a full-sized vesicle and areola; slept badly last night. This morning was much agitated and cried long—became blue as to the whole face—moaned for a long time. His mother supposed he CYANOSIS NEONATORUM. 705 " was going into a fit," and could not otherwise account for his strange appearance. (She has had six children.) The child was crying when I arrived. The upper lip was very livid, and the countenance wore an air of distress. I laid it down upon its right side; it became quiet, and the livid color vanished. I turned it on the left side, and the dark livor of the upper lip reappeared. Upon rolling it on the right side again the color disappeared, but returned when I replaced the infant on its left side. I gave it a teaspoonful of oil, with orders to lay it on the right side. Feb. 12th. Had a good night, and seems well to day. In dressing it, the mother says, it became livid. She observed that it was on the left side, but upon turning it on the right it recovered, and has been well ever since. Jan. 3, 1849, I believe this child has had no indisposition since the foregoing date. 935. Case.—In March, 1848, I attended Mrs. G. T----, who was at the time delivered of a child at six months and ten days. It was deeply cyanosed for four days after its birth. The nurse kept it almost wholly reclined on its right side, and the infant, now about nine months old, presents a good prospect of a successful rearing of it. In this case, the child was certainly relieved when laid upon the right side. 936 CASE—In the early part of the year 1848, I delivered Mrs. -, Thirteenth Street, of a foetus at six months. It breathed well at first and uttered loud cries. But cyanosis came on the third day. I many times caused the livor to disappear by turning it on the right side, and made it return by rolling the child gently over to the left side, and vice vers^, as often as I repeated the experiment It died after some days. The foramen ovale was slightly open, and the lungs were partially affected with atelectasis. Here is another letter, dated Antrim, Alleghany County, Penn Feb. 11 1848 which was addressed to me by Dr. S. Schreiner, a graduate of the Jefferson Medi- cal College. 9*7 Case-"Mrs. A. S----r was delivered on Tuesday, Jan. 11, 1848 at 7 P M., of a male infant. Nothing peculiar transpired during he gestation or delivery. Parents healthy; mother quitelusty Snnoosed weight of the child about eight pounds; it seemed of full LTTely -d well to do. About 9 P.M., it seemed to have a violent attack of colic; cried violently. All attempts to pacify it were vain, until about midnight, when it became quiet, and was laid in bed behind the mother, where it remained until about 8 A. n. on 706 CYANOSIS NEONATORUM. Wednesday. At that time the mother awoke, and thinking it breathed strangely, asked the nurse to take it up, to see what was the matter. She did so, and observed that it was of a dark-purple hue; the breath- ing seemed to cease; it was strongly convulsed, the fingers being clenched firmly against the palms of the hands." Dr. S. informs me that the child was now removed from the lying-in chamber in order that the mother, after she had been told it was dying, might not wit- ness its last agony. " Upon remaining so for some time, it gasped for breath, the purple discoloration faded from it, and the paroxysm was over. It remained quiet, without any motion whatever for about three hours, when the fit returned again; and again it did so, each paroxysm continuing longer and increasing in intensity until Thurs- day (the following day), between four and five P. M., at which time I first saw it. During this time it had seventeen attacks, the duration of the last one being over forty minutes. The attacks returned at intervals of a little more than an hour. Its appearance, when first seen, was as follows: It laid motionless upon a pillow in the nurse's arms: pulse irritable; cheeks suffused with a scarlet flush; respiration short and quick (it seemed as if fever was present); dusky color of the skin, except the bright spot on the cheeks. Soon its face, then its body and limbs, became of a dark purple or nearly black color; respiration, a short gasp at long intervals, gradually increasing until it was altogether suspended for twenty minutes; pulse grew fainter and fainter, until it ceased at the wrist, and the heart only gave a heavy throb at long intervals. Gradually, the pulse became (again) perceptible at the wrist—the discoloration vanished, and the paroxysm was over. Though the parents and all present declared there was no use in attempting anything for its relief, they consented that a trial should be made. I had it laid in the position recommended by you in your course of lectures, and in your " Phil. Prac. of Mid.," upon the right side, at an angle of 30°, enjoining strict adherence to the position. From its flushed appearance, and the congestion seemingly present, I should have recommended leeches, had they been at com- mand. I remained long enough for another paroxysm to have taken place, judging from the previous intervals, but it did not take place. During this time it attempted to cry, but made no sound whatever, though it seemed to cry violently. After this it passed some meco- nium, and took a little milk and water which it sucked from a rag placed in its mouth. I was told these were the first motions of the kind it had made for twenty-four hours. They had before poured some nourishment down its throat, but it appeared to bring on a fit, and they desisted. I saw it again the next morning. It had two returns CYANOSIS NEONATORUM. '07 of the disease: so very slight, however, as only to be observed by the face becoming darker: but they continued only a few minutes. I should not forget to mention that, after each of these, perspiration ensued ; slight attacks first, but after the second very copious. Pulse at this time appeared normal; respiration easy, but somewhat quick. I saw it again to-day. Has had" no return of the paroxysm, and is in excellent health, with the exception of an occasional attack ol colic." 938. The Condition of the Lungs in a Foetus and in a Neonatus.—I beg the Student here to reflect upon the nature of the foetal circulation, and remember that it tends to undergo a constant change, from an early period of embryonal existence up to the time of the complete uterine development. For example, in the commence- ment, the embryon has no lung at all, and of course, all the blood of the right or pulmonic heart, passes over to the left or systemic heart, by means either of the foramen ovale or the ductus arteriosus. In proportion as the child approaches its viable age, its lungs become more and more fitted for their breathing office, and the pulmonary artery and veins acquire power to transfer larger and still larger quan- tities of blood through the lungs. As the pulmonary artery increases in power, the ductus arteriosus grows less, so as to be ready to transfer the whole of the work to the pulmonary artery as soon as the foetal lung freed by the act of respiration from its foetal atelectasis, is also liberated from what might be perhaps properly denominated its atelec- tasis of pulmonary vessels, or vascular atelectasis. Previous to its toll the lungs of the child are solid-or rather the air-tubes of them are in a collapsed state-but, the descent of the diaphragm, and the expansion of the lungs, opens all those air-tubes to the atmosphere, rn~ir lowe/cell." In the same manner the Penary artery with its branches, is at the same moment set free from its quasi To lap or atelectasis; and the blood of the right ventricle finds an collapse or ate circulation; whereas, a major part of Z XZ hUante—y, been a—ed to do. off by the that blood naa J ventricle, in taking its dnctns artenosus Th Wood o g .^^ rf ^ - Tte t0f Prions ; to the establishment of respiration, the diastobc power «™°™£ l for , one.half 0f the sum ofthe ventrideconldbesad o xpandfor y ^ PUlm°dTts rriv ofVe h ood into the left auricle. The right auricle ^ftrntTb "inning, fully expanded in diastole; not so as to the T^ht ventr le It i"« curious fact that, though the auricle was 708 CYANOSIS NEONATORUM. ab origine in full possession of diastolic power, the pulmonary artery, capillaries, and veins—as well as the pulmonic, ventricle, were left in a state of partial atelectasis, from which they could be delivered only by the act of respiration, which at the same instant put an end to the fcetal atelectasis pulmonum. This sudden expansion of the thorax serves as the means of instantly converting the fcetal characteristics into those of the respiring mammal; and when the conversion is plenary, or complete, the function may be said to be established. It often happens, however, that instead of this complete establishment of the circulation, it is only partially effected, and the child fails to acquire the bright or florid tint that results from a full and perfect aeration of its blood. It remains in a torpid condition, and the hue of its skin is, perhaps, only less livid than it was when it depended for its aeration upon the placenta alone. 939. Many causes may serve to bring about this failure in the con- version. All those that act in such a way as to compel the blood, in part, to pass, as before birth, through the foramen ovale, can be cured by any method that shall be able to close the valve of the foramen ovale; and this is evident, because if the foramen ovale be shut by its valve, all the blood of the right auricle must pass beneath the tricuspid valves, and so by the right ventricle and pulmonary artery, to be aerated in the lungs. The publications I have in various ways made of this doctrine have had the effect to institute far and wide in the land the knowledge of the method which I discovered, and which I humbly here claim to be my own. I do not believe that any phy- sician ever thought of it or put it in practice before that occasion, which I have mentioned in 920, to wit, in November, 1832. I look upon it as an important discovery, which, I have no doubt, has already saved, and will in future save many lives that could not by any other means be preserved. Many persons have asserted that my explanation is erroneous, and that the lift of the valve of Botalli is not the cause of cyanosis, but that stricture or contraction ofthe orifice of the pulmonary artery is the cause, and that when the pulmonary artery cannot deliver with sufficient rapidity what it receives, the current is backed on the venous system, and so gives rise to the cya- notic hue and the other symptoms. After carefully weighing these objections to my rationale, I am compelled to reject them, and hold fast to my own, not, I trust, from pride of opinion, or a wish to arro- gate a vain and undeserved merit as a discoverer, but because I find, in my own rationale, encouragement to apply my method, while the other rationale gives no such encouragement, and does not, indeed, CYANOSIS NEONATORUM. 709 offer a suggestion of treatment, but leaves us where we were before November, 1832. 940. I shall here set forth many other reasons that compel me to adhere to the views I have long maintained, and—1. If the foramen ovale could remain after parturition of the same size as before the birth, the orifice of the pulmonary artery would also retain its embryonal or fcetal diameter. Indeed, the pulmonic ventricle wrould continue in its state of partial ante partum atelectasis; for nobody, I think, will pretend that the heart dilates to compel the blood to enter as by a suction power, or exhaust-power. It is always dilated by the blood forced into it during the instant of its muscular relaxation, and so, distending its walls. But if hal: the blood flows off by the foramen ovale, it cannot receive, with the remainder, a quantity sufficient to compel a full diastole. 2. This condition serves to keep the fora- men ovale open, the edge of the valve being driven off to the left by the stream. 3. If the valve be now shut down, the ventricle must yield, and make a complete diastole. Its contraction driving its contents through the orifice of the pulmonary artery serves as a dilator to the artery, and the stricture vanishes, sooner or later, under this dila- ting force. To shut down Botalli's valve, then, is to open the ventricle and its pulmonic orifice, while to constringe either the ventricle or the orifice is to lift the valve. 4. The difference between me and my objectors is simply this, that according to them, the pulmonic constric- tion causes the cyanosis, but the lift of the valve allows the constriction, according to my view. 5. In the cases I have cited at 721 and 728, I have shown that my explanation gives a foundation of a successful method- and I am convinced that many hundreds of lives have already'been preserved by it. If this be true, then, it ought to sus- tain my position, since so many children have been at once and com- pletely rescued by closing the valve. If they are rescued, it could only be by the closure of the valve; and even if the cyanosis arose from the want of expansion of the ventricle, or of its pulmonic aper- ture, the close of the valve completed that expansion and cured he patients. 6. My objectors seem almost to lose sight of Botalli s valve n this discussion, and forget that it is a reality, and must have the function to close the foramen. Either it does this or it does nothing If it does this in order to establish the pulmonary circulation but sometimes fails to do its office, let us help it, or compel it to do its duty, by laying the child on the side to shut the valve down. 941 Morbus Cceruleus.-The disorder produced by these acci- dents used to be called m o r b u s c os r u 1 e u s, or blue disease now known as cyanosis. Let us inquire what is the real nature of this 710 CYANOSIS NEONATORUM. cyanosis, and the causes why it produces its peculiar symptoms. The blood is either venous or arterial, or, as Bichat denominates it, black or red blood. The red blood of the arteries is transferred to the veins by the channels of the capillaries. It is in traversing the capil- laries that the red blood deposits its oxygen, and so, when arrived on the venous segment of the cirele, has become black. The capillaries may be regarded then as a sort of strainers or filters, whose office, in part, it is, to take oxygen out of the blood for the service of the tissues. Whenever the tissues are capable of taking oxygen from the capillary blood, the tissues in which capillaries exist have their normal hue or coloration ; but if there be none, or an insufficient supply of oxygen, they become livid. Cyanosis, therefore, is not due to any backing of the venous circulation by a check received at the orifice of the pulmonary artery. Such backing would produce en- gorgement of a red, not of a cyanose hue. Cyanosis is black blood from want of aeration in the lungs, and not from backing of the cur- rent. Rokitanski is in error in maintaining his view of the backing up of the blood. I maintain that cyanosis, as a disease, is essentially of the same nature as asphyxia. But the question now recurs, as to what is asphyxia. In my opinion asphyxia, essentially considered, is black blood in the capillaries of the brain. Some physicians insist that asphyxia is black blood in the lungs. The lungs always contain black blood, which is reddened in the lung-capillaries; therefore I contend that asphyxia is black blood in the brain. Asphyxia is a state of the brain in which that organ cannot extricate, or give out the life-force—the innervative force—the stream or current of nervous force—the biotic force—and I contend that it fails to do so, for want of oxygen to react upon the neurine. Cyanosis is the sign of the presence within the brain-capillaries of non-oxygeniferous blood, which is dark or purple or black blood, as Bichat calls it. The purple, or dark hue of cyanosis, is caused by the presence of black blood only in the capillaries. But, when this dark hue of the cutaneous capilla- ries is seen, it is evidence of a similar hue of all the capillary blood whether in the abdominal, the thoracic, or the cephalic cavities and organs. This purple state of the blood is not fatal, except it exist in the brain, whose power it suspends. If it be chased out of the brain, by oxygeniferous streams of arterial blood, all the organs and tissues that lie under the control and domination of the nervous system, immediately recover their power. If the brain dies, they all perish in its fall. If a man die, therefore, with asphyxia, he dies because he has black blood in the brain, not because he has it in his leg or arm or skin. A man may die from fainting, or lypothymia; and in this CYANOSIS NEONATORUM. 711 case he loses life, because the action of the brain is suspended. The suspension, in this instance, appears to me to depend upon lessened tension of the encephalic mass from the sudden withdrawal of a portion of the blood that ordinarily distends its vessels, as in sudden violent hemorrhage, in certain pathemata mentis, sudden changes of posture, &c. &c.; it is an anasmia of the brain. 942. Asphyxia.—Asphyxia is lessened or suspended somatic in- nervation from privation of the oxygen-reagent. Fainting is a similar suspension from reduced tension and pressure, or anaemia of the brain; either may be fatal; but each requires its appropriate treat- ment, which is different in each case. In a certain sense, therefore, fainting is asphyxia, or soon leads to it. Asphyxia is not a status of the trunk or members; it is a status of the brain, and only of the brain. The livid hue is a result, or an accidence of the asphyxia. If the vessels of the brain be injected by the carotids and vertebral with carboniferous blood, the intellectual or perceptive, and the co-ordinat- ing and motion-giving brains cease to do their office; if new injections fill these same vessels with oxygeniferous blood which chases out the former, the powers of the brain are reinstated, provided the mischief have not already gone too far. A man etherized, or affected with chloroform, is, to a certain extent, asphyxiated, besides being poisoned ; the same is true of him as of the well-digger, who descends into a well containing carbonic acid gas. The man in the well dies, not because his glottis is closed by spasm, as has been asserted, but because there is no oxygen in the well to be carried to the brain. It is indifferent to him whether his glottis be shut or open, since there is nothing to enter in that can do him good or harm; he dies from want of oxygen; and it may be, that the carbonic acid, if it enter his lungs, may do some mis- chief there; an indifferent mischief in the greater mischief. I said that asphyxia is black blood in the brain-not in the sinuses and veins of the brain, but in the capillary part ofthe vascular system of the brain The greater part of the whole sum of the blood, variously com- puted to be about thirty pounds, exists in the systemic part of the vascu- lar circle Only a small portion of it is in the venous side. In the lungs, for example, where the pulmonary artery is a vein, and the pulmonary veins arteries, there is a great excess of the aerated, over the quantity of carboniferous blood, for not only is the capillary system full, but the venous system is full. But the carboniferous blood of the femora,, of the iliac, of the portal vein, and the cava, produces no asphyxia; nor is it true that, in death from carbonic acid inspired in a well, the demise depends upon the presence of black blood in the trunk or mem- 712 CYANOSIS NEONATORUM. bers; it depends upon its presence in the brain, particularly the respiratory, oxygenating brain, whose pneumogastric branches, and all other sources of respiratory innervation, are suspended and cut off' indeed, of their force, because their neurine is flooded with carbonife- rous blood in which there is no power to extricate the biotic force— the nervous force, or neurosity, as M. Cerise denominates it. If it be true that there is a valve on the left side of the auricular septum, it must be that its purpose is to prevent regurgitation of the blood from left to right. It could have no other use or design. Even in a case where greater power of the right auricle impels a portion of the black blood through the valved orifice, any resistance offered by the valve must tend to diminish or prevent the transit from right to left. If in any such cases, the plane of the septum auricularum be rendered horizontal, by placing the child upon its right side, the blood of the left auricle must tend to close the aperture by pressing the valve down, and keeping it down. The blood has gravitation, and its law of gravitation is as rigorous in the auricle as it would be in a cup, or in the air. Its weight must shut the valve, or t e n d to shut it, if any valve exist. But, with a shut valve, all the blood of the auricle must pass to the right ventricle, and so to the lungs to be aerated. It can- not pass the lungs without becoming aerated if the nervous power is intact. But, if the blood becomes truly aerated, it becomes oxygeni- ferous, and, transferring the oxygen to the capillaries of the brain, will there extricate the biotic force in a normal manner. All the irregular and diseased innervations depending upon the antecedent carboniferous quality of the blood in the encephalic capillaries must vanish before the steady innervative streams that proceed from a healthy brain, duly supplied with its quantum of oxygen. There are many of my medical brethren who deny that my explanation of cyanosis neonati is correct, or even philosophical; contending that cyanosis is a status of the lung, or of the vessels of the heart, bring- ing about a modality of the lung alone; or a backing of the blood into the whole venous side of the circle, and a detaining of it in the capil- laries; while I aver that the condition of the lung, or of the trunk and members, is nothing in the category, or rather a mere accident, which relates, in fact, only to the state of the brain. I am quite conscious that a man's opinion cannot determine the least of Nature's laws to operate this way or that; and St. Matthew tells us, "Neither shalt thou swear by thy head, because thou canst not make one hair white or black." While, therefore, one gentleman sees only in a contracted pulmonary artery, or in a transposition of vessels, a cause of cyanosis, I am not to expect that he will come over to my way of thinking, be- CYANOSIS NEONATORUM. 713 cause I think thus or so, even had I the authority and power of the man of Pergamus, who ruled us for fifteen hundred years. I am, however, less concerned to witness the acceptation of my rationale, than the adoption of my precept. If they will turn the cyanosed child upon its right side and shut down the auricular valve, I ought to be satisfied ; and indeed, my distinguished friend, Professor Wood, recommends the practice, while he dispraises the principle upon which it is founded. Nevertheless, I admit that I sincerely desire to find a reasonable acceptation of my rationale; less perhaps on account of its application to the undeniable self-demonstrating in- stances of blue disease, than to the treatment of certain obscure, and more questionable forms of the accident, which I shall now proceed to mention. In order to explain my meaning more clearly, I shall relate cases that occurred to me a few years since, and upon which I put a construction that perhaps will not be admitted by those who oppose my rationale of cyanosis, either as to its mechanism or its real nature. 943. Case.—A lady had given birth to a child, apparently healthy. She was soon afterwards attacked with fever, which produced in her a series of distressing nervous symptoms. The young child, after many days, became indisposed with what seemed to be a bronchial catarrh, which was rebellious under the treatment. Dr. Bridges saw the child with me several times. It grew alarmingly ill. It was affected with a vast, troublesome collection of unexpectorated bron- chial mucus, that threatened speedy suffocation by filling the air-tubes and trachea. Upon entering the apartment on one occasion, I found it in the arms of the monthly nurse, sorely oppressed and nearly in- sensible. It was dying—or rather, I deemed it dying. My impression from inspecting the child was, that it was moribund ; and I still believe that the condition was that of the moribund, and that its life could not have been protracted beyond one or two hours, but for remedies em- ployed to rescue it. After observing it for some time, and noticing a livid areola about its mouth, I took it from the nurse to inspect it more closely. The precise processes of thought by which I arrived at a conclusive opinion, have now escaped me; but I was led to ima- gine that the whole of the phenomena ought to be referred to a state primary in the brain, and not to a state primary in the bronchial mucous membrane. I supposed that the sources of innervation becoming modified by the presence of carboniferous blood in the brain-capillaries, the organs had suffered in consequence of the cessa- tion or the irregular action of the administrative power. Upon cutting, in a surgical operation, certain branches of the trifacial °46 714 CYANOSIS NEONATORUM. nerve, the eye becomes instantly inflamed. Dr. J. Warren says that, under etherization, the conjunctiva is often injected with blood. The same thing occurs in asthenic fevers. So, in any hindrance of the current of the pneumogastric nerve-force, the lung might likewise become the seat of consecutive disorder. I was convinced that the child's foramen ovale admitted its venous blood to the systemic side of the circle thus vitiating the life power of the nervous mass of the child. I turned it on its right side, and kept it there. In a few moments it was relieved, and in a very short time gave no further reason for alarm, or concern of mind. In fact, the right lateral de- cubitus cured it, and that right speedily. This is a fact. 944. Case.—In the month of January, 1846, I attended Mrs. H------, at the Indian Queen, South Fourth Street, in a confinement in which she gave birth to a healthy child. As she was ill many days with a fever, I gave but little attention to the child. It was between two and three weeks old, when I was summoned to it by three rapidly repeated messages. I found it insensible; affected at intervals of one or two minutes with convulsions, in which the head rotated to the right in strong extension; the right arm, stiffened, was elevated as strongly as possible by spasmodic innervation of the del- toid and triceps, while the left arm, also stiffened, was pointed down- wards and outwards. The inferior extremities were also affected with rigid spasm. The mouth was open, and could not be closed, but by force. The pulse was feeble, and the respiration low, except when troubled by the recurring spasm. Many persons surrounded the infant, which was lying on its back on a pillow, supported on the lap, and supposed to be nearly dead. The child had been well but a short time before. The attack had been a sudden one. Upon contemplat- ing the infant, which had two or three attacks of this spasm or con- vulsion while I was looking on it, I reasoned with myself as to the probable cause. There was no assignable hygienic causation. Its mouth was bluish, though not in a very marked degree. I took the child on its pillow, and laid it on my knees, in order the better to in- spect it. I reflected as follows: here is a faulty innervation of the muscles of the head, neck, arms, legs, and lower jaw: with supended consciousness. Are the parts in fault, or is the brain in fault? Whence these irregular intromissions of nerve-force into the organs ? Is the nervous mass imperfectly oxygenated because the child sends its carboniferous blood into the left auricle, and so, to the brain? Let us try that point. I laid it on its right side in the cradle, its trunk elevated at about 15°, and I said, "Leave it in this position until I CYANOSIS NEONATORUM. 715 return. Perhaps it will die very soon; but I have some reason to hope it may be saved, if you should not change its position. I shall be absent three hours. Do not venture to move it, until I come again." In the mean time while I remained, it changed its appear- ance speedily and visibly for the better; it had no return of the spasm. It fell into a calm sleep, and was perfectly well when it awoke. It required no further cure! Was this a post hoc, and not a propter hoc cure? Who can say so? The treatment was reasoned beforehand, and the result looked for. As well might it be said that every therapeutical cure by emetics, cathartics, or narcotics, or diuretics, is a post hoc, and not a propter hoc cure. The blood in the auricle or ventricle is not exempt from the laws of matter; it gravitates as absolutely there as in a teacup, or in the air. When I lay a child upon its right side, gravitation of the blood is inevitable; and since the valve is as delicate as the arachnoid, and light as thistle-down, the smallest drop resting upon it could close, as the slightest force could open it. In this case, I brought the plane of the septum auricularum to be a horizontal plane; I compelled the blood of the inferior cava to rise in a vertical current to the fQssa ovalis, and thus lessened the power of Eustachi's valve, to direct it upon the fossa ovalis. When I shut the valve down by the weight of the superincumbent blood, all the blood of the right auricle passed through the iter ad ventriculum, in order to be breathed upon in the lungs. It is probable that half a dozen systoles of the heart had scarcely been effected, before the oxygeniferous streams had reached the neurine, and waking into orderly and healthful force, the before hebetized innervations of the child, all the dependent organisms and organs resumed their healthful movements and life-manifestations. 945. Case.—Nov. 20,1847,1 was called to the child of Mr. H----, in Pine Street below eighth. This child, a female, was born in Octo- ber, 1847, and was now six weeks old. Upon reaching the rendezvous, I was pained to find the infant dangerously ill with catarrho-pneumo- nia, so far advanced, that I informed its mother it was probably too late for me to do it any good service. The bronchial tubes and the trachea were oppressed with a great quantity of mucus, which so obstructed the respiration, that the child coughed at every breath, which was very scant, s a c c a d e e, and repeated sixty or seventy times per minute. Percussion and auscultation ofthe chest—careful examina- tion of the abdomen—inquiries into the rate of the pulsations, both by feeling the radial pulse, and by auscultation of the heart, led me to the painful expectation that my friends were about to suffer the loss 716 CYANOSIS NEONATORUM. of their daughter. I prescribed for it, under a diagnosis of catarrho- pneumonia. Some hours afterwards I repeated my visit. It was no better. Upon taking the child, which was on a pillow, and resting it on my knees in order to see it better, I found it in great danger of suffocation. Every breath was that compound of coughing and crying, which I cannot describe, but which every physician has observed. Upon inspecting it, I observed a livid areola about the mouth. The feet were bluish, as well as the finger-nails. It is true that such blue- ness might depend, and did in part depend, on the saburral state of the pulmonary mucous membrane—smeared as it was with mucus, and the tubes partly filled up. But, as the attack has been sudden— too sudden to be conformable to the normal march of such maladies, I reflected that the fault might not be primary in the respiratory mucous membrane, or pulmonary texture, but rather in the brain, which had lost its power of maintaining the status sanitatis in the lungs. I deposited the infant on its side, as for the treatment of cyanosis neonati. It seems to me that the valve of Botalli instantly fell down upon the foramen ovale, and that the carotid and vertebral injections of the brain immediately began to be thoroughly oxygeniferous. The administrative nervous mass commenced anew its government of its provinces, and, in a short time, the symptoms of the disease had vanished; I found, in the morning of Nov. 21, that no further treat- ment was necessary. I cured the broncho-pneumonia by shutting Botalli's valve, just as I should cure a conjunctivitis, by restoring the integrity of the trifacial branch cut off" in a surgical operation on the face, and the loss of whose innervative current might have determined the conjunctival inflammation. 946. The objectors do not deny that the fcetal circulation, up to the first act of respiration, is chiefly directed through the foramen ovale and the ductus arteriosus, and that it is so indispensably, and only because the operculum is raised. They cannot deny that the aperture virtually exists after birth, even for many days—nay, in some, during a long lifetime. To deny that the two symmetrical halves of the heart may act asymmetrically and asynchronously, is to deny an admitted truth. To deny the effect of such dissidence in time and force appears to me to be but a mere denial. 947.. Case.—I had many years ago charge of the health of a young woman, who labored under frequent attacks of cyanosis. She was often threatened with sudden death. In the intervals she appeared to be in good health, earning her bread by the needle. One day, while much indisposed, she sat up in bed, eating a dinner of codfish. She CYANOSIS NEONATORUM. 717 suddenly fell on her side dead, in her 28th year. I found a foramen ovale, into which I could put a swan-quill. 948. In the heart of the Archduke Joseph, the cyanosis had coin- cided all his life long with an open foramen ovale.—See "Gintrac," p. 228. If in my own heart there be an aperture as large as the end of my finger, it is indifferent to me in respect to my health, while the two auricles contract symmetrically. But if asymmetrically, then I am liable to sudden illness, or even sudden death. My patient pro- bably flooded her medulla oblongata with carboniferous blood, and ceased to breathe in consequence of the annihilation of that peculiar force that is evolved from the medulla. How often have we seen similar states of the system brought about in attacks of puerperal eclampsia? In this disease, an impetuous sanguine circulation gives rise to unmeasured, I had almost said explosive evolutions of biotic force. In eclampsia, the spasm and convulsion of the whole system, and particularly of the diaphragm, which often, during the paroxysm, makes aspirations of only three or four cubic inches of air, allow the carboniferous streams to overflow the encephalon. Under this want of aeration, the face gathers blackness apace—the protruded tongue is of a deep purple, and a true asphyxia intervenes to save the life of the patient; so that the sooner the blackness of the features and tongue come to assure us of the arrest of the cerebral excitation, the sooner is the patient to be extricated from her perilous predicament. If the medulla oblongata be overwhelmed with black blood, she dies; sometimes this is the case, and she dies outright, no trace of lesion being discoverable in the brain. Here we have no good and reliable sources of medication, save those that serve most rapidly and power- fully to diminish the momentum of the sanguine circulation in the encephalon, of which venesection is to be before all others preferred. A proper venesection, executed before the asphyxia is established, in general prevents that consummation, by substituting a state of deli- quium for the otherwise inevitable asphyxia ofthe eclampsic paroxysm; a far less dangerous and more speedy way of escape; less dangerous, since the sanguine engorgements and retardations coincident with the cyanosed state of the brain in eclampsia, expose the sufferer to peril- ous effusions or extravasation. As to the right lateral decubitus for the new-born child in cyanosis, no doubt rests on my mind, after multiplied experience since 1832, now thirty years. I am not dis- appointed by finding the treatment sometimes unsuccessful, because, when it is so, I can with confidence believe that failure to change the blood is effected through some other agency than that of an open aud used foramen ovale. 718 CYANOSIS NEONATORUM. 949. Case.—In the son of Mr. A. B----, I detected the existence of cyanosis neonati, and relieved the child, but could not cure it by my method. A series of diseased innervations, bringing the whole constitution into ill-health, continued to manifest themselves, notwith- standing all the precautions I could devise, and I announced, long before the death of the infant, which lived for several months, in addition to an open foramen ovale, the existence of an aperture in the septum ventriculorum, which was verified by the examination of its heart after its decease. 950. Case.—In a similar manner I announced in Mr. J. B----'s child, an open foramen ovale, as the cause of convulsive attacks which led at last to an effusion within the encephalon with separation of the sutures, and evident fluctuation, which opinion was verified necrosco- pically. 951. Case.—Professor Wood will bear me witness of the sudden and marked and indubitable relief and cure of Mr. H. W----'s infant, apparently dying with cyanosis when it was placed in the position. 952. Case.—In the eldest son of Mr. S. B----, jun., the respirations were but four to the minute ; the pulse was gone, and the child within two or three minutes of its death, nay, deemed by some to have breathed its last. The recovery was almost instantaneous. 953. Case.—The same is true of Mr. H. K----'s son, with the exception that the case was not so extreme ; so also of Mr. Eich's child, Mr. J. W----'s, and many others. I beg leave to refer again to the letter from Prof. Eve, at p. 730, reciting a case of cyanosis treated by him. A letter from Dr. Casey, of Hartford, Conn., informs me of a violent case successfully treated by the position. Dr. Hains, of this city, and many others, have succeeded in like manner. Prof. Charles A. Lee, of Geneva College, informs me that the treatment is well known in Western New York. 954. I can by no means adopt.the views as to the essential nature of the malady, set forth in Prof. Wood's late work on the Practice of Physic. That author, like others, appears to me to have mistaken the symptom, to wit, blue color for the disease, which, as I have so often said, is essentially a failure of innervation from absence of oxygen in the brain. He doubts the causation as dependent on the mixture of the two kinds of blood in the heart. I cannot understand that the leg or arm should suddenly die for want of oxygeniferous blood; and CYANOSIS NEONATORUM. 719 I cannot perceive how the constitution can live, if the nervous mass, which is the essential Ens, be dead or inert, as it certainly is when only the carbonized blood of the veins circulates in its capillary vessels. M. Gintrac himself, who originally made four kinds or species of cyanosis—of which the first consists of the melange du sang noir et du sang rouge, and the second a coloration bleue egalement constitute par ce melange—comes to the true conclusion at last, that, instead of four species, there is but one, although he calls that one two. 955. Rokitansky on Cyanosis—Prof. Rokitansky, in his "Patho- log. Anatomy," vol. ii. Part I. p. 510, gives an article on cyanosis, in which he treats at large of the various kinds of that affection, whether as depending on faulty development of the heart, or on causes extrinsical as to that organ. He says: "A distinction is generally drawn between an organic disease of the heart acquired in the later periods of life, occasioned by disease of the lung, and that form of cyanosis dependent upon congenital malformation of the organ. The latter is called cardiac cyanosis. It will appear that the essential cause and character of both are the same. Cyanosis occurring in cases of congenital malformation of the heart has been mostly attributed to the mixture of the two kinds of blood, or rather to the passage of the venous blood into the arteries either by way of the ventricles, or the auricles, or the vessels themselves; but, it has been common to refer this commingling of the currents and the accompanying symptom of cyanosis to deficiency as to the septa of the heart. We are of the opinion that cyanosis always depends, not upon the mixture of the two kinds of blood, which is in many cases problemati- cal and in some takes place in a directly opposite direction to what is supposed, but on the impeded reflux of the venous blood into the heart and a consequent habitual, or, in some instances, intermittent engorgement of the venous and capillary systems; and that herein all the varieties of cyanosis, however differing as to their original and acquired abnormal conditions of the heart and lungs, coincide, and may without violence be classed together." I shall not here repro- duce all M. Rokitansky's arguments and statement of facts ingeniously brought to the support of this doctrine. I shall merely state that the opinions set forth in this chapter as to the consecutive nature or accidental nature of those strictures of the pulmonary and other orifices of the heart, appear to me undeniable, and that it is always reasonably to be expected that an uncured attack of cyanosis neonati will lead to a constriction of the pulmonary artery, just as the free 720 CYANOSIS NEONATORUM. expansion of the pulmonary artery, after the first aspirations of the neonatus, leads to the abandonment of the ductus arteriosus and its early conversion into a ligamentum teres. Should this page be at some future day honored by the regard of that distinguished writer, the author would beg leave to direct his attention to the events and phenomena that occur in those cases in which a sudden coagulation of blood fills the right auricle and ventricle with a clot that is moulded by the cavities which it fills. Many examples are to be met with of these coagulations, some of which prove instantly fatal, while others admit of the prolongation of an ineffectual struggle for life during a period of from one to twenty days, according to my own clinical observation. 956. Now in the instance of a cardiomorphous clot, as above pro- posed, the blood is most effectually detained in the venous side of the circle, far more so than can be pretended of the intermittent forms of cyanosis, of which M. Rokitansky speaks. Yet, as long as the patient continues to survive, he continues to thrust betwixt the outer superfi- cies of the clot, or false polypus, and the inner walls of the auricle, tricuspid valve and ventricle, as well as the pulmonary artery, portions of blood that become thoroughly oxygenated in the lungs—for the respiratory effort is one ofdesperatio n—and the blood is probably charged to its very highest capacity with oxygen. It receives enough to maintain in the neurine the continual extrication of innervative force until the gradual augmentation of the clot at length cuts off the power of the circulation. In these cases the blue color, the cyanosis, the b lau- s u c h t, is scarcely to be discovered, the patient being, on the contrary, ghastly pale and sunken. If this be a true representation, I am right in denying that cyanosis depends on b a c k i n g the blood on to the venous segment; for such a heart-clot as I have seen, can obstruct the venous tide as eff'ectually as a ligature cast around the cava and drawn almost tight could do. If Prof. Rokitansky and Prof. Wood's views are just, then we ought to have in the case of the pre-enthanasial clot the most striking example of the cyanosed state, for, when the heart becomes thus tamponed with a cardiomorphous coagulum, the whole of the venous side of the circle is stopped, and the black blood backed into the capillaries. A small endocardial clot must have the same power to produce mechanical obstruction as contraction of the pulmonary artery; a large one is equivalent to a ligation of the cava. I deny not that a constriction of the pulmonary artery may produce cyanosis. Whatever restricts the action of the venous heart must do so. Great collections of fluid in the thorax produce it. Pressure upon the heart from dropsy ofthe pericardium; extensive injuries of the lungs from SUPPLEMENTARY. 721 tubercular degeneration; suppurations, and large vomicae; cynanche- trachealis or pseudo-membranous laryngitis; pneumothorax; atelec- tasis pulmonum ; a host, indeed, of accidents and diseases that ruin or disable the respiratory machinery, may produce cyanosis. But of these I have not spoken. I confine my observations and my method to the persistent use of the foramen ovale after birth, a case in which the blood of the veins takes the course originally followed by that of the placenta. There is no other treatment for cyanosis neonati than that I have suggested; at least there is no other reasonable treatment. Venesection, emetics, purgatives, diuretics, soporifics, baths, counter- irritants, cannot cure it. When cyanosis has introduced epiphenome- nal affections they may be treated. These affections will be found to relate chiefly to a state of the pulmonary circulation and excretions. In some instances, I have applied a large leech or two to the region of the heart, in order, haply, to assist in overcoming the pulmonary or cardiac engorgement, so apt to coincide with failure or disorder of the biotic power ofthe medulla oblongata. In general, however, when the malady has depended on the injection through Botalli's foramen, I have been content to place the infant in the proper position, and trust to that alone for the cure. CHAPTER XXV. SUPPLEMENTARY. 957. Before closing this volume, I wish to make the Student acquainted with the appearance and use of an instrument recently invented by Dr. Henry Bond, an eminent medical practitioner of this city, and which is designed for the purpose of restoring the womb to its proper situation in cases of its retroversion. The instrument, of which I annex a figure, half size (Fig. 129), 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 exte- rior 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. (See the figure.) The inner or smaller piece is attached to a sliding-piece, also mortised, overlap- ping by its edges the mortised plate-piece, and secured by a clamp or pinch traversing the mortises, and fastened or loosened by turning 7*22 SUPPLEMENTARY. 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 Fig. 129. ivory ball on the largest arc introduced into the rectum, while the oval one on the smaller arc should be introduced into the vagina. By sliding the smaller arc upwards, the two balls can be placed oppo- site 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 promontorium, they must carry the retro- verted uterus before them, and thus serve very eff'ectually and easily to reposit the dislocated organ. 958. In a difficult case of retroversion, which I lately saw in con- sultation with Dr. Bond, I in vain made repeated attempts, in which I employed great perseverance and force, to get the retroverted fundus out of the peritoneal c u 1 - d e - s a c, the bottom of which it had forced SUPPLEMENTARY. 723 almost down to the vulva. In this case, Prof. Simpson's womb-sound could not be made use of, on account of the position of the os uteri, which was quite as high as, and close to, the top of the symphysis pubis, and so firmly pressed against it as with difficulty to admit of reaching the os tineas with the indicator-finger. I could by no means succeed in several attempts that I made, to introduce the probe-point of Dr. Simpson's womb-sound into the os, for the canal of the cervix uteri made an acute angle with the posterior face of the symphysis pubis, and being in close contact with the top of the bone, it is clear that I could not introduce the end of the probe into it. I did bend the womb-sound near to its probe-point, so as to give it the shape of a blunt-hook, and, introducing the hook within the os uteri, endeavored to draw the vaginal cervix down the symphysis, but I could not make it move, and was obliged to abandon the attempt. Upon the failure of these efforts, the caoutchouc bottles were made use of as pessaries, as recommended by M. Hervez de Chegoin, in the " Mem. de l'Acad. Roy. de MeU" They doubtless served very usefully to eff'ect a partial elevation of the fundus; in the mean time the engorged uterus whose length could not have been much less than five inches, became grad- ually less hyperasmical, so that Dr. Bond was enabled, after three or four days, by means of the very ingenious instrument whose figure I have here given, to lift the fundus out of its dislocated position, whereupon the unfortunate lady was immediately relieved of a most distressing and painful accident. 959. A reviewer, in the January number of the " British and Foreign Quarterly," treats Prof. Simpson, in my opinion, with uncalled for severity on account of his womb-sound, of which I have above spoken. There is little danger to be apprehended of mischief resulting from the use of that beautiful instrument in competent hands; and the facility with which an ordinary case of retroversio uteri may be re- lieved by it together with the absolute safeness of its application in the proper cases, are qualities so very valuable, and the whole opera- tion is so much less disquieting to the fastidious patient, than the ordi- nary methods of treatment, that I think the profession should feel in the highest degree indebted to Dr. Simpson for his admirable inven- tion. As to the uses of it in diagnosis, it appears to me, since I have become acquainted with it, that it is an indispensable article in the apparatus of the physician and surgeon. In section 497 I described a case of retroversion healed by means of Braun's colpeurysis. On the 19th of the present month (September) I met the physician who con- sulted me on that case, and was informed by him that the lady is now and has been ever since the operation in fine health, and expects 724 SUPPLEMENTARY. shortly to be confined. I should have related the following most interesting case, in connection with what I have said on rupture of the uterus on a preceding page; but having mislaid Dr. Bayne's letter, I insert it as a supplement. The courage and judgment dis- played by Dr. Bayne on the occasion will ;be appreciated by every one who reads his relation of the event he describes. Extracts from a letter, dated Prince Geokge County, Md., July 13, 1856. Professor C. D. Meigs— My Dear Sir : I take the liberty to communicate to you the following case, which has recently occurred in my practice:— About twenty days since I was called to visit a patient who had been in labor two days. Found, on my arrival, there had been an entire cessation of uterine pain since the night previous; and on minute examination soon perceived that a rupture had taken place in the anterior and left side of the fundus of the uterus, sufficiently large for the escape of the entire foetus, secundines, and about one pint of sero-sanguineous fluid in the peritoneal cavity. The foetus was very large, and the rent very jagged and irregular. Inasmuch as we found it impracticable to deliver through the laceration and per vaginam, I proposed, as the only alternative, the Cassarean section. The patient was then in coma ; respiration very hurried, and pulse 130 per minute. In the presence of three medical gentlemen, I proceeded to perform the operation in the usual way. In a very short time after the ope- ration was completed, reaction came on, respiration improved and coma passed off. No untoward symptom has supervened, and the case is most favorably progressing. The patient expresses herself as being able to resume her duties as cook. Most respectfully, your ob't serv't, JNO. H. BAYNE. And now, that I have come to write the last paragraph of this volume, I take occasion to bid the Student God speed in his arduous path; to exhort him so to direct his course, that he may elevate him- self to the highest rank of the S c h o 1 a r -class, by which alone he can hope to reap the only and true reward of a life spent in'the service of them that are in pain, in fear, or in danger of death. And lastly, I assure him that he can never learn too much of the opinions and ex- perience of mankind, gained during the lapse of ages, on the subject of Disease and its Remedies. If he would, therefore, become a safe and useful minister in this art, let him never rest satisfied with clini- cal observation and experience alone, but let him devote daily a fair proportion of his time to the Medical Library.. INDEX. Abdominal pregnancy, 503 Abortion, 462-468 ergot in, 900 Abscess of Duverney's gland, 205 labium, 182 mammary, 909 Absence of the womb, 298-300 Acetabulum, 44 Adhesion of placenta, 613, 715, 798 ergot in, 900 Affixation of ovule, 344 After-pains, 607 Albuminuria, 710 Allantois, 409 Al-Mamun, Caliph, 514 Amenorrhoea, 308 Anaemia, 312 Anassthesia, 630 Analyses of the blood, 314 of the menses, 279 Ancient obstetric instruments, 749 Angulated bowel, 840 Aorta, development of the, 407 Arch of the pubis. 5 badly formed, 748 Arm presented, not to amputate, 689 Arnold on pelvic ligaments, 61 Asdrubali's case, 435 Asphyxia, 941 Atelectasis of the lungs, 913 Atresia of the womb, 891 of the vagina, 191,887 Auricular facette, 26 Auscultation, 507, 512 Axis of the pelvis, 49 pelvic of Carus, 57 Baer von, 241 Baudelocque, compressive power of 759 his forceps, 754 spontaneous cure inversion, 810 Bayne, gastrotomy, 959 Bearing down in labor, 527 Binder, 625 Biparietal diameter, 149 Blackall on albuminuria, 708 Bladder, prolapsed, 745 Blastoderm, 403 Blaud's pill, 336 Bleeding in childbed fever, 846 in labors, 578 Blood membrane, 332 Boarding school girls, 293 Boerstler's case, 424 Boivin, Madame, calliper, 742 Bond's placenta forceps, 470 retroversion instrument, 451 Bourgeois on amenorrhoea, 335 Bowels, state of in pregnancy, 3^8 prolapsed, in labors, 726 Bowman's capsules, 710 Braun's colpeurynter, 474 in placenta praevia, 701 in retroversion, 497 Breast, the female, 902 inflammation of, 909 Breech presentations, 657 conduct of, 735 delivery of the head in, 66tf diagnosis, 663 forceps provided, 671 mortality of children, 662 Bright's disease, 708 case mammary abscess, 910 Bruit de souffle, 518 Bulbs of vestibule, 208 and labial thrombus, 180 Caduca, the, 352 Caesarean operation, 785 Cancer of womb in a labor, 728-730 Cardinal points of pelvis, 44 forms of fevers, 817 Carus' curve, 49 Casts of tubes of kidney, 709 Case of albuminuria, 709 of arch of pubis, faulty, 744 of atresia vaginae, 888 uteri, 888 of bladder prolapsed, 745 of cancer uteri in a labor, 729 of Chamberlen's, 751 of Collins' childbed fever, 859 of colpeurysis, retroverted gravid, cured, 497 of cyanosis, 930 of concealed hemorrhage, 702 pregnancy, 510 of convulsions, 714-719 of cramps in a labor, 31 of doubtful signs of pregnancy, 505 of exomphalos in foetus, 412 of extra-uterine pregnancy. 501 of Mrs. E., her labor, 795 of face presentation, 649-652 of false pains, 540 of flooding labor, 608, 609, 611, 612, 615 of haeinatemesis. 314 of heart-clot, 614, 618, 621 forceps, 726 IND EX. Case of hemorrhage from bulb, 204 of inversion of womb, 800-808 of James', Dr., of sudden death, 611 of labor, conduct of a, 576, 580 of Lee, of ergotism, by Dr. R., 901 of mammary abscess, 910 of Mauriceau's sister, 907 of milk fever, 915 of oedema, 448 of opening of joints in labor, 67 of pelvic presentation, 671, 672, 674 of perineum ruptured, 762 of the Princess Charlotte, 616 of prolapsed bowel in a labor, 727 of retroversion, 481-485 of sacrum malformed, 744 of shoulder presentation, 680 Catamenia, 270 Causes of childbed fever, 827 Celsus—his uncus, 748 Cervix uteri, the, in labor, 220 in pregnancy, 367, 390 of porpoise, 368 Cephalic and pelvic presentation, 166 Cephalodym, 424 Chamberlens, the, 750 figures of their forceps, 751 Chapman's forceps, 752 Chapter I. The peivis, 1 II. Mechanism of pelvis, 86 III. Child's head and presentation of parts, 135 IV. External organs, 1^7 V. Ovaries. 226 VI. Menstruation, 270 VII. Amenorrhoea, 308 VIII. Pregnancy, 339 IX. Labor, 513 X. Conduct of Labor, 570 XI. Face presentations, 636 XII. Pelvic presentations, 657 XIII. Preternatural labor, 677 XIV. Preternatural labor, deformed pel- vis, 743 XV. Forceps, 748, 772 XVI. Embryotomy, 772 XVII. Induction of labor, 786 XVIII. Inversion of the womb, 790 XIX. Childbed fever, 811 XX. Atresia vaginae, 888 XXI. Ergot, 891 XXII. Milk fever, 903 XXIII. Diseases of infants, 914 XXIV. Cyanosis, 929 XXV. Supplementary, 957 Chaussier's method, 870 Child in utero, Fig. 16, 56 diseases of young, 923 management at birth, 915 size and weight; 161 bed fever, 811 Roberton on, 838 treatment for, 854 Chloroform formula, 632 Meigs's Letter to Simpson, 633 Simpson's Letter on, 632 Circulation of foetus, 413-414 Clarke, Dr. Jos., on childbed fever, 830 Clitoris, the, 196 Clot in the heart, 615 in the womb, to turn out, 564 Coccyx, the, 36 [ Cohesion of labia, 187 Collins, Dr., his letter to author, 859 ■ rigid os uteri, 685 Colostrum, 918 Colpeurynter, the, 474 Columns of the vagina, 210 Computation of term, 440 Concealed hemorrhage, 702 Conception, 342 Conduct of a labor, 571 in hydraemia, 720 Cone of cervix become cylinder, 720 Contagion of childbed fever, 833 Contractions of womb in labor-pains, 524 Convulsions, puerperal, 450, 708, 711, 713 tables of, .711 Cord, the, 41 around the neck, 546 knots in the, 421 prolapsed, 723 tying the, 601, 915 Corpus luteum, 250 Coryza, 697 Coste on the decidua, 356 on ovary, Fig. 247 Costiveness of infants, 923 in pregnancy, 388 Courses, the. 276 Coxal bones, 39 Cramps in labors, 31, 731, 735 Crosse, Dr. Jno. Greene, on spontaneous cure of inversion, 810 Crotchet, sharp, 757, 774, 782 Curling arteries, Hunter, 402 Curve of Carus, 49 of sacrum, 23 Cyanosis, 928-941 with catarrho-pneumonia, 945 Daillez, spontaneous cure of inversion, 810 Davis's forceps, 756 Debreiul's iron by hydrogen, 336 Decidua, 352 Coste on the, 396 Hunter on, 354 invests whole ovum, 406 Velpeau's figure of, 354 Decubitus in hemorrhage, 697 in labors, 581 Deer's suet ointment, 907 Definition of pregnancy, 340 Deformed pelvis, 710 Naegele's, 740 Mrs. R.'s case, 777 turning for, 741 De Graaf, 236 Delivery of the head in breech cases, 637 of the placenta, 602 of the shoulders, 101, 597 Delphinus—its double cervix, 368 Departure of chin, 80 Depaul, 511 Depots of milk in childbed fevers, 814 Depths of pelvis, 73 Dewees on face presentations, 650 on keyed head, 730 on placenta hook, 469 Diameters of head, 147 of pelvis, 69, 72 of womb, gravid, 389 non-gravid, 391 Diarrhoea, infantile, 922 INDEX. Didelphis, 358 Diet for lying-in woman, 626 for infant, 918 Dilatation of os uteri, 220 Diseases of infants, 913 Doable foetus, 424-690 Doulcet's method in childbed fever, 867 Dress for the child, 910 Dropsy of the ovum, 505 Dubois on the axis, 52 Duncan and Flockhart's formula, 632 Duration of gestation, 342, 432 of labors, 517 of labor-pains, 524 Duverney's glands, 205 Face presentations, 636, 652 cases of, 649-652 Dewees on, 650 Forceps in, 641 Fainting, heart-clot to be feared in, 615 labors in, 724 post-partum, 615 Fecundation, 341 when possible, 345-50 Fever, childbed, 811 milk, 912 Fillet, the, 735 Flexion and extension, 550 occipito-posterior in, 764 Floodings, 693 in abortions, 468 Bourgeois method, 690 labors, 693, 707 placenta praevia, 696 tampon in, 475, 628 Flourens on nervous mass, 838 on placenta, 394 Foetal circulation, 414, 913 dimensions, 161 haematosis, 325 head, 135 presentations, 157. 169, 679 Follicles of De Graaf, 230 Fontanels, 153 Food for infants, 918 Foramen ovale, 913 Foramina of sacrum, 21 Forceps, 748 Baudelocque's, 690 Chamberlen's, 750 Chapman's, 752 Davis's, 750 Levret's, 753 Pean's, 754 pelvic presentations in, 671, 770 Siebold—Huston's, 756 Smellie's, 753 Fourchette, 189 Fourth position vertex, 115 breech, 673 Fox's cases, 785, 793 Gastrotomy, 747, 959 Generative organs, 177 Genevoix's iron, 336 Germ, the, 403 Germinal vesicle, 233 spot, 244 Gestation, duration of, 432 Gibson's Caesarean section, 785 Gideon, Ann, 437 Gland, Duverney's, 205 tubular, of womb, 356 Gordon, Alexander, 855 Graafian vesicles, 230 Granular membrane, 231 Gravid womb, size of, 391 Grinding pains, 527 Haematemesis, a case, 314 Hand, prolapsed, 686 Hatch, Dr., case of inversion, 809 Head of foetus, 135 positions, 173 presentations, 168 Heart at birth, 414 clot, 615-621, 956 embryonal. 407, 913 Hemorrhage after delivery, 608-615 in labors, 693-696 sources of the blood in, 412 unavoidable, 696 Hepatodym, 426 Hila of the follicle, 282 Hohl on the binder, 625 ovate pelvis, 29 wings of sacrum, 25 Hour-glass contraction, 603 Hugh Chamberlen, 750 Huguier on Duverney's gland, 205 Hydatids, 453 Hydraemia, case of, 314-325 in labors, 720 Hydrometra, 461 Hymen, 190 Icterus of infants, 926 Ileo-pectinea, linea, 8 Inclination of pelvis, 11 ischial planes, 55 Induction of labors, 794 Infantile diseases, 913 Inferior strait, diameters of, 9. 69, 72 planes of, 71, 73 Ingreville, Mad., a case, 4.']2 E., Dr. Jno., Letter to, on Induction, 795 Ecker's figures tubuli uriniferi, 710 Eclampsia, 450, 711 Ectopy of liver, 412 Elephant, gestation of, 434 Emansio mensium, 323 Embryo-heart, 392-414 diseases of, 419 sacrum of, 19 Embryo germ processes, 360 Embryonal membrane, 427 Embryotomy, 772, 785, 793 instruments of author, 288 Emmenagogues, 334 Endangium, 328 Epidemic childbed fever, 824 table of, 828 Ergot, chapter on, 890 in flooding labors, 894 in abortions, 901 Etherization, 630 Evolution of pregnant womb, 370 Examination or Touching, 534 External organs, 177 Extra-uterine pregnancy, 500 728 INDEX. Instruments, obstetric, of ancients, 749 modern, 757 Intermedia, pars, 200 wound of the, 204 Internal hemorrhage, 702 genitals, 214 Intestine, prolapsed, 728 Intoxication pyaemic, 877 urasmic, 708 Inversion of womb, 798 case by Hatch, 809 Levis, 808 Moehring, 800 spontaneous cure, 810 Cross on, 810 Daillez on, 810 James, Dr., his case of sudden death from rising up after delivery, 611 Jaundice, infantile, 926 Jewish law, clean or unclean, 284 John Ocularius and the Caliph, 514 Joints of pelvis relaxed in labor, 63 Junction, sacro-iliac, 27 Keyed neck of foetus, 739 Kidneys, albuminuric condition in pregnancy, 710 Kidneys, casts from tubuli of the, 708 Kiwisch, method in premature labor, 797 ovum, 266 Knots on the cord, 420 Kobelt on the genitals, 200 bulbs of vestibule, 201 Kolrausch on the pelvis, 76 Labia, abscess of, 182 cohesion of, 187 majora, 177 minora, 185 thrombus of, 179 Labor, 513, 570 causes of, 520 colpeurysis in, 474 conduct of, 571 cramps in a, 31 decubitus in, 581 definitions of, 514 dynamics of, 541 induction of, 794 mechanism of, 558 pains, 524-527 duration and number of, 843 false, 538 Saccombe, 525 signs of, 532 Laceration of vagina and womb, 725-747 Lachapelle, Mad., face presentations, 654 Lamotte, protracted pregnancy, 438 Lait repandu, 814 Lee, Dr. Robt., childbed fever, 835 ergot for abortion, 901 orifices in womb walls, 696 turning in deformed pelvis, 741 Leroux of Dijon, inversion, 798-804 Lever, Dr., albuminuria, 708 pelvic tumors, 746 Levis, Dr., inversion case, 808 Levret's forceps, 753 Ligaments, pelvic, 62 triangular, 743 Linea ileo-pectinea, 8 Lochia, 565 -570, 629 Locked head, 907 Loop of bowel prolapsed, 726 Lungs of foetus and neonatus, 973 Maculae germinativae, 294 Malformed pelvis, 775 symphysis, 743 Malpighi's corpuscles, 710 Mammal ovule, 241 Mammary abscess, 909 Manchester epidemic, 833 Margin or brim, 8 Mauriceau and C.iamberlen, 750 and his sister, 707 Mechanism of breech labors, 667 evolution of foetus, 679-689 head, 584 labors, 558 pelvis, 86 Meigs' embryotomy instruments, 788 Membrana granulosa, 232 vasorum, 324 Menagoga, 334 Menstruation, 78, 79, 80, 90, 270, 349 Mensuration of pelvis, 742 Merriman's tables of gestation, 439 Metritis, 810 Metro-peritonitis, 816 Milk abscess. 909 depots of Puzos, 814-817 fever, 902 Moehring's case of inversion, 807 Moles, 457 Monstrosity, 429 Morbus caeruleus, 918-940 Mucous tubular membrane, 356 Mulder's history of forceps, 752 Naegele's computations, 440 pelvis, 740 position of the head, 556 Nausea and vomiting. 378 Navel, 920 pouting of the, 386 tying the string, 601, 915 Nervous mass, Oken and Prochaska on the, 887 Nipple, countersunk, 911 sore, 907 Noortwyck on allantois, 412 Nymphae, the, 185 Obliquity of the womb, 447 of pelvis, 740 Occipito-posterior positions, forceps, 764 Ocularius and the Caliph, 514 (Edema gravidarum, 448 Ointment of deer's suet, 907 Oken, the nervous mass, 887 Omphalo-mesenteric system, 408 Opening of the joints, 63 Os innominatum, 39 uteri, 223 Ould, Sir Fielding, 86 Ovaries, the, 226 Coste's figure of, 347 menstrua, during the, 222 stroma of the, 227 Ovulation, 276 Ovum of mammalia, 251 Baer on the, 241 IND EX. 729 Ovum, Coste on, 243-247 Purkinje, 237 Wharton Jones, 244 Part I. Anatomy of the genitalia, 1 II. Physiology of Reproduction, 280 III. Therapeutics and Surgery of Mid- wifery, 513 IV. Young Child and its diseases, 913 Pars intermedia, 200 Pains, 220, 524 duration of, 893 number of, 221 Pelvis, the, 134 axis of the, 49 bones of the, 17 brim, 6-8 deformed, 740 depth of the, 69, 72 etymology of the, 4 excavation of the, 8, 46 inclined planes of, 11, 55 Kolrausch's, 76 ligaments of, 59 mechanism of, 86 mensuration of the, 22, 69, 742 Naegele's 740 Simpson's deformed, 740 straits of the, 8-9 tumors within the, 746 Perineum, 593 ruptured, 762 Peritonitis child-bed, in, 816 Pfeiffer's Monster, 424, C90 Phlebitis of womb, 816 Physometra, 458 Placenta, 392 adherent, 603 praevia, 696 Plane of ischium, 55 superior strait, 11 Pore of Graafian vesicle, 282 Positions, 165, 550 Boivin on, 554 Lachapelle, 555 Naegele, 556 Pouchet on ovulation, 265 Pregnancy, 339 extra-uterine, 500 ventral, 503 Premature labor induction, 795 Presentations, 156 in brute animals, 2 two only, 165 Proligerous disk, 233 Promontory of sacrum, 22 Prochaska on nervous mass, 887 Protracted pregnancy, 436-439 Pudenda, 177 Purging in young infants, 922 Purkinje, 233 Quevenne's iron, 236 Quickening, 511 Raciborski on the veins, 401 Rainalde, Thos., 748 Rainard's tables of gestation, 433 Randolph's ease, atresia, Ss8 Reproduction, 339 Retained placenta, 705 Retroversion, 4S2-492 ■±7 Retroversion, Bond's instrument, 470 cases of, 484-487-491 womb sound for, 959 Rita, Christina, 424 Roberton on Manchester epidemic, 833 Rohrer's case, 424 Rokitansky, cyanosis, 955 Rotation, 584, 703 Saccombe, describes a labor, 525 Sacrum bone, 18 elements of, 19 etymology, lutz, 18 hollow of the, 20 faulty, 743 wings of the, 25 a case, 590 Scarlatina in pregnancy, 733 Secale cornutum, 890, 900 Section of pubis, 771 Seiler on placenta, 394 Serres on monstrosity, 425 Shoulder presentations, 101, 176, 597, 679 turning for, 739 two for each shoulder, 681 Sigault, 771 Signs of labor, 532 pregnancy, 375, 504 a case, 510 Simpson, Professor, a letter from and to, 032- 633 Sims, Dr. John, his letter to Clarke, 616 Sitting up, 614 Six vertex positions, 173 Smallpox in pregnancy, 731 Smellie's forceps, 753 Smith, Dr. Tyler, account ofthe vagina, 207 planes of pelvis, 56 Sore mouth, 925 nipples, 907 Spontaneous cure of inversion, Daillez, 810 evolution, 679-89 Straits of pelvis, 8 Stricture of vagina, 889 Stroma of the ovary, 228 Strophulus or gum, 924 Table, cases of convulsions, 711 epidemic child-bed fever, 828 heads measured, 151 Merriman's, 439 presentations, 168 Tampon, 475 never, 628 Term to compute, 440 Tertullian cited, 748 Thickness of womb-wall, 442 Third vertex position, 111 Therapeutics and Surgery of Midwifery, 513 Thrombus labii, 179 Tonics for amenorrhoea, 535 Torpor of uterus, 219, 323, 542 Touching, 534 for signs of pregnancy, 506 Triangular ligament, 743 Tubal pregnancy, 265 Tubular glands of womb, 356 Tumors in pelvis, 746 Turning, 6S3 case, 737 operation, 736 placenta praevia, 701 730 INDEX. Turning, shoulder cases, 679, 683, 739 Twins, 738 Turn out the clot, 624 Umbilical cord, 411 hernia, 412 knots, 421 prolapse, 723 vesicle, 233 Umbilicus, 919 Unavoidable hemorrhage, 696 Uncus of Celsus, 748 Uraemia, 708 Uterine phlebitis, 816 Uterus, 214 changes in labor, 522 dynamics of, 218 gravid, size and weight, 391 hour-glass, 603, 704 inverted, 790 retroverted, 482 virgin, 214 Vaccination, pregnancy, never, 722 Vagina, the, 206 laceration of, 744 Variola in pregnancy, 731 Vectis of Chamberlen, 751 Ventral pregnancy, 503 Vertex, the, 153 dip of the, 94, 160 presentation, 166, 173 Vertex, positions, 173, 550 Vesicle, germinal, 233 Purkinjean, 233 umbilical, 410 Vesicocele of vagina, 745 Vestibulum, 186 bulbs of the, 201 Viability, 913 Vigarous, 814 Wagner, macula germinativa, 246 Weaning, 919 Weber, placenta, 397 White, Dr. Chas., on binder, 625 inversion, 802 Wigand, 515, 539 Womb delivered, 606 dynamics of, 218 ergotism of, 891 hour-glass. 603, 705 inverted, 790 lacerated, 747 obliquity of, 447 sound of Simpson, 959 torpid, 542 Yardley, case retroversion with extra-uterine pregnancy, 495 heart clot, a case, 621 Zona pellucida, 248 THE END. ;;*prtt-iO«;;£><-.r.r-r>.-H ii >r#r.ifwfur .i>r>o" •■!■• ' T.r.f>f*csO{i •' .,.!■. >l .»«(<<* - " ■' m >c «>.(-»(* ---1 i a.fffxrw..,. 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